java library barcode reader C Hypervolemic Hypotonic Hyponatremia in Objective-C

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C Hypervolemic Hypotonic Hyponatremia
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1 Water restriction The treatment of hyponatremia is that of the underlying condition (eg, improving cardiac output in congestive heart failure) and water restriction (to < 1 2 L of water daily) 2 Diuretics and V2 antagonists To hasten excretion of water and salt, use of diuretics may be indicated Because diuretics may worsen hyponatremia, the patient must be cautioned not to increase free water intake A potential role for V2 antagonists for the treatment of hyponatremia in congestive heart failure is under investigation 3 Hypertonic (3%) saline Hypertonic saline administration is dangerous in volume-overloaded states and is not routinely recommended In patients with severe hyponatremia (serum sodium < 110 mEq/L) and central nervous system symptoms, judicious administration of small amounts (100 200 mL) of 3% saline with diuretics may be necessary Emergency dialysis should also be considered
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Castello L et al Hyponatremia in liver cirrhosis: pathophysiological principles of management Dig Liver Dis 2005 Feb; 37 (2):73 81 [PMID: 15733516] Ellison DH et al Clinical practice The syndrome of inappropriate antidiuresis N Engl J Med 2007 May 17;356(20):2064 72 [PMID: 17507705] Goldsmith SR Current treatments and novel pharmacologic treatments for hyponatremia in congestive heart failure Am J Cardiol 2005 May 2;95(9A):14B 23B [PMID: 15847853] Hoorn EJ et al Diagnostic approach to a patient with hyponatremia: traditional versus physiology-based options QJM 2005 Jul;98(7):529 40 [PMID: 15955797] McDade G Disorders of sodium balance: hyponatraemia and drug use (and abuse) BMJ 2006 Apr 8;332(7545):853 [PMID: 16601056] Reynolds RM et al Disorders of sodium balance BMJ 2006 Mar 25;332(7543):702 5 [PMID: 16565125]
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Riggs JE Neurologic manifestations of electrolyte disturbances Neurol Clin 2002 Feb;20(1):227 39 [PMID: 11754308] Schrier RW et al; SALT Investigators Tolvaptan, a selective oral vasopressin V2-receptor antagonist, for hyponatremia N Engl J Med 2006 Nov 16;355(20):2099 112 [PMID: 17105757]
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is characteristic of central and nephrogenic diabetes insipidus Nephrogenic diabetes insipidus, seen with lithium or demeclocycline therapy, after relief of prolonged urinary tract obstruction, or with interstitial nephritis, results from renal insensitivity to ADH Hypercalcemia and hypokalemia may be contributing factors when present
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Occurs most commonly when water intake is inadequate, as in patients with altered mental status Urine osmolality helps differentiate renal from nonrenal water loss
General Considerations
An intact thirst mechanism usually prevents hypernatremia (> 145 mEq/L) Thus, whatever the underlying disorder (eg, dehydration, lactulose or mannitol therapy, central and nephrogenic diabetes insipidus), excess water loss can cause hypernatremia only when adequate water intake is not possible, as with unconscious patients Rarely, excessive sodium intake may cause hypernatremia Hypernatremia in primary aldosteronism is mild and usually does not cause symptoms Hypernatremia in the presence of salt and water overload is uncommon but has been reported in very ill patients in the course of therapy
Treatment of hypernatremia is directed toward correcting the cause of the fluid loss and replacing water and, as needed, electrolytes In response to increases in plasma osmolality, brain cells synthesize solutes or idiogenic osmoles which increase osmotic flow of water back into the brain cells to regulate their volume This begins 4 6 hours after dehydration and takes several days to reach a steady state If hypernatremia is too rapidly corrected, the osmotic imbalance may cause water to preferentially enter brain cells, causing cerebral edema and potentially severe neurologic impairment Fluid therapy should be administered over a 48-hour period, aiming for a decrease in serum sodium of 1 mEq/L/h (1 mmol/L/h) Potassium and phosphate may be added as indicated by serum levels; other electrolytes are also monitored frequently
A Choice of Type of Fluid for Replacement
1 Hypernatremia with hypovolemia Severe hypovolemia should be treated with isotonic (09%) saline to restore the volume deficit and to treat the hyperosmolality, since the osmolality of isotonic saline (308 mosm/kg) is often lower than that of the plasma This should be followed by 045% saline to replace any remaining free water deficit Milder volume deficit may be treated with 045% saline and 5% dextrose in water 2 Hypernatremia with euvolemia Water drinking or 5% dextrose and water intravenously will result in excretion of excess sodium in the urine If the GFR is decreased, diuretics will increase urinary sodium excretion but may impair renal concentrating ability, increasing the quantity of water that needs to be replaced 3 Hypernatremia with hypervolemia Treatment consists of providing water as 5% dextrose in water to reduce hyperosmolality, but this will expand vascular volume Thus, loop diuretics such as furosemide (05 1 mg/kg) should be administered intravenously to remove the excess sodium In severe renal injury, hemodialysis may be necessary
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