⽔・Na代謝異常 輸液 考え⽅ - nishikawaclinic.com

1 6 2015/10/161 Na Water & Electrolyte 6 2015 OVERVIEW 0 20 LNaCl 0 500mEqK0 500mEqH0 200mEqCa 0 30gP0 30g 60% Na 140 day 6 2015/10/162 NaCl10g/ NaCl10g/ L 100mEq 100mEq ICFECF 70kg28L14L11L3L (TBW)42L 11L 3L (ICF)28L (ECF)14L2/31/3 3 Osmolality 360 mg/dl == 20 mOsm/Lmg/dl x 10mOsm/L360 x 10180= 6 2015/10/163 OsmolalityECF=2Na + += 2x140+ += 290 mOsm/LICF=290 effective osmole(Na, , ) Glucose Urea tonicity (Osmolality) ( tonicity )TOTALOSMOLALITY =+INEFFECTIVEOSMOLALITY2 (Na) +Glucose(mg/dl)18 EFFECTIVEOSMOLALITY( tonicity )BUN(mg/dl) ) 2) Na, : ECF.

2 TBW 3) + 6 2015/10/164 ICFECFGlu 90Na 140urea 14urea 14290 290 Na ECF ICF ICFECFGluWater313 313 (Hypertonicity)350 Glucose 140gICFECFGlu 90Na 140urea 14urea 14290 290 Na ECF ICF 250 ICFECFGluWater277 277 (Hypotonicity)Water120 Osmolality 2(Na) 2(Na+K)Glucose tonicity 2(Na) 2(Na+K) Glucose Ureatonicity urea Summary 6 2015/10/165 tonicity ECF = ICF ECF = ICF = skin turgor = JVD, (D5W) (NS) /2 (1/2NS) IV 1 L of NSICFECF tonicity ECF 750ml 250ml 1 6 2015/10/1661 L of D5 WICFECF free water TBW 80ml2 5% free water solute-free water 1 L of 1/2NS500ml NS ECF500ml water 1/3 ECF 2/3 ICFICFECF half-normal saline3 1 L of 5% salineICFECF tonicity ICF ECF 4 5% 6 2015/10/167 iso-oncotic albumin 18-24 1 L of 5% albuminICF ECF"crystalloid and colloidcontraversy" 5 5% Oncotic pressureAlbumin( ).

3 ECFICFKNaGluUreaUreaUreaNaGlu Crystalloid 2-5 Colloid , AIDS 6 2015/10/168 ICF ICF D5W IVICF ICF skin turgor ECF NS IV ECF sign of vol. NSor ECF or Excess disorder K K K Na Na HCO3- HCO3- Na ADH (osmoregulation) Edema 4-5 L ECF NS (isotonic fluid) D5W 15 L Na Na , Special thanks to Washy. 6 2015/10/169 Na Na<130mEq/l Na Na free water Na Na Na 140mEq/lNaNaNaNaNaNaNa NaNaNaNaNaNaNa Volume regulation vs Osmoregulation Na Na Na Na 6 2015/10/1610 Na ECF volumedepletion Na Na Na Na 135145 5% Na V2 2000mlNaCl5g = 86meqK 60 meq 800kcalGlucose200 gwater 1000mlNa 40 meq/LK30meq/L100g/L 10% Glucose1 L NSWaterK 60meqGlucose200g+ +NaCl 6 2015/10/1611isotonic hypertonic hypotonic3%salineNS1/2 NS1/3 - 1/4 NSD5W = + 24 Start Hx & PELab 6 hr 12 - 24 hrPELab 48 - 72 hrPELab 6 2015/10/1612 ( tonicity )

4 PNa140mEq/LNaNaNaNaNaNaNaNaNaNaUNa+ UK140mEq/L NS (free water) Na 6 2015/10/1613 Hx , , , PE 4 Na 3-5 (L)(%) 2-44-6>65-1010-15>15 Dehydration (free water) Volume depletion Na 6 2015/10/1614 ICFECF Posm ( tonicity ) Na ICFECF Posm ( tonicity ) Na ICFECF (pure water) Posm ( tonicity ) Na 6 2015/10/1615 2000ml1500ml500ml 4 4 4 or V2 Na Na ECF volumedepletion Na Na 135145 5% Na dehydration D5W + free water D5W 6 2015/10/1616 6 2015 CASE STUDY 28 BP120/60, P 90/min C BUN 32, Cr , Na 138, K , Cl 98, TP Na 140mEq/l 6 2015/10/1617 Heat cramp Na 4kg 4L 2 78 3.

5 BP110/70 mmHg 100/min, C RR 20/min Na125, K , Cl 87, Na Na Na 125mEq/l 6 2015/10/1618 400 600 800 100012001400 mOsm/kgGlucose 350 35-40 mOsm/L 35 - 40 x 15 = 525 - 600 mOsm/LNormal range 2 Na Na Na Na ADH ( Na Volume 3 78 51kg BP120/50 HR96/min Af, CVP skin turgor EJV Na160,K , Cl 130, BUN35, Cr , 6 2015/10/1619 Na Na Na 160mEq/l volume depletion 3 Na Na Na D5W) 1 Na Na Na Na 6 2015/10/1620 ECFECFECFECF Na Na Na ECFECF Na volume depletion V2 Na ECF volumedepletion Na Na Na Na 135145 5% Na 3 70 3 2 BP164/94, 96/min, T CR 24/min, SpO290% Serum:Na140, K , Cl 108, HCO325 BUN 24mg/dl, Cr mg/dl 6 2015/10/1621 70 3 2 BP164/94, 96/min,RR24/min, C,SpO290% Serum.

6 Na140, K , Cl 108, HCO325 BUN 24mg/dl, Cr mg/dl =Na Na 70 -1 20mgIV 12 36 Nrs crackle BP150/92, P 96/min, T C, RR 20/min Serum:Na145, K , Cl 108, HCO325 BUN 32mg/dl, Cr mg/dl Urine: 2L/24hr Na 50mEq/L K 20mEq/L 300mOsm/L (=Na) UNa+UK=70mEq/L Na( ) NS 2L D5W1L 6 2015/10/1622 SIADH (free water) 2L free water 1 LNSNS Free water 74 10 8kg Na124,K , Cl 88, BUN33, Cr , TP , Alb , Glu 112, TCho 473 U/A SG , ,prot(3+), glu (-), 1-4/hpf, WBC 1-4/hpf, Na Na 124mEq/L (isotonic fluid) NaNaNaNaNaNaNaNaNaNaNaNaNaNaD5W (free water)

7 6 2015/10/1623 46 46 BP 110/70 mmHg Pulse 90/min, Temp C RR 20/min Finger-Nose test WBC 8500/ l, Hb g/dl, Ht , pl l Na 117, K , Cl 81, BUN 6mg/dl, Cr , ABG: pH , ,pH ,prot(-),glucose(-) 6 2015/10/1624 Step1: Na Step 2: Na Euvolemic hypotonic hyponatremia vs SIADH very low 80ml/hr IV Na Na V2 Na ECF volumedepletion Na Na Na Na 135145 5% Na 5 6 6 2015/10/1625 2015 2015 REVIEW Na Na Na Na Na Na Na NaCl10g/ NaCl10g/ 1%70%20%5-8% 150L/ 6 2015/10/1626Na Volume regulation RAA ANP NaCl ECF Na ECF Na Na Na Na Sodium retention RAA ANP NaCl ECF Na ECF Na Na (ECF )

8 Na Na Water diuresis Posm ADH Posm Posm 6 2015/10/1627 AntidiuresisPosm ADH 70%20%5-8% 1% ADH ADH ADH Posm280 (Na135mEq/l) ADH Posm290 (Na140mEq/l) 6 2015/10/1628 Na Na Posm ADH Inappropriate ADH Na Posm ADH SSRI Na SIADH free water Na Posm ADH 140mEq/lWt60kgwater load140mEq/l 6 2015/10/1629 Na ADH Na 140mEq/l120 mEq/lwater load ADH Primary polydipsia free water Na 140mEq/l125mEq/lwater load140mEq/l ADH Na 140mEq/lNaNaNaNaNaNaNa NaNaNaNaNaNaNaADH Na NaNaNaNaNaNaNaADH(++) Na Na NaNaNaNaNaNaNaADH 6 2015/10/1630 Na Na 1) 2)

9 Hypovolemic Hypervolemic EuvolemicStep 1 Na Na ? (<280 mOsm/kg) (280-285 mOsm/kg) (>280 mOsm/kg) Na Na Na Na Na Na ( Na ) 6 2015/10/1631 Na Na Na Na 154 mEq/L 154 x 143 mEq/LNa 154 mEq/L 154 x 123 mEq/L93 7% 20% 80 NaNaNaNaNaNaNaNaNaNaNa Step 1 ? (<280 mOsm/kg) (280-295 mOsm/kg) (>295 mOsm/kg) Na Step 2 Third space Addison SIADH Reset osmostatUNa<10 UNa<10 UNa>20 UNa>20 UNa= UNa Na (mEq/L)NaNaNa Na Na Na ECFECF ECF ECF ECFECFECFECFECF ECF ECF ECF Na 6 2015/10/1632 Na ECF volumedepletion Na Na 135145 Na Third space SIADH Reset osmostat Na V2 PfizerPRO 2015 10 PfizerPRO 10 1 2015/5/29 [JCHO ] 2 2015/6/12 [ ] 3 2015/7/24 [ ] 4 ER 2015/8/21 [ ] 5 ER Pitfalls!

10 Minor emergencies 2015/9/18 [ ] 6 Na 2015/10/16 [ ] 7 2015/11/13 [ ] 8 ER 2015/12/11 [ ] 9 2016/1/29 [ ] 10 2016/2/12 [ ]