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Electrolytesdisorders 100329234501-phpapp02
 

Electrolytesdisorders 100329234501-phpapp02

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  • Osmotic gradient develops across blood brain barrier causing water to move into brain. -Two protective mechanisms: - Movement of interstitial fluid into the CSF - Loss of cellular potassium and organic osmolytes Acute hyponatremia (Na < 120) developing < 24 hours OR rate of fall of > 0.5 meq/L per hour: -Muscular twitching, seizures, coma Acute severe hyponatremia with CNS changes – mortality rate 50%. CPM – correction of hyponatremia faster than the brain can recover solute.
  • Protective mechanism – ADH - Released in response to decreased blood volume - Increased ADH present in almost all hyponatremic conditions - Increases water reabsorption by renal tubules (seems counterproductive) - Potent vasoconstrictor: - Increased peripheral vascular resistance - Increased blood flow to liver and kidneys at expense of skin and muscle
  • Movement of water from ICF to ECF dilutes the ECF. Volume replacement with sodium containing fluids.
  • Hyperproteinemia Multiple Myeloma Waldenstrom Macroglobulinemia
  • Results in intracellular volume expansion with derangement of cellular function. Obtain serum and urine electrolytes Obtain plasma and urine osmolality
  • Clinical manifestations due to volume deficit rather than hyponatremia.
  • Unequal loss of electrolyte and water loss produces a contracted ECF volume with hyponatremia. Maintained by effect of volume depletion on kidneys inhibiting free water excretion. - Decreased GFR. - Increased proximal tubular resorption of solute and water. - Decreased deliver of fluid to the diluting segment of the nephron. - ADH released by nonosmotic stimuli.
  • Slightly expanded ECF No clinical edema, near normal total body Na Sx usually relative to CNS hypotonicity
  • CHF – perceived as low flow state, stimulates ADH Nephrotic Syndrome – low serum protein due to urinary loss Cirrhosis – low intravascular oncotic pressure due to decreased protein production
  • Comatose or bedridden patients susceptible since they are unable to obtain adequate fluid. All hypernatremic states are hyperosmolar.
  • ADH response to low volume and hypertonicity UO < 20 mL/h
  • Doughy abdominal skin when pinched between fingers Accumulation of amino acids in the brain
  • Iatrogenic Na – NaHCO3, hypertonic saline Mineralocorticoid/Glucocorticoid excess Primary aldosternoism Cushing’s syndrome Ectopic ACTH hormone production
  • Iatrogenic Na – NaHCO3, hypertonic saline Mineralocorticoid/Glucocorticoid excess Primary aldosternoism Cushing’s syndrome Ectopic ACTH hormone production
  • Mortality rate Overall 10% 25 to 50% if plasma osmolality > 350
  • Mortality rate Overall 10% 25 to 50% if plasma osmolality > 350
  • Cerebral edema due to presence of idiogenic osmoles
  • 6.5 to 7.5 meq/L 7.5 to 8.0 meq/L 10 to 12 meq/L
  • Membrane stabilization Effect w/in 1 to 3 min, active for 1 hour Central line Glucose/Insulin 50 g glucose with 5-10 units regular insulin Onset 30 min, durastion 4 to 6 hrs NaHCO3 Onset 5 to 10 min, duration 1 to 2 hrs
  • Membrane stabilization Effect w/in 1 to 3 min, active for 1 hour Central line Glucose/Insulin 50 g glucose with 5-10 units regular insulin Onset 30 min, durastion 4 to 6 hrs NaHCO3 Onset 5 to 10 min, duration 1 to 2 hrs Kaexalate Given with Sorbital to avoid constipating effects and speed bowel transit time
  • Most abundant mineral in the body
  • In presence of albumin, total Ca may be low but ionized Ca remains normal Vit D deficiency Sunlight/dietary deficiency Malabsorption (Gastrectomy)
  • Chvostek – Twitch at corner of mouth when tapped over facial nerve just in front of ear. Trosseau – Carpal spasm produced when BP cuff to upper arm maintains a pressure above systolic for 3 min. Fingers spastically extend at the IP joints and flex at the MCP joints. Wrist flexed, forearm pronated,
  • Give over 10 to 20 min, then drip 1g CaCl over 6-12 hrs
  • Hypo K, Hypo Mg will worsen with diuresis

Electrolytesdisorders 100329234501-phpapp02 Electrolytesdisorders 100329234501-phpapp02 Presentation Transcript

  • ELECTROLYTE DISORDERS EMPA Residency UTHSCSA K + + Na Mg 2+ 2+ Ca 4 PO - - Cl
  • ELECTROLYTE DISORDERS
    • Composition of body fluids
    • Fluid Compartments
    • Fluid balance
    • Specific Electrolytes
      • Sodium
      • Potassium
      • Magnesium
      • Calcium
      • Phosphorus
    • Key points
    • Questions
    Outline
  • ELECTROLYTE DISORDERS Total fluid volume 42 liters ECF 33% --- 1) Plasma 7% 2) Interstitial Fluid 26% 3) Lymph <1% ICF 67% Body Fluid Composition   mEqui per liter         Cations Plasma ISF Cell Na + 142.0 145.1 12 K + 4.3 4.4 150 Ca 2+ 5 2.4 4 Mg 2+ 3 1.5 34 Total 154 153.0 200         Anions Plasma ISF Cell Cl - 104 117.4 4 HCO 3 - 24 27.1 12 Phosphates 2 2.3 40 Proteins 14 0.0 54 Other 5.9 6.2 90 Total 149.9 153.0 200
  • ELECTROLYTE DISORDERS Fluid Compartments
  • ELECTROLYTE DISORDERS
    • Serum Osmolality
      • Number of osmoles (osmotically active particles) in the serum
      • Normal range
        • 275 to 295 mosm/L
    Fluid Balance 2[Serum Na + ] + ------------ + ------------ Glucose BUN 18 2.8
  • ELECTROLYTE DISORDERS
    • Major extracellular cation
    • Normal range
      • 135 to 150 meq/L
    Sodium
  • ELECTROLYTE DISORDERS
    • Serum Na + < 135 meq/L
      • Primary water gain or Na + loss > water
      • Altered distribution of body water
      • Sx’s related to rate of change > Na + value
      • Sx at Na + < 120 meq/L
      • Seizures likely at Na + < 113
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Pathophysiology: CNS
      • Water shifts into brain cells
          • Apathy – Altered Consciousness
          • Agitation – Seizures
          • Headache – Coma
      • Risk of brain damage > during treatment
          • Central Pontine Myelinolysis (CPM)
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Pathophysiology: Cardiovascular
      • Effect depends on arterial blood volume
      • Volume depletion
        • Water shifts from ECF ICF
        • Shock at lesser degrees of TBW depletion
      • ADH Opposes effects of fluid shifts
        • Increases water reabsorption ?????
        • Potent vasoconstrictor
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Pathophysiology: Musculoskeletal System
      • Muscle cramps & weakness with exercise
      • Sx if sweat losses replaced with water
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Pathophysiology: Renal System
      • Production of dilute urine
      • Impacted by amount of ADH present
      • Urine Na + < 10 renal handling of NA intact
      • Urine Na + > 20 intrinsic renal tubular damage
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Diagnosis
    Hyponatremia Plasma Osmolality Normal (275-295) Isotonic hyponatremia Low (< 275) Hypotonic hyponatremia High (> 295) Hypertonic hyponatremia Hypovolemic Hypervolemic Euvolemic
  • ELECTROLYTE DISORDERS
    • Hypertonic Hyponatremia (P osm > 295)
      • Large quantities of solute in ECF
      • Water moves from ICF ECF
      • Hyperglycemia most common cause
        • Each 100 mg/dl plasma glucose will serum Na + by 1.6 meq/L
      • Treatment
        • Volume replacement
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Isotonic Hyponatremia (P osm 275 - 295)
      • “ Pseudohyponatremia”
      • Artifact in serum Na + measurement
        • 2 ° High levels of plasma proteins and lipids
      • Etiology:
        • Hyperlipidemia
        • Hyperproteinemia
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Hypotonic Hyponatremia (P osm < 275)
    Hyponatremia Plasma Osmolality Normal (275-295) Isotonic hyponatremia Low (< 275) Hypotonic hyponatremia High (> 295) Hypertonic hyponatremia Hypovolemic Hypervolemic Euvolemic
  • ELECTROLYTE DISORDERS
    • Hypotonic Hyponatremia
      • Hypovolemic vs Hypervolemic vs Euvolemic
        • Plasma electrolytes and osmolality
        • Urine electrolytes and osmolality
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Hypovolemic Hyponatremia
      • Loss of Na + and water
      • Replacement with hypotonic fluids
      • Sodium loss “renal” vs “extrarenal”
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Hypovolemic Hyponatremia
      • Renal Na + loss
        • Urine Na + > 20 meq/L
        • Etiology:
          • Diuretic use
          • Salt-wasting nephropathy (renal tubular acidosis, chronic renal failure, interstitial nephritis)
          • Osmotic diuresis (glucose, urea, mannitol, hyperproteinemia
          • Mineralocorticoid (aldosterone) deficiency
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Hypovolemic Hyponatremia
      • Extrarenal Na + loss
        • Urine Na + < 20 meq/L
        • Etiology:
          • Volume replacement with hypotonic fluids
          • GI loss (vomiting, diarrhea, fistula, tube suction)
          • Third-space loss (burns, hemorrhagic pancreatitis, peritonitis)
          • Sweating (cystic fibrosis)
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Hypovolemic Hyponatremia
      • Treatment
        • Re-expansion of ECF with isotonic saline
        • Correction of underlying disorder
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Euvolemic Hyponatremia
      • Normal volume status and hyponatremia
      • Sx usually 2 ° CNS hypotonicity
      • Urine Na + > 20 meq/L
      • SIADH most notable cause
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Euvolemic Hyponatremia
      • SIADH
        • Hypotonic hyponatremia
        • Inappropriately elevated urine osmolality (usually > 200 mosm/kg)
        • Elevated urine Na + (> 20 meq/L)
        • Clinical euvolemia
        • Normal adrenal, renal, cardiac, hepatic, and thyroid function
        • Correctable with water restriction
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Euvolemic Hyponatremia
      • Etiology:
        • Hypothyroidism
        • Pain, stress, nausea, psychosis (stimulates ADH)
        • Drugs: ADH, nicotine, sulfonylureas, morphine, barbs, NSAIDS, APAP, Carbamazepine, Phenothiazines, TCAs, Colchicine, Clofibrate, Cyclophosphamide, Isoproterenol, Tolbutamide, MAOIs
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Euvolemic Hyponatremia
      • Etiology (Cont):
        • Water intoxication (psychogenic polydipsia)
        • Glucocorticoid deficiency
        • Positive pressure ventilation
        • Porphyria
        • Essential (reset osmostat or sick cell syndrome)
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Euvolemic Hyponatremia
      • Treatment
        • Fluid restriction
        • Work-up and management of underlying disorder
        • Hospital admission usually warranted
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Hypervolemic Hyponatremia
      • Total body water in great excess
      • Sx of volume overload
        • Peripheral/pulmonary edema
      • Impaired water excretion
      • Water retention in excess of Na + retention
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Hypervolemic Hyponatremia
      • Without advanced renal insufficiency
        • Urine Na + < 20 meq/L
        • Cirrhosis, ascites, CHF, Nephrotic syndrome
      • Advanced acute or chronic renal insufficiency
        • Urine Na + > 20 meq/L
        • Renal failure (inability to excrete free water)
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Hypervolemic Hyponatremia
      • Treatment
        • Optimize treatment for underlying disorder
        • Judicious salt and water restriction
        • + Diuretics
        • + Dialysis
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Treatment of Severe Hyponatremia
      • Indications:
        • Serum Na + < 120 meq/L
        • Rapid development ( Na + > 0.5 meq/L/hr)
        • Patient in extremis (coma, seizures)
      • 3% Saline Solution (513 meq/L) @ 25 - 100 ml/hr
        • Na + should not exceed 0.5 – 1.0 meq/L/hr
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Complications of Therapy
      • Central Pontine Myelinolysis (CPM)
        • 2 ° excessively rapid correction of hyponatremia
        • Fluctuating level of consciousness
        • Behavioral disturbances
        • Dysarthria
        • Dysphagia
        • Convulsions
        • Pseudobulbar palsy
        • Quadriparesis
    Hyponatremia
  • ELECTROLYTE DISORDERS
    • Serum Na + > 150 meq/L
      • D ecrease in total body water
        • Reduced intake
        • Excessive loss
      • Thirst is body’s defensive mechanism
    Hypernatremia
  • ELECTROLYTE DISORDERS
    • Pathophysiology
      • 2 Primary Mechanisms
        • Renal response to ADH
          • Conservation of free water
          • Urine output with osmolality > 1000 mosm/kg
        • Failure of ADH response
          • Inability to excrete Na + properly
          • Urine osmolality 200-300 mosm/kg
          • Urinary Na + 60-100 meq/kg
    Hypernatremia
  • ELECTROLYTE DISORDERS
    • Pathophysiology
      • Rapid hypertonicity or short duration
        • Loss of 10% of body wt 2° dehydration
          • Skin turgor, “doughy” skin
        • CNS cellular dehydration
          • Hemorrhage
          • Tearing of cerebral blood vessels 2° brain shrinkage
      • Gradual hypertonicity
        • Idiogenic osmoles prevent brain shrinkage
    Hypernatremia
  • ELECTROLYTE DISORDERS
    • Etiology
      • Excessive sodium intake
        • Iatrogenic Na + administration
        • Seawater ingestion
        • Mineralocorticoid or glucocorticoid excess
      • Pure water loss
        • Inability to swallow, bedridden, comatose
    Hypernatremia
  • ELECTROLYTE DISORDERS
    • Etiology (Cont):
      • Loss of water in excess of Na +
        • Gastrointestinal
          • Vomiting, diarrhea
        • Renal
          • Central Diabetes Insipidus
          • Impaired renal concentrating ability
        • Drugs
          • Alcohol, Lithium, Phenytoin, Propoxyphene, Sulfonylureas
    Hypernatremia
  • ELECTROLYTE DISORDERS
    • Etiology (Cont):
      • Loss of water in excess of Na +
        • Skin loss
          • Burns, sweating
        • Peritoneal dialysis
    Hypernatremia
  • ELECTROLYTE DISORDERS
    • Clinical Features:
      • Acute sx at Na + > 158 meq/L
      • Osmol
      • Restless, irritability 350-375
      • Tremulousness, ataxia 375-400
      • Hyperreflexia, twitching, spasticity 400-430
      • Seizures and death > 430
    Hypernatremia
  • ELECTROLYTE DISORDERS
    • Treatment
      • **Volume replacement**
        • NS/LR until tissue perfusion restored
        • 0.45% Saline until urine output > 0.5mL/kg/hr
      • in Na + should not exceed 10-15 meq/L/day
        • Monitor serum electrolytes frequently
      • Manage underlying disorder
    Hypernatremia
  • ELECTROLYTE DISORDERS
    • Complications of therapy
      • Excessively rapid correction
        • Cerebral edema
        • Seizures
        • Permanent neuro sequelae
        • Death
    Hypernatremia
  • ELECTROLYTE DISORDERS
    • Major intracellular cation
    • Normal range
      • 3.5 to 5.5 meq/L
    • Serum level does not reflect total body K +
    Potassium
  • ELECTROLYTE DISORDERS
    • Serum K + < 3.5 meq/L
    • Pathophysiology
      • K + shifts into cells as ECF pH rises
        • 0.10 in pH causes 0.5 meq/l in serum K +
      • K + losses usually via GI tract or kidneys
      • Aldosterone 2 ° volume loss
        • Na + & HCO 3 - retention in exchange for K +
    Hypokalemia
  • ELECTROLYTE DISORDERS
    • Etiology
      • ECF ICF shifts
        • Metabolic alkalosis
        • Trtm of DKA (increased insulin)
      • Decreased intake
      • GI loss
        • Vomiting, diarrhea, malabsorption
    Hypokalemia
  • ELECTROLYTE DISORDERS
    • Etiology (Cont)
      • Renal loss
        • Diuretics, Aldosteronism
        • Osmotic diuresis
        • Licorice, chewing tobacco
      • Drugs/Toxins
        • PCN, Amphotericin B, Lithium, Thalium, Dopamine
      • Sweat loss
    Hypokalemia
  • ELECTROLYTE DISORDERS
    • Clinical Features
      • Sx onset at serum K + < 2.5 meq/L
      • Cardiovascular
        • Increased HTN
        • Orthostatic hypotension
        • Dysrhythmias
        • EKG abnormalities
          • Flat T-waves, prominent U-waves, ST-segment depression
    Hypokalemia
  • ELECTROLYTE DISORDERS
    • Clinical Features (Cont):
      • Neuromuscular
        • Malaise, weakness, fatigue
        • Hyporeflexia, cramps, paresthesias
      • Renal
        • Increased ammonia production encephalopathy
        • Decreased GFR
      • Gastrointestinal
        • Ileus
    Hypokalemia
  • ELECTROLYTE DISORDERS
    • Treatment
      • Replace K +
        • Oral
        • Intravenous
          • 10-20 meq/L in 100 mL NS
          • Not > 40 meq in a single liter IV fluid
          • Not > 40 meq in 1 hour
          • Concentrations > 20 meq/L require a central line
        • 20 meq will serum K + ≈ 0.25 meq/L
      • Cardiac monitor during replacement therapy
    Hypokalemia
  • ELECTROLYTE DISORDERS
    • Serum K + > 5.5 meq/L
      • Oliguric renal failure
      • Severe hemolysis
      • Excessive tissue breakdown
    • Pseudohyperkalemia
      • Hemolysis during blood draw
      • Cell breakdown after 30 minutes
    Hyperkalemia
  • ELECTROLYTE DISORDERS
    • Etiology
      • ICF ECF shifts
        • Acidosis
        • Beta blockade
        • Insulin deficiency
        • Digitalis intoxication
      • K + load
        • Supplements, foods, K + containing drugs
        • Blood transfusion
        • Rhabdomyolysis
    Hyperkalemia
  • ELECTROLYTE DISORDERS
    • Etiology (Cont)
      • Decreased excretion
        • Renal failure
        • Drugs
          • K + sparing diuretics, B-Blockers, NSAIDs, ACE Inhibitors
        • Aldosterone deficiency
    Hyperkalemia
  • ELECTROLYTE DISORDERS
    • Clinical Features
      • Cardiovascular
        • V-Fib, complete heart block, asystole
        • EKG abnormalities
          • Tall, peaked T-waves, short QT, prolonged PR
          • QRS widening, flattening of P-wave
          • QRS complex degrades into sine wave pattern
    Hyperkalemia
  • ELECTROLYTE DISORDERS
    • EKG
    Hyperkalemia
  • ELECTROLYTE DISORDERS
    • Clinical Features (Cont)
      • Neuromuscular
        • Weakness, paresthesias
        • Areflexia, ascending paralysis
      • Gastrointestinal
        • N/V, intestinal colic
        • Diarrhea
    Hyperkalemia
  • ELECTROLYTE DISORDERS
    • Treatment
      • Membrane stabilization
        • Cardiac irritability or K + > 7.5 meq/L
        • 10% Calcium Gluconate or Calcium Chloride
      • Redistribution (Shift K + to the ICF)
        • Glucose/Insulin (bolus, infusion)
        • NaHCO 3 - 50 to 100 meq IV over 2 min
        • B-Agonists (Albuterol neb)
    Hyperkalemia
  • ELECTROLYTE DISORDERS
    • Treatment
      • Remove K + from the body
        • Diuretics
          • Lasix 40 mg IV
        • Kaexalate PO/PR
          • Each gram eliminates 1 meq K +
        • Dialysis
          • Severely ill or already on dialysis
    Hyperkalemia
  • ELECTROLYTE DISORDERS
    • Normal range
      • 8.5 to 10.5 mg/dL
      • Ionized fraction is physiologically active
    Calcium
  • ELECTROLYTE DISORDERS
    • Hypocalcemia
      • Serum Ca 2+ < 8.5 mg/dL
      • Ionized level < 2.0 meq/L
      • Common Causes
        • Shock
        • Sepsis
        • Renal failure
        • Pancreatitis
    Hypocalcemia
  • ELECTROLYTE DISORDERS
    • Etiology
      • Hypoalbuminemia
      • Vitamin D deficiency
        • Hypoparathyroidism
        • Hyperphosphatemia
        • Malignancy
      • Drugs
        • Cimetidine, Phosphates, Dilantin, Phenobarbital, Glucagon, Aminoglycosides, Cisplatin, Heparin, Theophylline, Protamine, Norepinephrine, Loop diuretics, Glucocorticoids, Magnesium Sulfate, Nitroprusside
    Hypocalcemia
  • ELECTROLYTE DISORDERS
    • Clinical Features
      • Neurological
        • Circumoral & digital paresthesias
        • Tetany
        • Chvostek sign
        • Trousseau sign
        • Impaired memory, confusion
        • Hallucinations, dementia, seizures
    Hypocalcemia
  • ELECTROLYTE DISORDERS
    • Clinical Features (Cont)
      • Muscular
        • Spasms, cramps, weakness
      • Dermatologic
        • Hyperpigmentation
        • Coarse, brittle hair
        • Dry, scaly skin
    Hypocalcemia
  • ELECTROLYTE DISORDERS
    • Clinical Features (Cont)
      • Cardiovascular
        • Heart failure
        • Vasoconstriction
        • EKG abnormalities
          • Prolonged QT
      • Skeletal
        • Osteodystrophy
        • Rickets
        • Osteomalacia
    Hypocalcemia
  • ELECTROLYTE DISORDERS
    • Clinical Features (Cont)
      • Skeletal (Cont)
        • X-Ray abnormalities
          • Craniotabes
          • Frontal skull bossing
          • Rachitic rosary ribs
          • Widened rib cage
          • Bowed legs
          • Bone demineralization
    Hypocalcemia
  • ELECTROLYTE DISORDERS
    • Treatment
      • Asymptomatic
        • Oral replacement
      • Symptomatic or Severe
        • 10% Calcium Gluconate IV, 10-30 ml
        • 10% Calcium Chloride IV, 10 ml
    Hypocalcemia
  • ELECTROLYTE DISORDERS
    • Total Ca 2+ > 10.5 mg/dL
    • Ionized Ca 2+ > 2.7 meq/L
    Hypercalcemia
  • ELECTROLYTE DISORDERS
    • Etiology
      • Malignancy
      • Endocrinopathies
        • Hyperparathyroidism
        • Pheochromocytoma
        • Adrenal insufficiency
      • Drugs
        • Hypervitaminosis D/A
        • Thiazides, Lithium
      • Immobilization
    Hypercalcemia 90%
  • ELECTROLYTE DISORDERS
    • Clinical Features
      • General
        • Malaise, weakness, dehydration, polydipsia
      • Neurologic
        • Confusion, apathy, decreased memory, irritability
        • Hallucinations, headache, ataxia
        • Hyporeflexia, hypotonia
      • Cardiovascular
        • HTN, dysrhythmias
        • EKG abnormalities
          • Short QT & ST, Wide T-wave
    Hypercalcemia
  • ELECTROLYTE DISORDERS
    • Clinical Features (Cont)
      • Gastrointestinal
        • N/V, anorexia, wt loss
        • Constipation, abdominal pain
        • PUD, Pancreatitis
      • Skeletal
        • Fractures, bone pain, deformities
      • Urologic
        • Polyuria, polydipsia
        • Renal insufficiency
        • Nephrolithiasis
    Hypercalcemia
  • ELECTROLYTE DISORDERS
    • Memory Aid
      • Stones ---- Renal Calculi
      • Bones ---- Osteolysis
      • Moans ---- Psychiatric disorders
      • Groans ---- Abdominal (PUD, Pancreatitis)
    Hypercalcemia
  • ELECTROLYTE DISORDERS
    • Treatment
      • Treat dehydration
        • IV NS until ECF volume restored
        • Lasix 40 to 100 mg IV q 2-4 hrs
      • Decrease bone absorption
        • Calcitonin
        • Mithramycin
        • Hydrocortisone
        • Indomethacin
      • Monitor for hypokalemia, hypomagnesemia
    Hypercalcemia
  • ELECTROLYTE DISORDERS
    • Intracellular cation
    • Normal range
      • 1.5 to 2.5 meq/L
    Magnesium
  • ELECTROLYTE DISORDERS
    • Serum Mg 2+ < 1.5 meq/L
    • Coexistent disorders
      • Hypokalemia
      • Hypocalcemia
    Hypomagnesemia
  • ELECTROLYTE DISORDERS
    • Etiology
      • Redistribution
        • Trtm of DKA
      • Decreased intake
        • Alcoholism, malnutrition
        • Bowel resection, malabsorption
      • Extrarenal loss
        • Lactation, sweating
        • Burns, sepsis
        • Diarrhea
    Hypomagnesemia
  • ELECTROLYTE DISORDERS
    • Etiology (Cont)
      • Renal loss
        • Drugs
          • Loop diuretics, Aminoglycosides, Amphotericin B, Vitamin D intoxication, Alcohol, Cisplatin
        • SIADH
        • Hyperthyroidism, Hyperparathyroidism
    Hypomagnesemia
  • ELECTROLYTE DISORDERS
    • Clinical Features
      • Neuromuscular
        • Tetany
        • Muscle weakness
        • Cerebellar (ataxia, nystagmus, vertigo)
        • Confusion, obtundation, coma
        • Seizures
        • Apathy, depression
        • Irritability
        • Paresthesias
    Hypomagnesemia
  • ELECTROLYTE DISORDERS
    • Clinical Features
      • Gastrointestinal
        • Dysphagia, anorexia, nausea
      • Cardiovascular
        • Heart failure
        • Dysrhythmias
        • Hypotenstion
        • EKG abnormalities
          • Prolonged PR & QT, wide QRS
          • Depressed ST segment, inverted T-waves
    Hypomagnesemia
  • ELECTROLYTE DISORDERS
    • Treatment
      • Oral
      • IV replacement
        • Severe proven hypomagnesemia
        • Alcoholics with DTs
        • Up to 8-12 g MgSO 4 day 1, then 4-6 g/day
      • Monitor for hypokalemia, hypocalcemia, & hypophosphatemia
    Hypomagnesemia
  • ELECTROLYTE DISORDERS
    • Serum Mg 2+ > 2.5 meq/L
    • Coexistent disorders
      • Hyperkalemia
      • Hypercalcemia
    Hypermagnesemia
  • ELECTROLYTE DISORDERS
    • Etiology
      • Renal failure (most common)
      • Increased Mg 2+ load
        • Laxatives, antacids, enemas
        • Untreated DKA
        • Rhabdomyolysis
      • Increased renal absorption
        • Hyperparathyroidism
        • Hypothyroidism
        • Mineralocorticoid/adrenal insufficiency
    Hypermagnesemia
  • ELECTROLYTE DISORDERS
    • Clinical Features
      • Nausea > 2.0 meq/L
      • Somnolence > 3.0 meq/L
      • Decreased/absent DTRs > 4.0 meq/L
      • Resp compromise, apnea > 8.0 meq/L
      • Hypotension, heart block ≈ 15.0 meq/L
      • EKG abnormalities > 5.0 meq/L
        • Prolonged PR & QT
        • Prolonged QRS duration
    Hypermagnesemia
  • ELECTROLYTE DISORDERS
    • Treatment
      • D/C Mg 2+ administration
      • Dilution using IV NS
      • Lasix 40-80 mg IV
      • Dialysis
    Hypermagnesemia
  • ELECTROLYTE DISORDERS
    • Intracellular anion
    • Normal range
      • 2.5 to 4.5 mg/dL
    Phosphate
  • ELECTROLYTE DISORDERS
    • Serum PO 4 < 2.5 mg/dL
    • Sx onset at PO 4 < 1.0 mg/dL
    Hypophosphatemia
  • ELECTROLYTE DISORDERS
    • Etiology
      • Decreased oral intake
        • Malnutrition (Alcoholics)
      • Excessive loss
      • Shift from ECF ICF
        • Respiratory/Metabolic Alkalosis
      • Hyperalimentation
      • Hyperparathyroidism
      • DKA, AKA
    Hypophosphatemia
  • ELECTROLYTE DISORDERS
    • Clinical Features
      • Progressive weakness and tremors
      • Circumoral & fingertip paresthesias
      • Absent DTRs
      • Mental obtundation
      • Hyperventilation
      • Anorexia
    Hypophosphatemia
  • ELECTROLYTE DISORDERS
    • Treatment
      • Serum PO 4 level < 1.0 mg/dL
        • IV replacement
        • 2.5 mg/kg IV over 6 hours
        • Check serum PO 4 after each dose
    Hypophosphatemia
  • ELECTROLYTE DISORDERS
    • Complications of therapy
      • Hypocalcemia
      • Metastatic calcification
      • Hypotension
      • Hyperkalemia
    Hypophosphatemia
  • ELECTROLYTE DISORDERS
    • Serum PO 4 > 4.5 mg/dL
    • Etiology
      • Decreased renal excretion
      • Shift from ICF ECF
      • Increased intake
      • Most common with renal dysfunction
      • Hypoparathyroidism
    Hyperphosphatemia
  • ELECTROLYTE DISORDERS
    • Clinical Features
      • Sx related to renal failure
      • Sx of hypocalcemia
      • Sx of hypomagnesemia
    Hyperphosphatemia
  • ELECTROLYTE DISORDERS
    • Treatment
      • Treat underlying cause
      • Restrict Calcium Phosphate intake
      • Dilution using IV NS
      • Acetazolamide 500 mg q 6 hrs
      • Aluminum Carbonate/Hydroxide
        • Absorbs phosphate secreted into gut
      • Hemodialysis
    Hyperphosphatemia
  • ELECTROLYTE DISORDERS
    • Things to remember
      • Treat the patient, not the lab value
      • Rate of correction should mirror rate of change
      • Correct in orderly fashion
        • 1. Volume
        • 2. pH
        • 3. Potassium, Calcium, Magnesium
        • 4. Sodium and Chloride
      • Consider impact of interventions overall
    Key Points
  • ELECTROLYTE DISORDERS Questions K + + Na Mg 2+ 2+ Ca 4 PO - - Cl