ICU cases and Review report

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ICU cases and Review report

• Presented by Intern ???
• 2008.04.09

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Case 1

• ?X 77 y/o female
• Phx dementia, old CVA /c left hemiparesis, DM,
  HTN
• Problem left renal and peri-renal abscess
• 3/14? left radical nephrectomy? SICU
• 3/26?ileostomy due to colon perforation with
  initially presentation of stool-like content
  passage from drain
• catheter tip culture MRSA,
• on Ertapenem for treatment

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Case 1

• Now active problem
• (1)  endo weaning failure, Ventilator
  FiO2 25, PEEP5 pressure24
• (2)  hypervolemic hyponatremia Na
  131?125, I/O 1301
• (3)  malnutrition on TPN, may try water?
  try N-G diet, 500cal
• ?albumin 2.5gt2.4gt2.0gt1.7gt1.1
• ?Na 135-137-136-132-131-125

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Case 2

• ?X? 64y/o female
• Phx left breast IDC s/p MRM with brain, lung,
  liver and bone metastasis
• Problem respiratory failure s/p ETT?weaning
  failure

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Case 2

• GOT/GPT 61/88-gt95/205-gt122/156-gt76/121
• Bil. T 4.98-gt7.75-gt14.46-gt18.53(D12.06)
• Alb. 2.2-gt1.8-gt1.3
• Na 135-gt139-gt145gt148
• K 3.9-gt3.0-gt3.3-gt2.3
• Ca 9.5-gt7.4-gt7.4-gt7.1

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Review

• Treatment of electrolyte disorders in adult
  patients in the intensive care unit
• Michael D. Kraft, Imad F. Btaiche, Gordon S.
  Sacks, and Kenneth A. Kudsk
• American Society of Health-System Pharmacy
  Services Vol. 62 Aug. 15, 2005

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Induction

• Severity of symptoms related to electrolyte
  disorders generally correlates with
• the severity of the disorder
• the rate at which the disorder developed
• Before correcting any electrolyte disorder?
  attention to renal function

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Sodium

• Extracellular
• 135-145 meq/L
• Osmolality 275-290 mosmole/kg water
• Common disorders in ICU patients
• Caution inappropriate correction

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Hyponatremia

• lt135 meq/L
• S/S change in serum osmolality and consequence
  fluid shift in CNS
• headache, restlessness, lethargy, disorientation,
  N/V, muscle weakness or cramps, seizures, coma,
  death
• More severe acute reduction in Na of 12 hours
  or less

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Hyponatremia

• Na deficit (meq) TBW x (140- measured serum
  Na)
• TBW 0.6L/kg x weight in men ,0.5L/kg x weight in
  women
• Short term target gt120-130 meq/L
• Monitor
• Q2H-Q4H until asymptomatic
• Q4H-Q8H until normal range

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Hyponatremia

• Corrected rate
• Symptomatic hyponatremia or
• severe acute hyponatremia (change gt0.5 meq/L./hr
  or onset less than 48 hours)
• 1-2 meq/L/hr
• Chronic hyponatrremia or unknown time
• ?0.5meq/L/hr
• Maximum increase 8-12 meq/L per day
• 50 of estimated deficit in 24 hours and
  remainder over next 24-72 hours

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Hyponatremia

• 1 L of 3 saline
• Change in Na 512 meq/L serum Na /TBW1
• Initiation appropriate starting point 15-50
  ml/hr

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Hyponatremia

• Hypovolemic hypotonic
• 0.9 normal saline or lactated Ringers solution
• Isovolemic hypotonic
• Water restriction
• Mild diuresis with loop diuretic (lasix 20-40 mg
  Q6h-Q12H)
• Common SIADH
• Hypervolemic hypotonic
• Critically ill patient cardiac, renal, hepatic
  disease
• Post-op patients i.v. administration of large
  volumes of resuscitation fluids
• Treat underlying disease
• Sodium and fluid restriction (1000-1500 ml/day)
• Diuresis with loop diuretic

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Hypokalemia

• lt3.5 meq/L
• Severe lt 2.5 meq/L or symptomatic
• S/S
• N/V, weakness, constipation, paralysis,
  respiratory compromise, rhabdomyolysis

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Hypokalemia

• Common causes in ICU
• Intracellular shifts
• metabolic alkalosis, insulin, ß-agonists,
  theophylline, caffeine
• increased losses
• loop and thiazide diuretics, HD, CRRT, GI
  lossesltdiarrhea or N-G draingt
• decreased ingestion

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Hypokalemia
If impaired renal function ?50 of recommended
Recheck total 60-80 meq before further potassium
administer (1-4 hours) Total daily 240-400
meq/day
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Refractory hypokalemia

• Check if hypomagnesaemia
• Accelerated renal potassium loss
• Impairment of sodium-potassium pump activity

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Calcium

• 8.6-10.2 mg/dL
• 1 in the serum, 40-50 is bound to albumin
• Active form
• Ionized
• 50
• 1.12-1.30 mmol/L

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Hypocalcaemia

• Total lt 8.6 mg/dL, ionized lt 1.1 mmol/L
• Primarily due to hypoalbuminemia
• S/S tetany

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Hypocalcaemia
Asymptomatic due to hypoalbuminemia no need
therapy
Usually effective in 2 hours or less
total lt 7.5 or innized lt 0.9mmol/L
citrated blood transfusion 1.35meq for each
100ml of blood transfused Monitoring during
infusion Q6H Routine monitor QD or QOD
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Thanks for your attention!!