ELECTROLYTE DISORDERS EMPA Residency UTHSCSA K + + Na Mg 2+ 2+ Ca 4 PO - - Cl
ELECTROLYTE DISORDERS <ul><li>Composition of body fluids </li></ul><ul><li>Fluid Compartments </li></ul><ul><li>Fluid bala...
ELECTROLYTE DISORDERS Total fluid volume 42 liters ECF 33% --- 1) Plasma 7% 2) Interstitial Fluid 26% 3) Lymph <1% ICF 67%...
ELECTROLYTE DISORDERS Fluid Compartments
ELECTROLYTE DISORDERS <ul><li>Serum Osmolality </li></ul><ul><ul><li>Number of osmoles (osmotically active particles) in t...
ELECTROLYTE DISORDERS <ul><li>Major extracellular cation </li></ul><ul><li>Normal range </li></ul><ul><ul><li>135 to 150 m...
ELECTROLYTE DISORDERS <ul><li>Serum Na +  < 135 meq/L </li></ul><ul><ul><li>Primary water gain or Na +  loss > water </li>...
ELECTROLYTE DISORDERS <ul><li>Pathophysiology:  CNS </li></ul><ul><ul><li>Water shifts into brain cells </li></ul></ul><ul...
ELECTROLYTE DISORDERS <ul><li>Pathophysiology:  Cardiovascular </li></ul><ul><ul><li>Effect depends on arterial blood volu...
ELECTROLYTE DISORDERS <ul><li>Pathophysiology:  Musculoskeletal System </li></ul><ul><ul><li>Muscle cramps & weakness with...
ELECTROLYTE DISORDERS <ul><li>Pathophysiology:  Renal System </li></ul><ul><ul><li>Production of dilute urine </li></ul></...
ELECTROLYTE DISORDERS <ul><li>Diagnosis </li></ul>Hyponatremia Plasma Osmolality Normal (275-295) Isotonic hyponatremia Lo...
ELECTROLYTE DISORDERS <ul><li>Hypertonic  Hyponatremia (P osm  > 295) </li></ul><ul><ul><li>Large quantities of solute in ...
ELECTROLYTE DISORDERS <ul><li>Isotonic  Hyponatremia (P osm  275 - 295) </li></ul><ul><ul><li>“ Pseudohyponatremia” </li><...
ELECTROLYTE DISORDERS <ul><li>Hypotonic  Hyponatremia (P osm  < 275) </li></ul>Hyponatremia Plasma Osmolality Normal (275-...
ELECTROLYTE DISORDERS <ul><li>Hypotonic  Hyponatremia </li></ul><ul><ul><li>Hypovolemic vs Hypervolemic vs Euvolemic </li>...
ELECTROLYTE DISORDERS <ul><li>Hypovolemic  Hyponatremia </li></ul><ul><ul><li>Loss of Na +  and water </li></ul></ul><ul><...
ELECTROLYTE DISORDERS <ul><li>Hypovolemic  Hyponatremia </li></ul><ul><ul><li>Renal Na +  loss </li></ul></ul><ul><ul><ul>...
ELECTROLYTE DISORDERS <ul><li>Hypovolemic  Hyponatremia </li></ul><ul><ul><li>Extrarenal Na +  loss </li></ul></ul><ul><ul...
ELECTROLYTE DISORDERS <ul><li>Hypovolemic  Hyponatremia </li></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><ul><li>Re-...
ELECTROLYTE DISORDERS <ul><li>Euvolemic  Hyponatremia </li></ul><ul><ul><li>Normal volume status and hyponatremia </li></u...
ELECTROLYTE DISORDERS <ul><li>Euvolemic  Hyponatremia </li></ul><ul><ul><li>SIADH </li></ul></ul><ul><ul><ul><li>Hypotonic...
ELECTROLYTE DISORDERS <ul><li>Euvolemic  Hyponatremia </li></ul><ul><ul><li>Etiology: </li></ul></ul><ul><ul><ul><li>Hypot...
ELECTROLYTE DISORDERS <ul><li>Euvolemic  Hyponatremia </li></ul><ul><ul><li>Etiology (Cont): </li></ul></ul><ul><ul><ul><l...
ELECTROLYTE DISORDERS <ul><li>Euvolemic  Hyponatremia </li></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><ul><li>Fluid...
ELECTROLYTE DISORDERS <ul><li>Hypervolemic  Hyponatremia </li></ul><ul><ul><li>Total body water in great excess </li></ul>...
ELECTROLYTE DISORDERS <ul><li>Hypervolemic  Hyponatremia </li></ul><ul><ul><li>Without advanced renal insufficiency </li><...
ELECTROLYTE DISORDERS <ul><li>Hypervolemic  Hyponatremia </li></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><ul><li>Op...
ELECTROLYTE DISORDERS <ul><li>Treatment of Severe Hyponatremia </li></ul><ul><ul><li>Indications: </li></ul></ul><ul><ul><...
ELECTROLYTE DISORDERS <ul><li>Complications of Therapy </li></ul><ul><ul><li>Central Pontine Myelinolysis (CPM) </li></ul>...
ELECTROLYTE DISORDERS <ul><li>Serum Na +  > 150 meq/L </li></ul><ul><ul><li>D ecrease in total body water </li></ul></ul><...
ELECTROLYTE DISORDERS <ul><li>Pathophysiology </li></ul><ul><ul><li>2 Primary Mechanisms </li></ul></ul><ul><ul><ul><li>Re...
ELECTROLYTE DISORDERS <ul><li>Pathophysiology </li></ul><ul><ul><li>Rapid hypertonicity or short duration </li></ul></ul><...
ELECTROLYTE DISORDERS <ul><li>Etiology </li></ul><ul><ul><li>Excessive sodium intake </li></ul></ul><ul><ul><ul><li>Iatrog...
ELECTROLYTE DISORDERS <ul><li>Etiology (Cont): </li></ul><ul><ul><li>Loss of water in excess of Na + </li></ul></ul><ul><u...
ELECTROLYTE DISORDERS <ul><li>Etiology (Cont): </li></ul><ul><ul><li>Loss of water in excess of Na + </li></ul></ul><ul><u...
ELECTROLYTE DISORDERS <ul><li>Clinical Features: </li></ul><ul><ul><li>Acute sx at Na +  > 158 meq/L </li></ul></ul><ul><u...
ELECTROLYTE DISORDERS <ul><li>Treatment </li></ul><ul><ul><li>**Volume replacement** </li></ul></ul><ul><ul><ul><li>NS/LR ...
ELECTROLYTE DISORDERS <ul><li>Complications of therapy </li></ul><ul><ul><li>Excessively rapid correction </li></ul></ul><...
ELECTROLYTE DISORDERS <ul><li>Major intracellular cation </li></ul><ul><li>Normal range </li></ul><ul><ul><li>3.5 to 5.5 m...
ELECTROLYTE DISORDERS <ul><li>Serum K +  < 3.5 meq/L </li></ul><ul><li>Pathophysiology </li></ul><ul><ul><li>K +  shifts i...
ELECTROLYTE DISORDERS <ul><li>Etiology </li></ul><ul><ul><li>ECF  ICF shifts </li></ul></ul><ul><ul><ul><li>Metabolic alka...
ELECTROLYTE DISORDERS <ul><li>Etiology (Cont) </li></ul><ul><ul><li>Renal loss </li></ul></ul><ul><ul><ul><li>Diuretics, A...
ELECTROLYTE DISORDERS <ul><li>Clinical Features </li></ul><ul><ul><li>Sx onset at serum K +   <  2.5 meq/L </li></ul></ul>...
ELECTROLYTE DISORDERS <ul><li>Clinical Features (Cont): </li></ul><ul><ul><li>Neuromuscular </li></ul></ul><ul><ul><ul><li...
ELECTROLYTE DISORDERS <ul><li>Treatment </li></ul><ul><ul><li>Replace K + </li></ul></ul><ul><ul><ul><li>Oral </li></ul></...
ELECTROLYTE DISORDERS <ul><li>Serum K +  > 5.5 meq/L </li></ul><ul><ul><li>Oliguric renal failure </li></ul></ul><ul><ul><...
ELECTROLYTE DISORDERS <ul><li>Etiology </li></ul><ul><ul><li>ICF  ECF shifts </li></ul></ul><ul><ul><ul><li>Acidosis </li>...
ELECTROLYTE DISORDERS <ul><li>Etiology (Cont) </li></ul><ul><ul><li>Decreased excretion </li></ul></ul><ul><ul><ul><li>Ren...
ELECTROLYTE DISORDERS <ul><li>Clinical Features </li></ul><ul><ul><li>Cardiovascular </li></ul></ul><ul><ul><ul><li>V-Fib,...
ELECTROLYTE DISORDERS <ul><li>EKG </li></ul>Hyperkalemia
ELECTROLYTE DISORDERS <ul><li>Clinical Features (Cont) </li></ul><ul><ul><li>Neuromuscular </li></ul></ul><ul><ul><ul><li>...
ELECTROLYTE DISORDERS <ul><li>Treatment </li></ul><ul><ul><li>Membrane stabilization </li></ul></ul><ul><ul><ul><li>Cardia...
ELECTROLYTE DISORDERS <ul><li>Treatment </li></ul><ul><ul><li>Remove K +  from the body </li></ul></ul><ul><ul><ul><li>Diu...
ELECTROLYTE DISORDERS <ul><li>Normal range </li></ul><ul><ul><li>8.5 to 10.5 mg/dL </li></ul></ul><ul><ul><li>Ionized frac...
ELECTROLYTE DISORDERS <ul><li>Hypocalcemia </li></ul><ul><ul><li>Serum Ca 2+  < 8.5 mg/dL </li></ul></ul><ul><ul><li>Ioniz...
ELECTROLYTE DISORDERS <ul><li>Etiology </li></ul><ul><ul><li>Hypoalbuminemia </li></ul></ul><ul><ul><li>Vitamin D deficien...
ELECTROLYTE DISORDERS <ul><li>Clinical Features </li></ul><ul><ul><li>Neurological </li></ul></ul><ul><ul><ul><li>Circumor...
ELECTROLYTE DISORDERS <ul><li>Clinical Features (Cont) </li></ul><ul><ul><li>Muscular </li></ul></ul><ul><ul><ul><li>Spasm...
ELECTROLYTE DISORDERS <ul><li>Clinical Features (Cont) </li></ul><ul><ul><li>Cardiovascular </li></ul></ul><ul><ul><ul><li...
ELECTROLYTE DISORDERS <ul><li>Clinical Features (Cont) </li></ul><ul><ul><li>Skeletal (Cont) </li></ul></ul><ul><ul><ul><l...
ELECTROLYTE DISORDERS <ul><li>Treatment </li></ul><ul><ul><li>Asymptomatic </li></ul></ul><ul><ul><ul><li>Oral replacement...
ELECTROLYTE DISORDERS <ul><li>Total Ca 2+  > 10.5 mg/dL </li></ul><ul><li>Ionized Ca 2+  > 2.7 meq/L </li></ul>Hypercalcemia
ELECTROLYTE DISORDERS <ul><li>Etiology </li></ul><ul><ul><li>Malignancy </li></ul></ul><ul><ul><li>Endocrinopathies </li><...
ELECTROLYTE DISORDERS <ul><li>Clinical Features </li></ul><ul><ul><li>General </li></ul></ul><ul><ul><ul><li>Malaise, weak...
ELECTROLYTE DISORDERS <ul><li>Clinical Features (Cont) </li></ul><ul><ul><li>Gastrointestinal </li></ul></ul><ul><ul><ul><...
ELECTROLYTE DISORDERS <ul><li>Memory Aid </li></ul><ul><ul><li>Stones  ---- Renal Calculi </li></ul></ul><ul><ul><li>Bones...
ELECTROLYTE DISORDERS <ul><li>Treatment </li></ul><ul><ul><li>Treat dehydration </li></ul></ul><ul><ul><ul><li>IV NS until...
ELECTROLYTE DISORDERS <ul><li>Intracellular cation </li></ul><ul><li>Normal range </li></ul><ul><ul><li>1.5 to 2.5 meq/L <...
ELECTROLYTE DISORDERS <ul><li>Serum Mg 2+  < 1.5 meq/L </li></ul><ul><li>Coexistent disorders </li></ul><ul><ul><li>Hypoka...
ELECTROLYTE DISORDERS <ul><li>Etiology </li></ul><ul><ul><li>Redistribution </li></ul></ul><ul><ul><ul><li>Trtm of DKA </l...
ELECTROLYTE DISORDERS <ul><li>Etiology (Cont) </li></ul><ul><ul><li>Renal loss </li></ul></ul><ul><ul><ul><li>Drugs </li><...
ELECTROLYTE DISORDERS <ul><li>Clinical Features </li></ul><ul><ul><li>Neuromuscular </li></ul></ul><ul><ul><ul><li>Tetany ...
ELECTROLYTE DISORDERS <ul><li>Clinical Features </li></ul><ul><ul><li>Gastrointestinal </li></ul></ul><ul><ul><ul><li>Dysp...
ELECTROLYTE DISORDERS <ul><li>Treatment </li></ul><ul><ul><li>Oral </li></ul></ul><ul><ul><li>IV replacement </li></ul></u...
ELECTROLYTE DISORDERS <ul><li>Serum Mg 2+  > 2.5 meq/L </li></ul><ul><li>Coexistent disorders </li></ul><ul><ul><li>Hyperk...
ELECTROLYTE DISORDERS <ul><li>Etiology </li></ul><ul><ul><li>Renal failure (most common) </li></ul></ul><ul><ul><li>Increa...
ELECTROLYTE DISORDERS <ul><li>Clinical Features </li></ul><ul><ul><li>Nausea   > 2.0 meq/L </li></ul></ul><ul><ul><li>Somn...
ELECTROLYTE DISORDERS <ul><li>Treatment </li></ul><ul><ul><li>D/C Mg 2+  administration </li></ul></ul><ul><ul><li>Dilutio...
ELECTROLYTE DISORDERS <ul><li>Intracellular anion </li></ul><ul><li>Normal range </li></ul><ul><ul><li>2.5 to 4.5 mg/dL </...
ELECTROLYTE DISORDERS <ul><li>Serum PO 4  < 2.5 mg/dL </li></ul><ul><li>Sx onset at PO 4  < 1.0 mg/dL </li></ul>Hypophosph...
ELECTROLYTE DISORDERS <ul><li>Etiology </li></ul><ul><ul><li>Decreased oral intake </li></ul></ul><ul><ul><ul><li>Malnutri...
ELECTROLYTE DISORDERS <ul><li>Clinical Features </li></ul><ul><ul><li>Progressive weakness and tremors </li></ul></ul><ul>...
ELECTROLYTE DISORDERS <ul><li>Treatment </li></ul><ul><ul><li>Serum PO 4  level < 1.0 mg/dL </li></ul></ul><ul><ul><ul><li...
ELECTROLYTE DISORDERS <ul><li>Complications of therapy </li></ul><ul><ul><li>Hypocalcemia </li></ul></ul><ul><ul><li>Metas...
ELECTROLYTE DISORDERS <ul><li>Serum PO 4  > 4.5 mg/dL </li></ul><ul><li>Etiology </li></ul><ul><ul><li>Decreased renal exc...
ELECTROLYTE DISORDERS <ul><li>Clinical Features </li></ul><ul><ul><li>Sx related to renal failure </li></ul></ul><ul><ul><...
ELECTROLYTE DISORDERS <ul><li>Treatment </li></ul><ul><ul><li>Treat underlying cause </li></ul></ul><ul><ul><li>Restrict C...
ELECTROLYTE DISORDERS <ul><li>Things to remember </li></ul><ul><ul><li>Treat the patient, not the lab value </li></ul></ul...
ELECTROLYTE DISORDERS Questions K + + Na Mg 2+ 2+ Ca 4 PO - - Cl
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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 &lt; 120) developing &lt; 24 hours OR rate of fall of &gt; 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 &lt; 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 &gt; 350
  • Mortality rate Overall 10% 25 to 50% if plasma osmolality &gt; 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

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

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