I hope my videos will be helpful. Regarding the above video on hypernat. - when it comes to taking exams, as I mention at the end, most doctors use calculations of free water deficit to calculation fluid repletion rates. I think such calculations are unnecessary and not more accuate, but it could give a slightly different answer than the method I show here. It's prob not a clinically relevant difference, but might make a difference if the person grading you uses the other method. Good luck!
I hope you see this. What if patients dehydration is caused by reduced intake there by lost in urine eg if patient is stuck in a desert or elderly patient with decreased intake, what will be the choice of fluid? Also you mentioned ongoing loss, what about insensible loss? Do you add anything for insensible loss? If so how much do you add.
There is a exam called YDUS for anesthesia sub specialty in Turkey which on Saturday and there will be a lot of questions which you have mentioned in all the videos
In shock/septic hypernatremic states, what about using Ringers Lactate for correcting both hypotension, hypovolemia and hypernatremia (as it has leaser Na than Normal saline) ?
Hello Dr Eric I am studying this, and the exams asked me about the method in which is necessary to calculate free water deficit, in which I cannot understand how to calculate the solute deficit. They say you should give the 24h maintenance + the entire solute deficit + 1/2 of the free water deficit in the first 24h. Then I looked for your videos, which are outstanding, trying to find the explanation; however, you came with other method and during your explanation of the first example you use a volume of 5 to be divided by - 2.2 mEq/L. I do not know what is the reason to take that volume of 5, could you explain me this please? thank you in advance.
Thank you again for your insightful video! Two questions: 1) in your second example, aren't you actually correcting the patient's sodium level with 267 mL/hr of D5W? Wouldn't that correct his sodium level by more then 10 meq/L and thus risk cerebral edema? I wonder if it wouldn't be safer to give saline solution to account for the additional fluid loss 2) why are you calculating the rate of infusion per 12 h and not per 24 hours? Thanks a lot
nice video Dr Eric! I am an ICU registrar facing electrolyte imbalances everyday... theoretically this sounds great... but in the ICU, most of my patients either have an Ischaemic heart disease/Dialated Cardiomyopathy/Valvular diseases/Oliguria(unrelated to just hypovolemia)/septic cardiomypathy etc... now it would be impossible to transfuse them with such huge amounts of fluids even though the equations show that it is required. you being a clinician yourself must be facing these problems too... how do you go about it? thanks
+Darshan Jani Thanks for your comment and great question. In the population of patients I encounter, I honestly don't see too many examples of patients with severe cardiomyopathy and severe hypernatremia. The majority of hypernatremic patients I see are elderly patients with dementia who got just ill enough to not keep up with their fluid intake, but not ill enough for it to become immediately apparent to their caregiver/nursing facility that there was something wrong. In other words, my experience relevant to your question isn't as large as would be optimal in order to answer it. With that disclaimer out of the way, I think the approach would be almost the same as a patient without cardiac disease. If a patient is hypernatremic and volume depleted, they may still require the same amount of volume as estimated by the formulas, but there is less margin of error for overshooting. In other words, the formulas are just estimates. Most patients are fine if the estimate is too high, but patients with bad CHF or bad baseline renal disease may not be. To account for this, I would reduce the rate at which the fluid is infused, with an initial estimate of total volume to infuse being the same as usual; therefore, the total duration over which the fluid is infused will be increased. With frequent rechecks of the patient's exam and of the serum sodium, you should be able to still correct the hypernatremia without ending up in pulmonary edema - it will just take longer to do so. And always place the greatest emphasis on the most critical derangement. So if the patient is comatose from a sodium of 170, fixing the sodium level takes priority. But once the patient's mental status is near baseline, then priority might shift towards not causing iatrogenic pulmonary edema. All of the above assumes that the patient has already been ruled out from having hypervolemic hypernatremia (which is often iatrogenic), which would be my first thought if the patient was starting off both hypernatremic and already in decompensated congestive failure.
+Strong Medicine thank you for the brief answer!!! what really bothers me as an ICU trainee, is that most patients who present with Hypernatremia are, as you said old aged patients with multiple coexisting diseases like long standing diabetes and hypertension... and most of them in our part of the world have ischaemic heart disease... I agree that hypovolemic hyponatremia would initially permit the infusion of high doses of fluids as they are fluid responsive on the steeper part of the frank starling curve... but what happens is, that there is a time when there are other sick patients who divert your attention and at the same time the patient starts getting on the flat portion of the curve, they decompensate so rapidly that you have no other options but to either diurese them (which would be counter productive given the uncorrected Na+) or intubate them... and unfortunately, despite following VAP bundles strictly, the rates of VAP in our ICU's are very high in old aged/diabetics... and recovery from that is very difficult for these groups of patients... in younger patients with a competent immune system it would be easier to intubate and mechanically ventilate them while correction so you don't have to worry about pulmonary edema... this is also often the case in elderly relatively immune compromised patients who present with DKA... but i guess its not something that can be modified easily and we have to deal with it...
Exactly what I was looking for. Theoretically these calculations look good on paper but clinically you gotta be careful and use your judgement based on the clinical condition of the patient. And also you need to take into account the volume of other medications and the diluting agent you are using.
I hope you see this. What if patients dehydration is caused by reduced intake there by lost in urine eg if patient is stuck in a desert or elderly patient with decreased intake, what will be the choice of fluid? Also you mentioned ongoing loss, what about insensible loss? Do you add anything for insensible loss? If so how much do you add.
Dr Strong,thanks for the wonderful videoes.I have a doubt about your second example-can u attempt to correct hypernatremia with free water through ryles tube?And if yes,calculations remain same?
I would not recommend correcting symptomatic hypernatremia via NG (Ryles) tube unless there was a reason the patient could not receive IV fluids. (I can dream up a scenario in which a patient could get an NG tube but not a peripheral IV, but I've never personally seen such a scenario in real life) For the patient with mild, asymptomatic hypertremia, who isn't in the hospital already or who prefers not to have an IV (e.g. a stable but chronically ill patient in a nursing home who prefers to avoid hospital admissions), I would consider strong encouragement of increasing oral water intake prior to IV correction. The major limitation to this approach is whether the patient will be able to sufficiently adhere to the recommendation. And if attempting to correct mild hypernatremia by mouth, I personally would not bother with the calculations.
In the equasion is "Lean Body Weight". So I guess if the patient is 100kg and 160cm you have to calculate with roughly 60kg. Am I right? Thanks 4 the video :-)
DUde, you are the best.... I watch this over and over, and it never gets old.... Love the music (baroque?). Cheers!
This was greatly helpful. Thank you Dr Eric for all your efforts.
I hope my videos will be helpful. Regarding the above video on hypernat. - when it comes to taking exams, as I mention at the end, most doctors use calculations of free water deficit to calculation fluid repletion rates. I think such calculations are unnecessary and not more accuate, but it could give a slightly different answer than the method I show here. It's prob not a clinically relevant difference, but might make a difference if the person grading you uses the other method. Good luck!
I hope you see this. What if patients dehydration is caused by reduced intake there by lost in urine eg if patient is stuck in a desert or elderly patient with decreased intake, what will be the choice of fluid? Also you mentioned ongoing loss, what about insensible loss? Do you add anything for insensible loss? If so how much do you add.
This adrogue mafias formula for 12 hr or 24 hr???
I just discovered these videos. They're amazing. You've done amazing work here. I'm a site director in northern California and lean on your videos.
Thanks Dr.Eric.you are the best teacher.
Thank you Dr Strong. It is simple to understand , and practical.
Thanks a lot. I am looking forward to see next video.
many thanks 4 you.really it is very helpful.
Thanks for the video Doc :)
Thank you!
There is a exam called YDUS for anesthesia sub specialty in Turkey which on Saturday and there will be a lot of questions which you have mentioned in all the videos
In shock/septic hypernatremic states, what about using Ringers Lactate for correcting both hypotension, hypovolemia and hypernatremia (as it has leaser Na than Normal saline) ?
Hello Dr Eric
I am studying this, and the exams asked me about the method in which is necessary to calculate free water deficit, in which I cannot understand how to calculate the solute deficit. They say you should give the 24h maintenance + the entire solute deficit + 1/2 of the free water deficit in the first 24h.
Then I looked for your videos, which are outstanding, trying to find the explanation; however, you came with other method and during your explanation of the first example you use a volume of 5 to be divided by - 2.2 mEq/L. I do not know what is the reason to take that volume of 5, could you explain me this please? thank you in advance.
Thank you again for your insightful video! Two questions: 1) in your second example, aren't you actually correcting the patient's sodium level with 267 mL/hr of D5W? Wouldn't that correct his sodium level by more then 10 meq/L and thus risk cerebral edema? I wonder if it wouldn't be safer to give saline solution to account for the additional fluid loss 2) why are you calculating the rate of infusion per 12 h and not per 24 hours?
Thanks a lot
1) in second example he prefers Normal Saline over D5W.
2) yes ideally it should be 10meq over 24 hours (which is 5meq for 12hours)
nice video Dr Eric!
I am an ICU registrar facing electrolyte imbalances everyday... theoretically this sounds great... but in the ICU, most of my patients either have an Ischaemic heart disease/Dialated Cardiomyopathy/Valvular diseases/Oliguria(unrelated to just hypovolemia)/septic cardiomypathy etc...
now it would be impossible to transfuse them with such huge amounts of fluids even though the equations show that it is required. you being a clinician yourself must be facing these problems too...
how do you go about it?
thanks
+Darshan Jani Thanks for your comment and great question. In the population of patients I encounter, I honestly don't see too many examples of patients with severe cardiomyopathy and severe hypernatremia. The majority of hypernatremic patients I see are elderly patients with dementia who got just ill enough to not keep up with their fluid intake, but not ill enough for it to become immediately apparent to their caregiver/nursing facility that there was something wrong. In other words, my experience relevant to your question isn't as large as would be optimal in order to answer it.
With that disclaimer out of the way, I think the approach would be almost the same as a patient without cardiac disease. If a patient is hypernatremic and volume depleted, they may still require the same amount of volume as estimated by the formulas, but there is less margin of error for overshooting. In other words, the formulas are just estimates. Most patients are fine if the estimate is too high, but patients with bad CHF or bad baseline renal disease may not be. To account for this, I would reduce the rate at which the fluid is infused, with an initial estimate of total volume to infuse being the same as usual; therefore, the total duration over which the fluid is infused will be increased. With frequent rechecks of the patient's exam and of the serum sodium, you should be able to still correct the hypernatremia without ending up in pulmonary edema - it will just take longer to do so.
And always place the greatest emphasis on the most critical derangement. So if the patient is comatose from a sodium of 170, fixing the sodium level takes priority. But once the patient's mental status is near baseline, then priority might shift towards not causing iatrogenic pulmonary edema.
All of the above assumes that the patient has already been ruled out from having hypervolemic hypernatremia (which is often iatrogenic), which would be my first thought if the patient was starting off both hypernatremic and already in decompensated congestive failure.
+Strong Medicine thank you for the brief answer!!!
what really bothers me as an ICU trainee, is that most patients who present with Hypernatremia are, as you said old aged patients with multiple coexisting diseases like long standing diabetes and hypertension... and most of them in our part of the world have ischaemic heart disease... I agree that hypovolemic hyponatremia would initially permit the infusion of high doses of fluids as they are fluid responsive on the steeper part of the frank starling curve...
but what happens is, that there is a time when there are other sick patients who divert your attention and at the same time the patient starts getting on the flat portion of the curve, they decompensate so rapidly that you have no other options but to either diurese them (which would be counter productive given the uncorrected Na+) or intubate them... and unfortunately, despite following VAP bundles strictly, the rates of VAP in our ICU's are very high in old aged/diabetics... and recovery from that is very difficult for these groups of patients...
in younger patients with a competent immune system it would be easier to intubate and mechanically ventilate them while correction so you don't have to worry about pulmonary edema...
this is also often the case in elderly relatively immune compromised patients who present with DKA...
but i guess its not something that can be modified easily and we have to deal with it...
😊
Exactly what I was looking for.
Theoretically these calculations look good on paper but clinically you gotta be careful and use your judgement based on the clinical condition of the patient.
And also you need to take into account the volume of other medications and the diluting agent you are using.
I hope you see this. What if patients dehydration is caused by reduced intake there by lost in urine eg if patient is stuck in a desert or elderly patient with decreased intake, what will be the choice of fluid? Also you mentioned ongoing loss, what about insensible loss? Do you add anything for insensible loss? If so how much do you add.
Sir, what about the use of ringer lactate in the second example???
Would the rate of correction still be the same In the second example factoring in a possible AKI?
Dr Strong,thanks for the wonderful videoes.I have a doubt about your second example-can u attempt to correct hypernatremia with free water through ryles tube?And if yes,calculations remain same?
I would not recommend correcting symptomatic hypernatremia via NG (Ryles) tube unless there was a reason the patient could not receive IV fluids. (I can dream up a scenario in which a patient could get an NG tube but not a peripheral IV, but I've never personally seen such a scenario in real life)
For the patient with mild, asymptomatic hypertremia, who isn't in the hospital already or who prefers not to have an IV (e.g. a stable but chronically ill patient in a nursing home who prefers to avoid hospital admissions), I would consider strong encouragement of increasing oral water intake prior to IV correction. The major limitation to this approach is whether the patient will be able to sufficiently adhere to the recommendation. And if attempting to correct mild hypernatremia by mouth, I personally would not bother with the calculations.
How quickly would we correct the second patient's HyperNa if he had heart failure?
In the equasion is "Lean Body Weight". So I guess if the patient is 100kg and 160cm you have to calculate with roughly 60kg. Am I right? Thanks 4 the video :-)