VITAMINS, MINERALS, FLUIDS & ELECTROLYTES

VITAMIN THERAPY

• FAT SOLUBLE VITAMINS– A (CHART 12-1)– D– E– K

• WATER SOLUBLE VITAMINS– B VITAMINS– C (CHART 12-2)

Vitamin A

• AQUASOL (capsules, drops, tabs, IM)– Retinal function, bone growth, reproduction,

epithelial and MUCOSAL tissue integrity• Po forms require normal fat absorption• Protein bound• Stored in normal liver for 2 years

– MEN: 1,000 mcg re(retinol equivalents) or 4,000U

– WOMEN: 800mcg RE or 4,000 U

VITAMIN D

• Calciferol: Adults = 200 IU (PO, IM)– Rickets– Hypoparathyroidism– Familial phosphatemia

• Drug interactions:– Steroids antagonize Vit D– Thiazides can increase calcium– Verapamil AF due to high calcium

VITAMIN E

• Men: 10 alpha-tocopherol equivalents/15 IU• Women: 8 alpha-TE/12IU

– PO

• Depends on bile for absorption• Drug-Drug Interactions

– Increases daily iron need– Decreases Prothrombin– Antagonized Vit K

VITAMIN K

• Phytonadione (PO or IM, SC, IV) controls abnormal bleeding due to malabsorption, drug therapy, or Vit A toxicity– Men >25: 80 mcg– Women >25: 65 mcg

• PRODUCT IS LIGHT-SENSITIVE.

• WRAP IV BAG IN FOIL.

VITAMIN C

• RDA: ADULTS = 60 mg• Therapeutic use: 300 – 500 mg for short

course in burns, fractures, post-op healing, severe febrile or chronic disease.

• Low protein binding activity– Decreases with high dose ASA– Decreases warfarin– Increases estrogen; iron absorption

B Vitamins

• B1 – Thiamine (po, iv, im)• ANGIOEDEMA, CV COLLAPSE,

HEMORRHAGE, PULMONARY EDEMA

• B2 – Riboflavin ( Adults: 1.3 – 1.4 mcg)• Tissue respiration

• Use cautiously with probenecid

• Discolors urine yellow/orange

B Vitamins

• B3 - Niacin (PO, slow IV, IM, SC)

– Stimulates lipid metabolism, tissue respiration, glycogenolysis

– Decreases low density lipoprotein– Dilates peripheral blood vessels– Adverse reactions: arrythmias, hepatic

dysfunction– Potentiates orthostatic hypotension

B Vitamins

• B6 (Pyridoxine) (1.6 – 2 mg) PO, IV, IM

– Coenzyme in amino acid metabolism– Antidote for INH poisoning– Metabolized in liver decreased levels of

anticonvulsants– Alcoholics can experience delirium and lactic

acidosis

B Vitamins

• B 12 (cyancobolamin) : RDA = 2mcg – PO, IM/SC– for dietary supplementation or after sub-total

gastrectomy or in GI disease: 30 mcg IM qd x 5 days; then 100 – 200 mcg IM q month

– For pernicious anemia: 100 mcg IM/SC qd x 6-7 days; then 100 mcg IM/SC q month

• Avoid with ETOH, aminoglycosides, chloramphenicol, and PAS

• Anaphylaxis can occur

FOLIC ACID

• Vitamin B stimulates erthyropoiesis and nucleoprotein synthesis– Prevents megaloblastic anemia

• Adults: 180 – 200 mcg (higher in pregnancy)• Drug-drug concerns:

– Any folic acid antagonist, e.g., trimethoprim, methotrexate; decreases levels of anticonvulsants

– ETOH increases folic acid requirements

VITAMIN SUPPLEMENTS

• RATIONALE:– THE SOIL IN WHICH WE PRODUCE OUR FOOD

IS DEPLETED OF MINERALS

– THE AMERICAN DIET DOES NOT MEET OUR MINIMUM DAILY REQUIREMENT

• CAUTIONS:– MEGADOSES OF VITAMINS ARE NEITHER

NECESSARY NOR HARMLESS• EXCESS FAT SOLUBLE VITAMINS MAY BE STORED IN

THE BODY FOR EXTENDED PERIODS OF TIME

VITAMIN SUPPLEMENTS

• JUSTIFICATIONS– INADEQUATE ABSORPTION

• MALABSORPTION,• DIARRHEA • INFECTION • INFLAMMATORY BOWEL DISEASE

– IMPAIRED UTILIZATION• LIVER OR RENAL DISEASE • GENETIC DISORDERS

VITAMIN SUPPLEMENTS

• JUSTIFICATIONS– EXCESSIVE LOSSES

• FEVER

• HYPERTHYROIDISM

• HEMODIALYSIS

• STARVATION, CRASH OR LIMITED DIETS

VITAMIN SUPPLEMENTS

• JUSTIFICATIONS– INCREASED REQUIREMENTS

• GROWTH

• PREGNANCY

• DEBILITATING DISEASES

• GI SURGERY

• RESTRICTED DIETS

VITAMIN EXCESS

See Instructor’s Notes on the Web

FLUIDS & ELECTROLYTES

• FLUID REPLACEMENT– WATER

• ELETROLYTE REPLACEMENT– SODIUM, POTASSIUM

• ACID-BASE BALANCE

FLUID REPLACEMENT: crystalloid solutions

2.5% DEXTROSE IN WATER

5% DEXTROSE IN WATER

10% DEXTROSE IN NORMAL SALINE

0.45% SALINE 0.9% NORMAL SALINE SOLUTION or

LACTATED RINGER’S

3 % SALINE

COLLOIDS: large molecule solutions

• PROVIDE PROTEIN, FLUID, AND CALORIES FOR WOUND HEALING

• ALBUMIN, DEXTRAN

– Increase PLASMA VOLUME and OSMOTIC PRESSURE TO COUNTERACT SHOCK

• REDUCES RED CELL AGGREGATION AND ENHANCES BLOOD FLOW– Contraindicated in HEMORRHAGE, RENAL

FAILURE, DEHYDRATION THROMBOCYTOPENIA

COLLOID CONTROVERSY

• INCREASED COST OVER CRYSTALLOID SOLUTIONS

• DIFFERENTIAL MORTALITY

• THE ROLE OF HEALTH SERVICES RESEARCH

• INFLUENCE OF MANAGED CARE IN CLINICAL DECISIONS

ELECTROLYTES

• INTRACELLULAR: K– 140 mEq, mainly in muscle

• EXTRACELLULAR: Na– 140 mEq, mainly in serum

ACID – BASE BALANCE

• THE EQUILIBRIUM IN THE EXTRA- CELLULAR FLUID BETWEEN– SUBSTANCES ABLE TO GIVE UP H+ IONS

(ACIDS) AND – SUBSTANCES ABLE TO ACCEPT H + IONS

(BASES)• RESPIRATORY ACID-BASE CONTROL• RENAL MECHANISM FOR METABOLIC

CONTROL

CASE

• MR. BROWN, 68, HAS ACUTE PNEUMONIA, A PRODUCTIVE COUGH, CYANOSIS, LABORED BREATHING AT 28 BREATHS PER MINUTE– PaO2 = 56 mmHg– SaO2 =88%– pH=7.32 – PaCO2=50mmHg– HCO3=24 mEq/L

CASE

• MRS. C, 36, HAD DILATED CARDIOMYOPATHY, ORTHOPNEA, DOE, DRY, NON-PRODUCTIVE COUGH. SHE IS DIZZY, C/O TINGLING IN ETREMITIES. HAS FINE CRACKLES. R=32/MIN

– PaO2 = 93 mmHg

– SaO2 = 98%

– Ph = 7.48

– PaCO2= 32mmHg

– HCO3 = 24 mEq/L

CASE

• LAURIE, 6 MOS OLD, HAD A BOWEL RESECTION FOR HIRSCHSPRUNG’S DISEASE. SHE HAS AN NG TUBE, IVs. URINE OUTPUT IS 0.4CC/HR. RESPIRATIONS ARE NORMAL.

– PaO2 = 90 mmHg

– SaO2 = 95%

– pH = 7.49

– PaCO2 = 45mmHg

– HCO3 = 30 mEq/L

NUTRITIONAL SUPPORT

• INSERT TUBE ABOUT 25 CM IN ADULTS

• INSUFLATE WITH AIR AND ASPIRATE FLUID

• TEST ITS Ph and APPEARANCE• pH <5 + green/brown color = gastric location

• pH >6 + yellow bile stained = duodenum

• pH>6 + mucus, straw colored fluid = ?lung

BLOODLESS SURGERY

• MEETS THE NEEDS OF PATIENTS FOR WHOM TRANSFUSIONS ARE NOT POSSIBLE OR DESIREABLE– EPOGEN PREOPERATIVELY– INDUCED HYPOTENSION OR

HYPOTHERMIA– HEMODILUTION WITH COLLOIDS– REINFUSION AND AUTOINFUSION