1Renal Division, St Michaels Hospital, University of Toronto, Toronto, 2Division of Endocrinology, Hospital for Sick Children, Toronto, Canada and 3Nephrology Unit and Department of Internal Medicine, Stellenbosch University, Cape Town, South Africa
Correspondence and offprint requests to: M. L. Halperin, MD, FRCP (C), Division of Nephrology, St Michaels Hospital Annex, 38 Shuter Street, Toronto, Ontario, Canada M5B 1A6. Email: mitchell.halperin{at}utoronto.ca. The authors wish it to be known that, in their opinion, all of the authors contributed equally to this work.
Keywords: extracellular fluid volume contraction; haematocrit; hyperglycaemia; intravenous saline; oliguria; venous PCO2
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Case |
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Assessing the ECF volume |
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Haematocrit
When normal, her blood volume would be 1.5 l (75 ml/kg). With a haematocrit of 40%, her red blood cell (RBC) volume would be 0.6 l and plasma volume 0.9 l (Equation 1). In contrast, with a haematocrit of 61% and the same RBC volume, her blood volume would be
1 l. Thus, with the same 0.6 l RBC volume, her plasma volume would be 0.4 l, reduced by >50%. Only 16/98 respondents to our survey used the haematocrit to assess the degree of ECF volume contraction (Table 2).
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The combination of a low hydrostatic and high colloid osmotic pressure (high albumin concentration and charge: Donnan effect [4]) implies a greater percentage decline in her interstitial than plasma volume. For simplicity, we shall assume that her ECF volume was reduced from 4 l (20% wt) to 2 l. Her blood volume should be better preserved because of the unchanged RBC volume.
Venous PCO2
Normally, the venous PCO2 is 6 mmHg greater than the arterial PCO2. With a low cardiac output, there is a disproportionate rise in venous PCO2 [5]. On admission, her venous PCO2 was 69 mmHg (arterial PCO2: 43 mmHg), implying a very low blood flow rate. No respondent used the venous PCO2 to help assess the circulating volume and its response to therapy.
Oliguria
The extreme degree of hyperglycaemia (PGlu) and oliguria together with the modest elevation in plasma creatinine concentration (Table 1) suggested a recent but marked fall in glomerular filtration rate (GFR) its likely basis was very poor renal perfusion. Perhaps her high blood viscosity decreased flow, especially in the smaller arterioles.
Deficit of Na
The ECF Na deficit was >50% because of ECF volume contraction (>50%) and the PNa of 129 mM (Table 1). Virtually all respondents thought that the Na deficit must be much smaller because of the absence of hypotension (Table 2).
Basis for the extreme degree of hyperglycaemia
Hyperglycaemia is due to either more glucose in the ECF compartment and/or a low ECF volume. Had her GFR been only 20% of normal (0.33 l/h) for the initial 3 h in hospital, she would have excreted almost half of her ECF glucose content [1 l x (110 10) mM or 100 mmol vs an ECF glucose content of 220 mmol on admission (2l x 110 mM)]. A 50% decline in ECF volume raised her PGlu 2-fold. Hence, with the same glucose input from her gastrointestinal tract, the very low ECF volume and GFR could virtually quadruple her PGlu from 500 (27.5 mM) to 2000 mg/dl (110 mM).
Hyperglycaemia and the ECF volume
Hyperglycaemia leads to a higher ECF volume because glucose is an effective osmole for skeletal muscle [6]. Using an imaginary redistribution, her ECF was divided into two iso-osmotic solutions because the glucose-containing one will be excreted rapidly when the GFR rises. For this calculation, we assumed that the glucose solution had a PGlu equal to her effective plasma osmolality (Posm) 368 mOsm/kg H2O in 0.6 l (220 mmol/368 mmol/l). The other 1.4 l contains all the Na with an identical Posm [PNa 184 mM (one-half of 368 mM)]. Hence, this severe degree of hyperglycaemia permitted her to have an ECF volume that was 30% higher than it would have been in the absence of hyperglycaemia [7].
Normal PHCO3
Her low HCO3- content (25 mM x one-half ECF volume) and increased plasma anion gap suggested that she had occult metabolic acidosis. The increase in plasma anion gap was magnified by ECF volume contraction. Because her plasma L-lactate- was 0.9 mM, we suspected that she had diabetic ketoacidosis; unfortunately, her plasma ß-HB concentration was not measured.
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Treatment |
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Rate of infusion of saline. Because she was awake and responded appropriately to questions, her cerebral blood flow was probably not impaired sufficiently to merit aggressive saline administration (>10 ml/kg/h).
Avoiding a fall in the effective Posm. The PGlu will fall due to dilution (infused saline) and glucosuria when the GFR rises [6]. This will lower the effective Posm unless the PNa rises by a similar amount (about one-half the fall in PGlu) [8]. To achieve this constant effective Posm, the tonicity of the intravenous fluids should equal the Posm during oliguria and the urine osmolality (Uosm) during polyuria [11]. Fortunately, the effective Posm and Uosm are similar during a profound glucose-induced osmotic diuresis [12]. Luckily, the osmolality of isotonic saline plus 2040 mM KCl is similar to this Uosm. Her effective Posm on admission was 368 mOsm/kg H2O and 12 h later it fell to only 359 mOsm/kg H2O (PGlu 27 mM and PNa 166 mM). Later, the decline in PNa should occur gradually to minimize rapid brain cell swelling.
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Teaching points |
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i(ii) The rate of saline infusion should be influenced by the urine output and the clinical assessment of the central nervous system status.
(iii) Hypotonic fluids should not be given because of the risk of cerebral oedema.
Conflict of interest statement. None declared.
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References |
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