Marc B Goldstein

This is excellent advice and the table is a useful resource. I would add one important caveat, the ECF volume contraction is presumably a major basis for the ADH release, and as you restore the ECF volume, the ADH release will be turned off and the patient may well undergo a significant water diuresis, resulting in a rapid increase in [Na] and ODS. Therefore one should either administer ADH (2 ugm IV) at the time of volume restoration, or have it handy to administer when the water diuresis starts. As she has been vomiting, it is unlikely that she has a stomach full of water, but that is another risk to the administration of ADH prior to the water diuresis. Another cautionary note is that after you have given ADH, you must ensure water restriction.

Thanks for an excellent instructive presentation, I would add 2 additional points: Prior to the creation of any A/V access, one should ensure that there is no contraindication. Patients with significantly reduced cardiac output, may be tipped into a clically low output state by an A/V access, depending on its flow rate. Patients with pulmonary hypertension may have a worsening in their state subsequent the A/V access. The second point, in the inspection of the access, one should note the needling sites, to ensure that a rope ladder technique is being used. Patients often encourage the nurses to cannulate in specific areas, and we must discourage this to reduce the likelihood of development of aneurysmal dilatations, which become problemmatic with time.

Let me begin by congratulating your group on an outstanding contribution to the teaching/learning experience. This is an ideal way to address this complex and controversial area, where the heat exceeds the light.I look forward to a lot of interesting discussion.
I would be concerned with the use of a low Ca bath in such a patient. It will lower the [serum Ca], but where will it go? Down the drain. I would anticipate adding osteopenia/osteoporosis to the hyperparathyroid bone disease.When the [Ca] is elevated due to exogenous Ca and PTH is suppressed, a low Ca bath would be appropriate.In this case, I would focus on the cause of the hypercalcemia (suppress the PTH secretion, and/or identify the other causes). Keep up the excellent effort.

Let me begin by congratulating your group on an outstanding contribution to the teaching/learning experience. This is an ideal way to address this complex and controversial area, where the heat exceeds the light.I look forward to a lot of interesting discussion.
I would be concerned with the use of a low Ca bath in such a patient. It will lower the [serum Ca], but where will it go? Down the drain. I would anticipate adding osteopenia/osteoporosis to the hyperparathyroid bone disease.When the [Ca] is elevated due to exogenous Ca and PTH is suppressed, a low Ca bath would be appropriate.In this case, I would focus on the cause of the hypercalcemia (suppress the PTH secretion, and/or identify the other causes). Keep up the excellent effort.