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Сообщение от alex_md
First I would replace the VOLUME, so the answer sould be E. The patient has methabolic normal anion gap acidosis. His kidneys are trying to work hard to hold on to free water without any respect to osmolality! By restoring volume we will supress his high ADH and nornalize his sodium. Giving bicarb now is not correct. First need to restore perfusion. If you give the bicarb it will drive his K+ into the cells and may cause severe hypokalemia. I personally do not give bolus bicarb for if Ph> 6.9 but his not that sick, right?
PS: Low or high sodium is NEVER about sodium. It is ALWAYS about free water.
PPS: Hypertonic saline is givent in only ONE case in Medicine - Hyponatremic seizures. In all other cases it is considered malpactice. If you sodium increases by more then 10 in first 24 hours or so you will paralize the poor guy.
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Practically you'll start to repleate K as soon as you'll see, that the guy is urinating. His vitals are stable, and in many countries of the world he will be given oral, not iv , rehydration, which is much closer to bicarb by composition, then to NaCl.
So, again, somethimes difficult to say, what they are driving at. I think, it's just one more question on physiology- what's lost, what's should be repleated, what's the treatment for normal gap acidisis...
btw, hypertonic solution is also used in normo- natriemic patients , for example, in ARDS.
But the point of hypo-Na differential and correction is quite valid.
16.02.2007, 12:11
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