VITAMINS, MINERALS, FLUIDS & ELECTROLYTES
VITAMIN THERAPY
• FAT SOLUBLE VITAMINS– A (CHART 12-1)– D– E– K
• WATER SOLUBLE VITAMINS– B VITAMINS– C (CHART 12-2)
Vitamin A
• AQUASOL (capsules, drops, tabs, IM)– Retinal function, bone growth, reproduction,
epithelial and MUCOSAL tissue integrity• Po forms require normal fat absorption• Protein bound• Stored in normal liver for 2 years
– MEN: 1,000 mcg re(retinol equivalents) or 4,000U
– WOMEN: 800mcg RE or 4,000 U
VITAMIN D
• Calciferol: Adults = 200 IU (PO, IM)– Rickets– Hypoparathyroidism– Familial phosphatemia
• Drug interactions:– Steroids antagonize Vit D– Thiazides can increase calcium– Verapamil AF due to high calcium
VITAMIN E
• Men: 10 alpha-tocopherol equivalents/15 IU• Women: 8 alpha-TE/12IU
– PO
• Depends on bile for absorption• Drug-Drug Interactions
– Increases daily iron need– Decreases Prothrombin– Antagonized Vit K
VITAMIN K
• Phytonadione (PO or IM, SC, IV) controls abnormal bleeding due to malabsorption, drug therapy, or Vit A toxicity– Men >25: 80 mcg– Women >25: 65 mcg
• PRODUCT IS LIGHT-SENSITIVE.
• WRAP IV BAG IN FOIL.
VITAMIN C
• RDA: ADULTS = 60 mg• Therapeutic use: 300 – 500 mg for short
course in burns, fractures, post-op healing, severe febrile or chronic disease.
• Low protein binding activity– Decreases with high dose ASA– Decreases warfarin– Increases estrogen; iron absorption
B Vitamins
• B1 – Thiamine (po, iv, im)• ANGIOEDEMA, CV COLLAPSE,
HEMORRHAGE, PULMONARY EDEMA
• B2 – Riboflavin ( Adults: 1.3 – 1.4 mcg)• Tissue respiration
• Use cautiously with probenecid
• Discolors urine yellow/orange
B Vitamins
• B3 - Niacin (PO, slow IV, IM, SC)
– Stimulates lipid metabolism, tissue respiration, glycogenolysis
– Decreases low density lipoprotein– Dilates peripheral blood vessels– Adverse reactions: arrythmias, hepatic
dysfunction– Potentiates orthostatic hypotension
B Vitamins
• B6 (Pyridoxine) (1.6 – 2 mg) PO, IV, IM
– Coenzyme in amino acid metabolism– Antidote for INH poisoning– Metabolized in liver decreased levels of
anticonvulsants– Alcoholics can experience delirium and lactic
acidosis
B Vitamins
• B 12 (cyancobolamin) : RDA = 2mcg – PO, IM/SC– for dietary supplementation or after sub-total
gastrectomy or in GI disease: 30 mcg IM qd x 5 days; then 100 – 200 mcg IM q month
– For pernicious anemia: 100 mcg IM/SC qd x 6-7 days; then 100 mcg IM/SC q month
• Avoid with ETOH, aminoglycosides, chloramphenicol, and PAS
• Anaphylaxis can occur
FOLIC ACID
• Vitamin B stimulates erthyropoiesis and nucleoprotein synthesis– Prevents megaloblastic anemia
• Adults: 180 – 200 mcg (higher in pregnancy)• Drug-drug concerns:
– Any folic acid antagonist, e.g., trimethoprim, methotrexate; decreases levels of anticonvulsants
– ETOH increases folic acid requirements
VITAMIN SUPPLEMENTS
• RATIONALE:– THE SOIL IN WHICH WE PRODUCE OUR FOOD
IS DEPLETED OF MINERALS
– THE AMERICAN DIET DOES NOT MEET OUR MINIMUM DAILY REQUIREMENT
• CAUTIONS:– MEGADOSES OF VITAMINS ARE NEITHER
NECESSARY NOR HARMLESS• EXCESS FAT SOLUBLE VITAMINS MAY BE STORED IN
THE BODY FOR EXTENDED PERIODS OF TIME
VITAMIN SUPPLEMENTS
• JUSTIFICATIONS– INADEQUATE ABSORPTION
• MALABSORPTION,• DIARRHEA • INFECTION • INFLAMMATORY BOWEL DISEASE
– IMPAIRED UTILIZATION• LIVER OR RENAL DISEASE • GENETIC DISORDERS
VITAMIN SUPPLEMENTS
• JUSTIFICATIONS– EXCESSIVE LOSSES
• FEVER
• HYPERTHYROIDISM
• HEMODIALYSIS
• STARVATION, CRASH OR LIMITED DIETS
VITAMIN SUPPLEMENTS
• JUSTIFICATIONS– INCREASED REQUIREMENTS
• GROWTH
• PREGNANCY
• DEBILITATING DISEASES
• GI SURGERY
• RESTRICTED DIETS
VITAMIN EXCESS
See Instructor’s Notes on the Web
FLUIDS & ELECTROLYTES
• FLUID REPLACEMENT– WATER
• ELETROLYTE REPLACEMENT– SODIUM, POTASSIUM
• ACID-BASE BALANCE
FLUID REPLACEMENT: crystalloid solutions
2.5% DEXTROSE IN WATER
5% DEXTROSE IN WATER
10% DEXTROSE IN NORMAL SALINE
0.45% SALINE 0.9% NORMAL SALINE SOLUTION or
LACTATED RINGER’S
3 % SALINE
COLLOIDS: large molecule solutions
• PROVIDE PROTEIN, FLUID, AND CALORIES FOR WOUND HEALING
• ALBUMIN, DEXTRAN
– Increase PLASMA VOLUME and OSMOTIC PRESSURE TO COUNTERACT SHOCK
• REDUCES RED CELL AGGREGATION AND ENHANCES BLOOD FLOW– Contraindicated in HEMORRHAGE, RENAL
FAILURE, DEHYDRATION THROMBOCYTOPENIA
COLLOID CONTROVERSY
• INCREASED COST OVER CRYSTALLOID SOLUTIONS
• DIFFERENTIAL MORTALITY
• THE ROLE OF HEALTH SERVICES RESEARCH
• INFLUENCE OF MANAGED CARE IN CLINICAL DECISIONS
ELECTROLYTES
• INTRACELLULAR: K– 140 mEq, mainly in muscle
• EXTRACELLULAR: Na– 140 mEq, mainly in serum
ACID – BASE BALANCE
• THE EQUILIBRIUM IN THE EXTRA- CELLULAR FLUID BETWEEN– SUBSTANCES ABLE TO GIVE UP H+ IONS
(ACIDS) AND – SUBSTANCES ABLE TO ACCEPT H + IONS
(BASES)• RESPIRATORY ACID-BASE CONTROL• RENAL MECHANISM FOR METABOLIC
CONTROL
CASE
• MR. BROWN, 68, HAS ACUTE PNEUMONIA, A PRODUCTIVE COUGH, CYANOSIS, LABORED BREATHING AT 28 BREATHS PER MINUTE– PaO2 = 56 mmHg– SaO2 =88%– pH=7.32 – PaCO2=50mmHg– HCO3=24 mEq/L
CASE
• MRS. C, 36, HAD DILATED CARDIOMYOPATHY, ORTHOPNEA, DOE, DRY, NON-PRODUCTIVE COUGH. SHE IS DIZZY, C/O TINGLING IN ETREMITIES. HAS FINE CRACKLES. R=32/MIN
– PaO2 = 93 mmHg
– SaO2 = 98%
– Ph = 7.48
– PaCO2= 32mmHg
– HCO3 = 24 mEq/L
CASE
• LAURIE, 6 MOS OLD, HAD A BOWEL RESECTION FOR HIRSCHSPRUNG’S DISEASE. SHE HAS AN NG TUBE, IVs. URINE OUTPUT IS 0.4CC/HR. RESPIRATIONS ARE NORMAL.
– PaO2 = 90 mmHg
– SaO2 = 95%
– pH = 7.49
– PaCO2 = 45mmHg
– HCO3 = 30 mEq/L
NUTRITIONAL SUPPORT
• INSERT TUBE ABOUT 25 CM IN ADULTS
• INSUFLATE WITH AIR AND ASPIRATE FLUID
• TEST ITS Ph and APPEARANCE• pH <5 + green/brown color = gastric location
• pH >6 + yellow bile stained = duodenum
• pH>6 + mucus, straw colored fluid = ?lung
BLOODLESS SURGERY
• MEETS THE NEEDS OF PATIENTS FOR WHOM TRANSFUSIONS ARE NOT POSSIBLE OR DESIREABLE– EPOGEN PREOPERATIVELY– INDUCED HYPOTENSION OR
HYPOTHERMIA– HEMODILUTION WITH COLLOIDS– REINFUSION AND AUTOINFUSION