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Drinking & Dehydration

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Presentation on theme: "Drinking & Dehydration"— Presentation transcript:

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Dehydration

Jul 21, 2014

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Dehydration. Department of Geriatric Medicine Edward Warren, MD, Chair Geriatrics, Carolinas Campus, February 2012. Past Medical History. Recent CHF( congestive heart failure) Left Ventricular Ejection Fraction of 20% Cor pulmonale HTN (hypertension)

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• congestive heart failure
• mental status change
• physical exam
• medical history

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Dehydration Department of Geriatric Medicine Edward Warren, MD, Chair Geriatrics, Carolinas Campus, February 2012

Past Medical History • Recent CHF( congestive heart failure) • Left Ventricular Ejection Fraction of 20% • Corpulmonale • HTN (hypertension) • S/P (status post) CVA( cerebrovascular accident • Alzheimer's dementia • COPD ( chronic obstructive pulmonary disease) • Pulmonary hypertension

Surgical History • Cholecystectomy • Cardiac Catheterization without abnormality on recent hospital admission • 4 vessel CABG ( coronary artery bypass graft) 5 years earlier

History of Present Illness 98 Year old white female with increasing lethargy and mental confusion over the past 2 days. Patient has recently returned from the hospital after being successfully treated for congestive heart failure. Nursing staff states that she has being doing well since her return and that she has been eating and sleeping well, but awakening due to nocturia.

Medications • Aspirin 81 mg - 1 tab po daily • Sildenafil 20 mg - 1 tab po tid • Furosemide 40 mg - 2 tabs po bid • KCl 40 meq - 1 tab po qd • Lisinopril 20 mg - 1 tab po qd • Fluticasone/salmeterol 500/50 - 1 puff bid

Review of Symptoms • Patient is poorly arousable and denies shortness of breath (SOB), chest pain ,or headache. In fact she states that she feels “OK”. Staff relates that patient has had no bowel movement today and that they’re not sure when she last voided.

Physical Exam • Vitals: T 98.2 P 90 and reg.-supine, P 115 standing R 24 and regular BP120/80 supine and 100/60 standing O2 Sat 88%( staff states that this is “normal for her”) Weight 70 Kg Height 152.4 cm • Heent: PERRLA, EOM equal bilaterally, sclerae slightly injected, buccal mucosa dry and tacky, Not erythematous and not injected. • Neck: neck veins flat , no JVD, bruit, nor lymphadenopathy. • Heart: increased rate with regular rhythm, No S3/ S4, no murmurs • Lungs: clear to auscultation and percussion. • Abdomen: Obese, BS present but decreased in all quadrants, No organomegaly • Extremities: No clubbing nor cyanosis. Trace pitting edema bilateral lower extremities • Skin: Dry, with widespread tenting, cap refill >3 sec • Neuropsych: patient is arousable to loud voice. Patient can answer simple questions but appears sleepy.

Case Question 1 The patient in the preceding case has a decreased level of consciousness. This is most likely due to • Myocardial infarction • Hypoxemia due to her CorPulmonale • Hyperkalemia • Dehydration • Congestive heart failure

Case Question 2 If this patients serum Creatinine is 2.0, what would be her rough estimate of GFR in ml/min ? a. 5.85 b. 15.65 c. 17.35 d. 20.85 e. 25.35

Case Question 3 This patient’s symptoms are due to hypovolemia and she has relatively normal renal function. Would you expect her to be FENa( Fractional Excretion of Sodium) to be a. Greater than 1% b. Less than 1%

Case Question 4 Which of her medications would you think most contributory to her current situation? a. Lisinopril b. Furosemide c. Fluticasone/salmeterol d. KCl e. Sildenafil

Case Question 5 Which of the following is most consistent in all parameters with dehydration in an elderly patient? a. Na 155,FENa < 1%, BUN 40, weight decreased b. Na 125,FENA > 1%, BUN 12.5, weight stable c. Na 155,FENa 4%, BUN 15, weight increased d. Na 125,FENA > 1%, BUN 10, weight unchanged e. Na 135,FENa > 1%, BUN 20, weight increased

Question Answers 1. Dehydration, “d”, is the answer. -An acute MI is not supported by any findings in the history such as chest tightness or dyspnea, and the coronaries were recently found to be OK. -Hypoxemia due to her corpulmonale and CHF is not the cause of the delirium because the hypoxia is mild at worst and it is said to be her usual state. -Hyperkalemia is not documented in the history at all. Even if it were there, it would not cause a mental status change. The dose of KCl is half of that indicated by the dose of furosemide. Still the lisinopril and renal failure could result in a high K. -CHF is unlikely with modest edema, no JVD, and clear lungs. 2. 17.35, “c” is the answer. Estimated creatinine clearance = [(140 - age) (weight in kg) (0.85 for female)] / [(72)(serum creatinine)] [(140 – 98)(70 kg)(0.85)] / [(72)(2 mg/dl)] = 17.35 • FENa is less than 1% in hypovolemia with normal renal function. This retains Na and water in the body to restore homeostasis. • The drug most responsible is furosemide (it is also a massive dose), “b”. The other listed medications would not do this, except for the lisinopril which does inhibit proper renal function.

Question Answers 5. “a”, Na 155,FENa < 1%, BUN 40, weight decreased is the correct answer. The Na is high due to difficulty in maintaining hydration in elderly. The FENa is low due to resorption of Na in the kidneys from the stimulus of hypovolemia. The BUN is elevated from prerenal azotemia. As the Na is resorbed, urea is resorbed with it passively. The weight is down due to water loss. Every pint lost is a pound.

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What is dehydration? - PowerPoint PPT Presentation

What is dehydration?

Dehydration occurs when the body loses more water than is taken in. it is often accompanied by disturbances in the body's mineral salt or electrolyte balance - especially disturbances in the concentrations of sodium and potassium. – powerpoint ppt presentation.

• WHAT IS DEHYDRATION?
• WHAT IS IT?
• Dehydration occurs when the body loses more water than is taken in. It is often accompanied by disturbances in the body's mineral salt or electrolyte balance - especially disturbances in the concentrations of sodium and potassium.  read more
• Mild dehydration is common and usually caused by not drinking enough fluids throughout the day. In children, diarrhoea is a common cause.  read more
• CONSEQUENCES
• A loss of body water equivalent to about 1 of body weight is normally compensated within 24 hours. Thirst stimulates drinking, so intake is increased and there is also a reduction in water loss by the kidneys. If losses are greater than this, reductions in physical and cognitive performance may occur and there may be some impairment of thermoregulation and cardiovascular function.  read more
• Dehydration occurs when the body loses more water than is taken in. It is often accompanied by disturbances in the body's mineral salt or electrolyte balance - especially disturbances in the concentrations of sodium and potassium.
• Under typical circumstances the body loses and needs to replace approximately 2 to 3 litres of water daily. Breathing, urinating, defecating, and perspiring all cause water losses that need to be replaced on a daily basis. If water is lost from the bloodstream, the body can compensate somewhat by shifting water from cells into the blood vessels, but this is a very short-term solution. If the lost water is not replenished, the body may suffer serious consequences.
• The body is able to monitor the amount of water it needs to function. The thirst mechanism signals the body to drink when the body water content is reduced. Hormones, including anti-diuretic hormone (ADH), work with the kidney to limit the amount of water lost in the urine when the body needs to conserve water. Water intake and output are highly variable but closely matched to less than 0.1 over an extended period through homeostatic control. Electrolyte intake and output are also closely linked, both to each other and to the hydration status.
• Failure to match intake and loss of water and minerals, especially sodium and potassium, may lead to dehydration. Depending on the ratio of water to electrolyte loss, dehydration can be classified as isotonic, hypertonic or hypotonic
• Is characterised by isotonic loss of both water and solutes from the extracellular fluid, that is when both water and sodium are lost in equivalent amounts, e.g. through vomiting, diarrhoea or through inadequate intake. There is no osmotic shift of water from the intracellular space to the extracellular space. This type of dehydration accounts for cases of dehydration in young children.
• In hypertonic dehydration water loss exceeds salt loss, that is when more water than sodium is lost (e.g. through inadequate water intake, excessive sweating, osmotic diuresis and diuretic drugs). This is characterised by an osmotic shift of water from the intracellular fluid to the extracellular fluid. This type of dehydration is more common in people who have diabetes, and it accounts for approximately 10 to 20 percent of all paediatric cases of dehydration with diarrhoea.
• In hypotonic dehydration more sodium than water is lost, e.g. in some instances of high sweat or gastro-intestinal water losses or when water and electrolyte deficits are treated with water replacement only, it is characterised by an osmotic shift of fluid from the extracellular area to the intracellular. It also occurs with excessive intakes of plain water or other liquids with little or no sodium content. This type of dehydration accounts for approximately 10 to 15 percent of all paediatric cases of dehydration with diarrhoea. This complication can be life-threatening if swelling causes pressure on the brain (cerebral oedema). This is called hyponatraemia.
• HOW IS DEHYDRATION CAUSED?
• CONSEQUENCES OF DEHYDRATION

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