severe hyponatremic dehydration calculation

[ketap]

hi..i have questions about phase 2 fluid n electrolytes repletion calculation:
1. in phase 2, should we subtract the resuscitation volume and electrolytes (given in phase 1) from the calculated total volume and electrolytes deficits?
if i should, but why harriet lane only advices us to " consider" it..

2. in severe (seizing) hyponatremic dehydration, is it true that after giving the resuscitation volume in phase1 , then we must first prioritize bringing back plasma sodium to 125 Meq/L rapidly by using bolus 4ml/kg NaCl 3% over 20-30 minutes?

i hope u understand my questions..
please help me to understand this..thx u

with regards,Ketap

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[BigRedBeta]

Okay I'll bite.

First, Harriet Lane is just a guide. Most of their guidance is theoretical/historical relic. It's probably wise not raise the sodium too fast, and depending on the volume needed easier to space it over 24 hours, but the argument could just as easily be made that IV rehydration is entirely unnecessary unless the patient is vomiting and can't tolerate oral rehydration. You can push 150ml/kg or more ORT solution via an NG and it'll be better tolerated than using IV fluids.

The other part of it is that you need to continue to reevaluate your patient. That's why HL says "consider". You may have overestimated the degree of dehydration, their sodium may be trending up faster than desired, or they may have on going fluid losses that you need to consider in your rehydration strategy.

As for your second question...I would worry about the seizure before everything else. Hyponatremic seizures are less likely to respond to anti-seizure medications. Fix the sodium and then worry about the rehydration status. If the patient is hypotensive/in shock and seizing then you'll be giving normal saline boluses while waiting for your 3% fluids to arrive (most places it has to come from pharmacy), but it's much more about concurrent therapies than "first I do this, then I do the next thing, then I do the next thing".

If this is for an exam question, remember your priorities are the ABC's