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Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 42 Agents Affecting the Volume and Ion Content of Body Fluids
2Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Drugs to Correct Disturbances Drugs used to correct disorders of fluid volume and osmolality Drugs used to correct disturbances of hydrogen ion concentration Drugs used to correct electrolyte imbalances
3Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Agents Affecting the Volume and Ion Content of Body Fluids Disorders of fluid volume and osmolality Acid-base disturbances Potassium imbalances Magnesium imbalances
4Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Fluid Volume and Osmolality Good health requires that both the volume and the osmolality of extracellular and intracellular fluids remain within a normal range Maintenance of both is primarily the job of the kidneys Volume contraction and volume expansion
5Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Volume Contraction and Volume Expansion Volume contraction Decrease in total body water Definition, causes, and treatment Isotonic, hypertonic, and hypotonic Isotonic, hypertonic, and hypotonic Volume expansion Increase in total body water Definition, causes, and treatment Isotonic, hypertonic, and hypotonic Isotonic, hypertonic, and hypotonic
6Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Isotonic Contraction Definition Volume contraction in which sodium and water are lost in isotonic proportions Decrease in total volume, but no change in osmolality Causes Vomiting, diarrhea, kidney disease, and misuse of diuretics Treatment Fluids that are isotonic to plasma 0.9% NS Replenish slowly to prevent pulmonary edema
7Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Hypertonic Contraction Definition Loss of water exceeds loss of sodium Reduced extracellular fluid volume and increase in osmolality Causes Excessive sweating, osmotic diuresis, concentrated food given to infants Secondary to extensive burns or CNS disorders that interfere with thirst Treatment Hypotonic fluids or fluids that contain no solutes at all (D 5 W) Initial therapy: drink water
8Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Hypotonic Contraction Definition Loss of sodium exceeds loss of water Both volume and osmolality of extracellular fluid are reduced Causes Excessive loss of sodium through the kidney (diuretic therapy, chronic renal insufficiency, lack of aldosterone) Treatment Mild: infusing isotonic sodium chloride solution for injection Severe: hypertonic solution (3%) NaCl Watch for signs of fluid overload
9Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Volume Expansion Definition Increase in the total volume of body fluid May be isotonic, hypertonic, hypotonic Causes Overdose with therapeutic fluids Disease states (congestive heart failure [CHF], nephrotic syndrome, cirrhosis with ascites) Treatment Diuretics Agents used for heart failure
10Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Acid-Base Disturbances Acid-base balance is maintained by multiple systems Bicarbonate–carbonic acid buffer system Respiratory system CO 2 (increase lowers pH) CO 2 (increase lowers pH) Kidneys HCO 3 – (increase raises pH) HCO 3 – (increase raises pH)
11Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Acid-Base Disturbances Respiratory alkalosis Respiratory acidosis Metabolic alkalosis Metabolic acidosis
12Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Respiratory Alkalosis Causes Hyperventilation causes decrease in CO 2 Treatment Mild: none needed More severe: rebreathe CO 2 -laden expired breath
13Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Respiratory Acidosis Causes Retention of CO 2 secondary to hypoventilation Depression of the medullary respiratory center Depression of the medullary respiratory center Pathologic changes in the lungs Pathologic changes in the lungs Treatment Correction of respiratory impairment Infusion of sodium bicarbonate if severe
14Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Metabolic Alkalosis Causes Excessive loss of gastric acid Administration of alkalinizing salts Treatment Solution of sodium chloride plus potassium chloride
15Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Metabolic Acidosis Causes Chronic renal failure Loss of bicarbonate during severe diarrhea Metabolic disorders Poisoning by methanol and certain medications Treatment Correction of the underlying cause of acidosis Alkalinizing salt if severe
16Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Potassium Most abundant intracellular cation Extracellular concentrations are low Major role in: Conducting nerve impulses Maintaining the electrical excitability of muscle Regulating acid-base balance
17Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Regulation of Potassium Levels Primarily by the kidneys Renal excretion increased by aldosterone Excretion also increased by most diuretics Potassium-sparing diuretics are the exception Influenced by extracellular pH Alkalosis potassium uptake enhanced Acidosis potassium exits cells Insulin has a profound effect on potassium level
18Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Hypokalemia Serum potassium levels less than 3.5 mEq/L Causes and consequences Most common cause is treatment with a thiazide or loop diuretic Less common: excessive insulin, alkalosis Less common: excessive insulin, alkalosis Adverse effects on skeletal muscle, smooth muscle, blood pressure, and the heart Hypokalemia increases the risk for hypertension and stroke
19Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Hypokalemia Treatment Potassium salts preferred because chloride deficiency frequently coexists with hypokalemia Oral potassium chloride: mild Sustained-release version has fewer GI effects Sustained-release version has fewer GI effects Abdominal discomfort, nausea and vomiting, diarrhea Abdominal discomfort, nausea and vomiting, diarrhea IV potassium chloride: severe or cannot take PO Must be diluted and infused slowly Must be diluted and infused slowly
20Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Hypokalemia Treatment Contraindications to potassium use Avoid in patients who are predisposed to hyperkalemia Severe renal impairment, use of potassium-sparing diuretics, hypoaldosteronism Principal complication of hypokalemia is hyperkalemia Assess renal function and changes in ECG ECG = electrocardiogram.
21Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Hyperkalemia Excessive elevation of serum potassium Causes Severe tissue trauma Severe tissue trauma Untreated Addison’s disease Untreated Addison’s disease Acute acidosis (draws K out of cells) Acute acidosis (draws K out of cells) Misuse of potassium-sparing diuretics Misuse of potassium-sparing diuretics Overdose with IV potassium Overdose with IV potassium
22Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Hyperkalemia Consequences Disruption of the electrical activity of the heart Earliest sign patient is in danger Mild elevation (5–7): T wave heightens; PR prolonged Mild elevation (5–7): T wave heightens; PR prolonged Severe elevation (8–9): cardiac arrest can occur Severe elevation (8–9): cardiac arrest can occur Noncardiac signs Confusion, anxiety, dyspnea, weakness or heaviness of legs, numbness/tingling of hands/feet/lips Confusion, anxiety, dyspnea, weakness or heaviness of legs, numbness/tingling of hands/feet/lips
23Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Hyperkalemia Treatment Withhold foods that contain potassium Withhold medicines that promote potassium accumulation Counteract potassium-induced cardiotoxicity Lower extracellular levels of potassium Calcium gluconate Calcium gluconate Infusion of glucose and insulin Infusion of glucose and insulin If acidotic: infusion of sodium bicarbonate If acidotic: infusion of sodium bicarbonate
24Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Magnesium Required for the activity of many enzymes Binding of messenger RNA to ribosomes
25Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Magnesium Imbalances Hypomagnesemia Causes Diarrhea Diarrhea Hemodialysis Hemodialysis Kidney disease Kidney disease Prolonged intravenous feeding Prolonged intravenous feeding Chronic alcoholism Chronic alcoholism Hypermagnesemia Hypermagnesemia Prevention and treatment Magnesium gluconate and magnesium hydroxide Magnesium gluconate and magnesium hydroxide Magnesium sulfate Magnesium sulfate
26Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Magnesium Imbalances Hypermagnesemia Most common in patients with renal insufficiency
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