By Richard Arthur Preston
Univ. of Miami, FL. Concise instruction manual on fixing difficulties bearing on complicated fluid, electrolyte, and acid-base problems. For scientific scholars, interns, citizens, nurses and nurse practitioners, and first-year nephrology fellows. Softcovers.
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Extra info for Acid-Base, Fluids, and Electrolytes Made Ridiculously Simple (1st Edition)
Loop diuretics and sodium restriction treat the sodium-overload problem (the cause of the edema). Water restriction is not necessary unless there is hyponatremia. It is also important to remember that thiazide diuretics are contraindicated in all patients with hyponatremia, even those with edema-forming states. Thiazides impair the ability of the kidney to produce a dilute urine and can worsen the hyponatremia. It is important to re-emphasize that in the absence of hyponatremia there is no indication to restrict water: I f there is edema (ECF sodium overload) alone, restrict only sodium.
Findings consistent with adrenal insufficiency or hypothyroidism should prompt the appropriate hormonal assays. Laboratory Studies A low measured serum osmolality excludes pseudohyponatremia or hyponatremia with increased tonicity. The urine osmolality may give an indication of the severity of the impairment in urine dilution. For example, a patient with a urine osmolality of 200 mOsm/L has less impairment of urine dilution than a patient with a urine osmolality of 600 mOsmIL. The urine sodium concentration may be helpful.
I check the sodium concentration every 1-2 hours to carefully monitor therapy. The purpose of using 3% saline in cases of severe acute, symptomatic hyponatremia is not to correct the sodium concentration per se, but to temporarily relieve cerebral edema and to prevent neurologic sequelae. I view the use of 3% as trying to "let off a little pressure" by the hypertonic effect of the 3% saline, which removes water from the swollen brain. This can generally be accomplished by correcting the sodium concentration by only 6-8 mEqn initially.