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Sodium And Water Balance

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Information about Sodium And Water Balance
Education

Published on January 4, 2008

Author: Funtoon

Source: authorstream.com

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Nutrition Support in the Hospitalized Patient: Water, Sodium and Fluid Balance:  Nutrition Support in the Hospitalized Patient: Water, Sodium and Fluid Balance Leah Gramlich MD, FRCP Royal Alexandra Hospital University of Alberta Objectives:  Objectives Describe water balance in health and disease Discuss sodium balance and review the relationship between sodium and water balance Review hyponatremia Review hyperatremia Mr. MT: 46yo male:  Mr. MT: 46yo male CC: Crohn’s disease presents with bowel obstruction; 3 previous bowel resections - to O.R.(PAD#8): resection 3 ft. small bowel; ileostomy(?) - POD #5: ileostomy output=5.5l/d Meds: Flagyl, Ancef solumedrol pantoloc IV octreotide lomotil Mr. MT:  Mr. MT O/E: T=37.2 B/P=110/65 HR=110 CBW=68kg UBW=75kg Ht=182cm IV=NS at 100cc/hr Dry mucous membranes Drowsy Abdomen soft Ileostomy healthy - clear effluent Mr. MT:  Mr. MT Labs: Hbg=112 WBC=13 Plt=350 Na=151 K=3.4 CO2=33 Alb=40 Cr=120 BUN=15 Ca=2.1 Mg=0.68 PO4=0.70 Glu=6.7 pH=7.52 pCO2=42 Mr. MT:  Mr. MT What is the volume status? -? I/O’s -? Are there insensible fluid losses? ? What is the IVF being used? -? Wt. -? Signs/Symptoms of volume deficiency or excess Water and Sodium: Composition of Body Fluids:  Water and Sodium: Composition of Body Fluids Water is the most abundant constituent in the body: Males=60% body weight Females=50% body weight Water Distribution: - 2/3 Intracellular (ICF) - 1/3 Extracellular (ECF) Composition of Body Fluids:  Composition of Body Fluids Na+ and Cl- are the most common electrolytes in the ECF K+ and PO4– are the most common electrolytes in the ICF Non-electrolytes = glucose, urea, Cr Osmolality (mosm/l) = (2x(Na+K))+BUN/2.8+glu - determines direction and extent of water movement between fluid compartments ECF osmolality = ICF osmolality Normal Exchange of Fluid and Electrolytes:  Normal Exchange of Fluid and Electrolytes Water: Gains = oral fluids and solids, oxidation products Losses = Stool, urine, insensible losses Salt: Gains = oral intake, IV fluids Losses = Renal excretion Gastrointestinal losses Average Daily Fluid Gains and Losses in Adults:  Average Daily Fluid Gains and Losses in Adults Body Fluid Changes:  Body Fluid Changes Volume: Hypovolemia/Hypervolemia Concentration: hyponatremia/hypernatremia Composition: acid base, potassium, magnesium Hypovolemia:  Hypovolemia Etiology: generally refers to a state of combined salt and water loss and ECF contraction ECF Volume Contraction: - Renal: diuretics, hypo-aldosteronism, osmotic diuresis, diabetes insipidus - Extrarenal: GI losses, Skin losses, hemmorhage ECF Volume Expansion: Reduced cardiac output, redistribution (hypolabuminemia – cirrhosis, nephrotic syndrome), increased capacitance (sepsis) Signs & Symptoms of ECF Depletion According to the Degree of Depletion:  Signs & Symptoms of ECF Depletion According to the Degree of Depletion Volume & Electrolyte Concentrations of Fluids Throughout the GI Tract:  Volume & Electrolyte Concentrations of Fluids Throughout the GI Tract Volume Changes: General Considerations:  Volume Changes: General Considerations Loss or Gain of an ISOTONIC solution -only volume of ECF changes - no changes in ICF as long as osmolality is unchanged Loss or Gain of a HYPOTONIC solution from ECF results in osmolality change and water will shift from the ICF to the ECF Diagnosis and Treatment of Hypovolemia:  Diagnosis and Treatment of Hypovolemia H&P Laboratory – BUN, Increase BUN:Cr ratio - Na may be high, low, normal - reduction in urine Na Treatment: restore normovolemia with fluid similar in composition to that lost and replace ongoing losses Diagnosis and Treatment of Hypervolemia:  Diagnosis and Treatment of Hypervolemia H&P: Comorbidity, IVF, weight, edema Laboratory: Osmolality, Na, Albumin Rx: Volume restrict Sodium restrict Diuretics Causes of Hyponatremia:  Causes of Hyponatremia Impaired Capacity of renal water excretion - Decreased ECF: Renal Na loss (diuretics, nephropathy)/Extrarenal loss (blood, diarrhea, sweat, 3rd spacing) - Increased ECF: CHF, Cirrhosis, pregnancy - Normal ECF: SIAD, Thiazides, AI, Hypothyroid Excessive Water Intake: polydipsia, Na free solutions, dilute infant formulae Hyponatremia:  Hyponatremia Na<136mmol/l Hypo-osmolar: Euvolemic: SIADH, hypothyroid Hypervolemic: CHF, ARF, Cirrhosis Hypovolemic: diuretics, diarrhea, 3rd spacing Iso-osmolar: - mannitol, pseudohyponatremia Hyperosmolar: extra osmoles in ECF draw water out of cells (eg. Glucose) Hyponatremia:  Hyponatremia Causes of SIAD:  Causes of SIAD Effects of Hyponatremia on the Brain:  Effects of Hyponatremia on the Brain Treatment of Hyponatremia:  Treatment of Hyponatremia Treat underlying cause Water Restrict Monitor sodium on ongoing basis Be careful of rate of correction (risk of CPM) Hypernatremia:  Hypernatremia Too little water relative to total body Na; always a hyperosmolar state Due to net water loss or hypertonic Na gain Less common than low Na (thirst, ADH) Causes of Hypernatremia:  Causes of Hypernatremia Net Water Loss: Pure water – insensible losses, reduced thirst, Diabetes insipdus (nephrogenic/neurogenic) Hypotonic Fluid – renal (diuretics, post ATN), GI losses, cutaneous losses Hypertonic Sodium Gain: IVF, enemas, intrauterine Na Hypernatremia:  Hypernatremia Diagnosis and Treatment of Hypernatremia:  Diagnosis and Treatment of Hypernatremia S/S: meuromuscuslar irritability, change mental status, thirst Dx.: H/P Rx: H2O Deficit=TBW x ( Na – 140)/140 replace free water deficit avoid fall in Na >12 mmol/d What is Mr. MT’s Volume Status?:  What is Mr. MT’s Volume Status? A. Euvolemic B. Hypovolemic: - deficit = 3.3 L C. Hypovolemic: - deficit = 10 L D. hypervolemic Mr.MT: Volume and Electrolytes:  Mr.MT: Volume and Electrolytes Volume: Deficit=3000ml > Replete 50% over 24hrs > Meet ongoing losses: 5.5 l/d and daily rqt.(~2.5l/d) ***Where salt goes, water follows*** Electrolytes: K+ > Replete deficit – 50-75 mmol > Meet ongoing requirements- 25 +70mmol/d Signs and Symptoms of ECF volume depletion are::  Signs and Symptoms of ECF volume depletion are: A. seen with volume loss of less than 10% B. associated with shock, tachycardia and reduced urine output if >30% C. are only associated with hyponatremia D. are not usually related to diuretic therapy References:  References Androgue HJ, Madias NE. Hypernatremia. NEJM 2000;342:1493-1499 Androgue HJ, Madias NE. Hyponatremia. NEJM 2000;342:1581-1589 Ellison DH, Berl T. The Syndrome of Inappropriate Antidiuresis. NEJM 2007;356:2064-2073

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