Lithium and fluid intake, need your input

Thunderwolf, MSN, RN · Jan 1, 2006

Adequate fluid intake is important while taking Lithium due to the Lithium crystals being filtered through the kidneys. Do not curtail reasonable fluid intake. Kidney functioning needs to be monitored as well. Your colleagues need to reread their texts.

Ex psych CNS, now Med Surg

kadokin, ASN, RN · Jan 1, 2006

Adequate fluid intake is important while taking Lithium due to the Lithium crystals being filtered through the kidneys. Do not curtail reasonable fluid intake. Kidney functioning needs to be monitored as well. Your colleagues need to reread their texts.
Ex psych CNS, now Med Surg

I noticed that you highlighted reasonable. Do you happen to have a parameter? At what point do you start worrying about h2o-intoxication? I know it is rare, but I have seen it. Is there some way to stop it before it happens? The only way I know to quantify it is by change in mentation and labs. As far as I know, a person has to be pretty confused/psychotic to even be ABLE to drink that much. Am I right? What have you seen?:)

elkpark · Jan 1, 2006

I, too, am accustomed to cautioning people about avoiding either too little or too much fluid intake with Li+, but the "too much" is like H20 intoxication country, not an extra glass of iced tea with lunch. Too little fluid intake is a much more realistic and common concern!

It may be that the reason it's hard to find definitions of H20 intoxication that talk about specific intake quantities is because it can result from a number of factors, including abnormal retention of fluid, not just oral intake. However, I did find one site that states that a healthy adult would have to drink ~two gallons of water a day to develop water intoxication:

http://www.healthofchildren.com/N-O/Overhydration.html

Because Li+ levels are so influenced by both H20 and NcCl levels, it's important to maintain a fairly steady, "normal" fluid intake of the ol' classic 8-10 8 oz. glasses/day, as you noted. It's also important to avoid situations in which you would be losing a lot of fluid through heavy sweating, like prolonged physical exertion, steam baths, etc.

Thunderwolf, MSN, RN · Jan 2, 2006

I agree that the 8-10 eight ounce glasses of fluid per day is adequate. For many who do not even take Lithium, THAT seems like a lot....for many folks walk around somewhat dehydrated anyway, especially the elderly. Water intox has only been an issue for some certain chronic schizophrenics who WILL drink water intoxicantly due to their condition. These type of Schizophrenics are put on very significant fluid restrictions because their Sodium levels are usually quite low...and you have to stay right on them in your monitoring because they will even drink from a toilet bowl if given the chance. However, this has nothing to do with Lithium levels, but Sodium. When Sodium levels are extremely low, there is a fluid shift to the brain which can aggravate confusion, often with aggression. To date, I've really not seen a Bipolar on Lithium having to curtail their fluids like this in this manner....only a few chronic Schizophrenics. I may have in the past ran across a couple Schizo-Affectives, but it was their Schizophrenic aspect of their illness that brought them in...not the Bipolar or Depressive component.

Hope this helps.

suzanne4, RN · Jan 2, 2006

But one thing that hasn't been mentioned is alcohol intake in excess. This causes an increase in diuresis, especially if it is beer, and can disturb lithium levels. An easy way to remember it and the way that I used to teach my students is that lithium is a salt in the system the same way that you have potassium and sodium. Anything that you do that can change those drastically, can also alter Lithium levels.

In the "olden" days, lithium levels were actually measured on the same machine that is used for measuring electrolytes.

Psychaprn · Jan 5, 2006

I, too, am accustomed to cautioning people about avoiding either too little or too much fluid intake with Li+, but the "too much" is like H20 intoxication country, not an extra glass of iced tea with lunch. Too little fluid intake is a much more realistic and common concern!
It may be that the reason it's hard to find definitions of H20 intoxication that talk about specific intake quantities is because it can result from a number of factors, including abnormal retention of fluid, not just oral intake. However, I did find one site that states that a healthy adult would have to drink ~two gallons of water a day to develop water intoxication:
http://www.healthofchildren.com/N-O/Overhydration.html
Because Li+ levels are so influenced by both H20 and NcCl levels, it's important to maintain a fairly steady, "normal" fluid intake of the ol' classic 8-10 8 oz. glasses/day, as you noted. It's also important to avoid situations in which you would be losing a lot of fluid through heavy sweating, like prolonged physical exertion, steam baths, etc.

Oh- and let's not forget, caffeinated beverages don't count in the fluid intake recommended for Li users due to the diuretic properties. I think the possibility of Li toxicity from inadequate fluids is more likely than Li dilution from excess fluids. The best thing to do is regular Li levels, lytes, kidney function and thyroid testing.-psych aprn

CharlieRN · Jan 23, 2006

The senario I have seen was not just increased fluid intake but increased salt intake with increased fluid intake. ie: Two bags of chips a day and an additional 2 liters of softdrinks during a summer heat wave. My understanding is that the body preferentially excretes li+ when Na+ is available to replace it. I usually caution Lithium patients not to make changes in their diet without consulting their Doctor. Low sodium diets particularly being a danger of inducing lithium toxicity.

hbncns35 · Mar 1, 2006

Fortunately there is enough salt in our food already.

In my experience having consumed 1200mg of Li+ per day x 21 years consistently I usually drink between 96oz and 120oz of water per day and I have never been toxic or had a problem with my kidneys. However I am aware that Calcium in high doses also competes for receptor sites usually reserved for Li+. I have also drank alcohol moderately on it and have occasionally skipped a dose for a day and then returned to schedule. The only time I have ever had a problem was with taking Calcium/Mg+ supplements which brought my levels way down and I was symptomatic. Salt really isn't a concern being that Li+ has its own salt properties. I have heard of nurses suggesting chips and so forth but I do not see the value in it. I also do not urinate any more often than anyone else I know. I drink proportionate to my output. Hope that helps your question. HB