Hyponatremia osmolarity 275 – 295 serum osmolarity 2 * Na, glucose / 18 BUN /2.8
High glucose, isotonic – pseudohyponatremia 275 – 295 proteins / lipids, low
Check volume status BP, mucosa
Hypovolemic dry mucosa
Hypervolemic – CHF, Cirrhosis, nephrotic syndrome 2/2 systemic edema
Normovolemic – SIADH, primary polydipsia
Hypovolemic – diarrhea vomiting / diuretics
ADH urine osmolarity
Urine Sodium cut off 20 < 20 or above indirect way of checking RAAS
Fena < 1 prerenal
Hypovolemic hypotonic hyponatremia – diuretics,
Euvolemic SIADH sodium above 20, hyperosmolar or primary poldipsia
Urine Na > 20 think CHF, nephrotic, Cirrhosis
Urine Na < 20 think more ESRD, chronic kidney disease
Hypernatremia
Hypervolemic or euvolemic without symptoms – fluid restrict
Hypovolemic w/o symptoms – 0.9% NS
Hypovolemic w/ symptoms – hypertonic saline 3%, below 120 hypertonic saline lethargy, coma
Hypernatremia – euvolemic, hypovolemic
High to low the brain will blow – cerebral edema
Hypervolemic, euvolemic – free water
Hypovolemic with symptoms NS, most
Hypovolemic – 1/2NS more gradual
Calcium
Blood transfusions – cause hypocalcemia citrate binds
Hypercalcemia – IV fluids
Potassium
Hyperkalemia – Calcium gluconate stabilizes cardiac membranes prevent arrhythmias, insulin pushes potassium into cells with glucose, Kaexelate binds potassium improves excretion
Magnesium
Hypermagnesemia – loss of dtr, IV calcium gluconate
PTH
PTH – bones increased calcium and phosphate, kidneys increase calcium and phosphate secretion, calidiol to calcitriol increase calcium and phosphate uptake
High PTH high calcium low phosphate treat with parathyroidectomy
High calcium and vitamin D3 shuts down
Kidney failure no calcidiol to calcitriol main function of kidney
Can’t absorb calcium and phosphate
Kidney tubules don’t work, can’t absorb calcium, can’t dump phosphate. Phosphate locked up in body. Bone increase phosphate and calcium,
kidney failure results in elevated PTH, low calcium, and high phosphate
hyperparathyroid – high PTH, high Ca, low phosphate
Primary hypoparathyroid – low PTH, low ca, high phos
CKD: High pth, low ca, high phos
Vitamin D deficiency high PTH, low Calcium, low phosphorous (celiac, cystic fibrosis), pancreatic cancer
PTHRP like PTH increase Ca, decrease phosphate, low PTH
Mechanical ventilation: PCO2 Vt and RR
PaO2 PEEP and FiO2
PH 7.35 – 7.45
Bicarb 22 - 28
Acid Base
PCO2 35-45, <35 respiratory alkalosis > 45 respiratory acidosis
HCO3: 22-28 < 22 metabolic acidosis 28+ metabolic alkalosis
AG: Na – (Cl – HCO3) > 12 AGMA
MUDPILES < 12 NAGMA – diarrhea, RTA
Metabolic alkalosis HCO3 > 28 pH > 7.45 UCl > 20 Renal problem < 20 GI problem
NAGMA RTA verse Diarrhea UAG Na + K – (Chlroide) NeGUTive (GI), Positive Kidney
#Anion-Gap Metabolic acidosis
Most likely ***. Ddx includes MUDPILES (methanol, uremia, DKA, propylene, Fe, isoniazid, lactic acidosis, ethanol, salicylates), acute or chronic kidney disease.
-NaHCO3- if severe acidosis pH < 7.1 or pH < 7.2 in severe AKI (avoid in CHF)
-RRT if pH < 7.1 and not responsive to bicarb tx
-trend BMP daily
#Hyperchloremic Non-Gap Metabolic acidosis
Most likely ***. Ddx includes HARDUPS: Hyperalimentation (started TPN), acetazolamide, RTA (Type I = distal; Type II = proximal; Type IV = hypoaldosteronism), diarrhea, uretosigmoid fistula, pancreatic fistula, normal saline excess.
-Urine Osm (Na, K, Cl). Calculate urine anion gap (urine AG = urine Na + urine K – urine Cl). If + RTA, If - diarrhea (neg GUT ive)
-NaHCO3- if severe acidosis pH < 7.1 or pH < 7.2 in severe AKI (avoid in CHF)
-RRT if pH < 7.1 and not responsive to bicarb tx
-trend BMP daily
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