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A Symptoms and Signs
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When dehydration exists, orthostatic hypotension and oliguria are typical findings Because water shifts from the cells to the intravascular space to protect volume status, these symptoms may be delayed Hyperthermia, delirium, and coma may be seen with severe hyperosmolality Symptoms in the elderly may not be specific; recent change in consciousness is associated with a poor prognosis
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B Laboratory Findings
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1 Urine osmolality > 400 mosm/kg Renal water-conserving ability is functioning a Nonrenal losses Hypernatremia will develop if water ingestion fails to keep up with hypotonic losses from excessive sweating, exertional losses from the respiratory tract, or through stool water Lactulose causes an osmotic diarrhea with loss of free water b Renal losses Whereas diabetic hyperglycemia can cause pseudohyponatremia (see above), progressive volume depletion from the osmotic diuresis of glycosuria can result in true hypernatremia Osmotic diuresis can occur with the use of mannitol or urea 2 Urine osmolality < 250 mosm/kg A dilute urine with osmolality less than 250 mosm/kg with hypernatremia
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B Calculation of Water Deficit
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When calculating fluid replacement, both the deficit and the maintenance requirements should be added to each 24hour replacement regimen 1 Acute hypernatremia In acute dehydration without much solute loss, free water loss is similar to the weight loss Initially, 5% dextrose in water may be used As correction of water deficit progresses, therapy should continue with 045% saline with dextrose 2 Chronic hypernatremia Water deficit is calculated to restore normal osmolality for total body water Total body
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every 1000 mg/L of ethanol This measured hyperosmolality does not produce symptoms by itself because of the equilibrium described, but in any case of stupor or coma in which measured osmolality exceeds that calculated from values of serum Na+ and glucose and BUN, ethanol intoxication should be considered as a possible explanation of the discrepancy (osmolar gap) Toxic alcohol ingestion, particularly methanol or ethylene glycol, also causes an osmolar gap characterized by anion gap metabolic acidosis (see 39) The combination of anion gap metabolic acidosis and an osmolar gap exceeding 10 mosm/kg is not specific for toxic alcohol ingestion Nearly 50% of patients with alcoholic ketoacidosis or lactic acidosis have similar findings, caused in part by elevations of endogenous glycerol, acetone, and acetone metabolites (see Metabolic Acidosis)
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water (TBW) (Table 21 1) correlates with muscle mass and therefore decreases with advancing age, cachexia, and dehydration and is lower in women than in men Current TBW equals 04 06 % current body weight [Na ] 140 Volume (in L) = Current TBW -------------------------140 to be replaced
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Adrogue HJ et al Hypernatremia N Engl J Med 2000 May 18;342(20):1493 9 [PMID: 10816188] Chassagne P et al Clinical presentation of hypernatremia in elderly patients: a case control study J Am Geriatr Soc 2006 Aug;54(8):1225 30 [PMID: 16913989] Lin M et al Disorders of water imbalance Emerg Med Clin North Am 2005 Aug;23(3):749 70 [PMID: 15982544]
VOLUME OVERLOAD
ESSENTIALS OF DIAGNOSIS
Disorder of excessive sodium retention in the setting of low arterial underfilling (eg, congestive heart failure or cirrhosis) Hyponatremia from water retention in edematous states is associated with sodium retention The hallmark of a volume overloaded state is sodium retention Abnormally low arterial filling, such as from congestive heart failure or cirrhosis, activates the neurohumoral axis, which stimulates the renin-angiotensin-aldosterone system, the sympathetic nervous system, and ADH (vasopressin) release Sodium retention with edema results The stimulus for the release of vasopressin is nonosmotic Instead, vasopressin is released in response to activation of baroreceptors because of a decrease in arterial baroreceptor stretch Vasopressin stimulates renal V2 receptors, which increase water reabsorption; hyponatremia may develop in the edematous state
Chen HH et al Pathophysiology of volume overload in acute heart failure syndromes Am J Med 2006 Dec;119(12 Suppl 1):S11 6 [PMID: 17113395] Sala C et al Central role of vasopressin in sodium/water retention in hypo- and hypervolemic nephrotic patients: a unifying hypothesis J Nephrol 2004 Sep Oct;17(5):653 7 [PMID: 15593031] Schrier RW Water and sodium retention in edematous disorders: role of vasopressin and aldosterone Am J Med 2006 Jul;119(7 Suppl 1):S47 53 [PMID: 16843085]
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