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Electrolyte and Metabolic Emergencies in Critical Care
 

Electrolyte and Metabolic Emergencies in Critical Care

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A review of the more common electrolyte abnormalities and metabolic crises seen in critical care

A review of the more common electrolyte abnormalities and metabolic crises seen in critical care

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    Electrolyte and Metabolic Emergencies in Critical Care Electrolyte and Metabolic Emergencies in Critical Care Presentation Transcript

    • Electrolytes and Metabolic Emergencies Edward Omron MD, MPH Pulmonary Service
    • Objectives
      • Review causes and clinical manifestations of severe electrolyte disturbances
      • Outline emergent management of electrolyte disturbances
      • Recognize and treat acute adrenal insufficiency, thyroid storm and myxedema coma
      • Describe management of severe hyperglycemic syndromes
    • Principles of Electrolyte Disturbances
      • Implies an underlying disease process
      • Treat the electrolyte change, but seek the cause
      • Clinical manifestations usually not specific to a particular electrolyte change, e.g., seizures, arrhythmias
    • Principles of Electrolyte Disturbances
      • Clinical manifestations determine urgency of treatment, not laboratory values
      • Speed and magnitude of correction dependent on clinical circumstances
      • Frequent reassessment of electrolytes required
    • Hypokalemia
      • K < 3.5 mmol/L
      • Etiology – alkalosis, diuresis, dka, ngs, n/v, hypomagnesemia
      • Manifestations – life threatening arrhythmias
      • Deficit poorly estimated by serum levels
    • Which one of the following ECG changes is least likely to occur with hypokalemia?
      • ST-T segment depression
      • T wave inversion
      • AV Blocks (2nd and 3rd degree)
      • PVC’s
      • U waves
      • QT prolongation
    • Hypokalemia
      • Treat aggressively in severe metabolic acidosis
      • Correct hypomagnesemia
      • ECG monitoring with emergent administration
      • Allowable maximum iv dose per hour controversial
        • Life threatening arrhythmias: 10 mmols/ 20 minutes
        • KCL 20 mmols/hr Central IV or 20 mmol/ PO q1 hour
        • KCL 10 mmols/hr peripheral IV (Inefficient)
    • Hyperkalemia
      • K>5.5 mmol/dL
      • Etiology – renal failure, acidemia, cell death, drugs( ACE/Succinylcholine )
      • Manifestations
        • arrhythmias: peaked t waves, QRS widening, sine wave.
    • Hyperkalemia – Treatment
      • Urgency of treatment- clinical manifestations
      • Stop intake
      • Give calcium for cardiac toxicity
      • Shift K + into cell – glucose + insulin, NaHCO 3 , inhaled  2-agonist (high dose)
      • Remove from body – diuretics, sodium polystyrene sulfonate, dialysis
    • Hyponatremia
      • Na < 135 mmol/L
      • Hypo-osmolar hyponatremia
        • Euvolemic ( SIADH,Hypothyroidism )
        • Hypovolemic ( Diuretics, Adrenal Insuff.)
        • Hypervolemic ( CHF, Cirrhosis, NS )
      • Normo- or hyperosmolar hyponatremia
      • Pseudohyponatremia
      • Manifestations – neurologic (brain edema)
    • 65 yo wm POD 2 TURP presents lethargic to ICU
      • HR =90, BP = 120/80, RR = 15
      • Na = 114, K =3.8, Cl = 78, HCO3 = 20, Cre = 1.2
        • Free Water Restriction
        • Isotonic Saline
        • Hypertonic Saline
        • Furosemide
        • Ringers Lactate
      • (infusate Na - serum Na)/ (TBW+1)
      • NS(154 mmol/L)
        • (154 - 114) / (42L + 1) = Delta 0.9 mmol
      • Hypertonic Saline
        • (514 - 114) / (42+1) = Delta 9.3 mmol
        • Given over 24 hours (40 cc/hr)
        • Correct 0.5 mmol/hr until Na > 120 mmol/L
      • Delta Plasma Na  from 1 liter of fluid
    • Hyponatremia – Treatment
      • Hypovolemic  Na – give normal saline, rule out adrenal insufficiency
      • Hypervolemic  Na – increase free H 2 O loss
      • Euvolemic hyponatremia
        • Restrict free water intake
        • Increase free water loss
        • Normal or hypertonic saline
      • Correct slowly due to possibility of demyelinating syndromes
    • Hypernatremia
      • Na > 145 mmol/L
      • Causes: diarrhea, vomiting, diuresis, thirst, diabetes insipidus
      • Manifestations- neurologic
      • Na = 160 mmol, 70 kg male
        • 1 L D 5 W changes Na by 4 mmol/L
        • H 2 O deficit (L) = [ 0.6  wt (kg) ] 
        • [ observed Na/140 - 1 ] = 6 Liter Free H 2 O
      • Urine Osmolality > 500 mOsmol/kg extrarenal or osmotic diuresis, < 300 mOsmol/kg diabetes insipidus
    • Hypernatremia – Treatment
      • Provide intravascular volume replacement
      • Consider giving one-half of free H 2 O deficit initially
      • Reduce Na cautiously: 0.5-1.0 mmol/L/hr
      • Secondary neurologic syndromes with rapid correction
    • Other Electrolyte Deficits Ca, PO 4, Mg
      • May produce serious but nonspecific cardiac, neuromuscular, respiratory, and other effects
      • All are primarily intracellular ions, so deficits difficult to estimate
      • Titrate replacement against clinical findings
    • Other Electrolyte Disorders
      • Hypocalcemia
        • Calcium chloride or gluconate
        • Bolus + continuous infusion
        • Albumin correction is useless
      • Hypercalcemia
        • Rehydration with normal saline
        • Loop diuretics
    • Other Electrolyte Disorders
      • Hypophosphatemia
        • PO4 < 2.5 mg/dL
        • Replacement iv for level < 1 mg/dL
      • Hypomagnesemia
        • Emergent administration over
        • 5–10 mins
        • Less urgent administration over 10–60 mins
    • What is most likely to present in a patient with severe magnesium deficiency?
      • Respiratory Depression
      • Bradycardia
      • Tetany
      • Hypotension
      • Loss of patellar reflex
      • 35 yo with fever, hypotension, and syncope
        • 2 months of fatigue, weight loss
        • BP 70/40, HR 110, temp 103, RR 18
        • Na = 128, K = 5.6, Cl = 102, HCO3 = 16
        • Glucose = 60, BUN = 28, Creat = 1.2
        • Bolus 3L NS, BP 80/50 Dopamine started
        • 1. Norepinephrine and decrease dopamine
        • 2. Dexamethasone 4 mg IV
        • 3. Infuse 1 liter hetastarch
        • 4. Thyroxine IV and hydrocortisone 100 mg IV
    • Acute Adrenal Insufficiency
      • Nonspecific manifestations
        • Abdominal pain, nausea, emesis
        • Orthostatic/refractory hypotension
      • Laboratory findings
        • Hyponatremia, hyperkalemia
        • Hypoglycemia
        • metabolic acidosis
        • Hypereosinophillia
    • Acute Adrenal Insufficiency
      • Baseline blood samples
      • Volume and glucose infusion
      • Dexamethasone or hydrocortisone
      • ACTH stimulation test if needed
      • Treat precipitating conditions
    • Hyperglycemic Syndromes
      • Diabetic ketoacidosis (DKA)
      • Hyperglycemic hyperosmolar state (HHS)
      • Manifestations – dehydration, polyuria/ polydipsia, altered mental status,  BP, nausea, emesis, abdominal pain
    • Hyperglycemic Syndromes – Laboratory
      • Hyperglycemia/hyperosmolality
      • Ketonemia/ketonuria (DKA)
      • Increased anion gap metabolic acidosis (DKA)
      • Electrolyte changes (K, PO 4 , Na)
    • Hyperglycemic Syndromes – Treatment
      • Identify and treat precipitating factors
      • Restore fluid/electrolyte balance
      • Insulin – iv bolus and infusion
      • Add glucose to infusion when glucose <250-300 mg/dL (13.9-16.7 mmol/L)
      • Treat electrolyte changes (K, PO 4 )
      • NaHCO 3 rarely needed
      • Lactated Ringers preferred crystalloid
      • 28 yo with schizophrenia, acute delirium
        • HR 120, T 101.6, BP 96/50
        • bibasilar rales, 2/6 systolic murmur
        • ECG with atrial fibrillation
        • WBC 10,000, CK 150, (-) LP, UA, and head CT
        • 1. Dantrolene
        • 2. Haloperidol
        • 3. Antibiotics
        • 4. Propylthiouracil, propranol
    • Thyroid Storm
      • Exaggerated manifestations of hyperthyroidism
      • Supportive measures
      • Specific measures
        • Propylthiouracil or methimazole
        • Propranolol
        • Potassium or sodium iodide
        • Dexamethasone, sodium ipodate
      • 56 yo obese female minimally responsive
        • HR 64, RR 10, BP 160/100, T 96.5
        • Distant heart sounds, 3+ LE non-pitting edema
        • CXR: bilateral effusions/ cardiomegaly
        • Na = 130, Hb = 10.2, CK = 500, WBC =13000
        • (-) head ct and lumbar puncture
        • 1. Intravenous thyroxine, hydrocortisone
        • 2. TTE
        • 3. Neurology consult
        • 4. flumazenil
    • Myxedema Coma
      • Manifestations of severe hypo-thyroidism
      • Supportive measures – airway, fluids, glucose, warming
      • Treat precipitating cause
      • Hydrocortisone
      • L-thyroxine