Nephrology/Electrolytes/IV Fluids


Creatinine (on BMP) is measured with Jaffe reaction, which will cause false elevation with acidemia.

Cystatin C is a more reliable measure of GFR.

Calcium Chloride (10 mL 10%) = 13.5 mEq (272 mg) Ca++
Calcium Gluconate (10 mL 10%) = 4.65 mEq (93 mg) Ca++

Over-resuscitation: http://pulmccm.org/main/2017/review-articles/primer-perils-intravenous-fluids-part-2/

Hypercalcemia:

Mild: <12 mg/dL (don't usually require treatment)
Moderate: 12-14 mg/dL (treat aggressively if symptomatic)
Severe: >14 mg/dL (always treat aggressively)
Adjust +0.8 mg/dL for every g/dL albumin <4

Treatment:
Na-containing fluids (increase renal excretion)
Loop diuretics (after hydration, increase renal excretion)
Glucocorticoids (Decrease 1,25-hydroxylase activity)
Calcitonin (inhibit osteoclasts and increase renal excretion)
Bisphosphonates (inhibit osteoclasts)
Denosumab (monoclonal Ab binds RANKL and inhibits osteoclasts)
Dialysis

Saline vs LR:

Raghunathan K, Shaw A, Nathanson B, Sturmer T, Brookhart A, Stefan MS, Setoguchi S, Beadles C, Lindenauer PK: Association between the choice of IV crystalloid and in-hospital mortality among critically ill adults with sepsis. Crit Care Med 2014, 42:1585-1591


Shaw AD, Raghunathan K, Peyerl FW, Munson SH, Paluszkiewicz SM, Schermer CR. Association between intravenous chloride load during resuscitation and in-hospital mortality among patients with SIRS. Intensive Care Medicine. 2014


Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M.  Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012 Oct 17;308(15):1566-72. 


O'Malley CM, Frumento RJ, Hardy MA, Benvenisty AI, Brentjens TE, Mercer JS, Bennett-Guerrero E.  A randomized, double-blind comparison of lactated Ringer's solution and 0.9% NaCl during renal transplantation.  Anesth Analg. 2005 May;100(5):1518-24.


Reid F, Lobo DN, Williams RN, Rowlands BJ, Allison SP. (Ab)normal saline and physiological Hartmann's solution: a randomized double-blind crossover study. Clin Sci (Lond). 2003 Jan;104(1):17-24.


Paul E Marik.  Iatrogenic salt water drowning and the hazards of a high central venous pressure.  Ann Intensive Care. 2014; 4: 21.

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