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Fluid and Electrolytes

Fluid and Electrolytes. De Jesus, Anthony De Robles, Shella De Silos, Jeriel. general data. EC, 41/F Paraňaque CC: loose watery stools. patient profile. CLD 2° to Schistosomiasis with sign of portal hypertension splenomegaly, portal gastropathy, gastroesophageal varices.

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Fluid and Electrolytes

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  1. Fluid and Electrolytes De Jesus, Anthony De Robles, Shella De Silos, Jeriel

  2. general data • EC, 41/F • Paraňaque • CC: loose watery stools

  3. patient profile • CLD 2° to Schistosomiasis with sign of portal hypertension • splenomegaly, portal gastropathy, gastroesophageal varices

  4. history of present illness • 2 days PTA (08/05) – patient and grandchildren had • Breakfast: bread • Lunch: rice and sardines • Dinner: rice and salted fish • Water Source: NAWASA, not boiled Patient was asymptomatic

  5. history of present illness • 1 day PTA (08/06) – patient and grandchildren developed diarrhea • loose watery, non-bloody, non-mucoid, non-foul smelling, profuse, >15 x • (-) vomiting, (-) fever • No consult done • Water therapy and bed rest

  6. history of present illness • On day of admission (08/08) – persistence of diarrhea, >10x, (+) abdominal pain and bilateral leg weakness, 1 episode of vomiting, (-) fever PGH-ER

  7. Review of systems • (-) headache, (-) decrease in appetite, (-) fever, (-) pallor • (-) cough, (-) difficulty of breathing • (-) chest pain, (-) palpitations • (-) melena/hematochezia • (-) frothy urine (-) tea colored urine, (-) change in urine output • (-) numbness (-) paresthesia • (-) weight loss, (-) polyuria (-) polydipsia

  8. past medical history • (-) HPN, DM, allergy, asthma, PTB • June 2009 – admitted for UGIB, s/p RBL x 4

  9. Family medical history • (-) HPN, DM, allergy, asthma, PTB, Ca OB History • G7P7 (7007), no complications

  10. Personal and social history • Housewife • 6 pack-years of smoking • Occasional alcohol beverage drinker • Denies use of illicit drugs

  11. DEMS (Triage) • patient arrived very weak, unable to speak • BP 70 palp, HR 120s, RR 16 T afebrile • Cold clammy extremities, faint pulses A> Hypovolemic Shock 2° GI losses AGE prob 1) cholera 2) amoebic CLD 2° to Schistosomiasis (1999) with portal hypertension P> Fast drip pNSS (double line)  1.750 cc pNSS Placed on NPO, Monitor: VS q1/Temp q4/UO q4 Labs requested: 1) ABG; 2) CBC with PBS; 3) Fecalysis/FOBT; 4) BUN, Crea, Na, K, Cl; 5) U/A

  12. DEMS (Triage) • Patient reassessed after 1.750cc of pNSS • More able to speak • BP 90/60, HR 104, RR 20 T afebrile • No hypotensive episode since then • (+) 3 episodes of watery diarrhea • Referred to Gen Med • Laboratory results

  13. CBC WBC 14.24 high Neu 0.900 Lym 0.069 Mon 0.099) RBC 5.64 Hgb 118 low Hct 0.395 low MCV 70.0 low MCH 20.9 low MCHC 299 low RDW 19.7 high Plt 129 Retics 0.025 PBS hypochromic, anisocytosis ++, poikilocytosis ++, no toxic granules seen ABG pH 7.244 pCO 2 28.7 PO2 108 HCO3 12.6, BEb -12.9 O2 sat 97.59% Urinalysis Yellow, cloudy, SG 1.030, pH 6, (-)sugar,(-)protein RBC 30-40/hpf , WBC 3-4/hpf, Epithelial cells +1 , bacteria +2, Mucus Thread rare, fatty cast , (-) crystal Blood Chem BUN 8.83 Crea 138 Alb 32 Na 137 K 2.8 Cl 100 AST 50 ALT 44 Glucose 7.44 Fecalysis Dark yellow , watery consistency, (-) RBC/hpf , WBC 0-1/hpf , no ova or parasites seen , (-) occult blood

  14. ABG • pH 7.240 • pCO2 28.7 • PO2 108 • HCO3 12.6, • BEb -12.9 • O2 sat 97.59% • Na 137 • Cl 100 Pure high anion gap metabolic acidosis

  15. Blood Chemistry • BUN 8.83 high • Crea 138 high • Alb 32 • Na 137 • K 2.8 low • Cl 100 • AST 50 high • ALT 44 • Glucose 7.44 high BUN/crea = 15 Pre-renal azotemia ? Hypokalemia K+ deficit =(desired –actual)/0.27 x 100 K+ deficit = (3.5 -2.8)/0.27 x100 = 260 meqs Stress Hyperglycemia

  16. CBC, PBS WBC 14.24 high Neu 0.900 Lym 0.069 Mon 0.099 RBC 5.64 Hgb 118 low Hct 0.395 low • MCV 70.0 low • MCH 20.9 low • MCHC 299 low • RDW 19.7 high Plt 129 Retics 0.025 PBS hypochromic, anisocytosis ++, poikilocytosis ++, no toxic granules seen • Leukocytosis predominantly neutrophilic = bacterial infection? • Anemia • Microcytic • Hypochromic • Reticulocyte index = 0.025 x (0.395/0.45) x 100 = 2.19 / 1.5 =1.46 Iron Deficiency Anemia

  17. Urinalysis yellow, cloudy, SG 1.030, pH 6, (-)sugar, (-)protein RBC 30-40/hpf, WBC 3-4/hpf, epithelial cells +1 , bacteria +2, Mucus Thread rare, fatty cast , (-) crystal

  18. Fecalysis /FOBT Dark yellow , watery consistency, (-) RBC/hpf, WBC 0-1/hpf, no ova or parasites seen, (-) occult blood

  19. Gen Med A> AGE prob 1) bacterial (cholera vs ETEC) 2) amoebic Hypovolemic Shock 2° to GI losses, resolved CLD 2° to Schistosomiasis (1999) with signs of portal hypertension Prerenal Azotemia Hypokalemia Stress Hyperglycemia Anemia prob 1) Nutritional 2) Chronic Disease

  20. Gen Med Ciprofloxacin 500 mg/tab 1 tab BID Metronidazole 500 mg/tab 1 tab q6 Praziquantel (still for procurement) ORS vol/vol replacement FeSO4 + FA 1 tab TID

  21. Hypokalemia Therapeutic Goals: • to prevent life-threatening complications (arrhthymias, respiratory failure) • correct the K+ deficit • minimize on-going losses through treatment of underlying cause (AGE) • Hypomagnesemia should be sought and corrected to allow effective K+ repletion Using the old formula: K+ deficit = (desired –actual)/0.27 x 100 = (3.5 -2.8)/0.27 x100 = 260 meqs New Paradigm: 4.0 to 3.0 = 200 meqs deficit 3.0 to 2.0 = 400 meqs deficit <2.0 = 600 meqs deficit Since K+ is 2.8 = 400 meqs deficit

  22. Hypokalemia Oral Therapy • safer • larger doses can be given IV Therapy • For patients with imminently life-treatening hypokalemia and those unable to take anything by mouth • MAX conc: • 40 meqs/L via a peripheral vein • 100 meq/L via a central vein • Rate of Infusion • 20 meq/hr unless paralysis or malignant ventricular arrhythmias are present

  23. Hypokalemia Correct half of the deficit in 24 hours, the rest for the next 3 days K+ deficit = 400 meqs correct 200 meqs for the first 24 hours Oral KCl 10 meqs/tab 5 tabs q6 for 4 doses IV KCl 10% sol’n, 40 meqs/30cc, 40 meqs in 1L pNSS x 6° for 5cycles For this patient, she was managed: KCl 10% drip 40 meqs in 1 L pNSS x x 6° for 3 cycles Oral KCl 3 tabs q8 for 3 doses then d/c

  24. Hypokalemia For this patient the hypokalemia was primarily due to GI losses Contributory Factors (Transcellular Shift) • Stress Hyperglycemia (insulin and cathecolamine – induced transcellular shift) • Anemia(anabolic state)

  25. Clinical Manifestations of Hypokalemia • Symptoms inlcude: • Fatigue • Myalgia • Muscular weakness • If severe, can lead to: • Progressive weakness • Hypoventilation • Complete paralysis • Hypokalemic periodic paralysis

  26. Approach to Hypokalemia

  27. ECG Findings Early changes: Flattening/inversion of T wave Prominent U wave ST-segment depression Prolonged QU interval Severe K depletion: Prolonged PR interval Widening of the QRS complex Increased risk of ventricular arrythmias

  28. Hypokalemia • Defined as a plasma concentration <3.5mmol/L • Causes: • Decreased intake • Redistribution into cells • Increased loss

  29. Decreased Intake • Starvation, clay ingestion • Normal K intake is 40-120 meq/day • Rarely the sole cause • However, can contribute to the severity if an underlying problem is present

  30. Redistribution Into Cells • Maintained by the Na-K-ATPase pump in the cell membrane • Metabolic/Respiratory alkalosis – promotes K entry into cells • Insulin – increases the activity of the Na-K-ATPase pump • B2-agonists – increases the activity of the Na-K-ATPase pump

  31. Increased Losses • GI losses usually seen in patients with: • Severe infectious diarrhea (usually secretory) • Villous adenomas • Vasoactive intestinal pepetide tumors • Laxative abuse • Primarily due to increased urinary losses • Results in volume depletion and metabolic alkalosis • Hypovalemia stimulates aldosterone release

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