Fluid intake restriction

Hyponatremia Clinically significant hyponatremia generally occurred during the first 3 months of treatment with oxcarbazepine, although there were patients who first developed a serum sodium less than 125 mmol/L greater than 1 year after initiation of therapy. Most patients who developed hyponatremia were asymptomatic, but patients in the clinical trials were frequently monitored and some had their oxcarbazepine dose reduced or discontinued or had their fluid intake restricted for hyponatremia. When oxcarbazepine was discontinued, normalization of serum sodium generally occurred within a few days without additional treatment. 

Adequate fluid intake is also important the recommended intake for people who do not require fluid restriction is 6 to 8 eight-ounce glasses of water daily. 

Fluid restriction is generally unnecessary as long as sodium intake is controlled. The thirst mechanism remains intact in CKD to maintain total body water and plasma osmolality near normal levels. Fluid intake should be maintained at the rate of urine output to replace urine losses, usually fixed at approximately 2 L/day as urine concentrating ability is lost. Significant increases in free water intake orally or intravenously can precipitate volume overload and hyponatremia. Patients with stage 5 CKD require renal replacement therapy to maintain normal volume status. Fluid intake is often limited in patients receiving hemodialysis to prevent fluid overload between dialysis sessions. 

Nonpharmacologic interventions include cardiac rehabilitation and restriction of fluid intake (maximum 2 L/day from all sources) and dietary sodium (approximately 2 to 3 g of sodium per day). 

Several factors predispose to lithium toxicity, including sodium restriction, dehydration, vomiting, diarrhea, drug interactions that decrease lithium clearance, heavy exercise, sauna baths, hot weather, and fever. Patients should be told to maintain adequate sodium and fluid intake and to avoid excessive coffee, tea, cola, and other caffeine-containing beverages and alcohol. 

Urinary alkalinization- Urates tend to crystallize out of an acid urine therefore, a liberal fluid intake is recommended, as well as sufficient sodium bicarbonate (3 to 7.5 g/day) or potassium citrate (7.5 g/day) to maintain an alkaline urine continue alkalization until the serum uric acid level returns to normal limits and tophaceous deposits disappear. Thereafter, urinary alkalization and the restriction of purine-producing foods may be relaxed. 

I.c.2.1. Fluid intake. This includes restriction of fluid intake to less than 1 liter per day if, as in oliguric renal failure, daily urine volumes are 500 ml or less and daily insensible losses are estimated to be 500-700 ml. In non-oliguric renal failure daily urine losses plus insensible losses may be in excess of 2 1/day and daily intake obviously has to be adjusted accordingly. Careful balance of intake and output of fluid and electrolytes is extremely important in ARF patients, both oliguric and non-oliguric. 

Geriatric Considerations - Summary Not well-studied in older adults however, a iapanese trial included older adults up to 85 years of age. Contraindicated in patients with creatinine clearance less than 50ml/min. Slow titration is required. Patients should maintain fluid intake to reduce the risk of renal stones. Restrictions for use in renal impairment prevent its use in many older adults. 

Case reports have indicated an association between SSRIs and the syndrome of inappropriate secretion of antidiuretic hormone. Symptoms include lethargy, headache, hyponatremia, increased urinary sodium excretion, and hyperosmotic urine. Acute treatment of this syndrome should consist of discontinuation of the drug as well as restriction of fluid intake. Patients experiencing severe confusion, convulsions, or coma should receive intravenous sodium chloride. Elderly persons may he at a higher risk for developing this syndrome. 

Since indinavir is an inhibitor of CYP3A4, numerous and complex drug interactions can occur (Tables 49-3 and 49-4). Combination with ritonavir (boosting) allows for twice-daily rather than thrice-daily dosing and eliminates the food restriction associated with use of indinavir. However, there is potential for an increase in nephrolithiasis with this combination compared with indinavir alone thus, a high fluid intake (1.5-2 L/d) is advised. 

Mr KT should be advised to reduce his weight and reduce his alcohol intake. He should restrict his intake of red meats and food with a high purine content (e.g. meat extracts, kidney, liver, crab, anchovies, mackerel and sardines) and he should aim to increase his fluid intake to about 2 litres per day (assuming that he is not fluid restricted). 

Eight years after stopping lithium because of polydipsia and polyuria, a 55-year-old woman was hospitalized with lethargy, coma, and hypernatremia (sodium concentration 156 mmol/1) after her fluid intake had been restricted (391). 

Dietary restriction of sodium causes lithium retention and an increased risk of toxicity. The same would be true of a diet that markedly restricted fluid intake. In brief, dietary extremes should be avoided. 

The first step in managing chronic HF is to determine the etiology or precipitating factors. Treatment of underlying disorders (e.g., anemia, hyperthyroidism) may obviate the need for treating HF. Nonpharmacologic interventions include cardiac rehabflitation and restriction of fluid intake (maximum 2 L/day from all sources) and dietary sodium (approximately 2 to 3 g of sodium per day). 

May need to restrict fluid intake because of risk of developing syndrome of inappropriate antidiuretic hormone secretion, hyponatremia and its complications... 

The electrolytes and acid-base balance should be restored in careful coordination with the renal function. In hyponatraemia, either the fluid intake should be reduced to 700-1,000 ml/day, or a combination of a hypertonic salt solution (3%) and a loop diuretic should be administered intravenously, (s. p. 308) Likewise, an attempt can be made using a combination of diuretics and urea diuresis. Generally, sodium and water intake should be restricted. It is imperative to achieve an even volumetric balance, possibly supported by the cautious intake of fluid. 

When diuretics are administered at the same time, it is not absolutely necessary to adhere to strict salt restriction. We followed the recommended 6-8 g/day. Indeed, such a moderate restriction is usually observed more reliably by the patient. Reducing water intake to 1.5-2.0 1/day is also sufficient. Only a hyponatraemic condition of <130 mmol/1 requires a reduction in fluid intake to <1,000 ml/day. Determination of fractional sodium elimination (FEnJ may point to potential success even before treatment has begun with a value of >0.5%, treatment steps 1 and 2 (see above) will achieve a probable success rate of about 95%. This favourable initial situation is supported by a still sufficient spontaneous sodium excretion of >40 mmol/day. Therapy resistance must be anticipated when fractional sodium elimination is <0.1% and sodium excretion is <10 mmol/day. If treatment steps 1—4 are unsuccessful or renal function is clearly impaired initially and FENa is <0.1%, the insertion of a peritovenous shunt (PVS) should be considered. This procedure is designed to make use of the principle of ascites reinfusion for as long as possible, (s. tabs. 16.14—16.18) (s. p. 311) TIPS may also prove to be an alternative to PVS, especially when using a polytetrafluoroethylene-covered stent to prevent occlusion. (Ill) (s. fig. 16.15) (s. pp 259, 314, 362)... 

In addition, one must remember that for infants the amount of fluid required for drug administration may take away from the amount of fluid available for nutrition. Thus, with medication administration, the fluid volume must be as restrictive as possible so that the bulk of the daily fluid intake can be saved for nutrition. Health care providers must closely monitor daily fluid intake from all sources to prevent fluid overload and must also watch the osmolality of medications with diluents. 

IV should be administered over 5-10 seconds restrict fluid intake. 

The urinary osmolality of normal individuals may vary widely, depending on the state of hydration. After excessive intake of fluids, for example, the osmotic concentration may fall as low as 50 mOsm/kg/H20, whereas in individuals with severely restricted fluid intake, concentrations of up to 1400mOsm/kg/H2O can be observed. In individuals on an average fluid intake, values of 300 to 900 mOsm/kg/H20 are typically seen. If a random urine specimen of a patient has an osmolality of >600 mOsm/kg/H20 (or >850mOsm/kg/ H2O after 12 hours of fluid restriction), it can generally be assumed that the renal concentrating ability is normal. 

The autonomous, sustained production of AVP in the absence of known stimuli for its release is called SIADH. In this syndrome, plasma AVP concentrations are inappropriately increased relative to a low plasma osmolality and to a normal or increased plasma volume. SIADH may be the result of one of several factors production of vasopressin by a malignancy (such as a small cell carcinoma of the lung), the presence of acute and chronic diseases of the central nervous system, pulmonary disorders, or a side effect of certain drug therapies. In addition, as many as 10% of patients undergoing pituitary surgery have a transient SIADH approximately 8 to 9 days after surgery (when the patient is at home), which responds to water restriction (2 to 3 days) and resolves without recurrence. In SIADH, a primary excess of AVP, coupled with unrestricted fluid intake, promotes increased reabsorption of free water by the kidney. The result is a decreased urine volume and an increased urine sodium concentration and urine osmolality. As a consequence of water retention, these patients become modestly volume expanded. The increase in intravascular volume causes hemodilution accompanied by dilutional hyponatremia and a low plasma osmolality. Volume expan-... 

Standardization of study conditions is important to minimize the magnitude of variability other than in the pharmaceutical products. Standardization should cover exercise diet fluid intake posture and the restriction of the intake of alcohol, caffeine, certain fruit juices and concomitant medicines for a specified time period before and during the study. 

All constituents of the KD need to be measured precisely to provide the same ratio in each meal. Calories are restricted to about 75-90% ofthe recommended daily allowance for age. All sources of carbohydrate must be accounted for and included in the daily allotment, including calories from medications (carbohydrate-based carriers) and even toothpaste. Appropriate vitamins and minerals are added. Some protocols include restriction of fluid intake to about 60 cm /kg/d (Freeman et al., 1994). The goal is to produce and maintain ketosis, and even minor deviations from the proscribed regimen terminates the ketosis and the antiseizure effect of the KD (Huttenlocher, 1976). Practical details regarding clinical use of the KD may be found in Freeman et al. (1994). 

Because a major compensatory response in heart failure is sodium and water retention, restriction of fluid intake and dietary sodium is an important nonpharmacologic intervention. Fluid intake... 

Supportive care goals for the critically ill patient with ARF include aggressive fluid management. Cardiac output and blood pressure must be supported to allow for adequate tissue perfusion. However, a fine balance must be struck in this regard. For example, fluids must be typically restricted in anuric and ohguric patients unless the patient is hypovolemic or is able to achieve fluid balance via renal replacement therapy. If fluid intake is not minimized, edema rapidly occurs, especially in hypoalbuminemic patients. In contrast, vasopressors like dopamine >2 mcg/kg per minute or norepinephrine are used to maintain adequate tissue perfusion, but may also induce kidney hypoxia via a reduction in renal blood flow. Consequently, S wan-Ganz monitoring is essential for critically ill patients. 

Other nutrition goals for ARF are patient-specific. It may be necessary to limit fluid intake in severely volume-overloaded patients even though this means restricting parenteral or enteral nutrition. Septic patients with ARF usually are hypercatabolic. The net protein catabolism results in rapidly rising BUN and serum creatinine values. The normalized protein catabolic rate has been reported to be 1.75 g/ kg per day, but this value varies widely with each patient. Most patients with ARF cannot tolerate the amount of fluid required to replace catabolized protein unless they are receiving continuous RRT or daily hemodialysis to remove excess volume. 

Fluid restriction is generally unnecessary provided sodium intake is controlled, although fluid intake between dialysis sessions is generally limited for hemodialysis patients. An intact thirst mechanism maintains total body water and effective plasma osmolality near normal. Since urine volume is relatively fixed at approximately 2 L/day, fluid restriction below this amount should be avoided. Large amounts of free water administered orally or as IV fluid may induce hyponatremia and volume overload. When the patient develops... 

Mild hypercalcemia (serum calcium <11 mg/dL) can be treated initially with the first two approaches restriction of dietary calcium and increased fluid intake. The patient should be advised to avoid sunlight, drink large amounts of fluids, and curtail intake of major sources of dietary calcium and vitamin D (183). 

Abbreviations. increase decrease oo, restrict dietary calcium F, high fluid intake CED, corticosteroid eye drops CP, cycloplegics C, corticosteroids— usually 20 to 40 mg prednisone equivalent/day M, methotrexate A, azathioprine I, infliximab CC, corticosteroid creams Cl, corticosteroid injections H, hydroxychloroquine CQ, chloroquine NSAID, non-steroidal anti-inflammatory drugs CYC, cyclophosjliamide. Source. From Ref 246. 

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