Cheever K.H.I.V. Therapy Demystified: A Self-Teaching Guide

"

I.V.

Therapy

Dem

ystified

H),p"""'remic condition, t),pic>lIy are

.,,,,,,,J

by treating the underlying

c

.....

fiB'. How"

..

,. pat

;'""

",ho

••

hibi, .iSn>

Of

symptoms

of

hyponatremia

t),pically have dangeroo.l),

low

..

rum

.ooium

""'el.

tha

t

Ole

~"than

120 mEqIL

am

may benefit from LV. infu,ion

of

.j"""

>.ali

..

0<

hype"""ic

..

Ii

...

" n....

pa

'

'''"''

mu.t

be

monitored <.refully bee,

"",

rebound """,br:al

edema

may

OCruf.

Loop di

"relic.

rueh as [urns< mide

(u..i.)

are frequently administered in'r:a

..

lIOIIsly

coocomilat" ,,'ith the hypenooic

..

Ii

..

to

help preven' cerebr.ol edema.' T

.....

""'nt

i.

halted

wben

,be

..

rum

sod

ium I,,',el

r.ad",

.

1ll-130

mEq/I.."

HYPERNATREMI

A

H)'P

"""

',,mia

i,

defil>f<l

as

oc<"llmns when

..

rum

.ooium

le,..,I,

.,ceed

145

mEqlL

Common

<.u""'

and clinic.1 manif

..

tationsofhypem.trem

i

••

re listed

in

T. ble

2_2.

The

most

OOHlmoo

c."",

of

hypem.lr<mi.

i.

dehydr:atioo. which may

result

from

"""iSlenl

diarrbe.

Of

vomiting,

..

,ere

bum

iniurie., and

.",

...

i,'e

u",

of

diuretics.

J>Of1i<ul:uly

oomoli<

d'"relic

s."

~

T"Ol"",n'

1<00>

to

"'

....

,.

arouoo

waling"'"

un<k,lying oau..,. LV.

're

atmen'

i.

_ Ntllmooly iodicatoJ

bee.u",

ocaI

r<hyd ... 'ion

i.

"'"

prefer=!

fi

..

,

_l

i""

"'.'men'

in """" c,"",.· In iMWlCeS

where paI;'ntsconllOl

'ole

.....

"",I

rehyd",'ioo.

lV,

h)'potonic

..

Ii".

..,Iu,ioo.

rruoy

be

iOOicated

for

",,.

',,,,,n',

n.e

...

p,uien"

.I

so may suffer from oe,ebr:al

ede

....

if

obey:ore rehydn"oJ

too

quickly,..-.d 'herefore. Ih< infu

.ion

mu"

proceed .Ic""!y

..-.d

be

"""""l"nied

by

oareful monitoring, In

geDer.ol,

i,

i.

recomm<r.ded 'hat

h.alf

obe

c.k-uI.,oJ

""Iuired

"o

lume

of

hypotonic

wine

should

be

odmini.lCred

"'

..

"

obe

fi",

24

IouB.

wi,h

"'"

balone.

infused

"'

..

" ,he fonov.' ing

72

hours,

n.e

infu.ioo

8"""

...

11),

i

••

topped

wilen

..

rum I. bonllory

""u

I"

iOOic>te

,ho,lh<

palie"'·.

sodium

helm.

..,>rbed Ih<

lowe,

limit

of

normal.

or

145

mEqiL"

Chloride Balance

Chlori<le

CODren

.... 'ioo in

..

rum

mim

..

!ha,

of

sodi

um

in

"'at

sodium..-.d

chloride

"00

to

biod

as

••

h in solUlioo,

n.erefore.

i,

i.

moSI

Iypical llIat when

hyponatremia

OC,""B

.

..,

<10<.

h),pochloremia

.•

od

in c

.....

of

hypern.ttemia.

h),perchloremia also

exi,,,,

lberefore.

'reatmen'

fo,

hypochloremi •

..-.d h)']><f<hloremi 1

mirron

Ih< Ilea'

"",n'

for e i Ihef h

ypon.'remia

or

h)'pern'l!emi

•.

respe<'ivel

y,

Normaloerum chloride 1",

..

1.

""'ge

from

9~

'0

106 mEqlL.

A._oJ

previc.uly. chloride i. Ih< primary

..

""",nu

lar onioo, and i

l>

role

in

m:Unl1ining

~w;i,

lorgely

rupplemen"

"'"

role

of

sodium. bu, i,

.Iso

pl.

ys its own key

role in rruointain ing

aci<l---ba.e

bal~.

CHAPTER

2 Fluids

and

Electrolytes

HYPOCHLOREMIA

H)'~""""

defined

a."

.....

m ohloride

~I

of

Icoo!ban

<r.!

mEqL

Com""",

cou

...

ond

oIinocal

","",festlll"",,,

'"

hypoohlon:mu.

....

I;'I«! in

Table 2-3. H)'poobion:m

..

to

"",,,,,,._NOd

moo,

f'""l""ntlyloy

hl'J'OlU

....

mi

a

"""

.-r"",

""'"

"'"

......

_'v,

fXl

....

"""

oli";.,,,( manif

..

...-

..

h~""",-

H""''"',

....

chloride c

..

bond

... ad,ly _ only

w,'uh

oocIilllD

b ...

abo

,,

-ith

h~"",

(H

').

Whoa

,b

..

0<CIIn.

h)'<lro<hl<rio

..

id (HCl) funDs.

11-.

,,

-

hm

1DdaboI",

.Ihlou.

"",,n

~

"'.

_

ofbrdrnlm

KIIL.-

abo

may

bo<

•

00II<"""

.....

Ioou

'"

cNoride.

no.

poIi ... u

"1th

mnaboIi<:

oIh1oo.i1

ODd

bypocloloo-rmo.

the.d"",

...

y

IftMbo<

...... 'Iy ond

""1"'""ly

in

an

.ffon

'"

COIIIf'"

......

ODd

ron-t<:I

"'"

alk

.....

"

loy

~

..

"'..,

""""'"

lIiou",

"'hdo

i&

..

-.-

.,..

.....

m

ClUI

form

....

boo

...

id.

"",uJU..,

i.

''''''0l0I')"

..

idooi •.

HYPERCHLOREMIA

li)l'"r:ltJo""""

""""

"he.

"'"

...... rn chloride

x.",

.,

<CCd.

106

mEqIL

Common

c

......

"""

<1,,,;.,,,(

....

'r

.... '

......

of

hYP<"<'hlon:m

....

li!lf'd

in

T

obI<

2-

1.

Hyperchion:MI' i."

r"",

...

n'

con.,"".,,,,,.

of

hypcmo .......... _

aoo

~

"'"

umo

co_'

..

fO<1OtO

we"nic

,,1

""",f.!I.e_

•.

fk,.,

.........

in

,

...

~

•

..

'here

IJIfUboloc

..

""""4

"""""

.nd

,hen: i.

on

.'<e>.

of

hyd"'l!<n ion.

~

01""

may

he

• <oneomi' ....

inc

.....

in

d,1oridt

1ev.1.

b«

......

"'"

''''''

ions

f-....n~y

"

,-

(."Ii

.It

..

M..,;r

....

_

'Iy_"'"

s_

..

~""

...

. y

.........

of

"-~

.

,.,....

....

(

...

-.-

"')

s,.,.", "'

.....

/010<

.

_.-

-

......

•

,

_,at"",""

,-

II

,.

......

,-

l"liooioool

M

,

~)I"-'-

S-

..

Mp

0000I

OJ

,

-

)'

h

"...-

~

(

_-'-'

.

l

)

s..'''''''''H' ,

-.

~-

•

,

-,-

,-

I.V.

Therapy Demystified

biod to

fOf11l

HCL

n.e

pati.nt

with

""""bo

l

ic

",,;oo,i. and hyperohloremia

therefore may

ahibit

t""hy"",,'

that

",fl.cr.

an effon to

com""n

..

te by

b

l

owin~

off carbon dioxide.

r"",ltin~

in

respin

tory

.1

••

100i

•.

Potassium Balance

"

Pot=ium

i. the major intracellular cation,

lOOeed.

intr>rollular po",

..

ium

",,·.1. ex.,.,.,,]

oxtrxellular

lewl.

by o,""r

JQ

ti

.....

, Normal serum poussium 1",·.1.

are approximately 3,5_S,0

mEq/L

Pouss

i

um

has

.n

importan' role

in

e",urin~

appropri.te oardi"" ""lIul

..

exci

ubi

lity

..

,,'ell

os

ok."""1 and .moooh muscle

c""tIXti"","

Bec

.....

cardi"".

"ek"'l,

and .mooIh mu",1e cel

l>

"'"

..

quisitely

..

n.itive to the infl

...

oce.

of

poI .

..

ium.

""'min~ly

mi

oo.-

de,il1ion.

from oocm.1

..

rum 1

",

..

1. may

ha

..

major imJ»C"

OIl

oocmol coliular beha,;c... panieularly

cardi"" ""lIul

..

excitability and impulse

roOOOC1ion.

HYPOKALEMIA

H)'P0lcakmia

oocun

"Oen

..

rum poI

...

ium

le",l.

are Ie

..

than 3.5 mEqIL

and i

...

ideoced

by

depre.sed eardi""

acitability

and dec

..

"",d

smoo<h

and

"ele"l

muscle

COIl

traction, Boc,u

..

,he body e.nOOl

.tore

poI=ium.

g."roin

t

c"in.1

los,

of

poussium

through vomiting

or

di •

..m..

can

",pidly

e.u",

hypobl<mi

•. In odditioo.

bee,u",

,he rcn.1 tubule. cxorete exec

..

diet",),

pota

..

ium, u""

of

lcop

diuretic

••

1",

m.y

""""ntuate

po

...

sium tubu

lar

exoretion

and cau""

hypoblemia.

The

..

and other etiologie • • nd clinical

m.nife

.... t

ioo.

of

hy

po

••

lemi. are l

i"ed

in

T.b

le 2_4.

n.e

.arlie"

clinic.1 m:utife .... tioo

of

hy

po

hl

em

i.

i • • n

..

ymplom

at

i<

depre

..

ion

of

,he T

"'

.

'"

00 the electrocardiogram

(ECG), A t),pical IiCG complex

fC4"

• !"'tien'

"'

i

th

hypoblemi.

i. com!",red with

• oomtltl ECG

oompb

in

Fi~,

2_3

la

\ Fir"_IiDe treatment

of

h)'poh

lemi'

""01,

..

"

..

ound

odmini"

..

tioo

of

onl

poI .

..

ium

.uppk...,n"

os

the

most

effecti,.., and

Ie

. " rostly treatment.

H"""",r.

many

J»

t

ien"

o.nOOl

,olerate

onl

pota

..

ium .gents,

n.e""

patients may need to

reoei"" poI

...

ium

'upple"",n,,1

.gents

in

t

..

,

..

""",ly.

Bee.u",

of

i" profound

effect>

on

o

..

di""

<xc

i

ubi

lit

y,

I,

V,

p<>t.assium

mu"

he

admini<lered cau'iou.ly. and

pa

t

ien"

tre. ted

thu.

should he pla<ed on COIltin",,",

e.rdi""

II»Ilitc.-ing.

Pou..ium

"",

..

r may

be

odmini"ered by

LV.

pu.h

C4"

by bolu.

dose

•. Ratber.

poI

...

ium shouk!

be odmiwd

with

an

LV.

",Iu

tioo and admini"ered by

an

infu,ion

"""troller

or

e""trooic

infu.ion device (i,e"

LV.

pump)'"

",'e

001

to exceed

10}

mEqlh.

In

e

.....

wbere • !",tient

i,

""

..

rely

hypobl.mi<

and the infu.ion c. n he administered

,i

••

cen,

...

1 line. then the odmini.tratioo

..

te

may be incre.sed to

20

mEqlh.

•

N

I

!

,

~

I

j

,

I

~

,

~

,

~

l

0

,

•

1

~

.-

J

ri!

!

1!

1

j.

JI

1

i!,

tj!lTil l

J

~~

lfl1

!jj

ljhh

•

-

~

.

!1'1

T

'!I

~

d

~

'ii

.

~

I

rj{:.ff~l

~J

t.>

~

::>.'!-(j(jl££::;""

N

,

~

,

~

E;:

,

£'

<

•

u

! ! 1 I II

Iii

'"I

'lI~~

f

.•

:i

"

'1

" .

,

f"

""

"

lH1i

j

hl

lllMll!n

•

!,

5 {

"r"

I

,!H-li'I'l'

-

ljllHl,l.'!W

Jl!

.,l,

ll,lm!

1

,

, -.

~

II

E

1

~

E

q

~

-=

~

, .

::i~

""

. , '

~

,.

2

Iii

~ ~!:

'

-

~ "l!~

.

~

. ,

• •

. , -

- "

.1'

<t

';

~

E

~

~=

-=

>

'

i~

.....

~

1!'

i:'

~

'j

e

~=

-e

<~H

~

E

~ ~

,g

!

~

]

.ii

~

.;;

h

~~

ll!

~

'2

! ,

""'~

~

"

I.V.

Therapy

Demystified

"

,

•

T

~'"

U

w.,.

'-

tgw

"

2",)

A rxroI1l ECG

..

"""P'f<'d

...

jlb

>II

EeG

from 1

pat"'l

,,'jill

hnlOul<mC:L

(Reptin1«l

~'

i

lh

po<mi

..

ion f

rom

N",,-.l

n.

Ilmdfool

AG: t·mv.'o.!,

of

furlwph)"ioi<>&)'

c

oo

",!",

a",j

'!'pplim';"'"

fa'

H,./,h

Ca,..

P"'ft";"",,h.

2nd

N.

IIooton: WCBJ

McG

....

"'_Hill.199\I:4

17.

)

HYPERKALEMIA

Pa!ienl> with

..,rum

potas.ium

1e>.1s

th

....

coed

5.0

mEqlL

ore

~~""I,mic,

Sine<

"'"

renal ,ubule> pl. y • key role in

e>cretin~

..

""w,

-e die""Y

poI

.

..

ium.

""'

ir failu ,e freqIXnlly

re

,u

l

..

in hyperk>l<mi •. [ngesuoo

of

too moch p<U>.ium.

particula

rly

ocal

poI=ium

,upple"","",

i.

another frequent rulpri' t

ha

t

c,u",

.

hYJ><fhlcmi •. Any

rood

i

ti"".

lhat

0'"'""

wide.pread

""Ilul

arde.lructioo.

iocluding

",.ore

bums. rt..bdomlol),.i._

and

rruolignanl

h),pertbenni.,

re

,u

l,

in

spillage

of

celiul..-rootonts. iocluding poI

...

ium.

in'o

II><

EC

F

'~.

c.u.ing

hype,

ble

mi

•. "

n....

and

otI>er c. u

..

,

and

rommon

clinical

rrum

if

e.lation.

of

hyperk

alemia

are

';<ted

in

T.ble

2-4.

One

of

[he earl;e>! cI .

..

ic

.ig'"

of

hype,b.lemi>

;11<100..

pealing

of

the T

",ye

00

"'"

ECG

(F

i

g.

2-4).

CHAPTER

2 Fluids and Etectrolytes

_.

~

.

...

F1f!u"

1·~

A r.ormoI

f.OO

..

"""p.n<l

"

'IIn

o.n

EOOIfrol

o~

..... w

illl

~

)'p<f1i.:ol<1ni"

(R

rpoinlr<l

..

-I'"

p<fITUWoo

from

1"<,.""

TI,

lI0n0;Jf<>I(J

AO:

£'u"tMb

oflbll.op/oJ"oWU'

COMe'pl<

a.w

Arr1k"""".

"',

1/,.1</,

c."

p"'fr";"""/', 2nd

«I

.

_too,

WCBI

M

<G,.

..

'·HlII

, ' '199:.,7.)

Sorn.,;"",. ,ho

I"""""",),

may ;nace" ... ,ely n:pon a

hi~

pot_ium

1e

..

1 0<1

II><

..

rum

<I><mi

..

')'

..

",

I

I,

. TIIi. rnay h""pt'fI if

II><

l,bo,,"O<)'

.p«im<n

i •

....

ined 01 Iftn.pontd "","moucally.

cau

..

",

dalf'UCli.O<I

'"

~

blood

""II.

(i",,,

1><"",ly.i.). and " "

II

.....

Ii

in 1

fll

..

ly

hi~

..

",m

pot

...

ium ",

...

1,

Thi.

i.

rrl~

I<>

IS

"u_y~rtal

.....

u..

Tho.

may

be

....

"""1«1

,,'hm

0

'l""'

i

m<n

reoull

>«rru

"'Ih

fOl

no

e"'

..

ly

idtnh~lb",

n:.-.

and , ....

polin'

_

....

"ympoomoljc. In

tht

..

in"",,",,.

""

"""

"lO

bI,,

.a

c,oIon-

call

tht

1

"""""0<)'

'0

"'

..

rmine

if

tht

""1,

...

1

'1"""""'"

..

,..

hemoly

....

01

.u!>mi

••

....:and

..,...,i

....

o

fOl

coofinn"""Y

....

Iy

....

"

LV.

Therapy

Demystified

""",,nt.

"'00

are

hypcrl>kmic

wi'" Icyels higber

tIwI

5.6 mEqL

C4"

",ho

.d

libit any clinical ffi2IIife.U1;OO'

of

h)'perbl<mi>

"'"

c.ndidates for

lV.

t1rropy.

The.., patients m

...

'

be

pboed

00

coo.i"""",

cami""

mooiton.

0...

of

the

rruoi

.....

ys

of

lhe

lreatment

ofhypcrblemi.;.

adrniru.terin~

de."'''''''

and ,,,,,,lin

..

an

l.V,

pus'"

As.-d

previously, i

...

lin

facilil2le.

tIr

sodiu~i"mpu"",

thereby

<h

...

in~

IOOre

pous>ium int"

tIr

ICF

c""l""'

....

nt and

out

of

the ECF

<""l""'

.... nt.

H""

.~

.

;

..

lIlin

mm'

be

..!ministered in

coojW>t1ioo

wi'"

de.",

.....

0<

hypoglycemia ""'Y

ensue.

lV.

c. lcium gllX'«\ale

(IWI

is

>II

>gem

IhaJ.

miv--

be

"",<I

to

.ubilire

tIr

electric.1 octi.i.y

of

Ihe

"""'.

Finall

y.

an infu.ion

of

sodium bicarbo"," •

.,

•

r:I1.

"'"

to

..

~

'i{l

mEqIh

C2/l

hove

the elfec1

of

pulling hydrogen ion

(H')oot

of!he ICF and

into

"'"

ECF.

"""iog

addilion:d

I""=,"m

to

be

pul

led

into the ICF compartment."

S

;1ttJ>

11

0

,,"

111,

<arii."

eli.ical

otll';j,,,atio.

of

ItjjN,kal,

..

ia

is a

Oft

,II<

ECG.

Magnesium

Balance

~

M.gnesium

1e,.1s oocmally

"'''ge

re,w.,.,"

1.3

and

to

2.2

mEqlL

)..hgoe

.ium

i.

i

mport.nt

in

e""uring

or,i,

..

,ioo

of

enzyme>. in regul>1ing DNA and RNA

'yot""';,

_ in •

.miliz

ing!he

sodiulJl---jlOWSi

um

pump.:and in m:rintaining

c.lcium

channeloctivity,

HYPOMAGNESEMIA

~

H'fpomag",,,mia

OCCUl'S

wOon

the ..,rum roocentr>.tioo

of

magnesium

i.

Ieos

tIwI

U

mEq.L

It

"""'''

.-

CO

IJllooruy wOrn there

i>

po<><

magnesium

dieury

in~

0<

ab>aptioo

0<

wOon

there

i.

""",,1Cr.OIeJ

magnc

"um

"""",tioo in

the

urine

...

....

y

t.:.ppoo

wOoo

maIly difforent t

ype.

of

diurctin are odmini>tored,'

1Iec

.....

hypoc.lcem;'

n • frequent oon«>mium ocrurrence. the

din"""

manifeswion<

of

hypomagnc""",i. are .imi

l:i

r

to

_ ofhypoc2lcemia

(rompare

Table.

2-~

.00

2-6

).

~

T,

..

tmem

""u)ves

"""'00

providing m:ognesium supplements

.•

ither

or.ol

ly

0<

rolmtonlly,

HYPERMAGNESEMIA

H~'1""""g.,."mia

i.

defined

"'

. serum

roocentn

tioo

of

m.g

....

ium

of

more

than

2.2 mEqlL,

It

.n

.....

"""t

oommooly

...

result

of

rmal

failure

or

bee.u"

of

iog."i""

of

too much m.gne>ium_

ba.ed

.nt>r

i

d,

lIec.u",

m.gne.ium

inhibits the

CHAPTER

2 Fluids and Electrolytes

"'

.....

of

~~kholi

........

ural

i'""'uon

..

~

..

,..

dm.,01 manif<>latioou

"'"

roml""'nI

...

illl

...

·Ido"""'ad

S<IIOOth

and

lhltul

mu","

A"""idily

at>d

!hri,

...........

nonn"po.,.;''''

......

Th,.In\II

..

i"ev<nI..w oardi..,

at>d

~

fail"",

. Conunon

~

at>d

dinkal

...... if

.....

""'"

0(

h~.

OK

di>pla~

011

T

....

2-~.

"

""'V""""'-

"''''''''<

..

.

""P'

...

.

h1*<".xI-'of

""""'''1)

-

.......,

--

--..,

-.

",

Z

""

....

-

'-

-

lI,po.k

......,...

....

~II

,-

M,,*_

"'1"".-,

.....

-

_Ie

...

.-.

I~i·<··

--.

_klootodo,

-Iorpoo

.......

-

--

1I

....

_k

I.V.

Therapy

Demystified

LV.

hyd ... tion to aocele

.....

mlI~ne>ium

reml

",«ction

mlIy be indicatod to

treat hypermoV"'",mi •.

LV.

1"''''

c.lcium

gluconate

mlIy

be admini,

..

red

bee.u",

c.lcium

IUlta~oniz.e.

the effects

of

ma~".&ium.

In

pat;"n" with ei,her

>eVere

hyperm'l\""",mi.

Of

r<n.1

f.ilur<,

hemodialy.i,

moy

he

iodic

..

od

'0

filter and

",cre"

"'''''

..

m.~".,ium.

"

Calcium

Balance

Normal

",rum

oalcium 1",..,1.

r:ange

be"",en

~3

and 5.5 mEqlL.

C.lc

ium

i.

the

prilTW)'

~lectro

l

)1e

tt..,

pr<wides

lh<

....

lIi,

for

""""

•. It

aI",

phy

. a vil2l role

in

ensuring . ppropri

at

e mu",ul>! ronlr>Ctioo .

nd

trnIYl1i

"ion

of

"""

... 1 impulse •.

In

addi,ion.

it

beh

....

os.

clotting factor in the clotting c.

",ade.oo

therefore has

a k

ey

role in

en,urin~

tt..t

hemostatic fuoction

is

maintained.

HYPOCALCEMIA

1I)'pocalc

~mia

i.

<lefined

•• a serum

c.lcium

level

of

Ie

..

th

. n 4

.5

mEqlL.

H)·]>O<.leemi. mlIy

be

c.u,od

by

lUI

in.dequate

in'

n e

of

c.lcium

_rich food.

0<

by

an inadequacy

in vitamin D level •. which

i.

""""""'Y

to en

,u

,e

prop<f

. boorp'ion

of

calcium. A

105,

in

p>r.I

thyroid t.om.one. which ""IS

by

mobilizing o.lcium

"ore'.

m.y

c.

u'"

hy]>O<.lcemi

•.

as

c. n :ocre

le

... ted renal

"'«Olion

of

calcium.

which m. y occur when loop diuretic> .

re

uoed. Injurie. and dise.

se.

tt..t

c.

u'"

wirie'l""ad ","""",i.

c.n

c.

u'"

hy]>O<.leem

i.

bee.

u",

c.lcium

tends to bind

'0

"""fOlic ti

"",,

. Common c.

u"'.

and clinic.1

manife"

..

ion.

of

hy]>O<.lcemi

••

re

li"ed

in

T.bl

e

2_6

Treat"",n' lends to

"""

I

..

around admini<lIatK>n

of

c.lcium

,uppleme

nt

s.

with the

Of

. 1 roule preferred.

If

the pa'ien' i.

",.

orely

h),poc.lcemic

or

.ymp<<>m

atic

.•

n

LV

. infu,ion

of

c.lcium

rruoy

be indic.led in the

form

of

c. lcium gluconate

0<

c.lcium

ohlofido

.'

HYPERCALCEMIA

H),pe!o:tlcemi.

occun

...

..

n tbe serum c. lcium 1e,

..

1

..

coeds 5.5 mEqlL.

Many pa'ien" who are h),percalcemic are

fr:ail

.nd

chrooic.lly ill. l10ey may

be

on

prolonged

bed rest.

c"",in~

<Ie]>!e,ion

of

c. lcium from the booy matrix.

or

,hey fTIlI)'

haY<

malignan' neopl

..

"",

that c.

u'"

hyperc.lcemi

a.

Otherc ....

sesofhyperc

.

lcemi.

ioc J

ude

an exee

..

i ,'e intake

of

eit

herc.lci

urn

0<

,.

itam

in

D and h)' perp.,,"hyroidism.'

CHAPTER

2 fluids and

ElectroLyte

s

"

Addilional

"",,,,,:and

elln.,ol "",nif

••

w"""

of

hy~

ak<mi

.

....

di""I'y«i

0<1

T:obIe

2-6.

~

n..

__

"""""""

ttnl

.....

nl

indk

.l<d

fOl

hypetcalcftni. i.

hydnt

.....

lhenpy

. I.

V.

by_ion

may

bo

ind,

<alnI

in

pol"."

,..he>

~

_.

on!

fluid.

:and

moy

bo

~ed

by

oak;""".

Mid

I.V. pu'" loop

diumin

_

..

f~

(

Uii

, ) ",....uI<1IoI< rmal

uaet_

0(

cakiDm."

&<

...........

""

...

of

<Ok;"'

..

......

.

I)

",J"n'POO"

odoJ

..... ...

I'rnIoop

boO

....

"'POI ' I '

o-

__

of

..

.,.;,

_.,

.

....

_"'

..

,";IP

"-""'''''1

,,1',

I'

_

.............

-,

--

_.

~~

~-...,.,.......~

C r .

..

H)p>«I\o1

..

~~

~

-

_Ie

.....

.,.

-

.........

..-

.

-

Cheever K.H.I.V. Therapy Demystified: A Self-Teaching Guide

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