PHAR 503 Exam 2

Rho Chi Acid-Base Disorders Which medication would most likely NOT lead to a ?

A. Loop Diuretic B. Thiazide Diuretic C. Desmopressin D. Citrate Which medication would most likely NOT lead to a metabolic alkalosis?

A. Loop Diuretic B. Thiazide Diuretic C. Desmopressin D. Citrate Diuretics increase loss of H+, vomiting, hypokalemia, citrate is metabolized to HCO3- A patient suffering from an acute panic attack might be at risk for developing:

A. Respiratory alkalosis B. Metabolic alkalosis C. D. A patient suffering from an acute panic attack might be at risk for developing:

A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory Acidosis D. Metabolic Acidosis

Hyperventilating -> blowing off CO2 (acid) If you have a patient who is experiencing a respiratory acidosis, which of the following sets of labs would most likely match the patient?

A. pH: 7.41, HCO3-: 20 B. pH: 7.35, CO2: 52 C. pH: 7.35, HCO3-: 20 D. pH: 7.45, CO2: 32 If you have a patient who is experiencing a respiratory acidosis, which of the following sets of labs would most likely match the patient?

A. pH: 7.41, HCO3-: 20 B. pH: 7.35, CO2: 52 C. pH: 7.35, HCO3-: 20 D. pH: 7.45, CO2: 32 Metabolic: HCO3- abnormalities, respiratory: PaCO2 What is the normal range for PaCO2?

What is the normal range for HCO3-? What is the normal range for PaCO2?

35-45 (40!)

What is the normal range for HCO3-?

22-26 (24!) ROME

Respiratory Opposite: PaCo2 and pH go in opposite directions

Metabolic Equal: HCO3- and pH go in the same direction Which of the following would NOT cause a metabolic acidosis? A. Ketoacidosis B. Salicylate poisoning C. Severe diarrhea D. CKD E. Decreased tidal volume Which of the following would NOT cause a metabolic acidosis? A. Ketoacidosis B. Salicylate poisoning C. Severe diarrhea D. CKD E. Decreased tidal volume (respiratory acidosis, Can’t breathe) A patient has developed a respiratory acidosis due to PE. If their PaCO2 was 60 mmHg and HCO3- was 24 mmol/L on admission, what would you expect the HCO3- to be 36 hours later?

What about 5 days later? What is this process called? A patient has developed a respiratory acidosis due to PE. If their PaCO2 was 60 mmHg and HCO3- was 24 mmol/L on admission, what would you expect the HCO3- to be 36 hours later? 26 mmol/L

What about 5 days later? 30 mmol/L What is this process called? Metabolic Compensation

In the previous question what if your HCO3- was higher than the predicted value?

What if it was lower?

What is it was lower but the respiratory acidosis only developed 12 hours ago? In the previous question what if your HCO3- was higher than the predicted value? Concurrent metabolic alkalosis What if it was lower? Concurrent metabolic acidosis What is it was lower but the respiratory acidosis only developed 12 hours ago? Not yet compensated 5-step approach:

A patient presents to the ED with a HCO3- of 20, PaCO2 of 40, and a pH of 7.3. Albumin: 3.0

Which values are abnormal? Is there an acidosis or alkalosis? Is this a metabolic issue or respiratory issue? 5-step approach:

A patient presents to the ED with a HCO3- of 20, PaCO2 of 40, and a pH of 7.3. Albumin: 3.0

Which values are abnormal? Is there an acidosis or alkalosis? Is this a metabolic issue or respiratory issue? Metabolic acidosis Calculate the for the patient. Would need Na+, and Cl- values. Remember to correct for albumin!

Calculate the delta ratio

Let’s Review

Metabolic Acidosis: immediately. Calculate via Winter’s Formula If PaCO2 is high: concurrent respiratory acidosis If PaCO2 is low: concurrent respiratory alkalosis

CALCULATE ANION GAP, DELTA RATIO Let’s Review

Metabolic Alkalosis: respiratory compensation immediately. Calculate PaCO2 = (0.7 x HCO3-) + 20 +/- 5 If higher than predicted: concurrent respiratory acidosis If lower than predicted: concurrent respiratory alkalosis Let’s Review

Respiratory Acidosis: metabolic compensation in acute and chronic ratios

Respiratory Alkalosis: metabolic compensation in acute and chronic ratios Hypercalcemia/Hypophosphatemia Calculate the patient’s corrected calcium.

Serum Ca = 8.3 mg/dL Albumin = 4g/dL

Corrected: 8.3 Which of the following drugs cause hypercalcemia?

A. Furosemide B. Cinacalcet C. Lithium D. Vitamin C

Bonus: Explain how the drug causes hypercalcemia.

Which of the following drugs cause hypercalcemia?

A. Furosemide B. Cinacalcet C. Lithium D. Vitamin C

Bonus: Explain how the drug causes hypercalcemia. Lithium resets PTH hormone

Which of the following statements is false?

A. Calcium levels correlate with signs and symptoms B. Acuity of rise in calcium levels determines therapy C. Chronic hypercalcemia results from primary hyperparathyroidism, sarcoidosis, and CKD D. Calcium can deposit in the heart, skin, and kidneys Which of the following treatments is used in symptomatic patients?

A. Zoledronic acid B. Calcitonin C. Furosemide D. Pamidronate Which of the following may cause hypophosphatemia?

A. Administration of insulin B. Constipation C. Normal vitamin D levels D. Respiratory acidosis A patient presents to the clinic complaining of irritability and muscle dysfunction. His Phos is 1.9mg/dL and his K+ is 5.5mg/dL. What medication would you use to treat his symptoms?

A. Neutra-Phos tablets B. KPhos Neutral & Phospha 250 Neutral tablets C. Phos-Na-K powder D. Phosphate supplement

Which of the following foods is rich in phosphate?

A. Chicken B. Potatoes C. Ice cream D. Broccoli Potassium/Magnesium Disorders All of the following lead to a decrease in plasma K+ concentrations except

a. Anabolism b. Metabolic Alkalosis c. Insulin excess d. B2 adrenergic antagonist, (B2 agonist would decrease K) Which of the following leads to decrease of plasma K+ concentrations?

a. Catabolism b. Exercise c. Alpha 1 antagonist, stimulates Na/K ATPase pump, decrease K d. Injury/Trauma

Measure the corrected K+ pH = 7.6 Measured K+ = 4.4

a. 2.0 b. 5.6 c. 4.2 d. 4.0 Calculation explanation

0.1 pH → 0.6mEq/L

7.6 is two 0.1 pH units above 7.4 2 x 0.6 → 1.2 4.4mEq + 1.2mEq = 5.6mEq All of the following can be present on an EKG in someone with hypokalemia except

a. QT prolongation b. T wave inversion c. ST segment elevation: associated with hyperkalemia d. Prominent U wave Which food item below has the highest K+ content

a. Bananas b. Dried figs c. Dates d. Broccoli Which ways can parenteral K+ be administered? Pick all that apply

a. IVP b. Continuous infusion c. IVPB d. IM e. SC What is the maximum rate for peripheral administration of K+?

a. 10mEq/hr or no cardiac monitoring, 20 meq/hr for central line with cardiac monitoring b. 40mEq/hr c. 20mEq/hr d. 100mEq/hr In hyperkalemia what is the first line treatment to normalize the EKG?

a. Insulin b. B2 agonist c. Kayexalate d. Calcium, IVP to stabilize the membrane, then intra cellular shift medications (insulin or albuterol) can be given and eliminiation medications (kayexalate) can be given Hypomagnesemia can lead to all except:

a. Torsades b. Muscle fasciculations c. Cutaneous vasodilation, muscle paralysis and hyporeflexia are all manifestation of hypermagnesemia

What is the maximum infusion rate of parenteral magnesium?

a. 2g/hr b. 1g/hr, if given too fast, kidney will eliminate the dose and it can cause hypotension and vasodilation c. 3g/hr d. 5g/hr Fluid Disorders Percentage of water of the body weight

Based on GENDER: Women … 50% Men … 60%

Based on AGE: Peds … 60-70% Elderly men … 50% Elderly women … 45%

Bonus: how would you calculate the percentage of water if you have a 50 YO patient weighing 180 lb? His IBW is 135lb. Decrease percentage by 5% becaues the patient is >130% of IBW. TBW = ECF + ICF; ECF = ISF + IVF Difference between tonicity, osmolality, and osmolarity

Tonicity: (AKA effective Osmolality: Osmolarity: solute/osmole or osmotic potential), physiological Total solute Osmolarity serum = 2x property, cant be concentration given a [Na+] + glucose/18 + measured weight of water in a given BUN/2.8 compartment Fluid tension b/w ECF Calculated: (mOsm/L and ICF depending on Measured: 280-295 H2O) relative solute mOsm/Kg H2O permeability (averaging 287.5 ~ 288 ↑ pOsm —> lack of H2O mOsm/Kg H2O) ↓ pOsm —> excess of H2O Hypertonic? Hypotonic? Isotonic?

Calculate osmolarity

Patient presents to the ICU with the following lab values:

Na: 144 mmol/L, K:3.4 mmol/L, CO2: 30 mmol/L; BUN: 14 mg/dL, SCr: 0.97 mg/dL glucose 105 mg/dL

Calculate serum osmolarity

2 x Na + glucose/18 + BUN/2.8 = 298.8 Choose the correct answer:

❏ Na+ is primarily an extracellular/intracellular cation

❏ K+ is primarily an extracellular/intracellular cation All of these stimulate the release of AVP except:

A. High plasma osmolality B. High BP, low BP would stimulate AVP C. Carbamazepine D. SSRIs E. TCA

Bonus: what other medications can influence the release of AVP? Haloperidol, opirates, cyclophosphamide For each presentation, choose whether it is likely to be hypovolemia or hypervolemia

Syncope, lethargy, confusion (hypovolemia/hypervolemia): HYPO Hypertension (hypovolemia/hypervolemia): HYPER Jugular vein distention (hypovolemia/hypervolemia): HYPER Dry mouth, , N/V (hypovolemia/hypervolemia): HYPO Pitting edema (hypovolemia/hypervolemia): HYPER Decreased skin turgor (hypovolemia/hypervolemia): HYPO Dyspnea (hypovolemia/hypervolemia): HYPER

Which of the following lead to hypovolemia s/t dehydration? (more than one answer is correct)

A. Increase of age B. Medications like anticholinergic C. Sweating or hyperventilating D. Vomiting and experiencing diarrhea E. Increased AVP secretion: this results in holding onto more water (hypervolemia) Goals of different volume therapies

Resuscitation - Maintain organ perfusion

Replacement - Replace volume lost

Maintenance -Prevent dehydration

Bonus: what do you monitor when you plan resuscitating a patient? BP, HR, mental status, output Match the characteristic with the appropriate fluid type Distributes similarly to water in the body _____ C

Used as a resuscitation fluid _____ A, E

Considered a colloid _____ D

A. NS (0.9% NaCl) B. 1/2NS (0.45% NaCl) C. D5W D. 5% Albumin E. Lactated Ringers (LR) All of the following are true regarding D5W except: (more than one) A. It provides osmotic activity and prevent hemolysis B. Act as free water - hypotonic solution C. Commonly used in general surgical and neurosurgical patient populations D. May cause hypernatremia E. May cause hyperglycemia Choose the correct option

You would like to replace free water, which fluid would make more sense to give? Explain.

0.9% NaCl or 0.45% NaCl , hypotonic, shift intracellularly Daily Fluid Requirement: KNOW THIS

Volume Status: (unit is per ml/kg/day)

Elderly or CHF : 30

Euvolemia : 35

Post-operative : 40

Dehydration : 45 Calculate maintenance fluid amount for a 50 YO man weighing 80 Kg with no significant history who is not allowed to eat or drink prior to a colonoscopy?

Euvolemic: 35 x 80 = 2.8 L/day

Bonus: what if the patient has CHF?

30 x 80 = 2.4 L/day How do we assess toxicity?

MONITOR - Fluids are DRUGS

What do we monitor? Daily weights, Na, other electrolytes, physical exam

What are some of the signs and symptoms of toxicity?

Pulmonary edema, peripheral edema, HF, decreased serum osmolarity, hyponatremia Colloids:

❏ Used for intravascular volume expansion (hypotensive patients) ❏ IV volume expansion > crystalloids ❏ Less readily available d/t cost ❏ ADR > crystalloids

Examples: PRBC, albumin 5%, albumin 25% Sodium Disorders A patient exhibiting Central Diabetes Insipidus would most likely be experiencing which condition?

A. Hypervolemic Hyponatremia B. Euvolemic Hypernatremia C. Euvolemic Hyponatremia D. Hypovolemic Hypernatremia A patient is experiencing symptoms of SIADH, what underlying condition are they most likely to have?

A. Hypovolemic Isotonic Hypernatremia B. Hypervolemic Hypertonic Hyponatremia C. Euvolemic Hypotonic Hyponatremia D. Euvolemic Hypotonic Hypernatremia A patient presents to the ED with a serum sodium of 162, BP of 100/75 and decreased skin turgor. What condition are they most likely experiencing? A. Hypervolemic Hypotonic Hypernatremia B. Hypovolemic Hypertonic Hypernatremia C. Hypervolemic Hypertonic Hypernatremia D. Hypovolemic Hypotonic Hyponatremia The most appropriate treatment for a patient presenting to the ER with AMS and signs of shock would be: A. NS B. D5W C. SWFI D. 3% NaCl Calculate the change in serum sodium concentration after administration of 1L of NS to this patient: Wt: 192lbs, Age: 51, Gender: Male, Sodium: 122

TBW: 87.3 kg x 0.6 = 52 L

Infusate Na - Serum Sodium / TBW + 1

154 - 122 / 53 = 0.6 meq increase Calculate the change in serum sodium concentration for the last patient if 3% NaCl was administered instead. 513-122/53 = 7.4 meq/L

Would this amount be safe to give? What side effects are you worried about? Yes, this is safe maximum is to increase by 8 meq/L in 24 hours. Worried about brain shrinking, PMS