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1 : : : : : 252 / / ADH receptor antagonistsvaptans / % (Hypokalemia) 3.5 meq/l ( ) ( )

2 (3.0~3.5 meq/l) (2.5~3.0 meq/l) ( 2.5 meq/l) (digoxin) (Serum potassium) (Urine potassium) 24

3 ( ) () β2-adrenergic agonist nebulized albuterol 0.2~0.4 meq/l 1 (Pseudoephedrine) (Ritodrine) (Terbutaline) meq/l () (Xanthine)Theophylline Caffeine 也會抑制細胞的磷酸酯解酶 (phosphodiesterase) Na+/K+- ATPase thophylline () (Insulin) () (Diuretics) Thiazide (loop diuretic) ( ) furosemidebumetanide ( ) () Penicillin 苷 (aminoglycoside) (antineoplastic) (antiviral) ( ) () (Corticosteroids) (mineralocorticoids) (glucocorticoids) ( ) () meq/ meq/

(Insulin) () (Diuretics) Thiazide (loop diuretic) ( ) furosemidebumetanide ( ) () Penicillin 苷 (aminoglycoside)

4 2. 3. (cushing's syndrome) 4. (aldosterone) sodium bicarbonate (Transcellular Shift) β2-receptor agonists Epinephrine Albuterol Terbutaline Salmeterol Ephedrine Pseudoephedrine Tocolytic agents Ritodrine Theophylline Caffeine Insulin overdose (Enhanced Renal Excretion) Diuretics Acetazolamide Thiazides Indapamide Furosemide Ethacrynic acid High-dose penicillins Ampicillin Penicillin Nafcillin Steroids Mineralocorticoids Miscellaneous Aminoglycosides Amphotericin B Cisplatin (Enhanced Fecal Elimination) Sodium polystyrene sulfonate Phenolphthalein Sorbitol

Pseudoephedrine Tocolytic agents Ritodrine Theophylline Caffeine Insulin overdose (Enhanced Renal Excretion) Diuretics Acetazolamide

5 Acetazolamide Amphotericin β2-receptor agonists Cisplatin Corticosteroid K + ( ) K + K + K + Na + K + H + Insulin and glucose Penicillin(Carbenicillin, piperacillin, ticarcillin) Aminoglycosides(Gentamicin) Thiazide and loop diuretic K + Na + K + K + K + Na + Na + -K + Na + [K]>3mEq/L 1mEq/L 100~200mEq [K]<3mEq/L 1mEq/L 200~400mEq 15% 30~40ml/day g 13.4 mmol 20mEq/hr

Aminoglycosides(Gentamicin) Thiazide and loop diuretic K + Na + K + K + K + Na + Na + -K +

6 5% 500 ml 15% 510 ml (Potassium chloride) (potassium phosphate) (potassium bicarbonate) ( ) 40~100 mmol 400 meq ( 3 meq/kg) 40~ meq/l 200 meq 30 meq/l 10 2mEq/L 400 meq 20 meq Cl - ( ) 3.

40~100 mmol 400 meq ( 3 meq/kg) 40~60 2.

7 ( ) (>1000 mg/100 g) (>500 mg/100 g) (>250 mg/100 g)

8 1. Pharmacotherapy Handbook - A Patient-Focused Approach 7th ed. Section 14 Renal Disorders. Chapter 78 Electrolyte Homeostasis. P Pharmacotherapy- A Pathophysiologic Approach, 7th ed. Section 5 Renal Disorders. Chapter 54 Disorders of Potassium and Magnesium Homeostasis. P Uptodate-Hypokalemia 4. Lin SH, Halperin ML. Hypokalemia: a practical approach to diagnosis and its genetic basis. Curr Med Chem 2007; 14:

Section 5 Renal Disorders. Chapter 54 Disorders of Potassium and Magnesium Homeostasis. P877-881 3.

9 37 1 (very low birth weightvlbw 1500 g) (feeding intolerance) (gastric residuals) (necrotizing enterocolitisnec) 1 Low-birth weight infants weigh. Very low-birth weight infants weigh. Extremely low-birth weight infants weigh <2,500 g <1,500 g <1,000 g

weight infants weigh. Very low-birth weight infants weigh.

10 Basal Energy ExpenditureBEE ( ) kcal/kg/day kcal/kg/day (nonprotein calorie to nitrogen ratio, NPC/N) kcal/g( 2) (nonprotein calorie to nitrogen ratio, NPC/N) NPC/N(kcal/g) NPC/N(kcal/g) 1501 ( ) ( )

150-200 kcal/g( 2) 55 30 15 2 (nonprotein calorie to nitrogen

11 3 3 (ml/kg) BW1250 g BW1250 g ( mg/dl 50 mg/dl) 5-8 mg/kg/min 5~6 mg/kg/min 1~2 mg/kg/min 11 ~ 12 mg/kg/min ( <1000g) 3.5mg/kg/min 1~2 mg/kg/min 12 mg/kg/min

120-140 ( 24 45 mg/dl 50 mg/dl) 5-8 mg/kg/min 5~6 mg/kg/min 1~2

12 (intraventricular hemorrhage) 12.5% 30% isoleucineleucinelysinemethionine phenylalaninethreoninetryptophan valine cysteineglutamineglycinehistidinetaurine tyrosine (hyperammonemia) (azotemia) 2~3 g/kg/day 3.5~4 g/kg/day (triglycerides) (phospholipids) (glycerol) (mediumchain triglycerides, MCTs ) MCTs (longchain triglycerides, LCTs )

cysteineglutamineglycinehistidinetaurine tyrosine (hyperammonemia) (azotemia) 2~3

13 20% 10% 10% 60% 0.5 g/kg/day 1 g/kg/day 0.25 ~ 0.5 g/kg/day 3 g/kg/day TG>400 mg/dl 4 TG>150 mg/dl TG>250 TG>350 mg/dl 4 (bone mineralization) (demineralization) ph 4 Preterm/Neonates Infants/Children Adolescents/Children >50kg Na 2-5 meq/kg 2-5 meq/kg 1-2 meq/kg K 2-4 meq/kg 2-4 meq/kg 1-2 meq/kg Ca 2-4 meq/kg meq/kg meq/day

mineralization) (demineralization) ph 4 Preterm/Neonates Infants/Children

14 Phos 1-2 mmol/kg mmol/kg mmol/day Mg meq/kg meq/kg meq/day Acetate As needed to maintain acid-base balance Chloride As needed to maintain acid-base balance kg >2.5 kg Zinc 400 mcg/kg 250 mcg/kg Copper 20 mcg/kg 10 mcg/kg Chromium 0.4 mcg/kg 0.1 mcg/kg Manganese 1 mcg/kg 2.5 mcg/kg Selenium 2 mcg/kg 1.5 mcg/kg 6 6 早產兒於靜脈營養之综合維生素他命每日建議使用量 Current regimen Estimate based Maximum not to based upon upon the needs exceed term infant pediatric of premature (unit/day)

5 meq/kg 10-30 meq/day Acetate As needed to maintain acid-base balance Chloride As needed to maintain acid-base balance 5 5 2.

15 multivitamin formulation (unit/kg/day) infants (unit/kg/day) A (microg) E (mg) K (microg) D (microg) C, Ascorbic acid (mg) B1, Thiamin (mg) B2, Riboflavin (mg) B6, Pyridoxine (mg) Niacin (mg) Pantothenate (mg) Biotin (microg) Folate (microg) Vitamin B12 (microg) Heparin Heparin 0.5-1units /ml Heparin (lipoprotein lipase)

2 B2, Riboflavin (mg) 0.56 0.15 1.4 B6, Pyridoxine (mg) 0.40 0.18 1 Niacin (mg) 6.8 6.

16 (necrotizing enterocolitis) -- (Bronchopulmonary dysplasia, BPD) 1. Parenteral nutrition in premature infants, 2013 Uptodate. 2. The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum Guidelines for Acute Care of the Neonate 20th Edition,

S.P.E.N. Pediatric Nutrition Support Core Curriculum.2010. 3.

17 ADH receptor antagonistsvaptans Hyponatremia <135mmol/LmEq/L < 275 mosm/kg ECF aldosterone 120 meq/l120 meq/l 120 meq/l SIADH 100 meq/l Antidiuretic Hormone ADH ADH SIADH SIADH ADH ADH TCAs SSRIscarbamazepinechlorpropamide alkylating agents hypovolemia euvolemia hypervolemia

Antidiuretic Hormone ADH ADH SIADH SIADH ADH ADH TCAs

18 hypovolemia TBW Na hypertonic usually: thiazide>loop diuretics osmotic diuresisglucose, urea, mannitol euvolemia TBW Nahypotonic SIADH ex. Addison disease SSRI, diuretics, barbiturates, carbamazepine, clofibrate, opioids, tolbutamide, vincristine, akylating agentspossibly: clclophosphamide, NSAIDS, oxytocin hypervolemia TBW Na hypotonic SIADH 0.9% 1 meq/l 2 meq/l/first 2-3 hr meq/l ml/day 3% salinecontain Na 513 meql/l +/- loop diuretic,+/- KCl vasopressin receptor antagonist 3% SIADH Osmotic Demyelination Syndrome ODS

agentspossibly: clclophosphamide, NSAIDS, oxytocin hypervolemia TBW Na hypotonic SIADH 0.

19 3% 46 meq/l 9 meq/l/first 24 hrsgrade 1B 0.9% SIADH 3% Desired change in Na TBW Total Body WaterTBW =0.6 body weightkg =0.5 body weightkg =0.45 body weightkg meq/l/hr 0.5mEq/L/h 0.5mEq/L/h 70kg 106mEq/L 112mEq/L meq 3% saline 513 meq/l L 3% saline 0.5mEq/L/h mEq =12 hr 3% saline 12 demeclocycline ADH 20-40% NDInephrogenic diabetes insipidus demeclocycline ADH NDI

5mEq/L/h 70kg 106mEq/L 112mEq/L 112-106 0.6 70 252 meq 3% saline 513 meq/l 252 5130.5 L 3% saline 0.

20 loop vaptans (usually acute or <115) (usually chronic or >120) ml/day 3% saline +/- loop diuretic,+/- KCl furosemide SIADH Vaptans Demeclocycli n Thyroid replacement therapy Corticosterlids Furosemide Vaptans & SIADH present Vaptans ADH angiotensin II ADH ADH V 1a V 2 Vaptans ADH V 2 diuretics vaptans aquaretics V 2 SIADH

replacement therapy Corticosterlids Furosemide Vaptans & SIADH present Vaptans ADH

21 aquaretics diuretics GFR renin BUNsCr ADH receptor antagonistsvaptans vaptans FDA Tolvaptan Conivaptan Tolvaptan Tolvaptan TolvaptanSamsca 15mg 1. Tolvaptan SIADH <125 meq/l Tolvaptan <125 meq/l SALT tolvaptan 15 mg 30 mg mg Clcr 10 ml/min Clcr <10 ml/min 13% 11%

22 Conivaptan Conivaptan Vaprisol 20 mg 100 ml hypervolemic euvolemia 20 mg 30 20mg mg/hr 24 40mg/day1.7mg/h 4 Note: If patient requires 40 mg/24 hours, may administer two consecutive 20 mg/100 ml premixed solutions over 24 hours ie, 20 mg over 12 hours followed by 20 mg over 12 hours Clcr 30 ml/min Clcr <30 ml/min anuria 10mg 20mg/day 4 hypovolemia Tolvaptan ADH V 2 SIADH 2013/ ,190 Conivaptan ADH V 2 SIADH 4 hypovolemia 20mg load IV 20mg/day IV 573 CYP3A4 eg, Ketoconazole, Itraconazole, Ritonavir, Indinavir, Nelfinavir, Saquinavir, Nefazodone, Telithromycin, Clarithromycin vaptans

23 2013 FDA tolvaptan tolvaptan Conivaptan Tolvaptan Lixivaptan Satavaptan Non-selective V2 & V 1a V 2 selective V 2 selective V 2 selective IV Oral Oral Oral Vaprisol Samsca Lixar 2012/09 FDA Astellas Otsuka Pfizer Sanofi 20mg/day; max:40mg/day 15mg/day loading dose; max: 60mg/day Clcr 30 ml/min Clcr 10 Clcr ml/min <30 ml/min anuria Clcr <10 ml/min CYP3A4 inhibitor & inducer vaptans

24 1. FDA : Samsca (tolvaptan) Drug Warning - Potential Risk of Liver Injury 2. Uptodate Hyponatremia 3. Clin Ther Jun;32(6): Treatment of hypervolemic or euvolemic hyponatremia associated with heart failure, cirrhosis, or the syndrome of inappropriate antidiuretic hormone with tolvaptan: a clinical review. Nemerovski C, Hutchinson DJ. Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.

25 ( ) ( ) Showmin eye drops ONSD 0.01% % 10ml/bot %Neostigmine5ml/bot 5ml/bot(Neostigmine) (Neostigmine) 3. (TSHO) (TONSD) Duasma HFA 10ml Duasma MDI 10ml 1. (Budesonide) (Budesonide) mcg/puff200dose/bot (TDUA-H) (TDUA1) 3. LACTUL SYRUP 300ml (Lactulose) (LLACT) Vitamin B6 Tablets 10mg (Pyridoxine HCl) (OVB6) Zodenox F.C. 10mg (Zolpidem ) (OZOD) Radi-K 595mg (Potassium chloride) (ORAD) Lamvita (Bcomplex)20ml (ILAM) Gibicef 1000mg/vial (Cefuroxime) (IGIBI) Voren-K SC 25mg (Diclofenac potassium) (OVOR-K) Tamso SR 0.2mg (Tamsulosin HCl) (OTAMS) LACOLY 300ml (Lactulose) (LLAC) Vitamin B6 10mg (Pyridoxine HCl) (OVITB6) Zolpi F.C. 10mg (Zolpidem ) (OZOLP) Slow K 600 mg (Potassium chloride) (OSLO) Pyricobamin(Bcomplex)20ml (IPYRI) Uroxime 1000mg/vial (Cefuroxime) (IUROX) Cataflam 25mg (Diclofenac potassium) (OCATA) Hanlosin SROD 0.2mg (Tamsulosin HCl) (OHAN) B ( ) 3. Thiamine 50mg,Pyridoxine 100mg, B12 1mg/20ml ( ) 2. 3.

26 ( ) ( ) Econazole VT 150mg Antifungal VT 1. (Econazole) 100mg (Miconazole) (TECO) (TANV) 2. Folina inj.(leucovorin)50mg (Leucovorin) (IFOL) CIPROXIN INF 200mg(Ciprofloxacin ) (ICIP200) Calciumfolinat- Ebewe100mg (Leucovorin) (ICAL-F) CIPROXIN INF 100mg (Ciprofloxacin) (ICIP) 3. Econazole nitrate 150mg/supp 3 1. (Methotrexate) mg/ml50mg/vial 1. CIPROFLOXACIN (1-17 ) (5-17) ( ) mg/100ml/vial ( ) ( ) Varivax MSD Varilrix (Varicella 1. (Varicella virus virus vaccine live) vaccine live) (IVARIV) (IVARI) ( ) Viramune XR 400mg (Nevirapine) 1. (OVIR400) HIV-1

27 ( ) NITHIODOTE 1. (INITH) 2. Sodium Nitrite 300mg/10mL/Vial + Sodium Thiosulfate 12.5 g/50ml/vial 3. ( ) ( ) Elonva ug/0.5ml GnRH antagonist (Corifollitropin alfa) 2. (IELON) Inlyta 1mg 1. sunitinibcytokine (Axitinib) 2. (OINL) XARELTO FC 1. (1) (non-valvular atrial fibrillation) Tab 15mg (Rivaroxaban) (systemicembolism) 75 (OXAR15) (transient ischemic attack) (2) Orencia 250mg 1. (1) Orenciamethotrexate (Abatacept) [ (IORE) methotrexate (MTX) (TNF) ] (2) Orenciamethotrexate [ (TNF) ] 6 6 **Orencia 6 (3) Orencia (RA) Prolia 60mg 1. (Denosumab) (IPRO06) Prolia

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