Acid-Base and Electrolytes » Department of Anesthesiology » College of Medicine

Hypernatremia

Hyponatremia

DKA

Acid-Base Disorders in the ICU

*Please take the quiz below the video to receive credit.

Objectives

Review the roles of the renal and respiratory system in acid-base homeostasis
Discuss simple steps in analyzing ABGs
Review acid-base disorders
Review anion gap and delta gap
Determine the appropriate treatment for specific acid-base disorders

Articles

Clinical Review: Acid-base abnormalities in the intensive care unit
Physiological Approach to Assessment of Acid-Base Disturbances

Lecture

Quiz

Acid-Base Disorders Quiz

Name*
First Last
1. Interpret this ABG: pH 7.27, PaCO2 53, PaO2 50, SaO2 79%, HCO3 24*
- a. Respiratory acidosis
- b. Respiratory alkalosis
- c. Metabolic acidosis
- d. Metabolic alkalosis
2. Interpret this ABG: pH 7.52, PaCO2 29, PaO2 100, SaO2 98%, HCO3 23*
- a. Respiratory acidosis
- b. Respiratory alkalosis
- c. Metabolic acidosis
- d. Metabolic alkylosis
3. Interpret this ABG: pH 7.18, PaCO2 44, PaO2 92, SaO2 95%, HCO3 16*
- a. Respiratory acidosis
- b. Respiratory alkalosis
- c. Metabolic acidosis
- d. Metabolic alkalosis
4. Interpret this ABG: pH 7.30, PaCO2 30, PaO2 68, SaO2 92%, HCO3 14*
- a. Partially compensated respiratory acidosis
- b. Partially compensated metabolic acidosis
- c. Mixed metabolic acidosis and and metabolic alkalosis
- d. Mixed respiratory acidosis and metabolic acidosis
5. Interpret this ABG: pH 7.60, PaCO2 56, PaO2 92, SaO2 98%, HCO3 35*
- a. Partially compensated respiratory alkalosis
- b. Partially compensated metabolic alkalosis
- c. Mixed metabolic alkalosis and metabolic acidosis
- d. Mixed respiratory alkalosis and metabolic acidosis
6. Interpret this ABG: pH 7.38, PaCO2 62, PaO2 93, SaO2 97%, HCO3 35*
- a. Fully compensated respiratory acidosos
- b. Fully compensated metabolic acidosis
- c. Mixed metabolic alkalosis and metabolic acidosis
- d. Mixed respiratory alkalosis and metabolic acidosis
7. Immediately postoperatively, an ABG returns with the following values: pH 7.26, pCO2 60mmHg, and a PO2 62 mmHg. The patient is currently mechanically ventilated with rate of 10, Vt 400cc, PEEP 0cmH20, FiO2 40%, I:E ratio of 1:3 and currently with a SaO2 of 97%. What next steps should be taken to correct the acid/base abnormality?*
- a. Increase rate or tidal volume to increase minute ventilation
- b. Increase the PEEP or FiO2
- c. Correct fluid deficit
- d. Give 1amp of sodium bicarbonate
- e. Both A and D
8. A patient is admitted to the ICU meeting criteria for severe sepsis. After being intubated and placed on mechanical ventilation, the initial ABG drawn returns with the following values: pH 7.20, pCO2 50 mmHg, and PO2 80mmHg. SaO2 is 95% with the current ventilator settings: RR 14, Vt400cc, PEEP 5cm H2O, FiO2 40%, with an I:E ratio of 1:2. What next steps should be taken to correct the acid/base abnormality?*
- a. Increase rate or tidal volume to increase minute ventilation
- b. Increase the PEEP or FiO2
- c. Correct fluid deficit
- d. Give 1amp of sodium bicarbonate
- e. Both A and C
9. A patient is admitted the ICU meeting criteria for severe sepsis and requires being placed on mechanical ventilation. Overnight, pulmonary function continues to worsen and, the next day, meets criteria for ARDS. The most recent ABG shows the following values: pH 7.20, pCO2 55mmHg, and a PO2 50mmHg. SaO2 is 85% on the following ventilator settings: RR 14, Vt 500cc, PEEP 5cm H2O, FiO2 70%,, with a I:E ratio of 1:2. Peak airway pressure is 55. Interpret this ABG Interpretation:*
- a. Partially compensated respiratory acidosis
- b. Partially compensated metabolic acidosis
- c. Mixed respiratory acidosis and metabolic acidosis
- d. Mixed metabolic acidosis and and metabolic alkalosis
10. A patient with severe COPD is being weaned from mechanical ventilation. His most recent ABG shows the following values: pH 7.35, pCO2 65mmHg, and pO2 78mmHg. His O2 saturation is 96% on the following ventilator settings: PS 12, PEEP 5cm H2O, FiO2 40%. What ventilator change or changes should be made?*
- a. Add a rate or increase pressure support to increase minute ventilation
- b. Increase the PEEP and decrease FiO2
- c. Add bicarbonate to maintenance fluids
- d. Both A and D
- e. No changes should be made

Hypernatremia

*Please take the quiz below the video to receive credit.

Objectives

Understand the causes of hypernatremia and normal physiology of sodium regulation
Describe the appropriate workup of hypernatremia and polyuria
Discuss management strategies for hypernatremia

Articles

Hypernatremia in Critically Ill Patients
Hypernatremia

Lecture

Quiz

Hypernatremia

Name*
First Last
1. When evaluating a patient with hypernatremia, what test would allow one to differentiate between renal causes and non-renal causes?*
- a. Urine Osmolality
- b. Plasma Osmolality
- c. Renal Ultrasound
- d. Urine Urea
- e. Plasma Urea
2. Causes of central diabetes insipidus include all of the following except:*
- a. Pituitary surgery
- b. Head trauma
- c. CVA
- d. Infections
- e. Hypercalciumia
3. Generally, how much of the free water deficit should be replaced in the first 24hrs*
- a. 25%
- b. 30%
- c. 50%
- d. 75%
- e. 100%
4. In a polyuric patient whose UOP is greater than 3L/day, an osmolar excretion rate greater than 1000mOsm/day would indicate which of the following as a possible cause of the polyuria?*
- a. Osmotic Diuresis
- b. Diabetes Insipidus
- c. Psychogenic Polydipsia
- d. Polyuric AKI
5. All of the following are listed as definite causes of drug induced DI except:*
- a. Amphotericin B
- b. Dopamine
- c. Lithium
- d. Oflaxacin
- e. Linezolid
6. An 80 y/o female who lives alone fell and fractured her hip and was not found until 2 days later. Exam showes skin tenting, dry mucous membranes and orthostatic hypotension. Na 152, K 5.4, Cl 112, HCO3 31, Cr 2.3. Urine Na 8, Urine Osm 820. What is the cause of her hypernatremia?*
- a. Insensible losses
- b. Nephrogenic diabetes insipidus
- c. Osmotic diuresis
- d. Increased sodium intake
7. Which would be the most appropriate choice as the first step in managing her hypernatremia*
- a. D5W infusion
- b. NS infusion
- c. Furosemide
- d. DDAVP
8. A 22 y/o male with bipolar disorder is admitted with epigastric pain and made NPO pending the results of GI workup. The next morning his labs are as follows. Na 149, K 4, Cl 115, HCO3 28, Glucose 160, BUN 25, Cr 1.0, Plasma osm 300, 24hr UOP 3L, Urine osm 307, What is the likely cause of his hypernatremia?*
- a. Insensible losses
- b. Diabetes insipidus
- c. Osmotic diuresis
- d. Increased Sodium intake
9. What underlying factor must be present for hypernatremia to occur from extrarenal processes?*
- a. Decreased water intake
- b. Increased sodium intake
- c. Increase in plasma osmolality
- d. Underlying renal dysfunction
10. After calculating a hypernatremic patient’s free water deficit, they are started on a D5W infusion. 2 Hours later. Urine Na 70, Urine K 30, plasma Na 152, Plasma K 5.0. Which of the following is mostly likely true?*
- a. The infusion should be increased to account for free water loss in the urine
- b. The infusion should be decreased to account for lack of free water lost in the urine
- c. The D5W infusion should be changed to normal saline
- d. The D5W infusion should remain the same

Hyponatremia

*Please take the quiz below the video to receive credit.

Objectives

Define osmolality and osmolarity and understand how they relate to sodium regulation physiology in the body
Understand physiological effects of changes in serum sodium
Discuss the appropriate workup and management strategies for hyponatremia

Articles

Management of Hyponatremia in the ICU
41st Critical Care Congress Review

Lecture

Quiz

Hyponatremia

Name*
First Last
1. True or False: Under normal physiological circumstances, an increase in serum osmolality will be accompanied by an increase in urine osmolality*
- True
- False
2. Hyperosmolar hyponatremia may be caused by which of the following?*
- a. Mannitol
- b. Glucose
- c. Hyperkalemia
- d. Inability to reabsorb sodium in the kidneys
- e. A and B
- f. A and D
3. Which best describes SIADH?*
- a. Euvolemic, Hypoosmolar, hyponatremia
- b. Hypovolemic, Hypoosmolar, hyponatremia
- c. Euvolemic, Hyperosmolar, hyponatremia
- d. Hypervolemic, Hypoosmolar, hyponatremia
- e. Hypovolemic, normo-osmolar, hyponatremia
4. A patient presents to the ICU with a Serum Na 130 and K 4.2, with a urine Na 180 and Urine K 120, Urine Urea 600, and Urine Osm 900. He s started on normal saline infusion for MIVF. What will be the likely effect on his serum sodium*
- a. No change
- b. Increase in serum sodium
- c. Decrease in serum sodium
5. A 70 yr old smoker presents with cough and hemoptysis. On exam he is euvolemic. CXR shows a solitary lung nodule. Serum Na 114, K 4.0, Cl 88, BUN 9, HCO3 24, Cr 0.8, Glucose 110. Urine shows a urine osm 650, urine Na 155, urine K 55. What is the likely cause of his hyponatremia?*
- a. Diabetes insipidus
- b. Nephrotic Syndrome
- c. Mineralocorticoid deficiency
- d. SIADH
- e. Cerebral salt wasting
6. A 70 yr old smoker presents with cough and hemoptysis. On exam he is euvolemic. CXR shows a solitary lung nodule. Serum Na 114, K 4.0, Cl 88, BUN 9, HCO3 24, Cr 0.8, Glucose 110. Urine shows a urine osm 650, urine Na 155, urine K 55. What would be the most appropriate way to manage his hyponatremia if free water restriction proves ineffective?*
- a. Isotonic saline infusion
- b. Hypertonic saline infusion
- c. DDAVP
- d. Hydrocortisone
7. All cases of hypoosmolar hyponatremia are characterized by which of the following?*
- a. An elevated level of ADH
- b. Increased water intake
- c. Increased urine sodium
- d. Decrease in serum BUN
8. Which of the following is considered a ineffective osmole in the urine*
- a. Na
- b. K
- c. Urea
- d. B and C
- e. None of the above are considered ineffective osmoles
9. Which of the following is true concerning the rate of serum sodium correction?*
- a. Should be limited to 1-2mEq/L per hour for acute or symptomatic hyponatremia
- b. Should be limited to 0.5mEq/L per hour for chronic hyponatremia
- c. Should not exceed a change of 12mEq/L in first day
- d. A and C are true
- e. All the above are true
10. A 70 y/o F presents to the clinic with complaint of generalized weakness and fatigue. She appears euvolemic on exam and labs reveal the following: Plasma Osm 270 Plasma Na 122, K 4.3, Cl 110, BUN 22, Cr 0.8, Glucose 114, Urine Osm 130, urine sodium 102, urine K 50. What is the likely cause of her hyponatremia*
- a. Tea and toast or Beer potomania syndrome
- b. Polydipsia
- c. SIADH
- d. Cerebral salt wasting
- e. Diuretics

Diabetic Ketoacidosis & Hyperglycemic and Hyperosmolar State

*Please take the quiz below the video to receive credit.

Lecture

Quiz

"*" indicates required fields

Name*

First Last

1. Which of the following confirms diagnosis of DKA?*

a. They are non-identifiable, erratic, wavy baseline

b. Hyperglycemia

c. Tachycardia

d. Leukocytosis

2. Which of the following crystalloid solutions is closest to a physiological state?*

a. FFP

b. Lactated ringers

c. Normal saline

d. Plasmalyte

3. Which of the following is a contraindication to insulin therapy in DKA?*

a. Concominante dextrose infusion

b. Potassium 2.8

c. pH 7.2

d. Glucose 220

4. Which of the following is not an effect of insulin on the body?*

a. Hyperglycemia

b. Decreased lipolysis

c. Decreased gluconeogenesis

d. Decreased muscle breakdown

5. The onset of DKA is usually within hours after cessation of insulin.*

a. True

b. False

6. The onset of HHS is usually within hours after cessation of insulin.*

a. True

b. False

7. Which of the following is NOT true regarding HHS?*

a. It has a slower onset than DKA

b. It never is associated with ketone production

c. It usually is associated with higher glucoses

d. It usually is associated with more volume depletion

8. While in the resuscitative phase of DKA, a patient has a potassium of 4.9 and is started on an insulin infusion. Which of the following is the best intervention?*

a. Replace potassium

b. Administer bicarb

c. Start dialysis

d. Diuresis

9. Phosphorous repletion is necessary, as it is necessary for ATP production.*

a. True

b. False

10. Euglycemic DKA is common with which of the following medications?*

a. SGLT2 inhibitors

b. ACE inhibitors

c. Diuretics

d. Beta blockers