56.3 🩺 內科專科考前版

56.3.0.1 📌 䞀頁重點

  • 22E: lokelma / patiromer 䞻流、tolvaptan 限甚、SGLT2i 圱響 Na/K
  • Taiwan: thyrotoxic periodic paralysis 高 (亞掲男)
  • Refeeding syndrome 認可 + protocol

56.3.0.2 💊 進階

56.3.0.2.1 Severe Symptomatic Hyponatremia
  • 3% NaCl 100 mL bolus q10 min × 3 (max 300 mL or sx 改善)
  • Goal Na ↑ 4-6 mEq/L within hours
  • Then slow rest of correction
56.3.0.2.2 Overcorrection Rescue
  • DDAVP 2 ÎŒg IV + D5W
  • 防止 ODS
56.3.0.2.3 Tolvaptan
  • For SIADH
  • Caveat: 肝毒 (FDA black box)
  • 䞍超過 30 days
  • 限 inpatient initiation
56.3.0.2.4 HRS-AKI
  • Terlipressin + albumin (US 2022)
  • Norepinephrine + albumin alt
56.3.0.2.5 Lokelma vs Patiromer
  • Lokelma (sodium zirconium cyclosilicate): faster (1-2 hr)
  • Patiromer: slower (7+ hr)
  • Both safer than kayexalate (no colonic necrosis)
56.3.0.2.6 SGLT2i
  • Glucosuria → osmotic diuresis → mild hypovol
  • Slight ↑ K (rare hyperK)
  • Euglycemic DKA risk

56.3.0.3 🌟 Pearls (10)

  1. Lokelma / patiromer > kayexalate
  2. Tolvaptan 30-day limit for hepatotoxicity
  3. DDAVP rescue for ODS prevention
  4. 3% NaCl bolus protocol for severe symptomatic hypoNa
  5. TPP: 亞掲 male + 甲亢 + hypoK paralysis
  6. Refeeding P, K, Mg + thiamine
  7. Pseudohyperkalemia in chronic leukemia / thrombocytosis (use plasma K, not serum)
  8. Cerebral salt wasting (CSW) vs SIADH (CSW = hypovol)
  9. MDMA hypoNa in young adults
  10. Vaptans contraindicated in hypovolemic hypoNa

56.3.0.4 🔍 特殊情境

56.3.0.4.1 CSW vs SIADH
  • 兩者郜 euvolemic-looking
  • CSW: hypovolemic (post-neurosurg, SAH); treat with NS
  • SIADH: euvolemic; treat with water restrict
56.3.0.4.2 Beer Potomania
  • Low solute diet + 倧量 beer
  • Free water excess
  • Treat with food + salt
56.3.0.4.3 Tea-and-toast Syndrome
  • Elderly low solute diet
  • Hypotonic hypoNa
  • Treat dietary
56.3.0.4.4 Marathon Hyponatremia
  • Excess hypotonic intake during exercise
  • 3% NaCl
56.3.0.4.5 Refractory Hypocalcemia
  • Check Mg first
  • Replace IV calcium gluconate (peripheral 1g/100mL D5W; central 1-2 g push)

56.3.0.5 📍 Taiwan Context

  • TPP 高 (亞掲 male thyroid)
  • 健保 lokelma / patiromer 限制
  • Tolvaptan 自費
  • Aristolochic acid → renal tubular injury
  • Heat stroke fluid loss

56.3.0.6 🎓 內專重點

  1. HypoNa workflow + correction
  2. HyperNa workflow
  3. HyperK 急救
  4. HypoK + Mg
  5. DI central / nephrogenic
  6. Refeeding syndrome
  7. Tolvaptan, vaptans

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