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Who is teaching 'Fluid and Electrolytes'?

Kettritz R, Luft FC - Clin Kidney J (2012)

View Article: PubMed Central - PubMed

Affiliation: Nephrology/Critical Care Medicine, Charité Campus Virchow, Berlin, Germany ; Experimental and Clinical Research Centre, Joint Cooperation between Charité Medical Faculty and Max-Delbrück Centre for Molecular Medicine, Berlin, Germany.

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Post-operatively, the patient showed little improvement and a nephrology consult was obtained on the morning of the second post-operative day when her serum sodium had decreased to 120 mmol/L... The consultant found a lethargic patient who promptly fainted in an upright posture... The urine pH had been five on admission and was now six... The sum of urine sodium plus potassium greatly exceeded the urine chloride value, which caused the consultant to conclude that ammonium production in face of this metabolic acidosis might be decreased... Even though the patient was not hyperkalaemic, the consultant next calculated the transtubular potassium gradient from the relationship TTKG = (U/P potassium)/(U/P osmolality)... The result was a modest value of 2.3... On the next day, the sodium level was 130, potassium 4.1, chloride 102, HCO3 19 (all mmol/L), the glucose was 8.27 mmol/L, and the patient's Hb had decreased to 100 g/L... The consultant did not attribute the decrease in Hb to ‘blood letting’ but rather argued that restoration of volume was responsible (Figure 2), an opinion supported by a decrease in creatinine and urea nitrogen values... The combination of hyponatraemia, hyperkalaemia, mild hyperchloraemic metabolic acidosis and modest elevations in the plasma creatinine, blood urea nitrogen and haematocrit are classical findings of Addison's disease... She had entered with a haematocrit of 45 vol%... This value decreased to 30 vol%... Our patient had no evidence of diabetes or gonadal failure. (1) Nephrologists have a traditional teaching role for fluid and electrolytes... This patient exemplifies that we have failed in our mission. (2) We believe that this patient is not an exception and that a concerted international effort is necessary for nephrologists to fulfil their traditional fluid and electrolyte teaching role. (3) Hyponatraemia and acid–base disturbances must always be worked up, especially in patients being considered for surgery.

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The patient presented with a deceptively normal haematocrit despite numerous shock signs. The normal Hb and haematocrit (Hct) were interpreted as representing the normal relationship between red cells and plasma volume. We believe that marked volume contraction was present in a patient who was otherwise anaemic, as revealed by volume expansion.
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fig2: The patient presented with a deceptively normal haematocrit despite numerous shock signs. The normal Hb and haematocrit (Hct) were interpreted as representing the normal relationship between red cells and plasma volume. We believe that marked volume contraction was present in a patient who was otherwise anaemic, as revealed by volume expansion.

Mentions: Eight hours later, sodium level was 128, potassium 4.7, chloride 103 and HCO3 17 (all mmol/L). Urine sodium was 47, potassium 27 and chloride 74 (all mmol/L) and the osmolality 283 mosm/kg H2O. The consultant recognized that the patient was now probably excreting ammonium and that the free-water clearance was now positive. On the next day, the sodium level was 130, potassium 4.1, chloride 102, HCO3 19 (all mmol/L), the glucose was 8.27 mmol/L, and the patient's Hb had decreased to 100 g/L. The consultant did not attribute the decrease in Hb to ‘blood letting’ but rather argued that restoration of volume was responsible (Figure 2), an opinion supported by a decrease in creatinine and urea nitrogen values. The pathologist observed ‘fibrosis of the submucosa’ in the appendix; a diagnosis that all parties were happy with, and following treatment, the patient felt much better. She thanked her surgeon for saving her life and left the hospital.


Who is teaching 'Fluid and Electrolytes'?

Kettritz R, Luft FC - Clin Kidney J (2012)

The patient presented with a deceptively normal haematocrit despite numerous shock signs. The normal Hb and haematocrit (Hct) were interpreted as representing the normal relationship between red cells and plasma volume. We believe that marked volume contraction was present in a patient who was otherwise anaemic, as revealed by volume expansion.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4400521&req=5

fig2: The patient presented with a deceptively normal haematocrit despite numerous shock signs. The normal Hb and haematocrit (Hct) were interpreted as representing the normal relationship between red cells and plasma volume. We believe that marked volume contraction was present in a patient who was otherwise anaemic, as revealed by volume expansion.
Mentions: Eight hours later, sodium level was 128, potassium 4.7, chloride 103 and HCO3 17 (all mmol/L). Urine sodium was 47, potassium 27 and chloride 74 (all mmol/L) and the osmolality 283 mosm/kg H2O. The consultant recognized that the patient was now probably excreting ammonium and that the free-water clearance was now positive. On the next day, the sodium level was 130, potassium 4.1, chloride 102, HCO3 19 (all mmol/L), the glucose was 8.27 mmol/L, and the patient's Hb had decreased to 100 g/L. The consultant did not attribute the decrease in Hb to ‘blood letting’ but rather argued that restoration of volume was responsible (Figure 2), an opinion supported by a decrease in creatinine and urea nitrogen values. The pathologist observed ‘fibrosis of the submucosa’ in the appendix; a diagnosis that all parties were happy with, and following treatment, the patient felt much better. She thanked her surgeon for saving her life and left the hospital.

View Article: PubMed Central - PubMed

Affiliation: Nephrology/Critical Care Medicine, Charité Campus Virchow, Berlin, Germany ; Experimental and Clinical Research Centre, Joint Cooperation between Charité Medical Faculty and Max-Delbrück Centre for Molecular Medicine, Berlin, Germany.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Post-operatively, the patient showed little improvement and a nephrology consult was obtained on the morning of the second post-operative day when her serum sodium had decreased to 120 mmol/L... The consultant found a lethargic patient who promptly fainted in an upright posture... The urine pH had been five on admission and was now six... The sum of urine sodium plus potassium greatly exceeded the urine chloride value, which caused the consultant to conclude that ammonium production in face of this metabolic acidosis might be decreased... Even though the patient was not hyperkalaemic, the consultant next calculated the transtubular potassium gradient from the relationship TTKG = (U/P potassium)/(U/P osmolality)... The result was a modest value of 2.3... On the next day, the sodium level was 130, potassium 4.1, chloride 102, HCO3 19 (all mmol/L), the glucose was 8.27 mmol/L, and the patient's Hb had decreased to 100 g/L... The consultant did not attribute the decrease in Hb to ‘blood letting’ but rather argued that restoration of volume was responsible (Figure 2), an opinion supported by a decrease in creatinine and urea nitrogen values... The combination of hyponatraemia, hyperkalaemia, mild hyperchloraemic metabolic acidosis and modest elevations in the plasma creatinine, blood urea nitrogen and haematocrit are classical findings of Addison's disease... She had entered with a haematocrit of 45 vol%... This value decreased to 30 vol%... Our patient had no evidence of diabetes or gonadal failure. (1) Nephrologists have a traditional teaching role for fluid and electrolytes... This patient exemplifies that we have failed in our mission. (2) We believe that this patient is not an exception and that a concerted international effort is necessary for nephrologists to fulfil their traditional fluid and electrolyte teaching role. (3) Hyponatraemia and acid–base disturbances must always be worked up, especially in patients being considered for surgery.

No MeSH data available.


Related in: MedlinePlus