Hyponatremia Case 1

Hyponatremia
ผป.เด็กอายุ 6 เดือน นํา้ หนัก 8 กิโลกรัม มีอาการท้องเสีย 3 วัน
1 วัน ก่อนมา รพ. ซึม ชัก ไปตรวจ รพ. เอกชน ได้
Pseudo hyponatremia
admit Rx: phenobarb
True hyponatremia
6 hr หลัง admit มีอาการชัก
Lab: Na 121, K 3.0, Cl 85, CO2 15
ได้ Rx: diazepam
start IV: 5%D/N/5 rate maintenance

10 hr หลัง admit มีอาการชัก

Lab: Na 115, K 4.0, Cl 80, CO2 22

Hyponatremia Hyponatremia
Pseudo hyponatremia Pseudo hyponatremia
True hyponatremia True hyponatremia
Normal POsm High POsm Normal POsm High POsm
Low POsm Low POsm

ICF ECF
Na = 125

Osm = 280 mOsm/L Osm = 250 mOsm/L

 Hyponatremia Hyponatremia
Pseudo hyponatremia Pseudo hyponatremia
True hyponatremia True hyponatremia
Normal POsm High POsm Normal POsm High POsm
Low POsm Low POsm

Cell edemaICF
- Brain edema ECF
Na = 125

Osm = 260 mOsm/L Osm = 260 mOsm/L

Hyponatremia Hyponatremia
ICF ECF
Pseudo hyponatremia Pseudo hyponatremia Na
Na
True hyponatremia True hyponatremia
Na
Normal POsm High POsm Normal POsm High POsm
Low POsm Low POsm
ICF ECF
Hyperglycemia
Na
Mannitol
Na
IVIG with maltose in renal failure
Na
Hyperlipidemia
Hyperproteinemia
ICF ECF
Na
Na
Na

Hyponatremia Hyponatremia
Pseudo hyponatremia Pseudo hyponatremia
True hyponatremia True hyponatremia
Normal POsm High POsm Normal POsm High POsm
Low POsm Low POsm
Hyperlipidemia Hyperglycemia Hyperlipidemia Hyperglycemia
Hyperproteinemia Mannitol Hyperproteinemia Mannitol
IVIG with maltose in renal failure IVIG with maltose in renal failure
Headache
Correct Na = Na + 0.25( total protein - 8 g/dL)
Lethargy
Correct Na = Na + 0.002( TG) Seizure
Correct Na = Na + 1.6 or 2.4 (Glucose -100)
Neurologic pulmonary edema
Death
100 Focal Neurologic symptom: Few
 ผป.เด็กอายุ 6 เดือน นํา้ หนัก 8 กิโลกรัม ผป.เด็กอายุ 6 เดือน นํา้ หนัก 8 กิโลกรัม
มีอาการท้องเสีย 3 วัน 10 hr หลัง admit มีอาการชักเกร็งกระตุกแขนขา
1 วัน ก่อนมา รพ. ซึม ชัก ไปตรวจ รพ. เอกชน ได้ Lab: Na 115, K 3.5, Cl 80, CO2 18
admit Rx: phenobarb �ǽ�IV diazepam 0.3 mL đff �ď� ę �� �ðá �ffęđ�
�
6 hr หลัง admit มีอาการชัก
�ģ č�
a ��ĕ ���ðð�ffë ��ċ ę�b
Lab: Na 121, K 3.0, Cl 85, CO2 15
ได้ Rx: diazepam 1 ให้อะไร.....................
start IV: 5%D/N/5 rate maintenance 2. กี.่ ............... CC
3. Rate เท่าไหร่.... cc/hr x ………hr
10 hr หลัง admit มีอาการชัก
4. แก้ไข Na ขึน
้ มา�ç�čเท่าไหร่..........mEq/L
Lab: Na 115, K 3.5, Cl 80, CO2 18
ไม่ควรเกินเท่าไหร่........mEq/day

Hyponatremia Hyponatremia
Pseudo hyponatremia • Treatment :
No
True hyponatremia – Any Symptoms ? Searching for
Normal POsm High POsm – Below Safety Point? etiology
Low POsm
Hyperlipidemia Hyperglycemia Yes
Hyperproteinemia Mannitol Na intake(mEq)
IVIG with maltose in renal failure Correction with 3%NaCl = Na x 0.6 x BW
Headache to safety point
Rapid Na depletion (3%NaCl 1cc=0.5mEq)
Lethargy (except chronic w/o symptoms)
Acute: < 120
Chronic: < 110-115 Seizure Raise 5mEq/L = 6xBW
Neurologic pulmonary edema
Raise 10mEq/L = 12xBW
Death
Safety Point: 120-125 Focal Neurologic symptom: Few

Hyponatremia How to calculate

• Treatment : • Initial treatment with 3%NaCl
No
– Any Symptoms ? Searching for = Na (mEq/L) x (TBW) (L)
– Below Safety Point? etiology = Na (mEq/L) x (0.6 x BW) (L)
Yes = (120 – 115) (mEq/L) x (0.6 x BW) (L)
Correction with 3%NaCl = (5) (mEq/L) x (0.6 x 8) (L)
to safety point = 24 mEq
Lazy or easy formula
3%NaCl 1 ml มี Na = 0.5 mEq 3%NaCl = 6 x BW raise 5 mEq/L
Rate ?? Depend on severity ถ้าต้องการ Na 24 mEq = 48 ml =6X8
= 48 ml
• severe: 4-8mEq/L/hr
• Not severe: 1-2 mEq/L/hr
 • ผป.เด็กอายุ 6 เดือน นํา้ หนัก 8 กิโลกรัม
How to calculate rate of 3%NaCl • 10 hr หลัง admit มีอาการชักเกร็งกระตุกแขนขา Lab:
• 3%NaCl = 48 ml Na 115, K 3.5, Cl 80, CO2 18 �ǽ� IV
• Rate assess severity = severe diazepam 0.3 mL đff �ď�ę �� �ðá �ffęđ�
�
• Rate = 4-8 mEq/L
48 ml/hr ได้ให้การรักษาด้วย off IV fluid
Rate
5 mEq/L 1 hr
• 3%NaCl 48 cc in 1- 5 hr (1- 5 mEq/L/hr) Or
• 3%NaCl 96 cc in 1 hr 15 min - 10 hr (1- 8 mEq/L/hr)
115 120
(safety point)
(48 ml in 5 hr)
9.6 ml/hr Avoid correcting serum sodium by
Rate
1 mEq/L 1hr 2hr 3hr 4hr 5hr >12 mEq/L/24 hr
or > 18-25 mEq/L/48 hr.
115 116 117 118 119 120
(safety point)

• ผป.เด็กอายุ 6 เดือน นํา้ หนัก 8 กิโลกรัม

Management
• 10 hr หลัง admit มีอาการชักเกร็งกระตุกแขนขา Lab:
Na 115, K 3.5, Cl 80, CO2 18 �ǽ� IV
• Correct Na 121 125 (to be continued)
diazepam 0.3 mL đff �ď�ę �� �ðá �ffęđ�
�
• Correct hypoglycemia
ได้ให้การรักษาด้วย off IV fluid
• 3%NaCl 48 cc in 1- 5 hr (1- 5 mEq/L/hr) Or TIPS: Have to continue IV fluid as 5%D/N/2-5%D/NSS
• 3%NaCl 96 cc in 1 hr 15 min - 10 hr (1- 8 mEq/L/hr) during 3%NaCl infusion
4 hr later transfer to hospital
PE: Drowsiness, on ET tube, looked euvolemia Then search for etiology
Na 121 K 3.5 Cl 88 CO2 20 BUN 10 Cr 0.3
DTX 30

True hyponatremia
Hyponatremia
Hypovolemia
Salt loss > water loss

Extrarenal loss Renal loss

NORMAL HYPONATREMIA
 Hyponatremia Hyponatremia
Hypovolemia Hypovolemia
Salt loss > water loss Salt loss > water loss

Extrarenal loss Renal loss

• GI loss: Diuretic: Thiazide
Vomiting, diarrhea, tube drainage Na wasting Nephropathy
• Skin loss: • Hypoaldosterone
Burn, CF, sweat • Post obstructive diuresis
• CSW: BNP

NORMAL HYPONATREMIA NORMAL HYPONATREMIA

1. ผป.เด็กอายุ 6 เดือน นํา้ หนัก 8 กิโลกรัม 3 วัน ก่อนมา รพ.

Hyponatremia ท้องเสียวันละ 10 ครั้ง กินได้น้อย
Lab: Na 115, K 3.5, Cl 80, CO2 18
Hypovolemia
Salt loss > water loss หลังได้ 3%NaCl 48 ml in 2 hr
Extrarenal loss Renal loss • Na 121 K 3.5 Cl 88 CO2 20
• BUN 10 Cr 0.3
UNa - High
• ตรวจร่างกายพบ mild dehydration
UNa - Low
Uspgr – High Uspgr – 1.010 จงคํานวณ IV fluid ในผู้ป่วยรายนี้
UO – Low UO - High
ให้ IV เป็ น…………..iv drip……….cc/hr
Rx: Fluid, salt Rx: Fluid. salt
NORMAL HYPONATREMIA

1. ผป.เด็กอายุ 6 เดือน นํา้ หนัก 8 กิโลกรัม 3 วัน ก่อนมา รพ.

ท้องเสียวันละ 10 ครั้ง กินได้น้อย
Hyponatremic Dehydration
Lab: Na 115, K 3.5, Cl 80, CO2 18
หลังได้ 3%NaCl 48 ml in 2 hr Add water deficit
+
• Na 121 K 3.5 Cl 88 CO2 20 water maintenance
• BUN 10 Cr 0.3 +
Ongoing water loss
• ตรวจร่างกายพบ mild dehydration
จงคํานวณ IV fluid ในผู้ป่วยรายนี้ Add sodium deficit
ให้ IV เป็ น…………..iv drip……….cc/hr +
How to correct Na 121 125 and correct mild dehydration sodium maintenance
+
NORMAL HYPONATREMIA Ongoing Na loss
 Hyponatremic Dehydration Hyponatremic Dehydration
Extrarenal loss
Add water deficit Acute • %deficit x 10 x BW
+ • ECF deficit 80% of water deficit Add water deficit • Weight loss
water maintenance • Na 145 mEq/L in normal ECF +
+ Holiday
Na def in ECF = Water deficit x 80% x 145 water maintenance Segar
Ongoing water loss (L)
+
ORS/LRS/
Na deficit in Ongoing water loss NSS/2
ECF fluid deficit
Na deficit making
Na x 0.6 x BW Add sodium deficit Na x 0.6 x BW + Na in ECF loss
patient hyponatremia
+
+ sodium maintenance 3mEq/kg
sodium maintenance
+ +
NORMAL HYPONATREMIA Ongoing Na loss Ongoing Na loss ORS/LRS/
NSS/2

Child BW 8 kg. acute diarrhea with mild dehydration with

serum Na = 121 mEq/L Hyponatremic Dehydration
Extrarenal loss Extrarenal loss

• %deficit x 10 x BW • %deficit x 10 x BW
• Weight loss
5 x 10 x 8 = 400 • Weight loss
5 x 10 x 8 = 400
1200 cc
Holiday 100 x 8 = 800 Holiday 100 x 8 = 800
Segar Segar

ORS/LRS/ ORS/LRS/
NSS/2 NSS/2

Na x 0.6 x BW 5 x 0.6 x 8 = 24 Na x 0.6 x BW 5 x 0.6 x 8 = 24

Na in ECF loss 145 x 0.8 x 0.4 = 46.4 Na in ECF loss 145 x 0.8 x 0.4 = 46.4 94.4 mEq
3mEq/kg 3 x 8 = 24 3mEq/kg 3 x 8 = 24
ORS/LRS/ ORS/LRS/
NSS/2 NSS/2

Hyponatremic Dehydration

5 x 10 x 8 = 400
1200 cc Case 2
100 x 8 = 800

1200  94.4
1000  78.6
5 x 0.6 x 8 = 24
94.4 mEq
145 x 0.8 x 0.4 = 46.4
3 x 8 = 24
5%DN/2 1000 cc IV drip 54 cc/hr
 Question
• ผป.เด็กอายุ 1 เดือน นํา้ หนัก 4 กิโลกรัม มีอาการปั สสาวะไม่พงุ่ ไหล Dx: Posterior urethral valve
เป็ นหยดๆ
• PE: BP – normal, both kidneys –palpable,
suprapubic mass
• Lab: Na 135, K 4.3, Cl 100, CO2 12 BUN 80 Cr 2.3

Question
• NPO, IV fluid: 5%D/N/5 drip 16 cc/hr

• After urinary catheter insertion, patient develops

polyuria. Urine output 30 cc/hr
Management
• Intake/ output in 8 hr = 128/240 cc

• BP: 60/40 PR 150

• Electrolyte: Na 125 K 3.6 Cl 90 CO2 15 BUN 60 Cr 2.0

• Urine Electrolyte: Na 90 K 30 Cl 100

Management TO MAINTAIN TBW: CONCEPT

• Rx shock: • Intake = Output
0.9%NaCl/ LR/ Acetar 20 cc/kg IV rapidly • Intake = (Lung + Skin) + (Urine)
• Maintenance (Holliday-Segar)
• Rx: post obstructive diuresis
= (Lung + Skin) + (Urine)
 Hyponatremic Dehydration Management
Extrarenal loss Renal loss
• Rx: post obstructive diuresis
• %deficit x 10 x BW
Add water deficit • Weight loss Fluid = IWL + deficit + UO
+
Holiday ISL
water maintenance Segar
+
ORS/LRS/ Urine output
Ongoing water loss NSS/2 Replace CC/CC/hr

Add sodium deficit Na x 0.6 x BW + Na in ECF loss

+
sodium maintenance 3mEq/kg
+
Ongoing Na loss ORS/LRS/ Urine Na
NSS/2

Management
ISL = 300-500 x (BSA) • Rx: post obstructive diuresis
Fluid = IWL + deficit + UO
Body surface area (BSA) = (500 x BSA) + deficit + UO (cc/cc)

√ W (kg) x H (cm)
3600

4W (kg) +7
W (kg) +90

Management Management
• Rx: post obstructive diuresis • Rx: post obstructive diuresis
Fluid = IWL + deficit + UO Fluid = IWL + deficit + UO
= (500 x BSA) + deficit + UO (cc/cc) = (500 x BSA) + deficit + UO (cc/cc)
= (500 x (4BW+7)) + deficit + UO = (500 x (4BW+7)) + deficit + UO
BW+90 BW+90
= (500 x 0.24) + deficit + UO
 Management Management
• Rx: post obstructive diuresis • Rx: post obstructive diuresis
Fluid = IWL + UO Fluid = IWL + UO
= 120 cc/day + deficit + UO (cc/cc) = 120 cc/day + deficit + UO (cc/cc)

Mod to severe
10% x 10 x BW
= 400 cc

Management Management
• Rx: post obstructive diuresis • Rx: post obstructive diuresis
Fluid = IWL + UO Fluid = IWL + UO
= 120 + deficit(400) + UO (cc/cc) = 120 +deficit(400) + UO (cc/cc)

water N/2 base on urine electrolyte

Strength of sodium?
Add Na deficit
1. ∆Na x 0.6 x BW
2. Na loss in ECF deficit
= 145 x deficit volume x 80%

Management Management
• Rx: post obstructive diuresis • Rx: post obstructive diuresis
Fluid = IWL + UO Fluid = IWL + UO
= 120 +deficit(400) + UO (cc/cc) = 120 cc/day + deficit (400) + UO (cc/cc)

water N/2 base on urine electrolyte

520 cc/day
1. ∆Na x 0.6 x BW
Add Na deficit = 10 x 0.6 x 4
= 24 mEq
2. Na loss in ECF deficit
= 145 x deficit volume x 80%
= 145 x 0.4 x 80%
= 46.4 mEq
 Management Management
• Rx: post obstructive diuresis • Rx: post obstructive diuresis
Fluid = IWL + deficit + UO Fluid = IWL + deficit + UO
= 520 + UO (cc/cc) = 520 + UO (cc/cc)

water N/2 base on urine electrolyte

water N/2 base on urine electrolyte
1. ∆Na x 0.6 x BW
= 10 x 0.6 x 4
Add Na deficit = 24 mEq Add Na deficit
2. Na loss in ECF deficit = 70 mEq 520 70 mEq
= 145 x deficit volume x 80% 1000  70 x1000 = 134 mEq
= 145 x 0.4 x 80%
= 46.4 mEq
520

Management Management
• Rx: post obstructive diuresis • Rx: post obstructive diuresis
Fluid = IWL + deficit + UO Fluid = IWL + deficit + UO
= 520 + UO (cc/cc) = 520 + UO (cc/cc)

5%D/NSS NSS/2 5%D/NSS NSS/2

NSS/2
30 cc/hr 30 cc/hr
22 cc/hr Depend on UO 22 cc/hr Dependcc/hr
30 on UO

Then replace UO 908070%

Until UO < 4 cc/kg/hr

• If there is no dehydration left

, What will IV fluid be in next day ?
Case 3
 ��
�
êđ�ǽ�
� á �đ ę�đ�1 ç�ĕ č �ff 10 kg.
ċ êď ĕ�đ�a�ĕč �gęđĕęċ ç ffē ē�ê�èǽè� ď�ðǽ�ð�
ċ ��ď�ð�. ć �g True hyponatremia
ER �ǽ�on ETT đ� �đ�� �PICU
� �a���è�
ęǽBUN 50 Cr 6.4
Na 115 K 3.5 Cl 98 HCO3 18 ç ff ē ē�ê�
ęę� č ę�đ 5 mL
gff ď� a��ĕ ���ððff
�č 8 á êffi � ë�

1. �ĕ �3%NaCl ĕð� ę�ď� ..............

2. IV �ç�č ę��ð............ rate �ć ��ĕð� ........cc/hr
3. � �ððff � ë���fig bfi
ď� g ċff Na)
ď (�� đê�
�
3.1 ............................
3.2 ............................
4. b �
� �ð�ĕ � ��
�
êđď�negative balance �ć ��ǽ

Hypervolumic hyponatremia 3%NaCl?

Salt & water excess • Symptom depends on
(hypervolemic) – concentration not volume
– Duration: Acute or Chronic
Decrease effective • To raise Na conc
renal blood flow Renal failure
•Heart failure – 3%NaCl
•Nephrotic
UNa - High – Free water loss
UNa - Low Uspgr – 1.010
Uspgr – High UO - Low
UO - Low Which one is faster??

• Rx: Fluid & salt restriction : ISL

NORMAL HYPONATREMIA
• Diuretic : Furosemide
NORMAL HYPONATREMIA

Maintenance fluid? : Restrict water and salt Maintenance fluid? : Restrict water and salt
output > intake 10%DW 8 ml/hr
ISL = ISL Glucose
Urine (to prevent hypoglycemia)
Na?
Vol = 400 (4BW + 7)
Lungs UO BW + 90
• Na = 0
(Negative • DW
ISL balance)
= 400 (4(10) + 7)
10 + 90
%Glucose ?
• Calculate GIR = 1-2
Skin = 188 ml/day • GIR = % x rate
Maintenance fluid = 8 ml/hr 6 x BW
(Holliday-Segar) • % = 6 x BW(10) x GIR(1.5)
rate(8)
• Solute clearance to remove Na excess • = 10
• Free water clearance to increase Na conc
INTAKE OUTPUT
NORMAL HYPONATREMIA
 Free Water Excess Free water excess
After 3%NaCl : 115  120 V1 – V2 = free water excess
V2 = V1 – free water excess

C1V1 = C2V2
FWE = TBW x (1 – Actual Na) actual Na(V1) = designed Na((V1)-FWE)
Designed Na Actual Na(V1) = V1 - FWE
designed Na
= 0.6 x 10 (1- 120) FWE = V1 – Actual Na (V1)
designed Na
125 FWE = V1(1 – Actual Na )
= 0.24 L designed Na
FWE = 0.6 x BW(1 – Actual Na )
= 240 ml. designed Na

��
�
êđ�ǽ�
� á �đ ę�đ�1 ç�ĕ č �ff 10 kg.
Maintenance fluid? : Restrict water and salt
ċ êď ĕ�đ�a�ĕč �gęđĕęċ ç ffē ē�ê�èǽè� ď�ðǽ�ð�
ċ ��ď�ð�. ć �g
output > intake 10%DW 8 ml/hr ER �ǽ�on ETT đ� �đ�� �PICU
� �a���è�
ęǽBUN 50 Cr 6.4
ISL = ISL Glucose Na 115 K 3.5 Cl 98 HCO3 18 ç ff ē ē�ê�
ęę� č ę�đ 5 mL
(to prevent hypoglycemia)
gff ď� a��ĕ ���ððff
�č 8 á êffi � ë�
Na?
Vol = 400 (4BW + 7)
UO BW + 90
• Na = 0

1. �ĕ �3%NaCl ĕð� ę�ď� ให้เมื่อ acute

(Negative • DW
balance)
= 400 (4(10) + 7) %Glucose ? ..............
2. IV �ç�č ę��ð............
10%DW rate �ć �� ĕð�
10 + 90 • Calculate GIR = 1-2 8
= 188 ml/day • GIR = % x rate
........cc/hr
= 8 ml/hr 6 x BW 3. � �ððff � ë���fig bfi
ď� ď (�� đê�g ċff Na)
�
• % = 6 x BW(10) x GIR(1.5)
rate(8) Furosemide
3.1 ............................
• Solute clearance to remove Na excess • = 10 Dialysis
• Free water clearance to increase Na conc 3.2 ............................
= 240 ml.
• Furosemide
4. b �
� �ð�ĕ � ��
�
êđď�negative balance �ć ��ǽ Pure water 240 ml
NORMAL HYPONATREMIA
• Dialysis

��
�
êđ�ǽ�
� á �đ ę�đ�1 ç�ĕ č �ff 10 kg.
Known case brain stem glioma ď�ǽ� êđ admit ǽ�êđ â ď� è �
PE: looked cachexia ć �č BD 1:1 Lab: BUN 8 Cr 0.1 Na 120 K 4.0 Cl 100
HCO3 24 urine SpGr 1.020 serum osm 265 Urine Na 75

Case 4 a��ĕ ���ððff

� ë�

1. �ĕ �total volume �� ç��êđ�ć ��ĕð�.............cc

ǽ�êđę� �ð.............................................
2. � �ððff � ë���fi g bfi
ď� ď
2.1.................
2.2..................
3. b �
� �ð�ĕ � ��ç��
êđď�negative balance………….cc
 True hyponatremia
SIADH
• Normal Condition
Hyponatremia → Low Posm → Inhibit ADH
Hypernatremia → High Posm → Increase ADH

• SIADH
Increase ADH → Hyponatremia → Low Posm

Inhibit

SIADH SIADH
ADH ADH

HYPONATREMIA HIGH URINE SODIUM

BLOOD URINE Na

Na

CLINICAL EUVOLEMIA
Activate ANP  Excrete water & salt
ADH Inhibit RAAS

ทําไม SIADH จึงจัดอยูใ่ นกลุม่ Euvolemia ??

ทําไม ไม่บวม ??

BLOOD
 Euvolumic hyponatremia Euvolumic hyponatremia
water excess + salt loss water excess + salt loss
Euvolemia Euvolemia

High ADH
High ADH = Uosm
= Uosm
Eg. Intake: solute 400 mOsm
water 2000 mL
UNa - High Urine osm should < 200 mOsm/L
Uspgr – High (SIADH) if the lowest urine osm
UO - low = 250 mOsm/L
Free water balance = + 400
NORMAL HYPONATREMIA NORMAL HYPONATREMIA

��
�
êđ�ǽ�
� á �đ ę�đ�1 ç�ĕ č �ff 10 kg.
Causes of SIADH
Known case brain stem glioma ď�ǽ� êđ admit ǽ�êđ â ď� è �
PE: looked cachexia ć �č BD 1:1 Lab: BUN 8 Cr 0.1 Na 120 K 4.0 Cl 100
HCO3 24 urine SpGr 1.020 serum osm 265 Urine Na 75

a��ĕ ���ððff
� ë�

1. �ĕ �total volume �� ç��êđ�ć ��ĕð�.............cc

ǽ�êđę� �ð.............................................
2. � �ððff � ë���fi g bfi
ď� ď
2.1.................
2.2..................
3. b �
� �ð�ĕ � ��ç��
êđď�negative balance………….cc

ถ้าคิดตามปกติคอื ให้ Vol = maintenance ตาม holiday segar = 1000 ml/day,

โดยให้เป็ น 5%NSS/2 (154 mosm/L ของ solutes) อีก 24 ชัวโมงถั
่ ดมา Na ของผูป้ ่ วยสามารถคิ ดได้ดงั นี้
24 hr ถัดมา • C1V1 = C2V2
Uspgr = 1.020
Uosm = 600
• Intake of water 1000 ml 600  1 L • TBW (V1) was 6 liters (0.6 x 10)
600  1000 ml
• solute 154 mosm 154  1000 x 154/600 • (V2) = 6.493 liters ( 6000 ml + 493 ml of freewater)
• Output of water 250 ml as insensible and GI losses
• 120 x 6 = [Na] x 6.493
507
257 ml as urine (1000 x 154/600)
• [Na] = 110 mEq/l
• •Netbalance + 493 ml of freewater
 ถ้า restricted to ISL with NSS • C1V1 = C2V2

• Intake of water 250 ml • TBW was 6 liters

• solute 75 mosm • will be 5.875liters

• Output of water 250 ml as insensible and GI losses (netbalance - 125mlof freewater)
• 125 ml as urine (1000 x 75/600)
• •120 x 6 = [Na] x 5.875
• •Netbalance: -125 ml of freewater.
• •[Na] = 122 mEq/liter after 24 hr.

SIADH
• ถ้า restricted to ISL with NSS • Keep negative Balance: Promote free water Clearance by
1. Fluid restriction:
• •Intake of water 250 ml – ISL
– 50%MT
• •Intake of solute 75 mosm 2. Increase Solute Intake:
– Salt supplement: Hypertonic Saline or NaCl tablet, high salt diet
• Output of water 250 ml as insensible and GI – High Protein diet
losses
3. Decrease urine osmolality : ADH antagonist
• 125 ml as urine (1000 x 75/600) – Diuretic: Furosemide
– V2R antagonist
• •Netbalance: - 125 ml of freewater. – Lithium

��
�
êđ�ǽ�
� á �đ ę�đ�1 ç�ĕ č �ff 10 kg.
How to calculation
Known case brain stem glioma ď�ǽ� êđ admit ǽ�êđ â ď� è �
PE: looked cachexia ć �č BD 1:1 Lab: BUN 8 Cr 0.1 Na 120 K 4.0 Cl 100
Intake • Output
HCO3 24 urine SpGr 1.020 serum osm 265 Urine Na 75
• Restrict fluid to ISL 1. FWE = TBW x (1 – Actual Na)
Designed Na
a��ĕ ���ððff
� ë� • = 500 x BSA
= 0.6 x 10 (1- 120)
• = 500 x 4BW + 7
1. �ĕ �total volume �� ç��êđ�ć ��ĕð�.............cc • BW+ 90
125
= 0.24 L
ǽ�êđę� �ð............................................. • = 235 ml
2. � �ððff � ë���fi g bfi
ď� ď
= 240 ml.
2. ISL
2.1.................
2.2..................
3. b �
� �ð�ĕ � ��ç��
êđď�negative balance………….cc
 ��
�
êđ�ǽ�
� á �đ ę�đ�1 ç�ĕ č �ff 10 kg.
How to calculation
Known case brain stem glioma ď�ǽ� êđ admit ǽ�êđ â ď� è �
PE: looked cachexia ć �č BD 1:1 Lab: BUN 8 Cr 0.1 Na 120 K 4.0 Cl 100
Intake • Output
HCO3 24 urine SpGr 1.020 serum osm 265 Urine Na 75
• ISL = 235 ml 1. FWE = 240 ml.

a��ĕ ���ððff
� ë� (negative balance)
2. ISL

1. �ĕ �total volume �� ç��êđ�ć ��ĕð�.............cc

235 ml
If we don’t want to furosemide to decrease urine osmolarity
ǽ�êđę� �ð............................................. Urine output = 240 ml (Na 120  125)
2. � �ððff � ë���fi g bfi
ď� ď Urine osm = 600 mosm/L means 1000 ml needs solute 600 mosm
Urine output 240 ml needs solute intake = 600 x 240
2.1................. 1000
2.2.................. = 144 mOsm
3. b �
� �ð�ĕ � ��ç��
êđď�negative balance………….cc 240 ml Restrict fluid intake to ISL = 235 ml with solute intake = 144 mOsm

How to calculation How to calculation

Intake • Output Intake • Output
• ISL = 235 ml 1. FWE = 240 ml. • ISL = 235 ml FWE = 240 ml.
(negative balance) (negative balance)
• Need solute 144 mosm • Need solute 144 mosm
2. ISL
144 = 1028 (X (L)) + 308 (0.235 - X)(L)
ใช้ NSS ได้หรือไม่ ? ใช้ NSS ร่วมกับ 3%NaCl? (mOsm) (mOsm/L) (mOsm/L)

NSS 1000 ml มี = 308 mOsm/L

NSS 1000 ml มี = 308 mosm 144 = 1028X + 72.38 - 308X
แต่เราต้องการ 144 mosm 3%NaCl 1000 ml มี = 1028 mOsm/L (mOsm) (mOsm) (mOsm) (mOsm)
Intake ISL 235 ml = 308 x 235
1000 แสดงว่า NSS มี osm ทีไ่ ม่พอ 144 - 72.38 = 1028X - 308X
Vol รวม(NSS + 3%NaCl) = 235 ml
= 72.4 mosm 71.62 = 720X
ถ้า 3%NaCl = X 3%NaCl = 100 ml

NSS = 235 - X 0.099 = X NSS = 135 ml

��
�
êđ�ǽ�
� á �đ ę�đ�1 ç�ĕ č �ff 10 kg.
How to calculation
Known case brain stem glioma ď�ǽ� êđ admit ǽ�êđ â ď� è �
PE: looked cachexia ć �č BD 1:1 Lab: BUN 8 Cr 0.1 Na 120 K 4.0 Cl 100
Intake • Output
HCO3 24 urine SpGr 1.020 serum osm 265 Urine Na 75
• ISL = 235 ml FWE = 240 ml.

a��ĕ ���ððff
� ë� • Need solute 144 mosm (negative balance)

Noted that
1. �ĕ �total volume �� ç��êđ�ć ��ĕð�.............cc
235 ml ใช้ เกลือแกง ใส่ใน BD? 1. if urine osm > 600 – 800 mOsm/L
ǽ�êđę� �ð.............................................
10%DNSS 135 ml/day + 3%NaCl 100 ml/day
เกลือ 1 g มี Na = 17 mEq
restrict fluid to ISL with NSS is not

2. � �ððff � ë���fi g
ď�bfi ď เกลือ 1 g มี osm = 17 x 2 = 34 mOsm
enough
2. Restrict fluid = restrict calories.
Furosemide
2.1................. เชค osmolarity ของ BD สามารถใส่เกลือแกงใน 3. Furosemide or ADH antagonist helps
Tolvaptan BD ที่ทานเพื่อได้ osm = 144 mosm to decrease urine osmolarity (easy to
2.2.................. ใน volume 235 ml/day manage intake)
3. b �
� �ð�ĕ � ��ç��
êđď�negative balance………….cc 240 ml
 ��
�
êđ�ǽ�
� á �đ ę�đ�1 ç�ĕ č �ff 10 kg.
Known case brain stem glioma ď�ǽ� êđ admit ǽ�êđ â ď� è �
PE: looked cachexia ć �č BD 1:1 Lab: BUN 8 Cr 0.1 Na 120 K 4.0 Cl 100
HCO3 24 urine SpGr 1.020 serum osm 265 Urine Na 75 • This patient was cachexia.
• How can we improve his nutrition in SIADH status?
a��ĕ ���ððff
� ë�

1. �ĕ �total volume �� ç��êđ�ć ��ĕð�.............cc

235 ml
ǽ�êđę� เกลือ แกง
�ð.............................................
+ BD (increase BD conc) 144 osm
2. � �ððff � ë���fi g
ď�bfi ď
Furosemide
2.1.................
Tolvaptan
2.2..................
3. b �
� �ð�ĕ � ��ç��
êđď�negative balance………….cc 240 ml