Fluids and Electrolytes Salman Bin AbdulAziz University College Of Pharmacy Fluids and Electrolytes Therapeutics I PHCL 416 Ahmed A AlAmer PharmD

His medical history includes hypertension and coronary artery disease. Case I A 65-year-old man with a 3-day history of temperature to 102°F, lethargy, and productive cough is hospitalized for community-acquired pneumonia. His medical history includes hypertension and coronary artery disease. His vital signs include HR 104 beats/minute, BP 112/68 mm Hg, and temperature 101.4°F. His weight is 80 kg, decreased skin turgor , urine output 10 mL/hour, BUN 16, Cr 1.7 mg/dL, and WBC 10.4. Other laboratory values are normal. What do you think this patient has ? Volume overload Volume depletion non

Subjective and objective for this patient are?

His medical history includes hypertension and coronary artery disease. Case I A 65-year-old man with a 3-day history of temperature to 102°F, lethargy, and productive cough is hospitalized for community-acquired pneumonia. His medical history includes hypertension and coronary artery disease. His vital signs include HR 104 beats/minute, BP 112/68 mm Hg, and temperature 101.4°F. His weight is 80 kg, decreased skin turgor , urine output 10 mL/hour, BUN 16, Cr 1.7 mg/dL, and WBC 10.4. Other laboratory values are normal. What do you think this patient has ? Volume overload Volume depletion non

Signs (like HR and BP) in patient with Intravascular Volume Depletion improved after a 500- to 1000-mL fluid bolus (T/F) Tachycardia is the earliest sign of volume depletion

What’s the goal of therapy in this patient ? Restore intravascular volume and prevent organ hypoperfusion. Fluid resuscitation is indicated for patients with signs or symptoms of intravascular volume depletion.

Which one of the following is most appropriate for this patient at this time? A. Furosemide 40 mg intravenously. B. Albumin 25% intravenously over 60 minutes. C. Hetastarch 6% 500 mL intravenously over 60 minutes. D. . 500- to 1000-mL fluid bolus (NS, LR)

A. IV fluids are infused rapidly, Fluid resuscitation Maintenance Intravenous Fluids A. IV fluids are infused rapidly, preferably through a central venous catheter. B . Intravenous fluids are administered as a 500- to 1000-mL bolus, after which the patient is reevaluated; this process is continued as long as signs and symptoms of intravascular volume depletion are improving.

Give examples of colloids ? Fluid resuscitation Maintenance Intravenous Fluids Crystalloids (0.9% NaCl or LR) are recommended for fluid resuscitation. Colloids ? are generally not superior to crystalloids and are associated with a considerably higher cost. Give examples of colloids ?

The goal of maintenance intravenous fluids ? Fluid resuscitation Maintenance Intravenous Fluids Maintenance intravenous fluids are indicated in patients who are unable to tolerate oral fluids. The goal of maintenance intravenous fluids ? prevent dehydration and maintain a normal fluid and electrolyte balance.

The KCl content can be adjusted for the individual patient. Fluid resuscitation Maintenance Intravenous Fluids Continuous infusion through a peripheral or central intravenous catheter typical maintenance intravenous fluid is D5W with 0.45% NaCl plus 20–40 mEq of KCl/L. The KCl content can be adjusted for the individual patient.

Which one of the following is most appropriate for this patient at this time? A. Furosemide 40 mg intravenously. B. Albumin 25% intravenously over 60 minutes. C. Hetastarch 6% 500 mL intravenously over 60 minutes. D. 500- to 1000-mL fluid bolus (NS, LR)

Which one of the following is most appropriate to initiate? After 2 days of appropriate antibiotic treatment, the patient in question 1 has WBC of 9, and he is afebrile. His BP is 135/85 mm Hg, and his urine output is now 45 mL/hour. His albumin is 3.2, BUN 14, and Cr 1.4 mg/dL. All other laboratory values are normal. His appetite is still poor, and he is not taking adequate fluids. He has peripheral intravenous access. Which one of the following is most appropriate to initiate? A. Peripheral PN to infuse at 110 mL/hour. B. Albumin 5% 500 mL intravenously over 60 minutes. C. D5W/0.45% NaCl plus KCl 20 mEq/L to infuse at 110 mL/hour. D. LR solution to infuse at 110 mL/hour. 2. Answer C This patient has no current signs or symptoms of intravascular volume depletion, so he does not require fluid resuscitation

Which one of the following is most appropriate to initiate? After 2 days of appropriate antibiotic treatment, the patient in question 1 has WBC of 9, and he is afebrile. His BP is 135/85 mm Hg, and his urine output is now 45 mL/hour. His albumin is 3.2, BUN 14, and Cr 1.4 mg/dL. All other laboratory values are normal. His appetite is still poor, and he is not taking adequate fluids. He has peripheral intravenous access. Which one of the following is most appropriate to initiate? A. Peripheral PN to infuse at 110 mL/hour. B. Albumin 5% 500 mL intravenously over 60 minutes. C. D5W/0.45% NaCl plus KCl 20 mEq/L to infuse at 110 mL/hour. D. LR solution to infuse at 110 mL/hour. Answer C This patient has no current signs or symptoms of intravascular volume depletion, so he does not require fluid resuscitation Sign and symptoms stopped ( no need Resuscitation) Need for maintenance iv fluid

Fluids and Electrolytes II Salman Bin AbdulAziz University College Of Pharmacy Fluids and Electrolytes II Therapeutics I PHCL 416 Ahmed A AlAmer PharmD

Hypernatremia, hypervolemia Hyponatremia , hypovolemia A 72-year-old woman , weight 60 kg , with a history of hypertension has after starting hydrochlorothiazide she experiences dizziness, fatigue, and nausea. 3 weeks earlier. Her serum Na+ is 116 mEq/L K+ is 4 mEq/L, BP is 86/50 mm Hg, and HR is 122 beats/minute. This patient has Hypernatremia, hypervolemia Hyponatremia , hypovolemia Hyponatremia, hypervolemia Sodium 135–145 mEq/L Potassium 3.5–5.0 mEq/L obtundation /ob·tun·da·tion/ (ob-tun-da´shun) mental blunting with mild to moderate reduction in alertness and a diminished sensation of pain This patient has (tachycardia Hypotension )… hypovolemia Serum Na+ … low (hyponatremia)

Symptoms of hyponatremia appears after what level ? < 130 mEq/L A 72-year-old woman , weight 60 kg , with a history of hypertension , has after starting hydrochlorothiazide she experiences dizziness, fatigue, and nausea. 3 weeks earlier. Her serum Na+ is 116 mEq/L K+ is 4 mEq/L, BP is 86/50 mm Hg, and HR is 122 beats/minute. U Na+ >40 mEq/L This patient has Symptoms of hyponatremia appears after what level ? < 130 mEq/L <140 mEq/L <120 mEq/L Sodium 135–145 mEq/L Potassium 3.5–5.0 mEq/L Mild Moderate Severe

The cause of hyponatremia is HCT ( hydrochlorothiazide) ? ( T/F) A 72-year-old woman , weight 60 kg , with a history of hypertension has after starting hydrochlorothiazide she experiences dizziness, fatigue, and nausea. 3 weeks earlier. Her serum Na+ is 116 mEq/L K+ is 4 mEq/L, BP is 86/50 mm Hg, and HR is 122 beats/minute. U Na+ >40 mEq/L This patient has The cause of hyponatremia is HCT ( hydrochlorothiazide) ? ( T/F) Sodium 135–145 mEq/L Potassium 3.5–5.0 mEq/L

A. 0.9% NaCl infused at 100 mL/hour. B. 0.9% NaCl 500-mL bolus. A 72-year-old woman , weight 60 kg , with a history of hypertension has after starting hydrochlorothiazide she experiences dizziness, fatigue, and nausea. 3 weeks earlier. Her serum Na+ is 116 mEq/L K+ is 4 mEq/L, BP is 86/50 mm Hg, and HR is 122 beats/minute. A. 0.9% NaCl infused at 100 mL/hour. B. 0.9% NaCl 500-mL bolus. C. 3% NaCl infused at 60 mL/hour. D. 23.4% NaCl 30-mL bolus as needed. 3. Answer B Although this patient is experiencing symptomatic hyponatremia, she is also showing signs of intravascular volume depletion. This intravascular volume depletion is a potent stimulus for ADH secretion, which will potentiate hyponatremia. In patients with hyponatremia and intravascular volume depletion, it is important to restore intravascular volume first to prevent organ hypoperfusion as well as to inhibit the secretion of ADH. Fluid resuscitation should be accomplished with 0.9% NaCl as a fluid bolus, followed by a reevaluation of fluid status. A slower infusion of 0.9% NaCl (Answer A) will not quickly restore intravascular volume. Once the intravascular volume is restored, secretion of ADH will cease. This can be followed by a water diuresis with a subsequent rise in the serum Na+ concentration. Of importance, the patient should be monitored closely to prevent a rise in serum Na+ greater than 10–12 mEq/L/day. If serum Na+ rises too fast, 0.45% NaCl can be infused to slow the rate of rise of serum Na+ concentration. Hypertonic saline (Answers C and D) would not be advisable unless the patient continued to have symptoms of hyponatremia after appropriate fluid resuscitation.

A. 0.9% NaCl infused at 100 mL/hour. B. 0.9% NaCl 500-mL bolus. A 72-year-old woman , weight 60 kg , with a history of hypertension has after starting hydrochlorothiazide she experiences dizziness, fatigue, and nausea. 3 weeks earlier. Her serum Na+ is 116 mEq/L K+ is 4 mEq/L, BP is 86/50 mm Hg, and HR is 122 beats/minute. U Na+ >40 mEq/L A. 0.9% NaCl infused at 100 mL/hour. B. 0.9% NaCl 500-mL bolus. C. 3% NaCl infused at 60 mL/hour. D. 23.4% NaCl 30-mL bolus as needed. Hypovolemia (bolus ) = fluid resuscitation 3. Answer B Although this patient is experiencing symptomatic hyponatremia, she is also showing signs of intravascular volume depletion. This intravascular volume depletion is a potent stimulus for ADH secretion, which will potentiate hyponatremia. In patients with hyponatremia and intravascular volume depletion, it is important to restore intravascular volume first to prevent organ hypoperfusion as well as to inhibit the secretion of ADH. Fluid resuscitation should be accomplished with 0.9% NaCl as a fluid bolus, followed by a reevaluation of fluid status. A slower infusion of 0.9% NaCl (Answer A) will not quickly restore intravascular volume. Once the intravascular volume is restored, secretion of ADH will cease. This can be followed by a water diuresis with a subsequent rise in the serum Na+ concentration. Of importance, the patient should be monitored closely to prevent a rise in serum Na+ greater than 10–12 mEq/L/day. If serum Na+ rises too fast, 0.45% NaCl can be infused to slow the rate of rise of serum Na+ concentration. Hypertonic saline (Answers C and D) would not be advisable unless the patient continued to have symptoms of hyponatremia after appropriate fluid resuscitation.

MCQ Correction the underlying cause in this patient means ? Discontinue hydrochlorothiazide Start patient on loop diuretics Give patient BB (beta blocker) to manage his HR

A. Increase Na+ concentration to 140 mEq/L. For the patient described above, which one of the following is the best treatment goal for the first 24 hours in correcting her serum Na+ from her initial value of 116 mEq/L? why ? A. Increase Na+ concentration to 140 mEq/L. B. Increase Na+ concentration to 132 mEq/L. C. Increase Na+ concentration to 126 mEq/L. D. Maintain serum Na+ between 116 mEq/L and 120 mEq/L. 4. Answer C To prevent central pontine myelinolysis in patients with hyponatremia, it is recommended that the serum Na+ concentration be raised by no more than 10–12 mEq/L in 24 hours. Of emphasis, the goal is not to achieve a normal serum Na+ concentration in 24 hours. Rapid correction of chronic hyponatremia can cause permanent neurologic damage.

Rapid correction of hyponatremia can cause permanent neurologic damage. (To prevent central pontine myelinolysis)

A. Increase Na+ concentration to 140 mEq/L. For the patient described above, which one of the following is the best treatment goal for the first 24 hours in correcting her serum Na+ from her initial value of 116 mEq/L? why ? A. Increase Na+ concentration to 140 mEq/L. B. Increase Na+ concentration to 132 mEq/L. C. Increase Na+ concentration to 126 mEq/L. D. Maintain serum Na+ between 116 mEq/L and 120 mEq/L. Why? …write down the answer 4. Answer C To prevent central pontine myelinolysis in patients with hyponatremia, it is recommended that the serum Na+ concentration be raised by no more than 10–12 mEq/L in 24 hours. Of emphasis, the goal is not to achieve a normal serum Na+ concentration in 24 hours. Rapid correction of chronic hyponatremia can cause permanent neurologic damage.

Correction limit in mild chronic hyponatremia is ? Correction limit in moderate acute hyponatremia is ? Correction limit in severe acute hyponatremia ?

How to calculate infusion rate for NS? Initial rate = desired serum [Na+] increase per hour (mEq/h) x patient weight (kg) (example:  Na+ by 1 mEq/L/h in 70 kg patient = 70 mL/h infusion,

to estimate effect of 1 L of any saline infusion on serum sodium change in serum sodium = (infusion sodium concentration [mmol/L] - serum sodium concentration [mmol/L]) / (total body water + 1) sodium concentrations of various infusates 5% sodium chloride in water = 855 mmol/L 3% sodium chloride in water = 513 mmol/L 0.9% sodium chloride in water = 154 mmol/L Ringer's lactate solution = 130 mmol/L 0.45% sodium chloride in water = 77 mmol/L 0.2% sodium chloride in 5% dextrose in water = 34 mmol/L 5% dextrose in water = 0 mmol/L total body water (in L) = weight (in kg) x age/gender-specific fraction of body weight 0.6 in children and adult nonelderly men 0.5 in adult nonelderly women and elderly men 0.45 in elderly women

Fluids and Electrolytes III Salman Bin AbdulAziz University College Of Pharmacy Fluids and Electrolytes III Therapeutics I PHCL 416 Ahmed A AlAmer PharmD

A 40-year-old man has been admitted to the hospital after several days of vomiting and diarrhea. In the emergency department, he had several runs of nonsustained ventricular tachycardia. His plasma K+ on admission was 2.8 mEq/L. After receiving 200 mEq of potassium chloride (KCl) infused over 24 hours, his repeat K+ is 3.2 mEq/L, and he continues to have runs of ventricular tachycardia.

Other laboratory values include Na+ 143 mEq/L, magnesium 1 Other laboratory values include Na+ 143 mEq/L, magnesium 1.1 mEq/L, phosphorus 3 mg/dL, Ca++ 9 mg/dL, and ionized Ca++ 1.1 mmol/L.

What information (signs, symptoms, laboratory values) indicates the presence and severity of the electrolyte abnormalities? ( SOAP ) S vomiting and diarrhea O he had several runs of nonsustained ventricular tachycardia. plasma K+ on admission was 2.8 mEq/L. include Na+ 143 mEq/L, magnesium 1.1 mEq/L, phosphorus 3 mg/dL, Ca++ 9 mg/dL, and ionized Ca++ 1.1 mmol/L. A Based on clinical presentation and lab values This patient has hypokalemia that’s resistant to the conventional treatment P ?

The cause of hypokalemia in this case ?

Causes of hypokalemia a Causes of hypokalemia a. Reduced intake seldom causes hypokalemia because renal excretion is minimized because of increased renal tubular absorption. b. Increased shift of K+ into cells can occur with the following: i. Increased pH ii. Insulin or a carbohydrate load iii. β2-Receptor stimulation caused by stress-induced epinephrine release or administration of a β-agonist (e.g., albuterol, dobutamine) iv. Hypothermia

c. Increased GI losses of K+ can occur with vomiting, diarrhea, intestinal fistula or enteral tube drainage, and chronic laxative abuse. d. Increased urinary losses can occur with mineralocorticoid excess and diuretic use (e.g., loop and thiazide type). ( common cause ) e. Hypomagnesemia is commonly associated with hypokalemia caused by increased renal loss of K+; correction of plasma K+ requires simultaneous correction of serum magnesium.

Complete Regarding symptoms of mild hypokalemia ( 3.5-3 mEq/L) ) patient is …………….. ( symptomatic / asymtomatic ) Regarding symptoms of moderate hypokalemia ( 3- 2.5 mEq/L) ) patient may complain of symptoms include …………….. Patient with severe hypokalemia ( <2.5 mEq/L) can have ………(signs ,symptoms ) ANSWER cramping, weakness, malaise, and myalgias ANSWER electrocardiogram (ECG) changes Musculoskeletal: Cramping and impaired muscle contraction.

MCQ What type of hyperkalemia this patient has ? Mild hypokalemia Moderate hypokalemia Severe hypokalemia Why? Check the level and ECG

Treatment of hyperkalemia Patients without EKG changes or symptoms Oral supplementation (eg KCl) . Patients with EKG changes or symptoms Oral Or IV ( Severe or with ECG changes ) Whenever possible, potassium supplementation should be administered by mouth

Treatment of hyperkalemia Patients without EKG changes or symptoms Oral supplementation (eg KCl) . (doses greater than 60 mEq should be divided to avoid GI adverse effects)

Treatment of hyperkalemia Patients without EKG changes or symptoms Oral supplementation (eg KCl) . Potassium Cl- is the preferred salt in patients with concurrent metabolic alkalosis because these patients typically lose Cl- through diuretics or GI loss. Other salts ? All the following can be taken orally K Chloride most common used + metabolic alkalosis K Phosphate patient with hypophosphatemia K Bicarbonate. metabolic acidosis. Potassium acetate IV K+ salts Potassium acetate …metabolic acidosis Potassium chloride

T/F IV K supplement is adminstired as bolus ( IV push) Doses more than 60 mEq of oral potassium can be administered as one dose why? To avoid gastric erosion To avoid irritation, no more than about 60 mEq/L should be administered through a peripheral vein. Recommended infusion rate is 10–20 mEq/hour to a maximum of 40 mEq/hour. Patients who receive K+ at rates faster than 10–20 mEq/hour should be monitored using a continuous EKG. (F) (F) (T) (T) (T)

Which one of the following suggestions is best to treat this patient’s hypokalemia? Administer KCl 20 mEq intravenously over 1 hour each × 4 doses and recheck K+. B. Administer magnesium sulfate as a 2-g slow intravenous infusion. C. Administer K+ phosphate 15 mmol intravenously over 4 hours. D. Administer Ca++ gluconate 2 g intravenously over 5 minutes.

Which one of the following suggestions is best to treat this patient’s hypokalemia? Administer KCl 20 mEq intravenously over 1 hour each × 4 doses and recheck K+. B. Administer magnesium sulfate as a 2-g slow intravenous infusion. C. Administer K+ phosphate 15 mmol intravenously over 4 hours. D. Administer Ca++ gluconate 2 g intravenously over 5 minutes.