Hyponatremia

Case 1
ผป.เด็กอายุ 6 เดือน นํา้ หนัก 8 กิโลกรัม มีอาการท้องเสีย 3 วัน
1 วัน ก่อนมา รพ. ซึม ชัก ไปตรวจ รพ. เอกชน ได้
admit Rx: phenobarb
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
Pseudo hyponatremia
True hyponatremia
 Hyponatremia
Pseudo hyponatremia
True hyponatremia
Normal POsm High POsm
Low POsm
 Hyponatremia
Pseudo hyponatremia
True hyponatremia
Normal POsm High POsm
Low POsm

ICF ECF
Na = 125

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

 Hyponatremia
Pseudo hyponatremia
True hyponatremia
Normal POsm High POsm
Low POsm

Cell edemaICF
- Brain edema ECF
Na = 125

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

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

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

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

Correct Na = Na + 0.25( total protein - 8 g/dL)

Correct Na = Na + 0.002( TG)

Correct Na = Na + 1.6 or 2.4 (Glucose -100)

100
 Hyponatremia
Pseudo hyponatremia
True hyponatremia
Normal POsm High POsm
Low POsm
Hyperlipidemia Hyperglycemia
Hyperproteinemia Mannitol
IVIG with maltose in renal failure
Headache
Lethargy
Seizure
Neurologic pulmonary edema
Death
Focal Neurologic symptom: Few
ผป.เด็กอายุ 6 เดือน นํา้ หนัก 8 กิโลกรัม
มีอาการท้องเสีย 3 วัน
1 วัน ก่อนมา รพ. ซึม ชัก ไปตรวจ รพ. เอกชน ได้
admit Rx: phenobarb
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 3.5, Cl 80, CO2 18
 ผป.เด็กอายุ 6 เดือน นํา้ หนัก 8 กิโลกรัม
10 hr หลัง admit มีอาการชักเกร็งกระตุกแขนขา
Lab: Na 115, K 3.5, Cl 80, CO2 18
�ǽ�IV diazepam 0.3 mL đff �ď� ę �� �ðá �ffęđ�
�
�ģ č�
a ��ĕ ���ðð�ffë ��ċ ę�b
1 ให้อะไร.....................
2. กี.่ ............... CC
3. Rate เท่าไหร่.... cc/hr x ………hr
4. แก้ไข Na ขึน
้ มา�ç�čเท่าไหร่..........mEq/L
ไม่ควรเกินเท่าไหร่........mEq/day
 Hyponatremia
Pseudo hyponatremia
True hyponatremia
Normal POsm High POsm
Low POsm
Hyperlipidemia Hyperglycemia
Hyperproteinemia Mannitol
IVIG with maltose in renal failure
Headache
Rapid Na depletion
Lethargy
Acute: < 120
Chronic: < 110-115 Seizure
Neurologic pulmonary edema
Death
Safety Point: 120-125 Focal Neurologic symptom: Few
 Hyponatremia
• Treatment :
No
– Any Symptoms ? Searching for
– Below Safety Point? etiology
Yes
Na intake(mEq)
Correction with 3%NaCl = Na x 0.6 x BW
to safety point (3%NaCl 1cc=0.5mEq)
(except chronic w/o symptoms)
Raise 5mEq/L = 6xBW
Raise 10mEq/L = 12xBW
 Hyponatremia
• Treatment :
No
– Any Symptoms ? Searching for
– Below Safety Point? etiology
Yes
Correction with 3%NaCl
to safety point

Rate ?? Depend on severity

• severe: 4-8mEq/L/hr
• Not severe: 1-2 mEq/L/hr
 How to calculate
• Initial treatment with 3%NaCl
= Na (mEq/L) x (TBW) (L)
= Na (mEq/L) x (0.6 x BW) (L)
= (120 – 115) (mEq/L) x (0.6 x BW) (L)
= (5) (mEq/L) x (0.6 x 8) (L)
= 24 mEq
Lazy or easy formula
3%NaCl 1 ml มี Na = 0.5 mEq 3%NaCl = 6 x BW raise 5 mEq/L
ถ้าต้องการ Na 24 mEq = 48 ml =6X8
= 48 ml
 How to calculate rate of 3%NaCl
• 3%NaCl = 48 ml
• Rate assess severity = severe
• Rate = 4-8 mEq/L
48 ml/hr
Rate
5 mEq/L 1 hr

115 120
(safety point)
(48 ml in 5 hr)
9.6 ml/hr
Rate
1 mEq/L 1hr 2hr 3hr 4hr 5hr

115 116 117 118 119 120

(safety point)
 • ผป.เด็กอายุ 6 เดือน นํา้ หนัก 8 กิโลกรัม
• 10 hr หลัง admit มีอาการชักเกร็งกระตุกแขนขา Lab:
Na 115, K 3.5, Cl 80, CO2 18 �ǽ� IV
diazepam 0.3 mL đff �ď�ę �� �ðá �ffęđ�
�

ได้ให้การรักษาด้วย off IV fluid

• 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)

Avoid correcting serum sodium by

>12 mEq/L/24 hr
or > 18-25 mEq/L/48 hr.
 • ผป.เด็กอายุ 6 เดือน นํา้ หนัก 8 กิโลกรัม
• 10 hr หลัง admit มีอาการชักเกร็งกระตุกแขนขา Lab:
Na 115, K 3.5, Cl 80, CO2 18 �ǽ� IV
diazepam 0.3 mL đff �ď�ę �� �ðá �ffęđ�
�

ได้ให้การรักษาด้วย off IV fluid

• 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)

4 hr later transfer to hospital

PE: Drowsiness, on ET tube, looked euvolemia
Na 121 K 3.5 Cl 88 CO2 20 BUN 10 Cr 0.3
DTX 30
 Management
• Correct Na 121 125 (to be continued)
• Correct hypoglycemia

TIPS: Have to continue IV fluid as 5%D/N/2-5%D/NSS

during 3%NaCl infusion

Then search for etiology

True hyponatremia
 Hyponatremia
Hypovolemia
Salt loss > water loss

Extrarenal loss Renal loss

NORMAL HYPONATREMIA
 Hyponatremia
Hypovolemia
Salt loss > water loss

Extrarenal loss
• GI loss:
Vomiting, diarrhea, tube drainage
• Skin loss:
Burn, CF, sweat

NORMAL HYPONATREMIA
 Hyponatremia
Hypovolemia
Salt loss > water loss

Renal loss
Diuretic: Thiazide
Na wasting Nephropathy
• Hypoaldosterone
• Post obstructive diuresis
• CSW: BNP

NORMAL HYPONATREMIA
 Hyponatremia
Hypovolemia
Salt loss > water loss

Extrarenal loss Renal loss

UNa - Low UNa - High

Uspgr – High Uspgr – 1.010
UO – Low UO - High

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
Lab: Na 115, K 3.5, Cl 80, CO2 18
หลังได้ 3%NaCl 48 ml in 2 hr
• Na 121 K 3.5 Cl 88 CO2 20
• BUN 10 Cr 0.3
• ตรวจร่างกายพบ mild dehydration
จงคํานวณ IV fluid ในผู้ป่วยรายนี้
ให้ IV เป็ น…………..iv drip……….cc/hr
 1. ผป.เด็กอายุ 6 เดือน นํา้ หนัก 8 กิโลกรัม 3 วัน ก่อนมา รพ.
ท้องเสียวันละ 10 ครั้ง กินได้น้อย
Lab: Na 115, K 3.5, Cl 80, CO2 18
หลังได้ 3%NaCl 48 ml in 2 hr
• Na 121 K 3.5 Cl 88 CO2 20
• BUN 10 Cr 0.3
• ตรวจร่างกายพบ mild dehydration
จงคํานวณ IV fluid ในผู้ป่วยรายนี้
ให้ IV เป็ น…………..iv drip……….cc/hr
How to correct Na 121 125 and correct mild dehydration
 Hyponatremic Dehydration

Add water deficit

+
water maintenance
+
Ongoing water loss

Add sodium deficit

+
sodium maintenance
+
NORMAL HYPONATREMIA Ongoing Na loss
 Hyponatremic Dehydration

Add water deficit Acute

+ • ECF deficit 80% of water deficit
water maintenance • Na 145 mEq/L in normal ECF
+ Na def in ECF = Water deficit x 80% x 145
Ongoing water loss (L)

Na deficit in
ECF fluid deficit
Na deficit making
patient hyponatremia Na x 0.6 x BW

+
sodium maintenance
+
NORMAL HYPONATREMIA Ongoing Na loss
Hyponatremic Dehydration
Extrarenal loss

• %deficit x 10 x BW
Add water deficit • Weight loss
+
Holiday
water maintenance Segar
+
ORS/LRS/
Ongoing water loss NSS/2

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

+
sodium maintenance 3mEq/kg
+
Ongoing Na loss ORS/LRS/
NSS/2
Child BW 8 kg. acute diarrhea with mild dehydration with
serum Na = 121 mEq/L
Extrarenal loss

• %deficit x 10 x BW
• Weight loss
5 x 10 x 8 = 400

Holiday 100 x 8 = 800

Segar

ORS/LRS/
NSS/2

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
3mEq/kg 3 x 8 = 24
ORS/LRS/
NSS/2
 Hyponatremic Dehydration
Extrarenal loss

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

ORS/LRS/
NSS/2

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 94.4 mEq
3mEq/kg 3 x 8 = 24
ORS/LRS/
NSS/2
 Hyponatremic Dehydration

5 x 10 x 8 = 400
1200 cc
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
Case 2
 Question
• ผป.เด็กอายุ 1 เดือน นํา้ หนัก 4 กิโลกรัม มีอาการปั สสาวะไม่พงุ่ ไหล
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
Dx: Posterior urethral valve
 Question
• NPO, IV fluid: 5%D/N/5 drip 16 cc/hr

• After urinary catheter insertion, patient develops

polyuria. Urine output 30 cc/hr

• 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
 Management
• Rx shock:
0.9%NaCl/ LR/ Acetar 20 cc/kg IV rapidly

• Rx: post obstructive diuresis

TO MAINTAIN TBW: CONCEPT
• Intake = Output
• Intake = (Lung + Skin) + (Urine)
• Maintenance (Holliday-Segar)
= (Lung + Skin) + (Urine)
Hyponatremic Dehydration
Extrarenal loss Renal loss

• %deficit x 10 x BW
Add water deficit • Weight loss
+
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
• Rx: post obstructive diuresis
Fluid = IWL + deficit + UO
ISL = 300-500 x (BSA)

Body surface area (BSA)

√ W (kg) x H (cm)
3600

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

Mod to severe
10% x 10 x BW
= 400 cc
 Management
• Rx: post obstructive diuresis
Fluid = IWL + UO
= 120 + deficit(400) + UO (cc/cc)

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

water N/2 base on urine electrolyte

Add Na deficit
1. ∆Na x 0.6 x BW
2. Na loss in ECF deficit
= 145 x deficit volume x 80%
 Management
• Rx: post obstructive diuresis
Fluid = IWL + UO
= 120 +deficit(400) + UO (cc/cc)

water N/2 base on urine electrolyte

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

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

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
2. Na loss in ECF deficit
= 145 x deficit volume x 80%
= 145 x 0.4 x 80%
= 46.4 mEq
 Management
• Rx: post obstructive diuresis
Fluid = IWL + deficit + UO
= 520 + UO (cc/cc)

water N/2 base on urine electrolyte

Add Na deficit
= 70 mEq 520 70 mEq
1000  70 x1000 = 134 mEq
520
 Management
• Rx: post obstructive diuresis
Fluid = IWL + deficit + UO
= 520 + UO (cc/cc)

5%D/NSS NSS/2
30 cc/hr
22 cc/hr Depend on UO
 Management
• Rx: post obstructive diuresis
Fluid = IWL + deficit + UO
= 520 + UO (cc/cc)

5%D/NSS NSS/2
NSS/2
30 cc/hr
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
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
True hyponatremia
Hypervolumic hyponatremia
Salt & water excess
(hypervolemic)

Decrease effective
renal blood flow Renal failure
•Heart failure
•Nephrotic
UNa - High
UNa - Low Uspgr – 1.010
Uspgr – High UO - Low
UO - Low

• Rx: Fluid & salt restriction : ISL

NORMAL HYPONATREMIA
• Diuretic : Furosemide
 3%NaCl?
• Symptom depends on
– concentration not volume
– Duration: Acute or Chronic
• To raise Na conc
– 3%NaCl
– Free water loss

Which one is faster??

NORMAL HYPONATREMIA
Maintenance fluid? : Restrict water and salt

Urine

Lungs
ISL
Skin
Maintenance fluid
(Holliday-Segar)

INTAKE OUTPUT
Maintenance fluid? : Restrict water and salt
output > intake 10%DW 8 ml/hr
ISL = ISL Glucose
(to prevent hypoglycemia)
Na?
UO Vol = 400 (4BW + 7)
BW + 90
• Na = 0
(Negative • DW
= 400 (4(10) + 7) %Glucose ?
balance)
10 + 90 • Calculate GIR = 1-2
= 188 ml/day • GIR = % x rate
= 8 ml/hr 6 x BW
• % = 6 x BW(10) x GIR(1.5)
rate(8)
• Solute clearance to remove Na excess • = 10
• Free water clearance to increase Na conc

NORMAL HYPONATREMIA
 Free Water Excess
After 3%NaCl : 115  120

FWE = TBW x (1 – Actual Na)

Designed Na
= 0.6 x 10 (1- 120)
125
= 0.24 L
= 240 ml.
 Free water excess
V1 – V2 = free water excess
V2 = V1 – free water excess

C1V1 = C2V2
actual Na(V1) = designed Na((V1)-FWE)
Actual Na(V1) = V1 - FWE
designed Na
FWE = V1 – Actual Na (V1)
designed Na
FWE = V1(1 – Actual Na )
designed Na
FWE = 0.6 x BW(1 – Actual Na )
designed Na
Maintenance fluid? : Restrict water and salt
output > intake 10%DW 8 ml/hr
ISL = ISL Glucose
(to prevent hypoglycemia)
Na?
UO Vol = 400 (4BW + 7)
BW + 90
• Na = 0
(Negative • DW
= 400 (4(10) + 7) %Glucose ?
balance)
10 + 90 • Calculate GIR = 1-2
= 188 ml/day • GIR = % x rate
= 8 ml/hr 6 x BW
• % = 6 x BW(10) x GIR(1.5)
rate(8)
• Solute clearance to remove Na excess • = 10
• Free water clearance to increase Na conc
= 240 ml.
NORMAL HYPONATREMIA • Furosemide
• Dialysis
 ��
�
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
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� ให้เมื่อ acute

..............
2. IV �ç�č ę� 10%DW rate �ć ��
�ð............ ĕð� 8
........cc/hr
3. � �ððff � ë���fig bfi
ď� ď (�� đê�g ċff Na)
�
Furosemide
3.1 ............................
Dialysis
3.2 ............................
4. b �
� �ð�ĕ � ��
�
êđď�negative balance �ć ��ǽ Pure water 240 ml
Case 4
 ��
�
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

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
ADH

HYPONATREMIA

BLOOD
 SIADH
ADH

HIGH URINE SODIUM

URINE Na

Na
ทําไม SIADH จึงจัดอยูใ่ นกลุม่ Euvolemia ??
ทําไม ไม่บวม ??
CLINICAL EUVOLEMIA
Activate ANP  Excrete water & salt
ADH Inhibit RAAS

BLOOD
Euvolumic hyponatremia
water excess + salt loss
Euvolemia

High ADH
= Uosm

UNa - High
Uspgr – High
UO - low

NORMAL HYPONATREMIA
Euvolumic hyponatremia
water excess + salt loss
Euvolemia

High ADH
= Uosm
Eg. Intake: solute 400 mOsm
water 2000 mL
Urine osm should < 200 mOsm/L
(SIADH) if the lowest urine osm
= 250 mOsm/L
Free water balance = + 400
NORMAL HYPONATREMIA
Causes of SIADH
 ��
�
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

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)

24 hr ถัดมา
Uspgr = 1.020
Uosm = 600
• Intake of water 1000 ml 600  1 L
600  1000 ml
• solute 154 mosm 154  1000 x 154/600
• Output of water 250 ml as insensible and GI losses
507
257 ml as urine (1000 x 154/600)

• •Netbalance + 493 ml of freewater

 ดมา Na ของผูป้ ่ วยสามารถคิดได้ดงั นี้
อีก 24 ชัวโมงถั
่
• C1V1 = C2V2

• TBW (V1) was 6 liters (0.6 x 10)

• (V2) = 6.493 liters ( 6000 ml + 493 ml of freewater)

• 120 x 6 = [Na] x 6.493

• [Na] = 110 mEq/l

ถ้า restricted to ISL with NSS
• Intake of water 250 ml

• solute 75 mosm

• Output of water 250 ml as insensible and GI losses

• 125 ml as urine (1000 x 75/600)

• •Netbalance: -125 ml of freewater.

• C1V1 = C2V2
• TBW was 6 liters

• will be 5.875liters

(netbalance - 125mlof freewater)

• •120 x 6 = [Na] x 5.875

• •[Na] = 122 mEq/liter after 24 hr.

• ถ้า restricted to ISL with NSS
• •Intake of water 250 ml

• •Intake of solute 75 mosm

• Output of water 250 ml as insensible and GI

losses

• 125 ml as urine (1000 x 75/600)

• •Netbalance: - 125 ml of freewater.

 SIADH
• Keep negative Balance: Promote free water Clearance by
1. Fluid restriction:
– ISL
– 50%MT
2. Increase Solute Intake:
– Salt supplement: Hypertonic Saline or NaCl tablet, high salt diet
– High Protein diet
3. Decrease urine osmolality : ADH antagonist
– Diuretic: Furosemide
– V2R antagonist
– Lithium
 ��
�
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

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
 How to calculation
Intake • Output
• Restrict fluid to ISL 1. FWE = TBW x (1 – Actual Na)
• = 500 x BSA Designed Na
= 0.6 x 10 (1- 120)
• = 500 x 4BW + 7
125
• BW+ 90 = 0.24 L
• = 235 ml = 240 ml.
2. ISL
 ��
�
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

a��ĕ ���ððff
� ë�

1. �ĕ �total volume �� ç�� 235 ml

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 240 ml
 How to calculation
Intake • Output
• ISL = 235 ml 1. FWE = 240 ml.
(negative balance)
2. ISL

If we don’t want to furosemide to decrease urine osmolarity

Urine output = 240 ml (Na 120  125)
Urine osm = 600 mosm/L means 1000 ml needs solute 600 mosm
Urine output 240 ml needs solute intake = 600 x 240
1000
= 144 mOsm
Restrict fluid intake to ISL = 235 ml with solute intake = 144 mOsm
 How to calculation
Intake • Output
• ISL = 235 ml 1. FWE = 240 ml.
(negative balance)
• Need solute 144 mosm
2. ISL
ใช้ NSS ได้หรือไม่ ?
NSS 1000 ml มี = 308 mosm
แต่เราต้องการ 144 mosm
Intake ISL 235 ml = 308 x 235
1000 แสดงว่า NSS มี osm ทีไ่ ม่พอ
= 72.4 mosm
 How to calculation
Intake • Output
• ISL = 235 ml FWE = 240 ml.
(negative balance)
• Need solute 144 mosm
144 = 1028 (X (L)) + 308 (0.235 - X)(L)
ใช้ NSS ร่วมกับ 3%NaCl? (mOsm) (mOsm/L) (mOsm/L)

NSS 1000 ml มี = 308 mOsm/L 144 = 1028X + 72.38 - 308X

3%NaCl 1000 ml มี = 1028 mOsm/L (mOsm) (mOsm) (mOsm) (mOsm)

144 - 72.38 = 1028X - 308X

Vol รวม(NSS + 3%NaCl) = 235 ml
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.
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�� 235 ml

êđ�ć ��ĕð�.............cc
ǽ�êđę� 10%DNSS 135 ml/day + 3%NaCl 100 ml/day
�ð.............................................
2. � �ððff � ë���fi g bfi
ď� ď
Furosemide
2.1.................
Tolvaptan
2.2..................
3. b �
� �ð�ĕ � ��ç��
êđď�negative balance………….cc 240 ml
 How to calculation
Intake • Output
• ISL = 235 ml FWE = 240 ml.
(negative balance)
• Need solute 144 mosm
Noted that
ใช้ เกลือแกง ใส่ใน BD? 1. if urine osm > 600 – 800 mOsm/L
restrict fluid to ISL with NSS is not
เกลือ 1 g มี Na = 17 mEq enough
เกลือ 1 g มี osm = 17 x 2 = 34 mOsm 2. Restrict fluid = restrict calories.
เชค osmolarity ของ BD สามารถใส่เกลือแกงใน 3. Furosemide or ADH antagonist helps
BD ที่ทานเพื่อได้ osm = 144 mosm to decrease urine osmolarity (easy to
ใน volume 235 ml/day manage intake)
 ��
�
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

a��ĕ ���ððff
� ë�

1. �ĕ �total volume �� ç�� 235 ml

êđ�ć ��ĕð�.............cc
ǽ�êđę� เกลือแกง + BD (increase BD conc) 144 osm
�ð.............................................
2. � �ððff � ë���fi g bfi
ď� ď
Furosemide
2.1.................
Tolvaptan
2.2..................
3. b �
� �ð�ĕ � ��ç��
êđď�negative balance………….cc 240 ml
 • This patient was cachexia.
• How can we improve his nutrition in SIADH status?