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Electrolyte disturbances

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  • 1. Electrolyte disturbances Moderator Dr Sumesh Rao Presenter Dr Nikhil MP
  • 2. Disorders of sodium balance
  • 3. Normal plasma sodium is 135 to 145 meq/l
  • 4. Hyponatremia
  • 5. Plasma sodium <135 meq/l
  • 6. Types
    • Hypoosmolal hyponatremia
    • Hyponatremia with normal plasma osmolality
    • Hyponatremia with elevated plasma osmolality
  • 7. Hypoosmolal hyponatremia
  • 8. Types
    • Hypovolemic
    • Euvolemic
    • Hypervolemic
  • 9. Hyopovolemic
    • Renal
    • diuretics
    • mineralocorticoid deficiency
    • salt wasting nephropathies
    • osmotic diuresis
    • renal tubular acidosis
    • Gastrointestinal
    • vomiting
    • diarrhea
    • fistula
    • integumentary
    • sweating
    • burns
  • 10. Euvolemic
    • Primary polydipsia
    • SIADH
    • Arginine vasopressin release due to pain,nausea
    • Glucocorticoid deficiency
    • Hypothyroidism
    • Chronic renal insufficiency
  • 11. Hypervolemic
    • Congestive cardiac failure
    • Cirrhosis
    • Nephrotic syndrome
  • 12. Pseudohyponatremia
      • Hyponatremia with normal plasma
      • osmolality
    • marked hyperlipidemia
    • marked hyperproteinemia.
    • TURP syndrome
    • Hyponatremia with elevated plasma osmolality
    • hyperglycemia
    • mannitol.
  • 13. Clinical features
  • 14.
    • mainly
  • 15. Clinical features
    • Primarily neurological
    • Increased ICF volume
    • severity:depends on rapidity of onset and absolute increase in plasma sodium concentration
    • Asymtomatic or nausea,vomiting
    • Depressed level of consciousness,confusion,agitation
    • Stupor,seizures and coma.
  • 16.
    • Cerebral edema < 120 meq/l
    • Cardiac symptoms < 100 meq/l
  • 17. diagnosis
  • 18.
    • history & physical examination
    • 3 tests
    • plasma osmolality
    • urinary osmolality
    • urinary sodium excretion
    • Plasma osmolality = 2 Na + glucose + BUN
    • 18 2.8
  • 19. cont…….
    • Plasma osmolality low
    • impaired function
    • assess renal status primary renal disease
    • normal
    • Assess volume status volume depletion volume overload
    • normovolemic CCF
    • urinary sodium(meq/l ) nephrotic
    • Adrenal & cirrhosis
    • thyroid insufficiency <10 >20
    • normal diarrhea salt wasting nephropathy
    • vomiting diuretics
    • Able to dilute urine
    • In response to water load dilute urine psyhogenic polydipsia
    • no yes
    • SIADH
  • 20. treatment
  • 21. Goals of therapy
    • To raise plasma sodium concentration by restricting water intake and promoting water loss
    • To correct underlying disorder
  • 22. principles
    • 0.9% & 3% saline : Hypovolemic
    • Water restriction :Euvolemic
    • &
    • Hypervolemic
  • 23. When to treat....?
    • Symptomatic
    • Plasma sodium < 120 meq/l
  • 24. Cont….
    • Rate of correction depends on absence or presence of neurologic dysfunction.
    • In asymptomatic patients :
    • 0.5 to 1 meq/l/hr or 10 to 12 meq/l over first 24 hours
    • Severe symptomatic hyponatremia (<110 meq/l)
    • hypertonic saline
    • 1 to 2 meq/l/hr for the first 3 to 4 hrs,total not exceeding more than 12meq/l/ 24hrs.
  • 25. To calculate Na deficit
    • Sodium deficit =total body water X
    • (desired Na - present Na)
    • TBW = body wt x 0.6 males
    • 0.5 females
  • 26. Change in plasma sodium
    • Infusate sodium/l - Serum sodium
    • TBW + 1
  • 27. Case history
    • A 45 yr male ,50 kg by wt presented with
    • altered sensorium and agitation.a diagnosis of
    • hypoosmolar hyponatremia is made.plasma
    • sodium is 110 meq/l .
  • 28.
    • sodium requirement= desired Na – serum Na X
    • TBW
    • = 130 - 110 X 0.6 X 50
    • = 600 meq
  • 29.
    • change in Na = infusate Na - serum Na
    • TBW + 1
    • = 513 - 110 = 403 = 13 meq/l
    • 30 + 1 31
    • 100 ml 1.3 meq/l
    • 800 ml over 24 hrs app 34 ml/hr
  • 30. Rapid correction can lead to…
    • osmotic demyelination syndrome(central
    • Pontine myelinolysis)
    • chronic hyponatremia
    • flaccid paralysis,dysarthria,dysphagia.
    • no specific treatment.
  • 31. Anaesthetic implications
    • Plasma Na > 130meq/l for patients undergoing elective surgery & is considered safe
    • Lower levels can result in signifcant cerebral edema
    • Decrease in MAC: intraoperatively
    • Agitation & confusion : postoperatively
  • 32. Hypernatremia
  • 33. Plasma sodium>145meq/l
  • 34. causes
  • 35.
    • Impaired thirst
    • coma
    • essential hypernatremia
    • Solute diuresis
    • diabetic ketoacidosis
    • non-ketotic hyperosmolar coma
    • excessive water loss
    • diabetes insipidus
    • sweating
  • 36. Types
    • Hypernatremia with low body sodium content
    • Hypernatremia with normal body sodium content
    • Hypernatremia and increased body sodium content
  • 37. Hypernatremia with low body sodium content
    • Water loss in excess of sodium loss.
    • eg:osmotic diuresis
    • diarrhea
    • sweating
  • 38. Hypernatremia with normal total body sodium content
    • Due to water loss
    • Diabetes insipidus
    • central diabetes insipidus
    • nephrogenic diabetes insipidus
  • 39. Hypernatremia and increased total body sodium content
    • Following administration of large quantities
    • of hypertonic saline solutions
  • 40. Clinical features
  • 41.
    • mainly
  • 42.
    • Mainly due to contracted ICF volume
    • Mainly neurological
    • alered mental status
    • irritability
    • weakness
    • focal neurological deficits
    • coma &death
    • Prone for intracerebral or subarachnoid haemorrhage
  • 43. diagnosis
  • 44.
    • ECF volume
    • not increased increased hypertonic Nacl or
    • sodium bicarbonate
    • min volume of max
    • concentrated urine no
    • yes
    • Insensible water loss urine osmole
    • Gastrointestinal excretion rate
    • >750 mosmol/d
    • no yes
    • renal response diuretic
    • to desmopressin osmotic diuresis
    • urine osmolality
    • increased unchanged
    • central DI nephrogenic DI
  • 45. treatment
  • 46. Goals of therapy
    • To correct water deficit
    • To stop ongoing water loss
  • 47. principles
    • Correction should be done over 48 to 72 hours .
    • Hypotonic solution like 5% dextrose.
    • Plasma Na should be lowered by 0.5 meq/l/hr or not more than 12meq/l/ 24 hrs.
  • 48. To calculate water deficit
    • Water deficit = plasma Na - 140 X TBW
    • 140
  • 49. Rapid correction can lead to…
    • Seizures or permanent neurologic damage
  • 50. Anaesthetic implications
    • Increases MAC
    • Enhance uptake of inhalation anaesthtics by decreasing cardiac output.
    • Predisposes to hypotension & hypoperfusion of tissues
    • Decreases volume of distribution and reduction in dose of intravenous agents
  • 51. Disorders of potassium balance
  • 52. Normal plasma potassium is 3.5 to 5 meq/l
  • 53. Hypokalemia
  • 54. Plasma potassium < 3.5 meq/l
  • 55. causes
  • 56.
    • Redistribution into cells
    • Increased loss
    • Decreased intake
  • 57. Redistribution into cells
    • Metabolic alkalosis
    • Hormonal
    • insulin
    • beta 2 agonist
    • alpha antagonist
    • Anabolic state
    • vit B12 /folic acid
    • total parentral nutrition
    • others
    • Hypokalemic periodic paralysis
    • hypothermia
    • barium toxicity.
  • 58. Increased loss
    • Renal
    • primary hyperaldosteronism
    • secondary hyperaldosteronism
    • congenital adrenal hyperplasia
    • cushings syndrome
    • bartters syndrome
    • liddles syndrome
    • renal tubular acidosis
    • diabetic ketoacidosis
    • diuretics,aminoglycosides,penicillin
    • amphotericin-B
    • Gastrointestinal
    • integumentary
  • 59. Decreased intake
    • Starvation
    • Clay ingestion
  • 60. Clinical features
  • 61.
    • Manifestations vary between patient
    • Asymptomatic
    • <3 mq/l
    • Fatigue,myalgia&lower extremity weakness
  • 62. Neuromuscular
  • 63. Neuromuscular
    • Fatigue,myalgia,muscular weakness
    • Progressive weakness and hypoventilation
    • as severity increases
    • Rhabdomyolysis
    • Paralytic ileus
  • 64. cardiovascular
    • Abormal electrocardiogram
    • Arrhythmias
    • Orthostatic hypotension
    • Decreased cardiac contractility
    • Potentiates arrhythmogenic potential of digoxin
    • Myocardial fibrosis
  • 65. ECG Changes
    • Appearance of U wave
    • Flattening or inversion of T wave
    • ST segment depression
    • Prolonged QT interval
    • Prominent U wave
    • Prolonged PR interval
    • Widening of QRS complex
    • Ventricular arrhythmias
  • 66.  
  • 67. diagnosis
  • 68.
    • history
    • urinary potassium excretion <15mmol/d >15mmol/d.
    • assess acid- base status
    • metabolic acidosis metabolic alkalosis
    • lower gastrointestinal loss diuretic
    • vomiting
    • k+loss via sweat
  • 69.
    • >15 meq/day
    • assess k+ excretion
    • TTKG>4 TTKG<2 salt wasting nephropathy
    • osmotic diuresis
    • Assess acid-base status diuretic
    • metabolic metabolic
    • acidosis alkalosis
    • yes
    • DKA hypertension mineralocorticoid
    • Proximal RTA no excess
    • Distal RTA vomiting liddles syndrome
    • bartters
    • diuretic abuse
    • hypomagnesemia
  • 70. treatment
  • 71. Therapeutic goals
    • To correct potassium deficit
    • To minimize ongoing losses
    • To prevent life threatening complications
  • 72. principles
    • Safer to correct potassium via oral route
    • A decrement of 1mmol/l in plasma potassium may represent a total body k+ deficit of 200 to 400meq
    • Dextrose containing solutions avoided
  • 73. treatment
  • 74. When to treat…..?
    • 3.5 to 4 mq/l
    • Increased intake of potassium containing food.
    • 3 to 3.5 mq/l
    • Only in high risk patients.
    • < 3 mq/l needs definitive treatment.
  • 75. Oral potassium
    • Safer
    • Potassium chloride preparation of choice
    • Potassium bicarbonate and citrate
    • Mild to moderate hyperkalemia kcl 60 to 80 meq/day in 3 to 4 divided doses
    • Severe or symptomatic – kcl 40 mq 6 th hourly under ECG monitoring
    • 15 ml solution=20 meq
    • 8 meq/tab
  • 76. Iv potassium
    • Severe symptomatic hypokalemia
    • Continous ECG monitoring & frequent k+ estimation
    • Never give KCl directly IV.
    • Rapid IV correction can cause dangerous hyperkalemia.
    • Use isotonic saline
    • Do not mix with dextrose containing solutions .
  • 77. Cont…..
    • 15% KCl solution in 10 ml ampoule.
    • 10 ml = 20 meq of potassium = 1.5 g KCl.
    • How long to give?
    • As cardiac rhythm returns to normal KCl drip is tapered and oral k+ initiated.
  • 78. Cont….
    • should not exceed 8meq/hr via peripheral vein
    • central venous catheter in case of faster replacements&should not exceed more than 20 meq/hour
  • 79. Anaesthetic implications
    • Chronic hypokalemia more succeptible for arrhythmias
    • ECG monitoring
    • Glucose free solutions
    • Potentiates neuromuscular blockers
    • Avoid alkalosis
    • Hyperventilation avoided
  • 80. Hyperkalemia
  • 81. Plasma potassium >5 meq/l
  • 82. causes
    • Decreased renal excreation of potassium
    • renal failure
    • primary hypoaldosteronism
    • secondary hypoaldosteronism
    • drugs
    • spironolactone
    • nsaids
    • ace inhibitors
    • trimethoprim
    • heparin
  • 83. Cont…
    • Due to extracellular movement of k+
    • acidosis
    • hyperkalemic periodic paralysis
    • succinylcholine
    • rhabdomyolysis
    • cell lysis following chemotherapy
    • digitalis overdose
    • Enhanced chloride reabsorption
    • cyclosporine
    • Gordons syndrome
    • Increased potassium intake
    • pseudohyperkalemia
  • 84. Clinical features
  • 85. skeletal
  • 86. skeletal
    • Weakness,flaccid paralysis
    • Hypoventilation
  • 87.
    • CVS
  • 88. cardiac
    • Increased T-wave amplitude 6 to 7 meq/l
    • Prolonged PR interval
    • QRS widening 7 to 8 meq/l
    • Loss of P wave
    • sine wave pattern 8 to 9 meq/l
    • Ventricullar fibrillation or asystole > 9meq/l
  • 89.  
  • 90.  
  • 91. diagnosis
    • Exclude pseudohyperkalemia&transcellular k+ shifts
    • Exclude oliguric renal failure
    • stop NSAIDs and ACE inhibitors
    • assess k+ secretion
  • 92. Cont……
    • TTKG < 5 TTKG > 10
    • decreased circulating vol
    • Response to low protien diet
    • 9a-fludrocortisone
    • TTKG >10 TTK<10
    • primary/secondary hypotension HTN
    • hypoaldosteronism high renin & low renin&
    • aldosterone aldosterone
    • pseudohypoaldosteronism Gordons syndrome
    • k+diuretics cyclosporine
    • distal RTA
  • 93. treatment
  • 94. principles
    • >6meq/l should be treated
    • To minimize membrane excitability
    • To shift potassium into cells
    • Promote potassium loss
  • 95. Calcium gluconate
    • 10% solution in 10 ml ampoules
    • 10ml of 10% calcium gluconate IV over 5 to 10 min
    • Repeated if no change in ECG is seen after 5 to 10 min
    • How it helps……?
    • protects the myocardium from toxicity to potassium
  • 96. Insulin & glucose
    • 10 to 20 units of regular insulin in 50 ml of 25 to 50 % dextrose
    • Initial bolus should be followed by continous infusion of 5% dextrose
    • effect begins in 15 min & peak in 60 min
  • 97. cont…..
    • Sodium bicarbonate
    • 7.5 % of 50 to 100 ml is given as IV slowly over 10 to 20 min.
    • Beta agonist
    • salbutamol 20 mg in 4 ml saline by nebulisation
    • Loop & thiazide diuretics
  • 98. Cont…
    • Cation exchange resins
    • sodium polystyren sulphonate
    • promote exchange of Na for K in
    • GIT
    • 25 to 50g with 100ml of 20% sorbitol 3 to 4 times a day
    • Haemodialysis
  • 99.  
  • 100. Anaesthetic implications
    • ECG monitoring
    • Succinylcholine avoided
    • Potssium free solutions
    • Avoid acidosis
    • Potentiates neuromuscular blockers
    • Mild hyperventilation
  • 101. Disorders of calcium balance
  • 102.
    • Normal plasma calcium 8.5 to 10.5 mg/dl.
    • 50% in ionized form ,40% protein bound,10% complexed with anions
  • 103. hypocalcemia
  • 104. Plasma calcium <8.5 mg dl
  • 105. causes
    • Hypoparathyroidism
    • Vitamin D deficiency
    • nutritional
    • malabsorption
    • Hyperphosphatemia
    • Precipitation of calcium
    • pancreatitis
    • rhabdomyolysis
    • Chelation of calcium
    • rapid blood transfusion
    • rapid infusion of large amount of albumins
  • 106.  
  • 107.
    • Hallmark of hypocalcemia is TETANY
    • Parasthesia in circumoral region & extremities
    • Laryngospasm,bronchospasm
    • Abdominal cramps,urinary frequency
    • Hypotension & arrhythmias
    • Latent hypocalcemia
    • Chvosteks sign
    • Trousseaus sign
  • 108.  
  • 109.  
  • 110. ECG
    • Prolongation of QT interval
  • 111. treatment
    • Symptomatic hypocalcemia – emergency
    • 10 ml of 10% calcium gluconate IV over 10 minutes.
    • Iv calcium should not be given with bicarbonate or phosphate containing solution
    • Serial calcium measurements
    • Correction of co-existing alkalosis
    • Calcium supplimentation in long term
  • 112. Anaesthetic implicatons
    • Corrected preoperatively
    • Serial ionized calcium level monitored
    • Potentiates negative inotropic effect of barbiturates and volatile anaesthetics
    • Laryngospasm
    • Alkalosis should be avoided
  • 113. hypercalcemia
  • 114.
    • plasma calcium > 10.5 mg/dl
  • 115. causes
    • Hyperparathyroidism
    • Malignancy
    • Pagets disease of bone
    • Excessive vitamin D intake
    • Granulomatous disorders
    • Milk- alkali syndrome
    • Drugs
    • thiazides
    • lithium
  • 116. Clinical features
    • Anorexia
    • Nausea,vomiting
    • Weakness
    • Polyuria
    • Ataxia
    • Irritability
    • Lethargy
    • confusion
  • 117. ECG changes
    • Pronged PR interval
    • Widened QRS complex
    • Shortened QT
  • 118.  
  • 119. treatment
    • Hydration with normal saline
    • Loop diuretics like frusemide
    • haemodialysis
    • Urine output > 3 litres /day
    • k+ and Mg+
    • Severe cases bisphosphonates
    • pamindronate 60 to 80 mg iv over 4 hrs
    • calcitonin 2 to 8 U subcut
    • 90% due to malignancy & hyperparathyroidism
  • 120. Anaesthetic implications
    • Saline diuresis
    • K+ & Mg+
    • decreased dose of neuromuscular blockers
    • Cvp & pulmonary pressure monitoring
    • Hyperventilation avoided
  • 121. Disorders of magnesium balance
  • 122. hypomangnesemia
  • 123. Plasma mg+ <1.7 meq/l
  • 124. causes
    • Inadequate intake
    • Reduced gasroinestinal absorption
    • malabsorption
    • small bowel /biliary fistula
    • severe diarrhea
    • prolonged nasogastric suctionig
    • Renal losses
    • diuresis
    • hyperparathyroidism
    • Drugs
    • theophylline
    • diuretics,ethyl alcohol
    • aminoglycoside,amphotericin B
  • 125. clinical features
    • Asymptomatic
    • Associated with hypocalcemia & hypokalemia
    • Anorexia,weakness,parasthesia
    • Confusion,seizures&coma
    • Atrial fibrillation
    • Potentiates digitalis toxicity
    • Prolongation of PR &QT interval
  • 126. treatment
    • Asymptomatic
    • 2g oral magnesium sulfate
    • Symptomatic
    • magnesium sulfate 1 TO 2 g IV over 10 min
    • 1 ml of 50% solution contains 4 meq
  • 127. Things to be monitored
    • Tendon reflexes
    • Respiratory rate
    • Urine output
  • 128.  
  • 129. Anaesthetic implications
    • No specific anaesthetic interactions
    • Coexistent electrolyte imbalances should be corrected
  • 130. Hypermagnesemia
  • 131. Plasma mg > 2.5 meq/l
  • 132. causes
    • Antacids or laxatives
    • Iatrogenic
    • Hypothyroidism
    • Adrenal insufficiency
    • Lithium administration
  • 133. Clinical features
    • Hyporeflexia ,drowsiness & skeletal muscle weakness
    • Hypotension
    • Prolonged PR interval & widening of QRS complex
    • Respiratory arrest
  • 134. treatment
    • 10 ml of 10% calcium gluconate IV over 10 min
    • Loop diuretic with ½ normal saline in 5% dextrose
    • Peritoneal / haemodialysis
  • 135. Anaesthetic considerations
    • tendon reflexes, respiratory rate & urine output
    • Potentiates negative inotropic effects of anaesthetics
    • Neuromuscular blockers decreased by 25 to 50%
  • 136. Referances
    • Harrisons ,16 th edition
    • Millers anesthesia,6 th edition
    • Clinical anesthesiologyMorgan,4 TH edition
    • Practical guidelines on fluid therapy , sanjay pandya
  • 137. thank you