Fluid, Electrolyte and Acid-Base Physiology. A Problem-Based Approach

506 Pages·2017·5.6 MB·English

by  Kamel S. Kamel

F I F T H E D I T I O N
Fluid, Electrolyte, and
Acid–Base Physiology
A Problem-Based Approach
Kamel S. Kamel, md, frcpc
St. Michael’s Hospital
University of Toronto
Toronto, Ontario, Canada
Mitchell L. Halperin, md, frcpc
St. Michael’s Hospital
University of Toronto
Toronto, Ontario, Canada
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
FLUID, ELECTROLYTE, AND ACID–BASE PHYSIOLOGY:
A PROBLEM-BASED APPROACH, 5TH EDITION ISBN: 978-0-323-35515-5
Copyright © 2017 by Elsevier, Inc. All rights reserved.
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than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and
to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any
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Previous editions copyright © 2010, 1999, 1994, 1988
Library of Congress Cataloging-in-Publication Data
Names: Halperin, M. L. (Mitchell L.), author. | Kamel, Kamel S., author.
Title: Fluid, electrolyte, and acid-base physiology : a problem-based
approach / Kamel S. Kamel, Mitchell L. Halperin.
Description: 5th edition. | Philadelphia, PA : Elsevier, [2017] | Author’s
names reversed on previous edition. | Includes bibliographical references
and index.
Identifiers: LCCN 2016037933 | ISBN 9780323355155 (hardcover : alk. paper)
Subjects: | MESH: Water-Electrolyte Imbalance--physiopathology | Acid-Base
Imbalance--physiopathology | Water-Electrolyte Imbalance--diagnosis |
Acid-Base Imbalance--diagnosis | Potassium--metabolism
Classification: LCC RC630 | NLM WD 220 | DDC 616.3/992--dc23 LC record
available at https://lccn.loc.gov/2016037933
Content Strategist: Maureen Iannuzzi
Senior Content Development Specialist: Joan Ryan
Publishing Services Manager: Catherine Jackson
Project Manager: Kate Mannix
Design Direction: Ryan Cook
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To Marylin and Brenda:
We are indeed extremely
grateful for your patience
and your strong,
unwavering support.
Acknowledgment
We are extremely grateful to our friend and colleague Professor
Martin Schreiber for his critical review of the entire book and the
several insightful comments he provided. Martin, you are truly a
good man.
vii
Preface
About 6 years have passed between this, the fifth edition of Fluid, Elec-
trolyte, and Acid–Base Physiology, and the fourth edition. For this edi-
tion, Professor Kamel S. Kamel has taken the role of lead author, while
Professor Marc Goldstein, because of other commitments and time
constraints, has decided not to participate.
Our initial intention with this edition was to provide limited
updates of a few chapters. We ended up, however, extensively revising
the book, so that it is almost entirely rewritten. Although the effort
was substantial and the time commitment was much more than we
anticipated, we could not be more proud of the product. In this fifth
edition of Fluid, Electrolyte, and Acid–Base Physiology, we have tried
to provide a comprehensive, go-to guide to the diagnosis and man-
agement of fluid-electrolyte and acid–base disorders. The book aims
to move from basic physiology to pathophysiology to practical clini-
cal guidance, taking into account new discoveries and new insights
into fluid-electrolyte and acid–base physiology, as well as new options
available for treatment. We emphasize principles of metabolic regu-
lation and biochemistry to promote an in-depth understanding of
metabolic acid–base disorders. We also emphasize integrative, whole-
body physiology to provide a more in-depth understanding of the
pathophysiology of fluid, electrolyte, and acid–base disorders. The
style of the book, which we believe has been appealing to readers, has
not changed. As in previous editions, we have attempted to provide
information in an easy-to-understand way, with emphasis on how to
apply the information to clinical practice, supported by numerous
diagrams, flow charts, and tables. To engage and challenge the reader,
we have included several clinical cases and questions throughout each
of the chapters in the book.
We believe that this fifth edition of Fluid, Electrolyte, and Acid–Base
Physiology will provide a useful resource to learners at different levels,
from medical students to postgraduate trainees, and to practitioners
such as general internists and specialists with an interest in the area of
fluid-electrolyte and acid–base disorders.
viii
Interconversion of Units
Because some readers will be more familiar with the International
System of Units (SI units) and others will prefer the conventional units
used in the United States, we provide the following conversion table.
To convert units, multiply the reported value by the appropriate con-
version factor.
SI TO
CONVENTIONAL CONVENTIONAL
PARAMETER TO SI UNITS UNITS
Sodium × 1 = mmol/L × 1 = mEq/L
Potassium × 1 = mmol/L × 1 = mEq/L
Chloride × 1 = mmol/L × 1 = mEq/L
Bicarbonate × 1 = mmol/L × 1 = mEq/L
Calcium × 0.25 = mmol/L × 4.0 = mg/dL
Urea × 0.36 = mmol/L × 2.8 = mg/dL
Creatinine × 88.4 = μmol/L × 0.0113 = mg/dL
Glucose × 0.055 = mmol/L × 18 = mg/dL
Albumin × 10 = g/L × 0.1 = mg/dL
ix
List of Cases
Chapter 2 Tools to Use to Diagnose Acid–Base Disorders
Case 2-1 Does This Man Really Have Metabolic Acidosis? . . . . . . 34
Case 2-2 Lola Kaye Needs Your Help . . . . . . . . . . . . . . . . . . . . . . . . . 35
Chapter 3 Metabolic Acidosis: Clinical Approach
Case 3-1 Stick to the Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Chapter 4 Metabolic Acidosis Caused by a Deficit of NaHCO
3
Case 4-1 A Man Diagnosed With Type IV Renal Tubular Acidosis . . . 80
Case 4-2 What Is This Woman’s “Basic” Lesion? . . . . . . . . . . . . . . . 81
Chapter 5 Ketoacidosis
Case 5-1 This Man Is Anxious to Know Why He Has
Ketoacidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Case 5-2 Hyperglycemia and Acidemia . . . . . . . . . . . . . . . . . . . . . . 112
Case 5-3 Sam Had a Drinking Binge Yesterday . . . . . . . . . . . . . . . . 127
Chapter 6 Metabolic Acidosis: Acid Gain Types
Case 6-1 Patrick Is in for a Shock . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Case 6-2 Metabolic Acidosis Associated With Diarrhea . . . . . . . . . 143
Case 6-3 Severe Acidemia in a Patient With Chronic
Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143
Chapter 7 Metabolic Alkalosis
Case 7-1 This Man Should Not Have Metabolic Alkalosis . . . . . . . 172
Case 7-2 Why Did This Patient Develop Metabolic Alkalosis
so Quickly? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173
Case 7-3 Milk-Alkali Syndrome, but Without Milk . . . . . . . . . . . . . . 173
Chapter 9 Sodium and Water Physiology
Case 9-1 A Rise in the P After a Seizure . . . . . . . . . . . . . . . . . . . 216
Na
Chapter 10 Hyponatremia
Case 10-1 This Catastrophe Should Not Have Occurred! . . . . . . . . 267
Case 10-2 This Is Far From Ecstasy! . . . . . . . . . . . . . . . . . . . . . . . . . 267
Case 10-3 Hyponatremia With Brown Spots . . . . . . . . . . . . . . . . . . 268
Case 10-4 Hyponatremia in a Patient on a Thiazide Diuretic . . . . . 268
Chapter 11 Hypernatremia
Case 11-1 Concentrate on the Danger . . . . . . . . . . . . . . . . . . . . . . . . 311
Case 11-2 What Is “Partial” About Partial Central Diabetes
Insipidus? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .311
Case 11-3 Where Did the Water Go? . . . . . . . . . . . . . . . . . . . . . . . . . 311
Chapter 12 Polyuria
Case 12-1 Oliguria With a Urine Volume of 4 L per Day . . . . . . . . . 340
Case 12-2 More Than Just Salt and Water Loss . . . . . . . . . . . . . . . . 340
xi
xii List of Cases
Chapter 13 Potassium Physiology
Case 13-1 Why Did I Become so Weak? . . . . . . . . . . . . . . . . . . . . . . . 361
Chapter 14 Hypokalemia
Case 14-1 Hypokalemia With Paralysis . . . . . . . . . . . . . . . . . . . . . . 394
Case 14-2 Hypokalemia With a Sweet Touch . . . . . . . . . . . . . . . . . . . 395
Case 14-3 Hypokalemia in a Newborn . . . . . . . . . . . . . . . . . . . . . . . . 395
Chapter 15 Hyperkalemia
Case 15-1 Might This Patient Have Pseudohyperkalemia? . . . . . . . . 435
Case 15-2 Hyperkalemia in a Patient Treated With Trimethoprim . . 435
Case 15-3 Chronic Hyperkalemia in a Patient with Type 2
Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436
Chapter 16 Hyperglycemia
Case 16-1 And I Thought Water Was Good for Me! . . . . . . . . . . . . 470
List of Flow Charts
Chapter 2 Tools to Use to Diagnose Acid–Base Disorders
Flow Chart 2-1 Initial Diagnosis of Acid–Base Disorders . . . . . . . . . 37
Flow Chart 2-2 Steps in the Clinical Approach to Patients
with Hyperchloremic Metabolic Acidosis
Based on Evaluating the Rate of Excretion
of NH + Ions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4
Chapter 3 Metabolic Acidosis: Clinical Approach
Flow Chart 3-1 Initial Steps in the Evaluation of the Patient
with Metabolic Acidosis . . . . . . . . . . . . . . . . . . . . 55
Flow Chart 3-2 Determine the Basis of Metabolic Acidosis . . . . . . . 62
Chapter 4 Metabolic Acidosis Caused by a Deficit of NaHCO
3
Flow Chart 4-1 Approach to the Patient with Metabolic
Acidosis and a Normal P . . . . . . . . . . . . . . 71
Anion gap
Flow Chart 4-2 Approach to the Patient with Hyperchloremic
Metabolic Acidosis (HCMA) and a Low Rate
of Excretion of NH + Ions . . . . . . . . . . . . . . . . . . 82
4
Flow Chart 4-3 Approach to the Patient with Distal Renal Tubular
Acidosis (RTA) and a Urine pH Close to 7 . . . . . 85
Chapter 7 Metabolic Alkalosis
Flow Chart 7-1 Pathophysiology of Metabolic Alkalosis
due to a Deficit of Cl– Salts . . . . . . . . . . . . . . . . . 177
Flow Chart 7-2 Clinical Approach to the Patient With Metabolic
Alkalosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Chapter 10 Hyponatremia
Flow Chart 10-1 Initial Steps in the Clinical Approach to the
Patient With Hyponatremia . . . . . . . . . . . . . . . . 276
Flow Chart 10-2 Diagnostic Approach to the Patient With
Chronic Hyponatremia . . . . . . . . . . . . . . . . . . . 286
Chapter 11 Hypernatremia
Flow Chart 11-1 Emergencies Associated With Hypernatremia . . . 322
Flow Chart 11-2 Hypernatremia: Assessing the Renal Response . . 324
Flow Chart 11-3 Hypernatremia With a High Urine Flow Rate . . . . . 325
Chapter 12 Polyuria
Flow Chart 12-1 Approach to the Patient With Polyuria . . . . . . . . . . 344
Flow Chart 12-2 Approach to the Patient With Water Diuresis . . . . 346
Flow Chart 12-3 Approach to the Patient with Osmotic Diuresis . . 350
Chapter 14 Hypokalemia
Flow Chart 14-1 Initial Steps in the Management of a Patient
With Hypokalemia . . . . . . . . . . . . . . . . . . . . . . . 401
Flow Chart 14-2 Determine Whether the Major Basis of
Hypokalemia Is an Acute Shift of K+ into Cells . . 402
xiii
xiv List of Flow Charts
Flow Chart 14-3 Chronic Hypokalemia and Metabolic Acidosis . . . 404
Flow Chart 14-4 Chronic Hypokalemia With Metabolic Alkalosis
and a High U /U . . . . . . . . . . . . . . . . . . 405
K Creatinine
Chapter 15 Hyperkalemia
Flow Chart 15-1 Initial Treatment of the Patient With
Hyperkalemia . . . . . . . . . . . . . . . . . . . . . . . . . . . 443
Flow Chart 15-2 Determine if the Cause of Hyperkalemia
Is a Shift of K+ Ions Out of Cells . . . . . . . . . . . . 445
Flow Chart 15-3 Steps in the Clinical Diagnosis of the Cause
of Chronic Hyperkalemia . . . . . . . . . . . . . . . . . . 446
Chapter 16 Hyperglycemia
Flow Chart 16-1 Diagnostic Approach to the Patient With
a Severe Degree of Hyperglycemia . . . . . . . . . . 482