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Fractional Excretion of Bicarbonate

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141. Toxicity, Mushrooms - Muscarine (Follow-up)

), 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 Pediatrics

142. Syndrome of Inappropriate Antidiuretic Hormone Secretion (Diagnosis)

, the nonphysiological secretion of AVP results in enhanced water reabsorption, leading to dilutional hyponatremia. While a large fraction of this water is intracellular, the extracellular fraction causes volume expansion. Volume receptors are activated and natriuretic peptides are secreted, which causes natriuresis and some degree of accompanying potassium excretion (kaliuresis). Eventually, a steady state is reached and the amount of Na + excreted in the urine matches Na intake. Ingestion of water is an essential (...) of the antidiuretic hormone arginine vasopressin (AVP) despite normal or increased plasma volume, which results in impaired water excretion. [ ] The key to understanding the pathophysiology, signs, symptoms, and treatment of SIADH is the awareness that the results from an excess of water rather than a deficiency of sodium. Signs and symptoms Depending on the magnitude and rate of development, hyponatremia may or may not cause symptoms. The history should take into account the following considerations: In general

2014 eMedicine Pediatrics

143. 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

144. 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

145. Syndrome of Inappropriate Antidiuretic Hormone Secretion (Overview)

, the nonphysiological secretion of AVP results in enhanced water reabsorption, leading to dilutional hyponatremia. While a large fraction of this water is intracellular, the extracellular fraction causes volume expansion. Volume receptors are activated and natriuretic peptides are secreted, which causes natriuresis and some degree of accompanying potassium excretion (kaliuresis). Eventually, a steady state is reached and the amount of Na + excreted in the urine matches Na intake. Ingestion of water is an essential (...) of the antidiuretic hormone arginine vasopressin (AVP) despite normal or increased plasma volume, which results in impaired water excretion. [ ] The key to understanding the pathophysiology, signs, symptoms, and treatment of SIADH is the awareness that the results from an excess of water rather than a deficiency of sodium. Signs and symptoms Depending on the magnitude and rate of development, hyponatremia may or may not cause symptoms. The history should take into account the following considerations: In general

2014 eMedicine Pediatrics

146. Toxicity, Mushrooms - Muscarine (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 Pediatrics

147. Fluid, Electrolyte, and Nutrition Management of the Newborn (Treatment)

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

148. Fluid, Electrolyte, and Nutrition Management of the Newborn (Overview)

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

149. Oliguria (Follow-up)

, and an estimation of fluid status is a prerequisite for initial and ongoing therapy. This is accomplished by determination of input and output, body weights, vital signs, skin turgor, capillary refill, peripheral edema, cardiopulmonary examination, serum sodium, and fractional excretion of sodium (FENa). Children with intravascular volume depletion require prompt and vigorous fluid resuscitation. Initial therapy includes isotonic sodium chloride or lactated Ringer solution at 20mL/kg over 30 minutes, which can (...) < 7.2), especially in the presence of hyperkalemia, requires IV bicarbonate therapy. Recognize that bicarbonate therapy requires adequate ventilation (to excrete the carbon dioxide produced) to be effective, and it may precipitate hypocalcemia and hypernatremia. Patients who cannot tolerate a large sodium load (eg, those with congestive heart failure) may be treated in an ICU setting with IV tromethamine (THAM), with provision of adequate ventilatory support pending institution of dialysis. Previous

2014 eMedicine Pediatrics

150. Acute Tubular Necrosis (Treatment)

. 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

151. Fluid, Electrolyte, and Nutrition Management of the Newborn (Diagnosis)

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

152. Renal Failure, Acute (Diagnosis)

that suggest prerenal ARF include the following: Urine specific gravity >1.018 Urine osmolality (mOsm/kg water) >500 Urine sodium (mEq/L) < 15-20 Plasma BUN-creatinine ratio >20 Urine-plasma creatinine ratio >40 Urine indices that suggest ATN include the following: Urine specific gravity < 1.012 Urine osmolality (mOsm/kg water) < 500 Urine sodium (mEq/L) >40 Plasma BUN/creatinine ratio < 10-15 Urine-plasma creatinine ratio < 20 Previous Next: Calculation of Fractional Excretion of Sodium The calculation (...) of fractional excretion of sodium (FeNa) is as follows: FeNa = (urine Na/plasma Na)/(urine creatinine/plasma creatinine) If FeNa is less than 1%, this suggests prerenal acute renal failure (ARF). If FeNa is greater than 1%, this suggests ATN. The advantages of FeNa compared with other indices include the following: Physiologic measure of sodium reabsorption Measured creatinine and sodium clearances, accounting for filtration and reabsorption of sodium FeNa increased before oliguric phase established

2014 eMedicine Emergency Medicine

153. Syndrome of Inappropriate Antidiuretic Hormone Secretion (Diagnosis)

, the nonphysiological secretion of AVP results in enhanced water reabsorption, leading to dilutional hyponatremia. While a large fraction of this water is intracellular, the extracellular fraction causes volume expansion. Volume receptors are activated and natriuretic peptides are secreted, which causes natriuresis and some degree of accompanying potassium excretion (kaliuresis). Eventually, a steady state is reached and the amount of Na + excreted in the urine matches Na intake. Ingestion of water is an essential (...) of the antidiuretic hormone arginine vasopressin (AVP) despite normal or increased plasma volume, which results in impaired water excretion. [ ] The key to understanding the pathophysiology, signs, symptoms, and treatment of SIADH is the awareness that the results from an excess of water rather than a deficiency of sodium. Signs and symptoms Depending on the magnitude and rate of development, hyponatremia may or may not cause symptoms. The history should take into account the following considerations: In general

2014 eMedicine Emergency Medicine

154. 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

155. Toxicity, Mushrooms (Follow-up)

), 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 Emergency Medicine

156. Syndrome of Inappropriate Antidiuretic Hormone Secretion (Overview)

, the nonphysiological secretion of AVP results in enhanced water reabsorption, leading to dilutional hyponatremia. While a large fraction of this water is intracellular, the extracellular fraction causes volume expansion. Volume receptors are activated and natriuretic peptides are secreted, which causes natriuresis and some degree of accompanying potassium excretion (kaliuresis). Eventually, a steady state is reached and the amount of Na + excreted in the urine matches Na intake. Ingestion of water is an essential (...) of the antidiuretic hormone arginine vasopressin (AVP) despite normal or increased plasma volume, which results in impaired water excretion. [ ] The key to understanding the pathophysiology, signs, symptoms, and treatment of SIADH is the awareness that the results from an excess of water rather than a deficiency of sodium. Signs and symptoms Depending on the magnitude and rate of development, hyponatremia may or may not cause symptoms. The history should take into account the following considerations: In general

2014 eMedicine Emergency Medicine

157. Renal Failure, Acute (Follow-up)

that suggest prerenal ARF include the following: Urine specific gravity >1.018 Urine osmolality (mOsm/kg water) >500 Urine sodium (mEq/L) < 15-20 Plasma BUN-creatinine ratio >20 Urine-plasma creatinine ratio >40 Urine indices that suggest ATN include the following: Urine specific gravity < 1.012 Urine osmolality (mOsm/kg water) < 500 Urine sodium (mEq/L) >40 Plasma BUN/creatinine ratio < 10-15 Urine-plasma creatinine ratio < 20 Previous Next: Calculation of Fractional Excretion of Sodium The calculation (...) of fractional excretion of sodium (FeNa) is as follows: FeNa = (urine Na/plasma Na)/(urine creatinine/plasma creatinine) If FeNa is less than 1%, this suggests prerenal acute renal failure (ARF). If FeNa is greater than 1%, this suggests ATN. The advantages of FeNa compared with other indices include the following: Physiologic measure of sodium reabsorption Measured creatinine and sodium clearances, accounting for filtration and reabsorption of sodium FeNa increased before oliguric phase established

2014 eMedicine Emergency Medicine

158. 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 Emergency Medicine

159. Toxicity, Antidysrhythmic (Overview)

, 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

160. Renal Failure, Acute (Overview)

that suggest prerenal ARF include the following: Urine specific gravity >1.018 Urine osmolality (mOsm/kg water) >500 Urine sodium (mEq/L) < 15-20 Plasma BUN-creatinine ratio >20 Urine-plasma creatinine ratio >40 Urine indices that suggest ATN include the following: Urine specific gravity < 1.012 Urine osmolality (mOsm/kg water) < 500 Urine sodium (mEq/L) >40 Plasma BUN/creatinine ratio < 10-15 Urine-plasma creatinine ratio < 20 Previous Next: Calculation of Fractional Excretion of Sodium The calculation (...) of fractional excretion of sodium (FeNa) is as follows: FeNa = (urine Na/plasma Na)/(urine creatinine/plasma creatinine) If FeNa is less than 1%, this suggests prerenal acute renal failure (ARF). If FeNa is greater than 1%, this suggests ATN. The advantages of FeNa compared with other indices include the following: Physiologic measure of sodium reabsorption Measured creatinine and sodium clearances, accounting for filtration and reabsorption of sodium FeNa increased before oliguric phase established

2014 eMedicine Emergency Medicine

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