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

Published in: Health & Medicine
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Electrolyte and Metabolic Emergencies in Critical Care

  1. 1. Electrolytes and Metabolic Emergencies Edward Omron MD, MPH Pulmonary Service
  2. 2. Objectives <ul><li>Review causes and clinical manifestations of severe electrolyte disturbances </li></ul><ul><li>Outline emergent management of electrolyte disturbances </li></ul><ul><li>Recognize and treat acute adrenal insufficiency, thyroid storm and myxedema coma </li></ul><ul><li>Describe management of severe hyperglycemic syndromes </li></ul>
  3. 3. Principles of Electrolyte Disturbances <ul><li>Implies an underlying disease process </li></ul><ul><li>Treat the electrolyte change, but seek the cause </li></ul><ul><li>Clinical manifestations usually not specific to a particular electrolyte change, e.g., seizures, arrhythmias </li></ul>
  4. 4. Principles of Electrolyte Disturbances <ul><li>Clinical manifestations determine urgency of treatment, not laboratory values </li></ul><ul><li>Speed and magnitude of correction dependent on clinical circumstances </li></ul><ul><li>Frequent reassessment of electrolytes required </li></ul>
  5. 5. Hypokalemia <ul><li>K < 3.5 mmol/L </li></ul><ul><li>Etiology – alkalosis, diuresis, dka, ngs, n/v, hypomagnesemia </li></ul><ul><li>Manifestations – life threatening arrhythmias </li></ul><ul><li>Deficit poorly estimated by serum levels </li></ul>
  6. 6. Which one of the following ECG changes is least likely to occur with hypokalemia? <ul><li>ST-T segment depression </li></ul><ul><li>T wave inversion </li></ul><ul><li>AV Blocks (2nd and 3rd degree) </li></ul><ul><li>PVC’s </li></ul><ul><li>U waves </li></ul><ul><li>QT prolongation </li></ul>
  7. 7. Hypokalemia <ul><li>Treat aggressively in severe metabolic acidosis </li></ul><ul><li>Correct hypomagnesemia </li></ul><ul><li>ECG monitoring with emergent administration </li></ul><ul><li>Allowable maximum iv dose per hour controversial </li></ul><ul><ul><li>Life threatening arrhythmias: 10 mmols/ 20 minutes </li></ul></ul><ul><ul><li>KCL 20 mmols/hr Central IV or 20 mmol/ PO q1 hour </li></ul></ul><ul><ul><li>KCL 10 mmols/hr peripheral IV (Inefficient) </li></ul></ul>
  8. 8. Hyperkalemia <ul><li>K>5.5 mmol/dL </li></ul><ul><li>Etiology – renal failure, acidemia, cell death, drugs( ACE/Succinylcholine ) </li></ul><ul><li>Manifestations </li></ul><ul><ul><li>arrhythmias: peaked t waves, QRS widening, sine wave. </li></ul></ul>
  9. 9. Hyperkalemia – Treatment <ul><li>Urgency of treatment- clinical manifestations </li></ul><ul><li>Stop intake </li></ul><ul><li>Give calcium for cardiac toxicity </li></ul><ul><li>Shift K + into cell – glucose + insulin, NaHCO 3 , inhaled  2-agonist (high dose) </li></ul><ul><li>Remove from body – diuretics, sodium polystyrene sulfonate, dialysis </li></ul>
  10. 10. Hyponatremia <ul><li>Na < 135 mmol/L </li></ul><ul><li>Hypo-osmolar hyponatremia </li></ul><ul><ul><li>Euvolemic ( SIADH,Hypothyroidism ) </li></ul></ul><ul><ul><li>Hypovolemic ( Diuretics, Adrenal Insuff.) </li></ul></ul><ul><ul><li>Hypervolemic ( CHF, Cirrhosis, NS ) </li></ul></ul><ul><li>Normo- or hyperosmolar hyponatremia </li></ul><ul><li>Pseudohyponatremia </li></ul><ul><li>Manifestations – neurologic (brain edema) </li></ul>
  11. 11. 65 yo wm POD 2 TURP presents lethargic to ICU <ul><li>HR =90, BP = 120/80, RR = 15 </li></ul><ul><li>Na = 114, K =3.8, Cl = 78, HCO3 = 20, Cre = 1.2 </li></ul><ul><ul><li>Free Water Restriction </li></ul></ul><ul><ul><li>Isotonic Saline </li></ul></ul><ul><ul><li>Hypertonic Saline </li></ul></ul><ul><ul><li>Furosemide </li></ul></ul><ul><ul><li>Ringers Lactate </li></ul></ul>
  12. 12. <ul><li>(infusate Na - serum Na)/ (TBW+1) </li></ul><ul><li>NS(154 mmol/L) </li></ul><ul><ul><li>(154 - 114) / (42L + 1) = Delta 0.9 mmol </li></ul></ul><ul><li>Hypertonic Saline </li></ul><ul><ul><li>(514 - 114) / (42+1) = Delta 9.3 mmol </li></ul></ul><ul><ul><li>Given over 24 hours (40 cc/hr) </li></ul></ul><ul><ul><li>Correct 0.5 mmol/hr until Na > 120 mmol/L </li></ul></ul><ul><li>Delta Plasma Na  from 1 liter of fluid </li></ul>
  13. 13. Hyponatremia – Treatment <ul><li>Hypovolemic  Na – give normal saline, rule out adrenal insufficiency </li></ul><ul><li>Hypervolemic  Na – increase free H 2 O loss </li></ul><ul><li>Euvolemic hyponatremia </li></ul><ul><ul><li>Restrict free water intake </li></ul></ul><ul><ul><li>Increase free water loss </li></ul></ul><ul><ul><li>Normal or hypertonic saline </li></ul></ul><ul><li>Correct slowly due to possibility of demyelinating syndromes </li></ul>
  14. 14. Hypernatremia <ul><li>Na > 145 mmol/L </li></ul><ul><li>Causes: diarrhea, vomiting, diuresis, thirst, diabetes insipidus </li></ul><ul><li>Manifestations- neurologic </li></ul><ul><li>Na = 160 mmol, 70 kg male </li></ul><ul><ul><li>1 L D 5 W changes Na by 4 mmol/L </li></ul></ul><ul><ul><li>H 2 O deficit (L) = [ 0.6  wt (kg) ]  </li></ul></ul><ul><ul><li>[ observed Na/140 - 1 ] = 6 Liter Free H 2 O </li></ul></ul><ul><li>Urine Osmolality > 500 mOsmol/kg extrarenal or osmotic diuresis, < 300 mOsmol/kg diabetes insipidus </li></ul>
  15. 15. Hypernatremia – Treatment <ul><li>Provide intravascular volume replacement </li></ul><ul><li>Consider giving one-half of free H 2 O deficit initially </li></ul><ul><li>Reduce Na cautiously: 0.5-1.0 mmol/L/hr </li></ul><ul><li>Secondary neurologic syndromes with rapid correction </li></ul>
  16. 16. Other Electrolyte Deficits Ca, PO 4, Mg <ul><li>May produce serious but nonspecific cardiac, neuromuscular, respiratory, and other effects </li></ul><ul><li>All are primarily intracellular ions, so deficits difficult to estimate </li></ul><ul><li>Titrate replacement against clinical findings </li></ul>
  17. 17. Other Electrolyte Disorders <ul><li>Hypocalcemia </li></ul><ul><ul><li>Calcium chloride or gluconate </li></ul></ul><ul><ul><li>Bolus + continuous infusion </li></ul></ul><ul><ul><li>Albumin correction is useless </li></ul></ul><ul><li>Hypercalcemia </li></ul><ul><ul><li>Rehydration with normal saline </li></ul></ul><ul><ul><li>Loop diuretics </li></ul></ul>
  18. 18. Other Electrolyte Disorders <ul><li>Hypophosphatemia </li></ul><ul><ul><li>PO4 < 2.5 mg/dL </li></ul></ul><ul><ul><li>Replacement iv for level < 1 mg/dL </li></ul></ul><ul><li>Hypomagnesemia </li></ul><ul><ul><li>Emergent administration over </li></ul></ul><ul><ul><li>5–10 mins </li></ul></ul><ul><ul><li>Less urgent administration over 10–60 mins </li></ul></ul>
  19. 19. What is most likely to present in a patient with severe magnesium deficiency? <ul><li>Respiratory Depression </li></ul><ul><li>Bradycardia </li></ul><ul><li>Tetany </li></ul><ul><li>Hypotension </li></ul><ul><li>Loss of patellar reflex </li></ul>
  20. 20. <ul><li>35 yo with fever, hypotension, and syncope </li></ul><ul><ul><li>2 months of fatigue, weight loss </li></ul></ul><ul><ul><li>BP 70/40, HR 110, temp 103, RR 18 </li></ul></ul><ul><ul><li>Na = 128, K = 5.6, Cl = 102, HCO3 = 16 </li></ul></ul><ul><ul><li>Glucose = 60, BUN = 28, Creat = 1.2 </li></ul></ul><ul><ul><li>Bolus 3L NS, BP 80/50 Dopamine started </li></ul></ul><ul><ul><li>1. Norepinephrine and decrease dopamine </li></ul></ul><ul><ul><li>2. Dexamethasone 4 mg IV </li></ul></ul><ul><ul><li>3. Infuse 1 liter hetastarch </li></ul></ul><ul><ul><li>4. Thyroxine IV and hydrocortisone 100 mg IV </li></ul></ul>
  21. 21. Acute Adrenal Insufficiency <ul><li>Nonspecific manifestations </li></ul><ul><ul><li>Abdominal pain, nausea, emesis </li></ul></ul><ul><ul><li>Orthostatic/refractory hypotension </li></ul></ul><ul><li>Laboratory findings </li></ul><ul><ul><li>Hyponatremia, hyperkalemia </li></ul></ul><ul><ul><li>Hypoglycemia </li></ul></ul><ul><ul><li>metabolic acidosis </li></ul></ul><ul><ul><li>Hypereosinophillia </li></ul></ul>
  22. 22. Acute Adrenal Insufficiency <ul><li>Baseline blood samples </li></ul><ul><li>Volume and glucose infusion </li></ul><ul><li>Dexamethasone or hydrocortisone </li></ul><ul><li>ACTH stimulation test if needed </li></ul><ul><li>Treat precipitating conditions </li></ul>
  23. 23. Hyperglycemic Syndromes <ul><li>Diabetic ketoacidosis (DKA) </li></ul><ul><li>Hyperglycemic hyperosmolar state (HHS) </li></ul><ul><li>Manifestations – dehydration, polyuria/ polydipsia, altered mental status,  BP, nausea, emesis, abdominal pain </li></ul>
  24. 24. Hyperglycemic Syndromes – Laboratory <ul><li>Hyperglycemia/hyperosmolality </li></ul><ul><li>Ketonemia/ketonuria (DKA) </li></ul><ul><li>Increased anion gap metabolic acidosis (DKA) </li></ul><ul><li>Electrolyte changes (K, PO 4 , Na) </li></ul>
  25. 25. Hyperglycemic Syndromes – Treatment <ul><li>Identify and treat precipitating factors </li></ul><ul><li>Restore fluid/electrolyte balance </li></ul><ul><li>Insulin – iv bolus and infusion </li></ul><ul><li>Add glucose to infusion when glucose <250-300 mg/dL (13.9-16.7 mmol/L) </li></ul><ul><li>Treat electrolyte changes (K, PO 4 ) </li></ul><ul><li>NaHCO 3 rarely needed </li></ul><ul><li>Lactated Ringers preferred crystalloid </li></ul>
  26. 26. <ul><li>28 yo with schizophrenia, acute delirium </li></ul><ul><ul><li>HR 120, T 101.6, BP 96/50 </li></ul></ul><ul><ul><li>bibasilar rales, 2/6 systolic murmur </li></ul></ul><ul><ul><li>ECG with atrial fibrillation </li></ul></ul><ul><ul><li>WBC 10,000, CK 150, (-) LP, UA, and head CT </li></ul></ul><ul><ul><li>1. Dantrolene </li></ul></ul><ul><ul><li>2. Haloperidol </li></ul></ul><ul><ul><li>3. Antibiotics </li></ul></ul><ul><ul><li>4. Propylthiouracil, propranol </li></ul></ul>
  27. 27. Thyroid Storm <ul><li>Exaggerated manifestations of hyperthyroidism </li></ul><ul><li>Supportive measures </li></ul><ul><li>Specific measures </li></ul><ul><ul><li>Propylthiouracil or methimazole </li></ul></ul><ul><ul><li>Propranolol </li></ul></ul><ul><ul><li>Potassium or sodium iodide </li></ul></ul><ul><ul><li>Dexamethasone, sodium ipodate </li></ul></ul>
  28. 28. <ul><li>56 yo obese female minimally responsive </li></ul><ul><ul><li>HR 64, RR 10, BP 160/100, T 96.5 </li></ul></ul><ul><ul><li>Distant heart sounds, 3+ LE non-pitting edema </li></ul></ul><ul><ul><li>CXR: bilateral effusions/ cardiomegaly </li></ul></ul><ul><ul><li>Na = 130, Hb = 10.2, CK = 500, WBC =13000 </li></ul></ul><ul><ul><li>(-) head ct and lumbar puncture </li></ul></ul><ul><ul><li>1. Intravenous thyroxine, hydrocortisone </li></ul></ul><ul><ul><li>2. TTE </li></ul></ul><ul><ul><li>3. Neurology consult </li></ul></ul><ul><ul><li>4. flumazenil </li></ul></ul>
  29. 29. Myxedema Coma <ul><li>Manifestations of severe hypo-thyroidism </li></ul><ul><li>Supportive measures – airway, fluids, glucose, warming </li></ul><ul><li>Treat precipitating cause </li></ul><ul><li>Hydrocortisone </li></ul><ul><li>L-thyroxine </li></ul>