presentazione standard di powerpoint · insulin/glucose insulin 0.1units/kg iv glucose d10 the most...
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Le Disionie
Ligia J DominguezDicembre 1 2016
Università degli Studi di Palermo. Facoltà di Medicina e ChirurgiaUnità Operativa Complessa di Geriatria e Lungodegenza
Scuola di Specilizzazione in Geriatria
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• 22239 patients in the ER, Bern, Jan 2010 to Dec 2011
• 8.5% one diuretic, 2.5% two, 0.4% three or four
• Loop diuretics: independent RF for hyperNa and
hypoK
• TZD: independent RF for hypoNa and hypoK
• Cox regression: ALL FORMS OF DYSNATREMIA
AND DYSKALEMIA WERE INDEPENDENT RF FOR IN
HOSPITAL MORTALITY
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HypoNa OR 1.55, p=0.004HyperNa OR 3.21, p=0.0001
Surv
ival
Na
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HypoK OR 1.89, p=0.0001HyperK OR 2.35, p=0.0001
Surv
ival
K
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• Possible causes of hospital admissions during extreme heat
• 23.7 million Medicare enrollees 1999-2010
•Heat exposure: 2 days with To > 99th percentile
• AMONG OLDER ADULTS, PERIODS OF EXTREME HEAT
WERE ASSOCIATED WITH INCREASED RISK OF
HOSPITALIZATION FOR:
o FLUID AND ELECTROLYTE DISORDERS
o RENAL FAILURE
o URINARY TRACT INFECTION
o SEPTICEMIAo HEAT SHOCK
Bobb et al., JAMA 2014
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Bobb et al., JAMA 2014
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Schirò, Dominguez, Barbagallo, G Geront 2015
Na
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Na
NEJM 2015
Astrocytes and the
Neurovascular Unit
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Total body water is commonly reduced
Impairments in thirst sensation
Impaired renal function
Less responsive to hormonal mediators
of water, electrolyte, and mineral balance
Changes in water and electrolyte
homeostasis with aging
MORE VULNERABLE TO IATROGENIC EVENTS
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Miller, et al 2016
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Miller, et al 2016
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Hyponatremia
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Iponatremia ipertonica (>295 mOsm/L)
Accumulo di soluti osmoticamente attivi
(i.e., iperglicemia)
Iponatremia isotonica o
pseudoiponatremia (280-295 mOsm/L)Iperlimidemia o iperproteinemia che
causano un Na falsamente ridotto
Iponatremia ipotonica o vera (<280
mOsm/L)
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VALUTAZIONE DELLA VOLEMIA
Ipovolemia
U [Na]>20
PERDITE RENALI:
- eccesso diuretici
- carenza mineralcort.
- nefropatie
- acidosi tubulare
- alcalosi metabolica
- chetonuria
- diuresi osmotica
U [Na]<20
PERDITE EXRARENALI:
- vomito
- diarrea
- sudorazione profusa
- ustioni
- traumi
- occlusioni intestinali
Euvolemia
U [Na]>20
- SIADH
- ipocortisolismo
- ipotiroidismo
- farmaci
- stress
- chirurgia
Ipervolemia
U [Na]>20
IRA o IRC
U [Na]<20
- S. nefrosica
- cirrosi
- scompenso cardiaco
Algoritmo diagnostico della iponatremia
Schirò, Dominguez, Barbagallo, G Geront 2015
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VALUTAZIONE DELLA VOLEMIA
Ipovolemia
U [Na]>20
PERDITE RENALI:
- eccesso diuretici
- carenza mineralcort.
- nefropatie
- acidosi tubulare
- alcalosi metabolica
- chetonuria
- diuresi osmotica
U [Na]<20
PERDITE EXRARENALI:
- vomito
- diarrea
- sudorazione profusa
- ustioni
- traumi
- occlusioni intestinali
Euvolemia
U [Na]>20
- SIADH
- ipocortisolismo
- ipotiroidismo
- farmaci
- stress
- chirurgia
Ipervolemia
U [Na]>20
IRA o IRC
U [Na]<20
- S. nefrosica
- cirrosi
- scompenso cardiaco
Algoritmo diagnostico della iponatremia
Schirò, Dominguez, Barbagallo, G Geront 2015
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VALUTAZIONE DELLA VOLEMIA
Ipovolemia
U [Na]>20
PERDITE RENALI:
- eccesso diuretici
- carenza mineralcort.
- nefropatie
- acidosi tubulare
- alcalosi metabolica
- chetonuria
- diuresi osmotica
U [Na]<20
PERDITE EXRARENALI:
- vomito
- diarrea
- sudorazione profusa
- ustioni
- traumi
- occlusioni intestinali
Euvolemia
U [Na]>20
- SIADH
- ipocortisolismo
- ipotiroidismo
- farmaci
- stress
- chirurgia
Ipervolemia
U [Na]>20
IRA o IRC
U [Na]<20
- S. nefrosica
- cirrosi
- scompenso cardiaco
Algoritmo diagnostico della iponatremia
Schirò, Dominguez, Barbagallo, G Geront 2015
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Hyponatremia
Clinical signs and symptoms
Nausea/vomiting
Lethargy
Headache
Confusion
Seizures
Non-cardiogenic pulmonary edema
Mostly due to CNS dysfun. and cerebral edema
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Hyponatremia - Therapy
3% NS for severely symptomatic
patients with caution
Na increase: 8-12 mEq/L/day with NS
Central pontine myelinolysis
may be irreversible
dysarthria, dysphagia, spastic
paresis, coma
Check Na frequently
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Hypernatremia
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Hypernatremia
Clinical signs and symptoms
Nausea/vomiting
Restless, irritable, or letargic
Anorexia
Stupor/coma
Subarachnoid hemorrhage
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NaIPERNATREMIA
IPOVOLEMIA
perdite renali
poliuria
PS basso
Nau >20 mEq/l
perdite extra-renali
oligo-anuria
PS alto
Nau <20 mEq/l
IPERVOLEMIA
eccessivo introito di
Na+
poliuria
Nau >20 mEq/l
EUVOLEMIA
ipodipsia
oligo-anuria
PS alto
Nau >20 mEq/l
diabete insipido
Poliuria
PS basso
Nau <20 mEq/l
Schirò, Dominguez, Barbagallo, G Geront 2015
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Hypernatremia - Causes
Free water loss
Diuretics (loop)
Post obstructive diuresis
Acute and chronic renal disease
Sweating, fistula, burns, diarrhea, vomiting
Diabetes insipidus (central, nephrogenic)
Sodium gain
Hypertonic saline or sodium bicarbonate
Parenteral nutrition
Hyperaldosteronism
Cushing’s syndrome
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Hypernatremia - Therapy
Underlying cause
Replace H20 po if possible
Correct hypovolemia with 0.45% NS and
Glucose 5
Frequent monitoring and fluid adjustment
with a goal of 0.5-1mEq/L decrease/hour
Vasopressin for central DI
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Consequences of rapid changes in plasma Na
NEJM 2015
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K Potassium Homeostasis – meal driven
NEJM 2015
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K Potassium Homeostasis – between-meal fasting
NEJM 2015
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K
NEJM 2015
Major cell types in the cortical collecting duct
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NEJM 2015
Circadian Rhythm of Urinary K Excretion in
Humans during Two levels of K Intake
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Hypokalemia
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Hypokalemia
Clinical signs and symptoms
Generalized muscle weaknessParalytic ileusCardiac arrhythmias
Atrial tachycardiaAV dissociation
EKG changesFlat/inverted T wavesST segment depressionU waves
Ascending paralysis and impaired respiratory function (K<2 mEq/L)
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Hypokalemia - Causes
GI lossVomiting, diarrhea (VIPoma, enteric fistula, malabsorption, jejunoileal bypass)
Renal loss Primary hyperaldosteronism, hypothermia, genetic syndromes (i.e. Liddle’s), type I and II RTA, drugs (I.e. amphotericin, foscarnet)
Transcellular shift Alkalosis, beta agonists, caffeine, insulin, thryrotoxicosis, hypokalemic periodic paralysis
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Hypokalemia - Therapy
Determine the cause
KCl po or IV
0.5-1 mEq/kg IV over 1 hour if severe
(monitoring ECG and blood K)
Correct hypomagnesemia!
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Hyperkalemia
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Hyperkalemia
Clinical signs and symptoms
Muscle weakness/paresthesiasK>6 mEq/LEKG changespeaked T wavesprolonged PR intervalwidened QRS
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Hyperkalemia - Causes
Impaired excretion Renal failure, hypocortisolism, drugs, type IV
RTA
Iatrogenic
Transcellular shift Acidosis, beta blockers, digitalis overdose,
somatostatin
Other Tumor lysis
rhabdomyolysis
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Hyperkalemia - Therapy
Calcium gluconate IV
Insulin/glucose Insulin 0.1units/kg IV
Glucose D10
The most effective way to quickly lower K!!!
Sodium bicarbonate 1-2mEq/kg
Hemodialysis
Kayexalate
Inhaled Beta-2 agonists
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101,945 persons in 17 countries
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