Nephrogenic Diabetes Insipidus with New-Onset Diabetic Ketoacidosis in a Child- Challenges in Fluid and Electrolyte Management

BackgroundIntensive care management of diabetic ketoacidosis (DKA) is targeted to reverse ketoacidosis, replace the fluid deficit, and correct electrolyte imbalances. Adequate restoration of circulation and treatment of shock is key. Pediatric treatment guidelines of DKA have become standard but complexities arise in children with co-morbidities. Congenital nephrogenic diabetes insipidus (NDI) is a rare hereditary disorder characterized by impaired renal concentrating ability and treatment is challenging. NDI and DKA together have only been previously reported in one patient.Case Diagnosis/TreatmentWe present the case of a 12-year-old male with NDI and new onset DKA with hyperosmolality. He presented in hypovolemic shock with altered mental status. Rehydration was challenging and isotonic fluid resuscitation resulted in increased urine output and worsening hyperosmolar state. Use of hypotonic fluid and insulin infusion led to lowering of serum osmolality faster than desired and increased the risk for cerebral edema. Despite the rapid decline in serum osmolality his mental status improved so we allowed him to drink free water mixed with potassium phosphorous every hour to match his urinary output (1:1 replacement) and continued 0.45% sodium chloride based on his fluid deficit and replacement rate with improvement in his clinical status.ConclusionsThis case illustrates the challenges of managing hypovolemic shock, hyperosmolality, and extreme electrolyte derangements driven by NDI and DKA.

Continuous diagnostic models for volume deficit in patients with acute diarrhea

Background Episodes of acute diarrhea lead to dehydration, and existing care algorithms base treatment around categorical estimates for fluid resuscitation. This study aims to develop models for the percentage dehydration (fluid deficit) in individuals with acute diarrhea, to better target treatment and avoid the potential sequelae of over or under resuscitation. Methods This study utilizes data from two prospective cohort studies of patients with acute diarrhea in Dhaka, Bangladesh. Data were collected on patient arrival, including weight, clinical signs and symptoms, and demographic information. Consecutive weights were obtained to determine the true volume deficit of each patient. Data were entered into two distinct forward stepwise regression logistic models (DHAKA for under 5 years and NIRUDAK for 5 years and over). Results A total of 782 patients were included in the final analysis of the DHAKA data set, and 2139 were included in the final analysis of the NIRUDAK data set. The best model for the DHAKA data achieved an R2 of 0.27 and a root mean square error (RMSE) of 3.7 (compared to R2 of 0.06 and RMSE of 5.5 with the World Health Organization child care algorithm) and selected 6 predictors. The best performance model for the NIRUDAK data achieved an R2 of 0.28 and a RMSE of 2.6 (compared to R2 of 0.08 and RMSE of 4.3 with the World Health Organization adolescent/adult care algorithm) and selected 7 predictors with 2 interactions. Conclusions These are the first mathematical models for patients with acute diarrhea that allow for the calculation of a patient’s percentage dehydration (fluid deficit) and subsequent targeted treatment with fluid resuscitation. These findings are an improvement on existing World Health Organization care algorithms.

Excessive distension absorption in patient went through hysteroscopic surgery distended with 5%mannitol solution : a retrospective study.

Objective: To estimate the incidence of excessive distension absorption in the patient went through hysteroscopic surgery distended with 5% mannitol solution, to evaluate the use of 5% mannitol solution for hysteroscopic surgical procedure specifically and to testify the safe threshold for distension absorption. Design: Retrospective. Setting: Academic medical center. Patients: 10693 patients went through inpatient hysteroscopic surgery distended with 5% mannitol solution using monopolar electrosurgical instrument from Jan. 2015 to Sep. 2020. Intervention(s): None. This study has been approved by the Ethics Committee of Sun Yat-sen Memorial Hospital. Measurements and Main Results: Fluid deficit more than 1000mL is defined as excessive distension absorption. Incidence of excessive distension absorption in all the inpatient hysteroscopic surgeries is 0.46% (49/10693). It is 2.57% (16/623) in transcervical resection of fibroid (TCRF), 2.36% (9/381) in retained products of conception (RPOC) removal, 1.20% (6/501) in hysteroscopic uterine septum resection (HSR), 0.53% (14/2621) in transcervical resections of adhesion (TCRA) while in the severe cases it was 2.34% (14/598), 0.48% (4/828) in transcervical resection of the endometrium (TCRE). Excessive distension absorption developed within ten minutes in two cases. Twelve of thirty nine patients with fluid deficit under 2500mL presented with clinical consequences related to circulation overload. Conclusion: Incidence of excessive distension absorption could be low generally however it would be five times higher in TCRP, RPOC removal and TCRA. Resection by needle electrode may contribute to the excessive distension absorption developed within short time. 30.77% of the patients could not tolerate the less than 2500mL distension absorption.

Fluid balance

This chapter will tell you how surgery affects fluid balance and how the body controls fluids. Fluid compartments in the body and the nature of fluids are described. Disorders of fluid balance, the use of fluids to restore blood volume, and extra cellular fluid volume are all discussed. Management of fluid deficit, fluid overload, and pulmonary oedema and how to correct electrolyte balance are all clearly set out. Recommendations for fluids after different types of surgery and fluids for patients with renal and cardiac failure are given.

Fluid assessment and associated treatment

This chapter explores the normal anatomy of the intravascular, interstitial, and intercellular fluid compartments, the mechanism of normal fluid homeostasis and compensatory mechanisms. The common causes of fluid deficit and fluid excess are highlighted alongside the role of fluid assessment and replacement using intravenous therapy using fluids or blood products. This also discussed with reference to the nurse’s role in evaluating fluid status. Finally, there is also a useful section on the metabolic emergencies of diabetic ketoacidosis and hyperglycaemic hyperosmolar syndrome.

Signs of Dehydration after Hip Fracture Surgery: An Observational Descriptive Study

Background and Objectives: Dehydration might be an issue after hip fracture surgery, but the optimal tools to identify the dehydrated condition have not been determined. The aim of the present study was to compare the characteristics of elderly postoperative patients who were classified as dehydrated according to the methods used in the clinic. Materials and Methods: Thirty-eight patients aged between 65 and 97 (mean, 82) years were studied after being admitted to a geriatric department for rehabilitation after hip fracture surgery. Each patient underwent blood analyses, urine sampling, and clinical examinations. Results: Patients ingested a mean of 1,008 mL (standard deviation, 309 mL) of fluid during their first day at the clinic. Serum osmolality increased significantly with the plasma concentrations of sodium, creatinine, and urea. Seven patients had high serum osmolality (≥300 mosmol/kg) that correlated with the presence of tongue furrows (p < 0.04), poor skin turgor (p < 0.03), and pronounced albuminuria (p < 0.03). Eight patients had concentrated urine (urine-specific gravity ≥ 1.025) that correlated with a low intake of liquid and with a decrease in body weight during the past month of −3.0 kg (25–75 th percentiles, −5.1 to −0.9) versus +0.2 (−1.9 to +2.7) kg (p < 0.04). Conclusions: Renal fluid conservation of water, either in the form of hyperosmolality or concentrated urine, was found in 40% of the patients after hip fracture surgery. Hyperosmolality might not indicate a more severe fluid deficit than is indicated by concentrated urine but suggests an impaired ability to concentrate the urine.

Regional brain responses associated with using imagination to evoke and satiate thirst

In response to dehydration, humans experience thirst. This subjective state is fundamental to survival as it motivates drinking, which subsequently corrects the fluid deficit. To elicit thirst, previous studies have manipulated blood chemistry to produce a physiological thirst stimulus. In the present study, we investigated whether a physiological stimulus is indeed required for thirst to be experienced. Functional MRI (fMRI) was used to scan fully hydrated participants while they imagined a state of intense thirst and while they imagined drinking to satiate thirst. Subjective ratings of thirst were significantly higher for imagining thirst compared with imagining drinking or baseline, revealing a successful dissociation of thirst from underlying physiology. The imagine thirst condition activated brain regions similar to those reported in previous studies of physiologically evoked thirst, including the anterior midcingulate cortex (aMCC), anterior insula, precentral gyrus, inferior frontal gyrus, middle frontal gyrus, and operculum, indicating a similar neural network underlies both imagined thirst and physiologically evoked thirst. Analogous brain regions were also activated during imagined drinking, suggesting the neural representation of thirst contains a drinking-related component. Finally, the aMCC showed an increase in functional connectivity with the insula during imagined thirst relative to imagined drinking, implying functional connectivity between these two regions is needed before thirst can be experienced. As a result of these findings, this study provides important insight into how the neural representation of subjective thirst is generated and how it subsequently motivates drinking behavior.