dysnatremias: hypernatremia and polyuria · • hypernatremia / hyponatremia reflects free water...
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Dysnatremias:HypernatremiaandPolyuria
AstoryofwaterandvolumeElaineM.Kaptein,[email protected]
Nodisclosures
OBJECTIVES
• Physiology/pathophysiologyoftotalbodywaterandvolume
• Evaluationandtreatmentofhypernatremia• Sodiumconcentrationsofbodyfluidlossesandparenteralandenteral“fluid”inputstoestimatewaterandvolumecomponents
• Challengesinassessingintravascularvolume• Applythisinformationtotheclinicalsetting
RegulationofTotalBodyWaterandSodium
WATER:Antidiuretichormone(ADH)
-Stimulatesthirstandrenalwaterreabsorption-Increasedbyhyperosmolality,hypothalamic hypoperfusion,nausea,vomiting,stressand narcotics
-decreasedbyhyponatremiaINTRAVASCULARVOLUME:Renin-Angiotensin-Aldosterone(RAAS)
-Stimulatessodiumreabsorptionbythekidney-Increasedbyrenalhypoperfusion-Decreasedbyhypervolemia,ACEI,ARBs,Spironolactone
DistributionofTBW
Proportions given for 70kg male1, may vary in illness2.
1. Randall HT. Water and electrolyte balance in surgery. The Surgical Clinics of North America. 1952: 445-469. 2. Randall HT. The shifts of fluid and electrolytes in shock. Annals of the New York Academy of Sciences. 1952; 55: 412-428
SODIUM POTASSIUM
Plasma ECF
Normalconditions
MJKaptein,MD
SerumSodiumConcentration
Serum[Na+]=exchangeablebody(sodium+potassium)totalbodywater=amountofsodium/volumeofECFwaterNormalserum[Na+]is140mEq/LofserumNormalsalineis154mEq/LofwaterWHY?Only91%ofserumiswater
HYPERNATREMIAS[Na+]>145mEq/L
S[Na+]canbemeasuredby1) AutoanalyzerforBMP2) FlamephotometerforABGorVBGQUESTIONS:1)Aretheyalwaysthesame?No.WHY?2)CanpseudohypERnatremiaoccur?
Normal plasma
95% plasma
water
5% protein/lipid
91% plasma
water
9% protein/lipid
Hypoproteinemic plasma
Pseudohypernatremia
Na 154 Na
154
Apparent concentration of Na in serum by indirect method (BMP)
154 x 0.91 = 140mEq/L of serum 154 x 0.95 = 146 mEq/L of serum
S[Na+] is “normal” if measured directly with ion-sensitive electrodes in undiluted PLASMA in the ABG lab in the presence of low protein and lipids.
PseudohypERnatremia• Lowserumproteinconcentrationsincreasethewaterphaseofserumto>91%andcanresultinanartifactualincreaseofserum[Na+]byindirectpotentiometry(BMP)comparedtodirectpotentiometry(ABG/VBG).
• >4mEq/Ldifferencein25%ofICU,8%ofhospitalizedspecimens
• 97%with>4mEq/Ldifferencewereduetolowproteinconcentrations.
• JCritCare27:326.e9-e12,2012
PseudohypernatremiainourICU(PaulLoener,MDRegionalACP2014)
• 30ICUpatientswithtotalproteinconcentrations<6g/dL
• Serum[Na+]byBMPgreaterthanonABGin29of30patients.
• 30%haddifferencesof>4mEq/LSIGNIFICANCE:FreewaterreplacementshouldbecalculatedusingdirectISEmethodstoavoidovercorrectionandhyponatremia.
DiagnosticApproachtoHypernatremia• AssessforPseudoHYPERnatreima(overestimatingS[Na+])CompareS[Na+]byBMPwithVBG/ABGS[Na+]maybeHIGHERonBMPthanVBG/ABGduetohypoproteinemia/hypolipidemiaincreasing%serumwater
CORRECTS[Na+]VALUEisviaVBG/ABG• AssessforHyperosmolarstates-watershiftsfromICFto
ECFwithincreasedglucose,mannitolorcontrastDecreaseinS[Na+]=2x(Serumglucose-100)/100
e.g.Ifserumglucoseis900,2x(900-100)/100=8x2=16,soS[Na+]isactually16mEq/LhigherthanonVBGorABGwhencorrectedforwatershiftduetohyperglycemia
CausesofHypernatremia
Freewaterintake<freewaterlosses or
AdministrationofhypertonicsodiumsolutionsResultinginatotalbodyfreewaterdeficitrelativetototalbodyexchangeablesodium
HYPERNATREMIATREATMENT1. Recognizeandcorrectunderlyingproblem2. Calculatethefreewaterdeficit5. Replace1/2offreewaterdeficitin24hours.
Nottodecreaseserum[Na+]>0.5mEq/L/hror8-10mEq/L/dtoavoidcerebraledema
7. Replaceongoingwaterlosses-insensiblelosses-GIlosses-renallosses5.Maintaineuvolemia.
HYPERNATREMIATREATMENT1. Recognizeandcorrectunderlyingproblem2. Calculatethefreewaterdeficit5. Replace1/2offreewaterdeficitin24hours.
Nottodecreaseserum[Na+]>0.5mEq/L/hror8-10mEq/L/dtoavoidcerebraledema
7. Replaceongoingwaterlosses-insensiblelosses-GIlosses-renallosses5.Maintaineuvolemia.
HYPERNATREMIACLINICAL CIRCUMSTANCES
Elderly/InfantsAMS
Decreased ThirstUnable to drinkReset osmostat
Central Nephrogenic
Diabetes Inspidus
Pure waterlosses
Renal, GIlung, skin
Water loss > Na loss
Hypotonic losses HypertonicNa Bicarbonate
3% SalineTPN
Renal• Purewaterlosses-DI• Osmoticdiuresis-glucose,
contrast,mannitol,urea,diuretics– Losses~1/2normalsaline(Ur[Na+]~80mEq/L)– Alwayscheckurine[Na+]
Non-renal• GI:
– Gastric– Osmoticdiarrhea:sorbitalor
lactulose
• SWEAT• RESPIRATION
Hypotonic“fluid”lossesWater losses > sodium losses
POLYURIA
Definition:
Urineoutput>3liters/day
CAUSESOFPOLYURIA
• OSMOTIC-uncontrolleddiabetesmellitus-ioniccontrast,mannitol,
electrolytes• WATER-psychogenicpolydispsia-centraldiabetesinsipidus-nephrogenicdiabetesinsipidus
PRIMARYPOLYDIPSIA
Aprimaryincreaseinwaterintake• Inpsychiatricillnesses+/-phenothiazines• Hypothalamiclesionsofthethirstcenter
– infiltrativediseasesuchassarcoidosis MaycausehyponatremiaIfwaterintake=waterlosses,S[Na+]unchangedIfwaterintake>waterloses,S[Na+]decreases
CENTRALDIABETESINSIPIDUS
Deficientsecretionofantidiuretichormone• Familial • Idiopathic-mostoften(?autoimmuneinjurytotheADH-producingcells)
• Acquired-trauma,pituitarysurgery,orhypoxicorischemicencephalopathyIfwaterlosses=waterintake,S[Na+]unchangedIfwaterlosses>waterintake,S[Na+]increases
NEPHROGENICDIABETESINSIPIDUS• Familial• Aquired
– RenalMedullaryDiseasesObstructiveuropathyAnalgesicnephropathyMedullarycysticdiseaseSicklecelldisease
– MetabolicDisorders-Chronichypokalemia, -Hypercalcemia
– Drugs:Lithium,demeclocycline,foscarnat,cidofovir
Ifwaterlosses=waterintake,S[Na+]unchangedIfwaterlosses>waterintake,S[Na+]increases
POLYURIAWater diuresis
Psychogenicpolydipsia
Decreased
Central DINo ADH
Nephrogenic DIHigh ADH
Increased
Serum Osmolality
POLYURIADefinition: >3 liters of urine/day
Do Water deprivation testif Sosm <300
U/P osm <0.7
Urine OsmHypotonic to serum
Pure water
>0.6 =electrolyteSaline
Bicarbonate
<0.4 =nonelectrolyteGlucose, Urea
Mannitol, Contrast
Electrolyte fraction=2(UNa+UK)/Uosm
U/P osm >0.8
Urine OsmIsotonic (300 mOsm/kg)
Osmotic
Complete:Increase>50%Partial:Increase>10%
DifferentiationofPolyuria Osmotic
diuresis Primary Polydipsa
Central DI Nephro DI
Posm Increased Decreased Increased Increased Uosm Isotonic Decreased Decreased Decreased Plasma AVP
Increased Decreased Decreased Increased
Uosm with Dehydration
No effect Increased No effect No effect
Uosm after AVP
No effect No effect Increased No effect
TherapyofDiabetesInsipidus
• CENTRALDI:DDAVP10-20UINq12-24hrsChlorpropamide,clofibrate,carbamazepineplusAPPROPRIATEFREEWATERINTAKE• NEPHROGENICDI:HCTZ/Amiloride,sodiumandproteinrestriction(decreasedosmolarload),?NSAIDsplusAPPROPRIATEFREEWATERINTAKE.
• PSYCHOGENICPOLYDIPSIA:Decreasefreewaterintake
HYPERNATREMIA
• CALCULATEFREEWATERDEFICIT– S[Na+]x0.5(TBwt)=140mEq/lxnewTBW
• Replaceongoinglosses– Insensible– Sensible
HYPERNATREMIATREATMENT1. Recognizeandcorrectunderlyingproblem2. Calculatethefreewaterdeficit5. Replace1/2offreewaterdeficitevery24hours.Donotdecreaseserum[Na+]>0.5mEq/L/hror8-10mEq/L/dtoavoidcerebraledema4. Replaceongoingwaterlosses-insensiblelosses-GIlosses-renallosses5.Maintaineuvolemia.
HYPERNATREMIA• CALCULATEFREEWATERDEFICIT
– S[Na+]x0.5(TBwt)=140mEq/lxnewTBW
Thepatientisa65yearoldfemale,founddown.Weight60kgS[Na+]165mEq/LSerumglucose75mg/dLSerumtotalprotein7.5g/dLNocontrastormannitolgivenTBW=0.5xTBwt=0.5x60kg=30litersS[Na+]x0.5(TBwt)=140mEq/lxnewTBW165x30/140=35.4liters=theTBWifS[Na+]were140mEq/LFreewaterdeficit=35.4-30liters=5.4liters
• Replace½thefreewaterdeficitin24hours(2.7L)nottodecreaseS[Na+]morethan8-10mEq/Lin24hourswithFREEWATERPOorIV
HYPERNATREMIATREATMENT1. Recognizeandcorrectunderlyingproblem2. Calculatethefreewaterdeficit3.Replace1/2offreewaterdeficitin24hours.Donotdecreaseserum[Na+]>0.5mEq/L/hror8-10mEq/L/dtoavoidcerebraledema
4. Replaceongoingwaterlosses-insensiblelosses-GIlosses-renallosses5.Maintaineuvolemia.
PROBLEM
Net“fluid”balanceandchangesintotalbodyweightreflectchangesinvolumeandwaterandareNOTuseful.Determiningongoingwaterandsodiumrequirementsinhospitalizedpatientsremainsdifficultsincesodiumconcentrationsofmostbodyfluidlossesareneitherknownorroutinelymeasured.
Sodiumconcentrationsofbodyfluids:Asystematic
literaturereview
KapteinEM,SreeramojuD,KapteinJS,KapteinMJClinicalNephrology2016
Sodium concentrations of body fluids: A systematic literature review
Kaptein EM, Sreeramoju D, Kaptein JS, Kaptein MJ
Clinical Nephrology October, 2016
Knowspecificsodiumandwatercontentof-Bodyfluidlosses,and-ParenteralandenteralfluidsadministeredUsethisinformationto1)replacesodiumandwaterlossesofspecificbodyfluidstominimizedevelopmentofwaterandvolumedisorders,and2)prescribeappropriatetherapyfor
hypo-andhypernatremia,andfor hypo-andhypervolemia.
Goals
• Systematicsearchandliteraturereviewof[Na+]ofbodyfluidslostinadulthumans– PubMeddatabase– Searchingrelatedreferences
• Reviewed>7,000titles,abstracts,full-textarticles• Inclusioncriteria:
– Peer-reviewed,extractablesodiumconcentrationsmeasuredinbodyfluidswhoselossesareroutinelyquantifiedinhospitalizedpatients.
Methods
MJKaptein,MD
Results • 107full-textarticleshadextractablesodiumconcentrations.
Overallmeansandstandarddeviations(SDs)areshownfrom84studieswithrawdataormeansandSDs.
• Sodiumconcentrationsarefluid-specificandconsistent.• Gastric[Na+]withhighacid(44+12mEq/L)vs.lowacid
(55+13mEq/L)wasstatisticallybutnotclinicallydifferent.• Sodiumconcentrationsofdiarrheaaremechanismspecific.• Pleural,peritoneal,andedemafluid,areisonatremicto
plasma,asareultrafiltratesofplasmawithhemodialysisandperitonealdialysis,sinceallarederivedfromplasma.
• Nodatawerefoundforwoundsorlymph(isonatremic).
MJKaptein,MD
Meansodiumconcentrationsofbodyfluidlosses
NS
SodiumconcentrationsofbodyfluidlossesBodyFluid [Na+]mEq/L Normalsaline(%) Water(%)
Gastric 50 33 67
Bile 185 100 0
Pancreatic 156 100 0
Smallbowel 120 75 25
DIARRHEA
cholera 128 85 15
non-osmoticlaxatives 88 50 50
secretorydiarrhea 53 33 67
sorbitol 63 40 60
lactulose 26 15 85
polyethyleneglycol 15 10 90
Pleural,peritoneal,dialysate,(wounds) 137 100 0
Sodiumconcentrationsofparenteralandenteralsolutions
ThesearepharmaceuticalsCHECK[Na+]foreachsolutionDivideby154mEq/LtoassessproportionofNSandH20
Background
Proportions for a 70kg male1, may vary in illness2
1) Randall HT. Water and electrolyte balance in surgery. The Surgical Clinics of North America. 1952: 445-469. 2) Randall HT. The shifts of fluid and electrolytes in shock. Annals of the New York Academy of Sciences. 1952; 55: 412-428
• RBCsstayintravascular.• Isonatremicsolutions
equilibrateacrosstheECF(IVplusEV).
• Hypervolemiaorhypovolemiareflecttotalbodysodiumexcessordeficit.
• Freewater(FW)equilibratesacrossbothECFandICF.
• Freewatergain/lossprimarilyaffectsserum[Na+].
• Hypernatremia/hyponatremiareflectsfreewaterdeficitorexcess.
MJKaptein,MD
Background
Proportions for a 70kg male, may vary in illness 3) Konstam MA, Gheorghiade M, Burnett JC, Jr., Grinfeld L, Maggioni AP, Swedberg K, Udelson JE, Zannad F, Cook T, Ouyang J, Zimmer C, Orlandi C: Effects of oral tolvaptan in patients hospitalized for worsening heart failure: The everest outcome trial. JAMA 2007;297:1319-1331 2007;297:1319-1331
• EVERESTtrialusingavaptantoblockrenalADHeffectshowed4.5literaquaresisdidnotchangeCHFmorbidityormortality3,suggestingfreewaterhasminimalvolumeeffect.
• Hyponatremiawasimproved.• Conclusion: water is not volume • [Na+]ofallfluidslostandgained
canbedividedby[Na+]ofplasmawater(normally154mEq/L)todeterminewhatproportionwilldistributeasisonatremicsolution.
MJKaptein,MD
ENTRIESINYELLOWAREAS gain/lossNS(mL) gain/lossH2O(mL)
ONLY(aspositivevalues)(use"Space,Backspace,Delete"toclearcells) [Na+](mEq/L) NET(mL) 0 0BODYFLUIDLOSTGastric 49.0Bile 185Pancreatic 156Smallbowel 117Diarrhea-non-osmotic 69.0Osmoticdiarrhea-sorbitol 63.0Osmoticdiarrhea-lactulose 26.0Osmoticdiarrhea-PEG 13.0Pleural/peritonealfluid/wounddrainage 137Dialysisnetultrafiltrateremoved 134Urine----enter[Na+]orestimate77mEq/LInsensiblelosses 0.0PARENTERALSOLUTIONSNetvolumegivenduringdialysis 154PackedPRBCs* 155albumin$/plasma/cryo/IVIG/platelets 130Normalsaline 154Plasma-lyteA 140Ringer'slactate 130D5W 0.0NaHCO3concentrate(50mEqper50mL) 1000100mEqNaHCO3in1LD5W 100TPN------------------------------enter[Na+]ENTERALSOLUTIONSPulmocare/Nutren2.0 57.0FibersourceHN 52.2ImpactPeptide1.5/NutrenPulmonary 50.9IsosourceHN 48.7DiabetisourceAC 46.1NovasourceRenal/Osmolyte/Jevity 41.1RepleteFiber 38.1Ensure/Nepro 36.8Peptamen 35.8Suplena 34.3VivonexRTF 30.4TwoCalHN 15.0Renalcal/Benaprotein 3.4Othersolutions-------------------enter[Na+]Othersolutions-------------------enter[Na+]
Case1• Asurgicalpatientiseuvolemicandnormonatremic.SerumCreatinine4.5mg/dL.
• Outputs:– Chesttubeandwounddrains:2500mL/24hours– Stool:500mL/24hours– Urineoutput:1500mL/24hours,Urine[Na+]60mEq/L
– Insensiblelosses:~1000mL/24hours
• Howshouldtheselossesbereplaced?
ENTRIESINYELLOWAREAS
gain/lossNS(mL)
gain/lossH2O(mL)
ONLY(aspositivevalues)(use"Space,Backspace,Delete"toclearcells)
[Na+](mEq/L)NET(mL) -3032 -2468
BODYFLUIDLOSTGastric 49.0Bile 185Pancreatic 156Smallbowel 117
Diarrhea-non-osmotic 69.0 500 -224 -276Osmoticdiarrhea-sorbitol 63.0Osmoticdiarrhea-lactulose 26.0Osmoticdiarrhea-PEG 13.0
Pleural/peritonealfluid/wounddrainage137 2500 -2224 -276Dialysisnetultrafiltrateremoved 134
Urine----enter[Na+]orestimate77mEq/L60 1500 -584 -916Insensiblelosses 0.0 1000 0 -1000PARENTERALSOLUTIONSNetvolumegivenduringdialysis 154PackedPRBCs* 155albumin$/plasma/cryo/IVIG/platelets 130Normalsaline 154Plasma-lyteA 140Ringer'slactate 130D5W 0.0NaHCO3concentrate(50mEqper50mL) 1000100mEqNaHCO3in1LD5W 100TPN------------------------------enter[Na+]ENTERALSOLUTIONSPulmocare/Nutren2.0 57.0FibersourceHN 52.2ImpactPeptide1.5/NutrenPulmonary 50.9IsosourceHN 48.7DiabetisourceAC 46.1NovasourceRenal/Osmolyte/Jevity 41.1RepleteFiber 38.1Ensure/Nepro 36.8Peptamen 35.8Suplena 34.3VivonexRTF 30.4TwoCalHN 15.0Renalcal/Benaprotein 3.4Othersolutions-------------------enter[Na+]Othersolutions-------------------enter[Na+]
Case1• Asurgicalpatientiseuvolemicandnormonatremic.SerumCreatinine4.5mg/dL.
• Outputs:– Chesttubeandwounddrains:2500mL/24hours– Stool:500mL/24hours– Urineoutput:1500mL/24hours,Urine[Na+]60mEq/L– Insensiblelosses:~1000mL/24hours
• Replacementestimates:– NSforallofchesttubeandwounddrains,½ofstooloutput,½ofurineoutput
– D5Wfor½ofstooloutput,½ofurineoutput,PLUSinsensiblelossesof1000mL
– Enteralandparenteralsodiumandwatercontributionshavetobeaccountedfor
NET:3000mLofNSand2500mLofwaterarerequiredtopreventhypovolemiaandhypernatremia
Case2
• AnelderlypatientwithESRDandperipheraledemadevelopspulmonaryedemaafterHD/UF.ShehasHgof4.5g/dLandaSTEMI.
• DuringHDshereceived1000mLofpRBCsandtolerated2000mLremovalwithUF.
Whathappened?
ENTRIESINYELLOWAREAS
gain/lossNS(mL)
gain/lossH2O(mL)
ONLY(aspositivevalues)(use"Space,Backspace,Delete"toclearcells)
[Na+](mEq/L) NET(mL) +1063 -263
BODYFLUIDLOSTGastric 49.0Bile 185Pancreatic 156Smallbowel 117Diarrhea-non-osmotic 69.0Osmoticdiarrhea-sorbitol 63.0Osmoticdiarrhea-lactulose 26.0Osmoticdiarrhea-PEG 13.0
Pleural/peritonealfluid/wounddrainage137Dialysisnetultrafiltrateremoved 134 2000 -1740 -260Urine----enter[Na+]orestimate77mEq/LInsensiblelosses 0.0PARENTERALSOLUTIONSNetvolumegivenduringdialysis 154
PackedPRBCs* 155 1000 2803 -3albumin$/plasma/cryo/IVIG/platelets 130Normalsaline 154Plasma-lyteA 140Ringer'slactate 130D5W 0.0NaHCO3concentrate(50mEqper50mL) 1000100mEqNaHCO3in1LD5W 100TPN------------------------------enter[Na+]ENTERALSOLUTIONSPulmocare/Nutren2.0 57.0FibersourceHN 52.2ImpactPeptide1.5/NutrenPulmonary 50.9IsosourceHN 48.7DiabetisourceAC 46.1NovasourceRenal/Osmolyte/Jevity 41.1RepleteFiber 38.1Ensure/Nepro 36.8Peptamen 35.8Suplena 34.3VivonexRTF 30.4TwoCalHN 15.0Renalcal/Benaprotein 3.4Othersolutions-------------------enter[Na+]Othersolutions-------------------enter[Na+]
Case2
• AnelderlypatientwithESRDandperipheraledemadevelopspulmonaryedemaafterHD/UF.ShehasHgof4.5g/dLandaSTEMI.
• DuringHDshereceived1000mLofpRBCsandtolerated2000mLremovalwithUF.
Whathappened?RESULT:Gainedapproximatelynet1000mLNSequivalentresultinginpulmonaryedema
Case3A58yearoldwomanwithCHFhasbeenon“fluid”restrictionandaloopdiureticfor1week.Shestillhas3+edemaofbothlegs.Herserumsodiumis155mEq/Landsheiscomplainingofthirst.Howshouldshebetreated?1) Continuefluidrestriction2) Givefreewater3) GiveNSandfreewater4) Givefreewater,restrictsodiumintakeand
continuetheloopdiuretic
Case3A58yearoldwomanwithCHFhasbeenon“fluid”restrictionandaloopdiureticfor1week.Shestillhas3+edemaofbothlegs.Herserumsodiumis155mEq/Landsheiscomplainingofthirst.Howshouldshebetreated?1) Continuefluidrestriction2) Givefreewater3) GiveNSandfreewater4) Givefreewater,restrictsodiumintakeand
continuetheloopdiuretic
Summary• Knowledgeofsodiumconcentrationsofbodyfluidlossesandofparenteralandenteralfluidscanbeusedtooptimizevolumestatusandsodiumconcentration.
• Specificreplacementofsodiumandwaterlossesshouldbemoreeffectiveinpreventingandtreatingimbalanceof
freewater(hyponatremia/hypernatremia)orsodium(hypovolemia/hypervolemia)
thanreplacementprotocolsbasedoncumulative“fluid”balanceortotalbodyweightchanges.
Assessment• Totalbodywaterstatus-useserum[Na+]
-calculatefreewaterdeficitandongoing losses
• Intravascularvolumestatus-moredifficult
ApproachtoHypernatremia• AssessS[Na+]foreffectsofchangesinserumprotein/lipidconcentrationsandosmoles
• Calculatefreewaterdeficitandongoinglossesandreplaceappropriately
• AssessECFandintravascularvolumestatus– Increased– Decreased– Euvolemic
• Hospitalizedandcriticallyillpatientsarefrequentlynotinsteadystate.
• Theyfrequentlyhavemismatch• betweenbloodpressureandintravascularvolume• betweenextravascularandintravascularvolume
• Physicalexam,CVP,andPCWPhavelimitedsensitivityandspecificitytodetermineintravascularvolume.
• Weneedapracticalwaytoassessintravascularvolumestatustoguidevolumetherapy.
Theproblem
Mismatchbetweenintravascularvolumeandbloodpressure(Statesinwhichbloodpressureisnotprimarilydeterminedbyintravascularvolume)
IntravascularvolumelowBloodpressurehigh
Vasoconstriction• Stimulants(cocaine,amphetamines),
catecholamines(pheochromocytoma,severestress,deliriumtremens)
• Severehypothyroidism
IntravascularvolumehighBloodpressurelow
Cardiacdysfunction• Cardiogenicshock• Severecardiomyopathy,heartfailure,valvular
heartdiseaseVasodilation• Distributiveshock+excessvolumeresuscitation• Autonomicneuropathy
MismatchbetweenintravascularandextravascularvolumeIntravascularvolumelowExtravascularvolumehigh
Vasodilationand/or“thirdspacing”• Distributiveshock(sepsis,anaphylaxis)• Hemorrhagicpancreatitis• CrushinjuryDelayedre-equilibration• Severerenalfailure+diuresisorultrafiltration• Nephroticsyndrome+diuresis• End-stageliverdisease+diuresisorlarge-volume
paracentesisorultrafiltration• Heartfailure+diuresisorultrafiltration
IntravascularvolumehighExtravascularvolumenothigh
• Rapidbloodtransfusion+anuriaorsevererenalfailure
• Rapidhypertonicsodiumbicarbonateorsalineinfusion
Ultrasoundoftheinferiorvenacavacollapsibilityindexforestimationofrelativeintravascularvolume.IVCCI=(IVCmax-IVCmin)/IVCmaxx100%
• IVCmeasured2cmfromrightatriumorathepaticvein
• CollapsibilityIndex=(IVCmax–IVCmin)/IVCmax
AssessIntravascularVolume
Intravascularoverload
Intravasculardepletion
IVCsmall,collapsing
IVCtotalcollapse
AdvantagesofbedsideIVCUS
• Assessmentofintravascularvolumeatthetimeofclinicalevaluationtoguidevolumeadministration,diuresisorultrafiltration
• Multipleassessmentsofintravascularvolumeasneededaftertherapeuticinterventionsorchangeinpatientstatus
• NodelaybetweenneedforassessmentandresultsofIVCUS
Principles for treatment of concurrent sodium and water disorders
AssessmentandManagementofHypernatremia
1) Correctfreewaterdeficitandreplaceongoingwaterlosses
2) Assessintravascularvolume3) Makethepatienteuvolemicandreplace
ongoingvolumelossesREQUIRES1) Knowledgeofinputsandoutputsthat
contributetointravascularvolumeandtotalbodywater
2) Accurateintravascularvolumeassessment
QUESTIONS?