IVF & Medication in HyponatremiaIVF & Medication in Hyponatremia

MR.JUMPON MR.JUMPON UTTA UTTA B.Pharm B.Pharm Pharmaceutical Sciences UBUPharmaceutical Sciences UBUPharmacistPharmacist Ubonratchatani Cancer CenterUbonratchatani Cancer Center 24 August 200724 August 2007

ObjectiveObjective Review of Sodium ion & hyponatremiaReview of Sodium ion & hyponatremia Understand type of IVFsUnderstand type of IVFs Calculate fluid therapy in hyponatremia Calculate fluid therapy in hyponatremia Medication use in hyponatremiaMedication use in hyponatremia

Review of Sodium IonReview of Sodium Ion It’s an electrolyte!It’s an electrolyte! Important:Important:

Maintenance of ECF Maintenance of ECF (Extra cellular Fluid)(Extra cellular Fluid) vol. vol. Effects osmotic pressureEffects osmotic pressure Essential for conduction of nerve impulsesEssential for conduction of nerve impulses Muscle contractionsMuscle contractions

Sodium Concentration in Body fluids

Disorders of SodiumDisorders of Sodium Serum Sodium > Osmolality < WaterSerum Sodium > Osmolality < Water

Regulated by thirst , ADH, & renal water handlingRegulated by thirst , ADH, & renal water handling A disruption in A disruption in water balancewater balance is manifested as an is manifested as an

abnormality in abnormality in serum sodiumserum sodium Sodium is a functionally impermeable solute, so it Sodium is a functionally impermeable solute, so it

contributes to tonicity and induces water movement contributes to tonicity and induces water movement across membranesacross membranes

Hypernatremia = hyperosmolar (hypertonic) Hyponatremia Hypernatremia = hyperosmolar (hypertonic) Hyponatremia = hyposmolar (hypotonic)= hyposmolar (hypotonic)

Hyponatremia(Found in 10-15% of hospitalized patients)

Decrease in measured serum Na Decrease in measured serum Na concentration below 135 mEq/Lconcentration below 135 mEq/L Mild 125-134mEq/LMild 125-134mEq/L Moderate 110-124mEq/LModerate 110-124mEq/L Severe 100-109mEq/LSevere 100-109mEq/L

Evalulateserum osmolarityEvalulateserum osmolarity If osmolarity ishypotonic, evaluate volume If osmolarity ishypotonic, evaluate volume

status:status: HypervolemiaHypervolemia EuvolemiaEuvolemia HypovolemiaHypovolemia

Hyponatremia: Clinical Hyponatremia: Clinical ManifestationsManifestations

Related to CNS dysfunction; sequelae Related to CNS dysfunction; sequelae are prominent when the decrease in are prominent when the decrease in serum sodium is rapid or largeserum sodium is rapid or large

Symptoms: Headache, nausea, Symptoms: Headache, nausea, vomiting, muscle cramps, lethargy, vomiting, muscle cramps, lethargy, restlessness, disorientation, and restlessness, disorientation, and depressed reflexesdepressed reflexes

If Na < 125 mmol/L: seizure, coma, brain If Na < 125 mmol/L: seizure, coma, brain damage, herniation, and deathdamage, herniation, and death

Effects of HyponatremiaEffects of Hyponatremia Impairs nerve conductionImpairs nerve conduction Low osmotic pressure in EC Low osmotic pressure in EC

compartment (Fig. 1)compartment (Fig. 1) Swelling of brain cellsSwelling of brain cells

HyponatremiaHyponatremia

Causes of Causes of HyponatremiaHyponatremia

CancerCancer Pulmonary TumorsPulmonary Tumors Mediastinal tumorsMediastinal tumors Extrathoracic tumorsExtrathoracic tumors

DrugsDrugs Diuretic drugs, low-salt dietDiuretic drugs, low-salt diet CyclophosphamideCyclophosphamide VincristineVincristine Opiate derivativesOpiate derivatives

Hormonal imbalances : ADHHormonal imbalances : ADH Renal failureRenal failure Excessive water intakeExcessive water intake

Fluid therapy for HyponatremiaFluid therapy for Hyponatremia Symptomatic: Hypertonic saline therapy Symptomatic: Hypertonic saline therapy

(can be combined with furosemide to (can be combined with furosemide to limit expansion of ECF)limit expansion of ECF) Correct 1-2 mmol/L/hour x several hours if Correct 1-2 mmol/L/hour x several hours if

severly symptomaticseverly symptomatic Target for increase in serum sodium of no Target for increase in serum sodium of no

more than 8 mmol/d to prevent osmotic more than 8 mmol/d to prevent osmotic demyelinationdemyelination

Asymptomatic: Fluid therapy is guided Asymptomatic: Fluid therapy is guided by Madias Formula by Madias Formula

Intravenous FluidsIntravenous Fluids Isotonic Isotonic Hypertonic Hypertonic Hypotonic Hypotonic

LRLR D5½NSSD5½NSS ½NSS½NSSRinger’s Ringer’s D5NSS D5NSS ..33%NaCl33%NaCl

NSSNSS D5LR D5LR D2.5%WD2.5%WD5W D5W 3% NSS 3% NSS Plasma-lytePlasma-lyte

7.5% NaCl7.5% NaCl

Hyponatremia: ManagementHyponatremia: ManagementRate of infusion is Rate of infusion is calculated using the calculated using the Madias FormulaMadias Formula which estimates the which estimates the change in serum change in serum sodium caused by 1 sodium caused by 1 liter of any infusate. liter of any infusate. The required volume, The required volume, and thus rate, is and thus rate, is determined by dividing determined by dividing the change in serum the change in serum sodium desired for a sodium desired for a given period of time by given period of time by the value obtained from the value obtained from Madias formula.Madias formula.

Hyponatremia: ManagementHyponatremia: Management Hyponatremia Hyponatremia

Na+ requirement (mmol)Na+ requirement (mmol)

== total body water x (desired Natotal body water x (desired Na++ - serum Na - serum Na++ ) )

Rate of infusion (cc/hr) Rate of infusion (cc/hr)

= = NaNa++ requirement requirement ((mmolmmol) ) x 1000x 1000 infusate infusate NaNa++ ( (mmolmmol//LL) ) x time x time ((hourshours))

Adrogue FormulaAdrogue Formula :: Change in serum Na+ Change in serum Na+

= = ((infusate Nainfusate Na++ + + infusate Kinfusate K++) - ) - serum Naserum Na++

total body water + 1total body water + 1

HyponatremiaHyponatremia

Hyponatremia: ManagementHyponatremia: Management

ACUTEACUTE : replace 1-2mEq/L/hr with NSS : replace 1-2mEq/L/hr with NSS or 3% NSS -SLOWLY!!! No > than 8 mor 3% NSS -SLOWLY!!! No > than 8 mEEq/24 hoursq/24 hours

CHRONICCHRONIC : replace 0.5mEq/L/hr with : replace 0.5mEq/L/hr with NSSNSS

exampleexample ผู้ปว่ยชายไทยคู ่อายุผู้ปว่ยชายไทยคู ่อายุ60 60 หนัก หนัก 7700 kgkg มีอาการชักเกร็ง เป็นระยะมีอาการชักเกร็ง เป็นระยะ Serum NaSerum Na++ = 120 mEq/L = 120 mEq/L ต้องการให้เพิ่มต้องการให้เพิ่ม serumserum NaNa++ ในปริมาณ ในปริมาณ 5 5

mEq/L mEq/L ใน ใน 24 hr24 hr เลือก เลือก IVF IVF ประเภทใด ประเภทใด หาปริมาณและ หาปริมาณและ Rate Rate การให้เป็น การให้เป็น ml/hrml/hr

วิธีทำาวิธีทำา TBW = 0.6 x (70) = 42 L TBW = 0.6 x (70) = 42 L ((1kg 1kg นำ้านำ้า=1 L)=1 L) Serum NaSerum Na++ = 120 = 120 mEq/LmEq/L จากโจทย์ต้องเลือก จากโจทย์ต้องเลือก IVF IVF เป็น เป็น HypotonicHypotonic

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