Pharm 343 Course Overview: Fluid Imbalance PDF

Pharmacy 343: Pharmacotherapy 2 Course Overview & Conditions of Fluid Imbalance Scot H. Simpson, BSP, PharmD, MSc Professor Pronouns: He, Him...

Pharmacy 343: Pharmacotherapy 2 Course Overview & Conditions of Fluid Imbalance Scot H. Simpson, BSP, PharmD, MSc Professor Pronouns: He, Him ©2024, Scot H. Simpson Copyright-protected material contained herein is reproduced either with permission from the rights holder or under the terms of the Copyright Act. This material is being made available for your individual use; other use of this material has not been authorized and may require permission of the rights holder  Lecture Objectives / Outline Provide a brief overview of Pharm 343 – Objectives, schedule, assessment, resources Describe conditions of fluid Imbalance (Dehydration & Edema) – Signs and Symptoms – General Approach to Management Related Readings (Pharmacotherapy 12th ed.): – Chapter 68 (Disorders of Sodium and Water Homeostasis) 2  Course Objectives Develop fundamental knowledge of the following: – Fluid / Electrolyte Imbalances – Laboratory Values – Renal Disease (Acute & Chronic) – Lower Urinary Tract Symptoms – Endocrine Conditions Help patients and clinicians with prevention and management of these conditions Epidemiology & Risk Factors Therapeutic Approaches 3  Course Topics Fluid/Electrolytes & Laboratory Values – Fluid Imbalances (1 lecture) – Electrolyte Imbalances (2 lectures & 1 seminar) – Laboratory Values (3 lectures) – Acid / Base Conditions (1 lecture & 1 seminar) Renal Conditions – Chronic Kidney Disease (6 lectures & 1 seminar) Drug dosing in Renal Impairment – Acute Kidney Injury (2 lectures & 1 seminar) Lower Urinary Tract Symptoms (4 lectures) Calcium / Parathyroid Hormone / Vitamin D (1 lecture) Renal Replacement Therapies (1 lecture) MIDTERM 4  Course Topics Diabetes (13 lectures & 2 seminars) – Type 1 (Insulin Management) – Type 2 (Oral Antihyperglycemic Drugs, Insulin & Others) – Complications (Acute and Chronic) Thyroid Conditions (2 lectures) Hypothalamus-Pituitary-Adrenal Axis Conditions (1 lecture) Natural Health Products for Diabetes & Course Review (1 lecture) FINAL (Cumulative) 5  Assessment Pre-Seminar Quiz (6x2.5%) – Multiple choice and short answer questions – Access opens at noon on Monday and closes at 9:30 AM Thursday Midterm (30%) – October 30 during class time (50 minutes) – Multiple choice, select all that apply, and short answer questions Final (55%) – December 13, 1 – 2:50 PM (1h50min) – Cumulative (approximately 20% of exam will come from pre-midterm) – Multiple choice, select all that apply, and short answer questions Read the section “Additional Information about Assessments” in the syllabus 6  Seminars Designed to help students integrate information from lectures, textbooks, and associated readings by using cases representing typical clinical encounters and questions Attendance is mandatory (Skill-based Outcomes) – Collaborative learning approach – Conduct patient assessments – Locate sources of information needed to provide patient care – Develop a therapeutic monitoring plan – Manage clinically significant adverse drug reactions and drug interactions Alternate Work for missed seminars – Google Form: provide brief responses to selected questions from seminar cases 7  Resources Required Textbook: – Pharmacotherapy: A Pathophysiologic Approach (DiPiro, Matzke, Posey, Talbert, Wells) Additional Textbooks & Other Readings: – Pathophysiology of Disease (Hammer, McPhee, Kwok) – Rang & Dale’s Pharmacology (Rang, Ritter, Flower, Henderson) – Clinical Practice Guidelines (e.g., Diabetes Canada) eClass – Questions from students (check for updates) Initial response will provide direction towards material that will help answer your question – General course information (e.g., Course Outline and Syllabus) – Seminar material (e.g., Group lists for seminar rooms) – Lecture handouts & supplemental materials – Recall questions (Google Form or Mentimeter) – Marks with class average 8 9  Lecture Objectives / Outline Provide a brief overview of Pharm 343 – Objectives, schedule, assessment, resources Describe conditions of fluid Imbalance (Dehydration & Edema) – Signs and Symptoms – General Approach to Management Related Readings (Pharmacotherapy 12th ed.): – Chapter 68 (Disorders of Sodium and Water Homeostasis) 10  Fluid (Water) Balance Total body water (TBW) represents 45-60% of total body weight Distribution into two (three?) compartments: H2 O 11 Source: www.peterloewen.com (Sodium & Water Assessment & Therapeutics)  Normal Fluid Balance Osmotic pressure maintains distribution of fluids in the compartments – Concentration of dissolved ions (electrolytes), proteins, and other large molecules – Water moves freely across cell membranes to maintain osmotic equilibrium WA TE WA R TE R Hypotonic Isotonic Hypertonic Solution Solution Solution 12  Normal Fluid Balance Osmotic pressure maintains distribution of fluids in the compartments – Concentration of dissolved ions (electrolytes), proteins, and other large molecules – Water moves freely across cell membranes to maintain osmotic equilibrium Intracellular fluid (ICF) volume is critical for normal cell function – e.g., alterations to ICF volume in the brain can result in significant dysfunction (confusion ⟹ death) Extracellular fluid (ECF) volume is essential for tissue perfusion (delivery of oxygen & nutrients; removal of metabolic waste products) 13  Conditions Related to Fluid Status When assessing a patient’s clinical fluid status, we are mostly concerned with the extracellular fluid volume (interstitial water and intravascular water [serum/plasma/blood volume]) Blood volume and serum osmolality are tightly regulated (homeostasis) Homeostasis can be disrupted by a variety of acute and chronic diseases as well as the intended and unintended effects of drug therapy 14  Patient Encounter - 1 Jane, a 35 year old female, is in your pharmacy asking for help with diarrhea. She is experiencing severe stomach cramps and diarrhea for the past 2 days. The diarrhea is watery, occurs several times per day, and does not have blood or mucous. Her temperature is 38°C. She thinks this may be the stomach flu as her youngest child was recently sick as well. What do you need to consider before developing a plan? 15  Patient Care Process 16 Source: Patient Care Process 2018. Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta & Regional Pharmacy Services, Alberta Health Services.  Patient Assessment Pause and reflect on the encounter information Mentimeter 1. List one item from the patient encounter that helps describe the History of Present Illness (HPI) (Recall the SCHOLAR-E questions…) 2. List one physical characteristic you would look for 17  Signs & Symptoms of Dehydration Dry mucous membranes Skin tenting (poor skin turgor) ↓Urine output Postural changes: (lying ⟹ standing) dizziness, HR↑, SBP↓ Cool extremities ↓Capillary refill ↓Cognitive function Sunken eyes (orbital depression) 18  Signs & Symptoms of Dehydration in an Infant or Young Child Dry mouth and tongue Lack of tears when crying No wet diaper for 3 hours Sunken eyes, cheeks Sunken soft spot on top of skull Listlessness or irritability (change from normal behaviour) Send for medical attention immediately. Jane’s youngest child was also recently sick – have they recovered or need medical attention? 19  Dehydration Management Typical maintenance is 2000-3000 mL/day – 6-8 x 250 mL glasses of water per day If the patient is mildly dehydrated, encourage them to drink (water, WHO-ORS, water+salt, sports drink) Depending on severity, referral for medical attention may be necessary along with intravenous fluid replacement Distribution of 1000 mL* Tonicity ICF ECF D5W (5% Dextrose†) Hypotonic 666 mL 333 mL 0.45% NaCl (half normal saline) Hypotonic 333 mL 666 mL Lactated Ringer’s Isotonic 30 mL 970 mL 0.9% NaCl (normal saline) Isotonic 0 1000 mL 3% NaCl (hypertonic saline) Hypertonic -2000 mL 3000 mL †Dextrose is an ineffective osmole 20 *Source: www.peterloewen.com (Sodium & Water Assessment & Therapeutics)  Patient Encounter - 2 William is a 62 year old, long-term client of your pharmacy. His medical history includes hypertension, hyperlipidemia, and heart failure. He is in the pharmacy today picking up a refill for one of his medications. You notice he is short of breath and ask about this condition. William says he has felt short of breath for the past 2-3 days and it feels worse at night when he lies down to go to sleep. 21  Signs & Symptoms of Edema Excess fluid volume in the extracellular compartment – Usually caused by heart, kidney, or liver failure – Also occurs in pregnancy and malnutrition First sign is often swelling in the feet, ankles, and lower legs ⟹ described as pitting edema http://www.med-health.net/images/10437462/image001.jpg 22 https://www.uptodate.com/contents/heart-failure-the-basics/print  Signs & Symptoms of Edema Pulmonary edema – Increase in respiratory rate – Shortness of breath sensation – Crackles (rales) present on auscultation Weight gain Increased jugular venous pressure Positive hepatojugular reflux: firm pressure over the liver temporarily increases venous return to the heart – https://www.youtube.com/watch?v=JxyECMTEmmc 23  Management Correct the underlying cause – Heart failure – Sodium restriction (1,000 to 2,000 mg/day) Medications: diuretics (↑ renal sodium excretion) – Loop diuretics (furosemide, ethacrynic acid) – Thiazide diuretics (hydrochlorothiazide, chlorthalidone, metolazone) – Potassium sparing diuretics (triamterene, amiloride, spironolactone) 24  Reflecting on the Learning Objectives… Review principles of fluid homeostasis Describe the signs and symptoms of fluid imbalance – Dehydration – Edema Describe an approach to management of conditions of fluid imbalance – Patient Care Process (focus on HPI) – Dehydration – Edema 25