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Fractional Excretion of Bicarbonate

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121. Perioperative Management of the Female Patient

% of the time. Although it is most commonly observed in women with small-cell carcinoma of the lung, SIADH is also observed in women with gynecologic and bladder cancers. The management of this disorder may be difficult. SIADH occurs in a state of euvolemic hyponatremia. The hyponatremia is caused by over-secretion of ADH. Because free water cannot be excreted normally, persistent ADH secretion causes water retention, hyponatremia, and progressive expansion of intracellular and extracellular fluid

2014 eMedicine.com

122. Azotemia (Diagnosis)

for hypothalamic production of antidiuretic hormone, which exerts its effect in the medullary collecting duct for water reabsorption. Through unknown mechanisms, activation of the sympathetic nervous system leads to enhanced proximal tubular reabsorption of salt and water, as well as BUN, creatinine, calcium, uric acid, and bicarbonate. The net result of these 4 mechanisms of salt and water retention is decreased output and decreased urinary excretion of sodium (< 20 mEq/L). Intrarenal azotemia Intrarenal (...) Failure Study Group. Kidney Int . 1996 Sep. 50 (3):811-8. . . Prakash J, Singh TB, Ghosh B, Malhotra V, Rathore SS, Vohra R, et al. Changing epidemiology of community-acquired acute kidney injury in developing countries: analysis of 2405 cases in 26 years from eastern India. Clin Kidney J . 2013 Apr. 6 (2):150-5. . . Carvounis CP, Nisar S, Guro-Razuman S. Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure. Kidney Int . 2002 Dec. 62(6):2223-9

2014 eMedicine.com

123. Hypocalcemia (Diagnosis)

: Pathophysiology Ionized calcium is the necessary plasma fraction for normal physiologic processes. In the neuromuscular system, ionized calcium facilitates nerve conduction, muscle contraction, and muscle relaxation. Calcium is necessary for bone mineralization and is an important cofactor for hormonal secretion in endocrine organs. At the cellular level, calcium is an important regulator of ion transport and membrane integrity. Calcium turnover is estimated to be 10-20 mEq/day. Approximately 500 mg (...) of calcium is removed from the bones daily and replaced by an equal amount. Normally, the amount of calcium absorbed by the intestines is matched by urinary calcium excretion. Despite these enormous fluxes of calcium, the levels of ionized calcium remain stable because of the rigid control maintained by parathyroid hormone (PTH), vitamin D, and calcitonin through complex feedback loops. These compounds act primarily at bone, renal, and GI sites. Calcium levels are also affected by magnesium

2014 eMedicine Emergency Medicine

124. Toxicity, Antidysrhythmic (Diagnosis)

, flecainide, propafenone, amiodarone Hemodialysis: Procainamide, mexiletine, sotalol Sodium bicarbonate: Class Ia and Ic antidysrhythmics (quinidine, procainamide, disopyramide, lidocaine, mexiletine, flecainide, propafenone) Magnesium: Class III agents, Ibutilide, dofetilide, sotalol, quinidine, procainamide, disopyramide Intravenous lipid emulsion: Verapamil; less evidence for lidocaine, flecainide, amiodarone Seizure control (benzodiazepines): Quinidine, procainamide, lidocaine, mexiletine, flecainide (...) Disopyramide In addition to sodium and potassium channel blockade, disopyramide is a muscarinic antagonist. See the following: Indications: Documented ventricular dyshythmias, atrial dysrhythmias in patients with hypertrophic cardiomyopathy (unlabeled use) Dosages: Dose adjustment is gradual; 100-200 mg orally every 6 hours; reduced dosage frequency recommended in renally impaired patients Metabolism: Metabolized by the liver (CYP3A4), 40-60% excreted by the kidneys Therapeutic concentrations: Atrial

2014 eMedicine Emergency Medicine

125. Respiratory Alkalosis (Overview)

quantity of volatile acid (carbon dioxide) and nonvolatile acid. The metabolism of fats and carbohydrates leads to the formation of a large amount of carbon dioxide. [ ] The carbon dioxide combines with water to form carbonic acid. The lungs excrete the volatile fraction through ventilation, and acid accumulation does not occur. Significant alterations in ventilation can affect the elimination of carbon dioxide and lead to a respiratory acid-base disorder. PaCO 2 is normally maintained in the range (...) 03, 2018 Author: Ryland P Byrd, Jr, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP Share Email Print Feedback Close Sections Sections Respiratory Alkalosis Overview Background Respiratory alkalosis is a disturbance in acid and base balance due to alveolar hyperventilation. Alveolar hyperventilation leads to a decreased partial pressure of arterial carbon dioxide (PaCO 2 ). In turn, the decrease in PaCO 2 increases the ratio of bicarbonate concentration to PaCO 2 and, thereby, increases the pH

2014 eMedicine.com

126. Respiratory Acidosis (Overview)

elevates plasma bicarbonate values, but only slightly (approximately 1 mEq/L for each 10-mm Hg increase in PaCO 2 ). The second step is renal compensation that occurs over 3-5 days. With renal compensation, renal excretion of carbonic acid is increased, and bicarbonate reabsorption is increased. The expected change in serum bicarbonate concentration in respiratory acidosis can be estimated as follows: Acute respiratory acidosis – Bicarbonate increases by 1 mEq/L for each 10-mm Hg rise in PaCO 2 (...) hypoventilation leads to an increased PaCO 2 (ie, hypercapnia). The increase in PaCO 2 , in turn, decreases the bicarbonate (HCO 3 – )/PaCO 2 ratio, thereby decreasing the pH. Hypercapnia and respiratory acidosis ensue when impairment in ventilation occurs and the removal of carbon dioxide by the respiratory system is less than the production of carbon dioxide in the tissues. Lung diseases that cause abnormalities in alveolar gas exchange do not typically result in alveolar hypoventilation. Often

2014 eMedicine.com

127. Metabolic Acidosis (Treatment)

and well tolerated, and was associated with improvements in bone quality, suggesting a beneficial effect of both alkali treatment and restoration of acid/base balance. The researchers concluded that potassium citrate may be superior to sodium bicarbonate, because it lacks volume effects and the obligatory calcium excretion associated with sodium administration. [ ] Go to and for complete information on these topics. Next: Type 1 Renal Tubular Acidosis Administration of an alkali is the mainstay (...) with placebo followed by escalating doses of oral sodium bicarbonate at 2-week intervals (0.3, 0.6, and 1.0 mEq/d per kg ideal body weight). [ ] Sodium bicarbonate was well tolerated, even at high doses; produced a dose-dependent increase in serum bicarbonate; and was associated with an improvement in lower extremity muscle strength and reduced urinary nitrogen excretion. The authors caution, however, that the results require further study and confirmation from a large randomized placebo-controlled study

2014 eMedicine.com

128. Cystinuria (Treatment)

range of 7-7.5. Acetazolamide inhibits the brush-border carbonic anhydrase of the proximal convoluted tubule, thereby increasing urinary bicarbonate excretion. Acetazolamide is not widely used as a first-line drug and is of questionable efficacy. Sodium bicarbonate was used in the past for alkalinizatoinbut is no longer recommended as a first-line agent. The sodium ion may actually increase the amount of cystine excreted. Chelating agents Cystine-binding and cystine-reducing agents share the ability (...) is important for decision-making processes, and stone site and size also influence further management. See the treatment algorithm image below. Treatment algorithm for cystinuria. Hydration The average homozygous patient with cystinuria excretes 600-1400 mg of cystine per day. The solubility of cystine at a pH level of 7 is 250-300 mg/L. Therefore, one of the oldest and most effective cystine stone–prevention techniques is hyperdiuresis to decrease urinary cystine concentration. Early studies by Dent et al

2014 eMedicine.com

129. Hypertension (Treatment)

[ , ] : (1) elevated BP, with a systolic pressure (SBP) between 120 and 129 mm Hg and diastolic pressure (DBP) less than 80 mm Hg, and (2) stage 1 hypertension, with an SBP of 130 to 139 mm Hg or a DBP of 80 to 89 mm Hg. In adults at increased risk of heart failure (HF), the optimal BP in those with hypertension should be less than 130/80 mm Hg. Adults with HFrEF (HF with reduced ejection fraction) and hypertension should be prescribed GDMT (guideline-directed management and therapy) titrated to attain

2014 eMedicine.com

130. Hypocitraturia (Treatment)

filtration rate (GFR) decreases, there is a stepwise decrease in the amount of citrate that is filtered; however, in the early stages of CKD, the increased fractional excretion of citrate prevents an abrupt decline in urinary citrate, such that overt hypocitraturia is not usually observed until advanced stages of CKD. [ ] Primary Hyperaldosteronism In this disease entity, both hypercalciuria and hypocitraturia occur via Na-dependent volume expansion and chronic hypokalemia. [ ] Previous Next: US (...) . Urol Res . 2006 Aug. 34(4):231-8. . Kessler T, Hesse A. Cross-over study of the influence of bicarbonate-rich mineral water on urinary composition in comparison with sodium potassium citrate in healthy male subjects. Br J Nutr . 2000 Dec. 84(6):865-71. . Pinheiro VB, Baxmann AC, Tiselius HG, Heilberg IP. The effect of sodium bicarbonate upon urinary citrate excretion in calcium stone formers. Urology . 2013 Jul. 82(1):33-7. . Seltzer MA, Low RK, McDonald M. Dietary manipulation with lemonade

2014 eMedicine.com

131. Metabolic Alkalosis (Overview)

tract. Vomiting or nasogastric (NG) suction generates metabolic alkalosis by the loss of gastric secretions, which are rich in hydrochloric acid (HCl). Whenever a hydrogen ion is excreted, a bicarbonate ion is gained in the extracellular space. Renal losses of hydrogen ions occur whenever the distal delivery of sodium increases in the presence of excess aldosterone, which stimulates the electrogenic epithelial sodium channel (ENaC) in the collecting duct. As this channel reabsorbs sodium ions (...) , the tubular lumen becomes more negative, leading to the secretion of hydrogen ions and potassium ions into the lumen. Shift of hydrogen ions into the intracellular space mainly develops with hypokalemia. As the extracellular potassium concentration decreases, potassium ions move out of the cells. To maintain neutrality, hydrogen ions move into the intracellular space. Administration of sodium bicarbonate in amounts that exceed the capacity of the kidneys to excrete this excess bicarbonate may cause

2014 eMedicine.com

132. Metabolic Acidosis (Overview)

. Comparison of Types 1, 2, and 4 RTA Characteristics Proximal (Type 2) Distal (Type 1) Type 4 Primary defect Proximal HCO 3 - reabsorption Diminished distal H+ secretion Diminished ammoniagenesis Urine pH < 5.5 when serum HCO 3 - is low >5.5 < 5.5 Serum HCO 3 - >15 mEq/L Can be < 10 mEq/L >15 mEq/L Fractional excretion of HCO 3 - (FEHCO 3 ) >15-20% during HCO 3 - load < 5% (can be as high as 10% in children) < 5% Serum K + Normal or mild decrease Mild-to-severe decrease* High Associated features Fanconi (...) concentrations. On the basis of this law, the addition of H + or bicarbonate (HCO 3 - ) drives the reaction shown below to the left. H 2 CO 3 (acid)↔H + + HCO 3 - (base) In body fluids, the concentration of hydrogen ions ([H + ]) is maintained within very narrow limits, with the normal physiologic concentration being 40 nEq/L. The concentration of HCO 3 - (24 mEq/L) is 600,000 times that of [H + ]. The tight regulation of [H + ] at this low concentration is crucial for normal cellular activities because H

2014 eMedicine.com

133. Milk-Alkali Syndrome (Overview)

and bicarbonate, for treatment of peptic ulcer disease. (See Pathophysiology, Etiology, Prognosis, Presentation, and Workup.) [ ] With the development of nonabsorbable alkali and histamine-2 blockers for treatment of peptic ulcer disease, milk-alkali syndrome became a rare cause of hypercalcemia; however, with the increased use and promotion of calcium carbonate for dyspepsia and for calcium supplementation, a resurgence of milk-alkali syndrome has occurred. (See Etiology and Epidemiology.) A few authors (...) . Adaptation of intestinal calcium absorption to oral intake may play a role and help to explain individual variability in the development of milk-alkali syndrome. Some persons maintain a high fractional absorption of calcium even with a high intake, while other persons decrease fractional absorption with a high intake. The former are likely at risk of developing milk-alkali syndrome. Calcium absorption is completed within 4 hours of intake. Avid absorption of large doses may lead to suppression

2014 eMedicine.com

134. Toxicity, Mushroom (Treatment)

), Boletus edulis (king boletus), Leccinium versipelle (brown birch boletus), and Albatrellus ovinus (sheep polypore). Many of these are identified in field guides as edible. Treatment is with aggressive IV fluid resuscitation and consideration for IV sodium bicarbonate to alkalinize the urine. In rare cases, dialysis may be needed if renal failure occurs. Agitation, commonly observed with hallucinogenic mushrooms, is treated with benzodiazepines; phenothiazines are best avoided in this setting. Other (...) of them demonstrate an important decrease in hepatic necrosis histologically. [ ] A large human case series found an association between both silibinin and NAC and higher survival rates. [ ] Corticosteroids, vitamin C, kutkin, aucubin, and thioctic acid have been used in the past but have no proven benefit and are no longer recommended. Charcoal hemoperfusion and hemodialysis are also ineffective in removing toxins because once the toxin is formed, it is rapidly excreted by the kidneys. Plasma

2014 eMedicine.com

135. Toxicity, Barbiturate (Treatment)

to be renally excreted. Urinary alkalinization is not recommended for short-acting barbiturates. Enhancement of urinary elimination may be accomplished with an initial sodium bicarbonate bolus of 1 mEq/kg followed by a constant infusion. This infusion may be made by adding 100-150 mEq of sodium bicarbonate to 850 mL of D5 and titrating to maintain a urine pH of greater than 7.5 with an arterial pH of less than 7.50. The goal should be a urine output of 150-250 mL/h. Risks include hypokalemia, fluid overload (...) it was administered at 30 minutes, 60 minutes, and 120 minutes, respectively, current guidelines in overdose management question its benefit. There is no evidence that the administration of activated charcoal improves clinical outcome. Indeed, its use has decreased to less than 5% of all reported ingestions in recent years. [ ] A single dose of activated charcoal may be given within an hour of overdose if the clinician estimates that a clinically significant fraction of the ingested substance remains in the GI

2014 eMedicine.com

136. Acidosis, Respiratory (Diagnosis)

, bicarbonate, and protein bound. It diffuses freely across cell membranes, and this diffusion allows it to be efficiently transported from peripheral tissues to the lungs for excretion. When hypercapnia is present, this same property causes excess carbon dioxide to shift intracellularly and decrease intracellular pH. Carbon dioxide (CO 2 ) normally combines with water (H 2 O) to form carbonic acid (H 2 CO 3 ), which then dissociates to release hydrogen ion (H + ) and bicarbonate (HCO 3 (...) substantial changes in pH, and approximately 10% of carbon dioxide is bound to hemoglobin to form carbaminohemoglobin. Cellular buffering elevates plasma bicarbonate (HCO 3 – ) only slightly and causes plasma HCO 3 – to increase by 1 mEq/L for every 10-mm Hg increase in P a CO 2 . Renal compensation for sustained hypercapnia begins in 6-12 hours, but 3-5 days pass before maximal compensation occurs. The kidneys increase excretion of hydrogen ions (predominantly in the form of ammonium [NH 4

2014 eMedicine Pediatrics

137. Rhabdomyolysis (Follow-up)

Dehydration (hematocrit >50, serum sodium level >150 mEq/L, orthostasis, pulmonary wedge pressure < 5 mm Hg, urinary fractional excretion of sodium < 1%) Sepsis Hyperkalemia or hyperphosphatemia on admission Hypoalbuminemia AKI has occasionally developed in severely dehydrated patients with peak CK levels as low as 2000 IU/L. To prevent renal failure, many authorities advocate urinary alkalization, mannitol, and loop diuretics. Alkalization of urine is believed to be helpful and is based (...) . These invasive studies can assist in the assessment of the intravascular volume.) Repeat the CK assay every 6-12 hours to determine the peak CK level. Aggressive and early hydration with isotonic sodium chloride solution is important for the prevention of pigment-associated renal failure. The composition of repletion fluid is controversial and may also include sodium bicarbonate. Initial fluid use in young children has been recommended to be 20 mL/kg; in adolescents, 1-2 L/h has been recommended. Subsequent

2014 eMedicine Pediatrics

138. Fluid, Electrolyte, and Nutrition Management of the Newborn (Follow-up)

output and a serum creatinine that does not decline postnatally or increases may have acute kidney injury (AKI). Urine electrolyte levels and specific gravity may be assessed. If the infant is being treated with diuretics, such as furosemide, results of these tests are difficult to interpret. Calculation of the fractional urinary excretion of sodium in relation to creatinine (FENa) and blood gas analysis may be indicated; metabolic acidosis may be a marker of inadequate tissue perfusion. Previous (...) + excretion and loss of bicarbonate. [ ] During the active growth period after the first week, the need for potassium may increase to 2-3mEq/kg/day, and the need for sodium and chloride may increase to 3-5mEq/kg/day. Some of the smallest preterm infants have sodium requirements of as much as 6-8mEq/kg/day because of the decreased capacity of the kidneys to retain sodium. Previous Next: Fluids and Electrolytes in Common Neonatal Conditions Infants with respiratory distress syndrome need appropriate fluid

2014 eMedicine Pediatrics

139. Uric Acid Stones (Treatment)

, Children, and Adults [ ] Neonates* Children Adults 29-33 wk 34-37 wk 38-40 wk 3-4 y 5-9 y 10-14 y 40-44 y Male Female Male Female Male Female Male Female Serum uric acid (mg/dL) 7.71±2.65 6.04±2.19 5.19±1.57 3.45±1.01 3.44±0.8 3.63±1.04 3.71±0.92 4.28±1.19 4.09±1.2 5.134±1.25 4.25±1.1 Uric acid excretion (mg/dL GFR † ) 4.8±2.23 2.81±0.93 1.69±0.84 0.34±0.11 0.403±0.095 Uric acid excretion (mg/kg/d) N/A N/A 19.6 13.5±3.75 (3 y) 11.5±3.75 (7 y) 9±3.75 (12 y) 10 Fractional excretion of uric acid (%) 61.24 (...) Stones Treatment & Management Updated: Jun 11, 2018 Author: Sahar Fathallah-Shaykh, MD; Chief Editor: Craig B Langman, MD Share Email Print Feedback Close Sections Sections Uric Acid Stones Treatment Medical Care The primary treatments are to alkalinize (citrate or bicarbonate) and dilute (large water intake) the urine. Sodium urate is 15 times more soluble than uric acid. At a urine pH level of 6.8, 10 times as much sodium urate as uric acid is present. At a urine pH level of 7.8, 100 times as much

2014 eMedicine Pediatrics

140. Acute Tubular Necrosis (Follow-up)

. This is accomplished by measuring input and output, serial body weights, vital signs, skin turgor, capillary refill, serum sodium, and fractional excretion of sodium (FENa). Children with intravascular volume depletion require prompt and vigorous fluid resuscitation. Initial therapy includes normal saline or lactated Ringer solution at 20 mL/kg over 30 minutes. It can be repeated twice if necessary, after careful monitoring to avoid possible fluid overload. Potassium administration is contraindicated until urine (...) is indicated. In addition to Kayexalate, administer intravenous sodium bicarbonate, which causes a rapid shift of potassium into cells. The magnitude of the potassium intracellular shift is variable, and thus, bicarbonate is not reliable in lowering the potassium level. Such therapy should be used with caution because it can precipitate hypocalcemia and sodium overload. Sodium bicarbonate uptake of potassium by cells can also be stimulated by infusion of glucose and insulin or by beta agonists (albuterol

2014 eMedicine Pediatrics

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