This document discusses water balance and fluid compartments in the human body. It notes that water makes up 60% of total body weight and is divided between intracellular fluid (2/3 of total body water) and extracellular fluid (1/3 of total body water), with the extracellular fluid further divided into intravascular, interstitial, and transcellular compartments. Daily fluid intake and losses are also summarized.
Hyponatremia is a common electrolyte disorder in diverse fields of medicine. A sound understanding of Physiology is essential for its management. Real life clinical examples are described
Hyponatremia is a common electrolyte disorder in diverse fields of medicine. A sound understanding of Physiology is essential for its management. Real life clinical examples are described
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
3. • Water is the major constituent of tha body (60%).
• 2/3 of total body water is concentrated in the intracellular
fluid compartment.
• 1/3 of total body water is in the extracellular compartment
which can be divided into:
i. extravascular/interstitial (25%) compartment.
ii. intravascular (8%) compartment.
iii. transcellular (2%) compartment eg : CSF, peritoneal
fluid
4. Water Gain = Water Loss
Fluid Intake :
Food intake : 1200 mL
Oxidation of nutrients : 300
mL
Sensible :
• Urine : 500 mL
• Stools : 100 mL
Insensible :
• Skin (evaporation) :
400mL
• Lungs : 500 mL
5. 1. Water intoxication
Causes:
• Iatrogenic
• Secondary to underlying CHF, renal insufficiency and cirrhosis.
Reflected by:
• Peripheral edema
• Raised JVP
• Pulmonary edema
Treatment:
• Depends on degree of overhydration.
• Gross pulmonary edema and life threatening : dialysis is indicated.
• Less severe causes and previous normal renal function : water
restriction + diuretics.
• if cardiac failure present, digitalisation may be indicated.
6. 2. Water depletion
• Associated with hypernatremia : increase plasma
osmolality, concentrated urine and low urine sodium
concentration despite hypernatremia.
• Most common causes are GI loses , bleeding, fistula
drainage, soft tissue injuries, infections, third spaces,
poor oral intake and burns and aggravated by general
anaesthesia.
• Clinical manifestations as hypernatremia.
• Treatment consist of administration IV D5%W
7. Indications:
1. Oral intake is not possible.
2. Severe vomiting, diarrhea, dehydration and shock.
3. Hypoglycemia.
4. For administration of some medications.
5. Nutrition.
8. Crystalloid Colloid
What Aqueous solution of LMW ions Solution containing HMW
substances (protein)
Example Normal Saline and Ringer’s lactate Albumin, dextran and starch
Usages Fluids losses Fluid replacement needs
exceeds 3-4L prior to
transfusion
Advantages Inexpensive
No allergic
No risk of infection
Not depend on organ for
metabolism and excretion
Smaller amount required
Prolonged increase
intravascular volume (6-24H)
Maintain or increased plasma
oncotic pressure
Disadvantage
s
Short lived (rapidly distributed
throughout extravascular space)
Require large amount
Expensive
Interference with coagulation
Allergic
10. • Aqueous solutions of mineral salts or other water-soluble
molecules.
• Have a balanced electrolyte composition and expand
total extracellular volume.
• Types:
1. Balanced salt solution: electrolyte composition and
osmolality similar to plasma; example: lactated Ringer’s
2. Hypotonic salt solution: electrolyte composition lower
than that of plasma; example: D5W.
3. Hypertonic salt solution: 3% NaCl.
11. Pharmacological basis Indications Contraindications
Provide major ECF
electrolytes
Water and salt depletion
eg: vomiting, diarrhea
Hypovolemic shock
Alkalosis with
dehydration
Avoid in CHF, renal
diseases and cirrhosis
Correct both water and
electrolyte deficit.
Severe salt depletion
and hyponatremia
Initial fluid therapy in
DKA
Hypercalcemia
Dehydration with severe
hypokalemia – deficit in
IC potassium
Increase iv volume
subtantially
Fluid challenge in
prerenal ARF
Large volume may lead
to hyperchloremic
12. Pharmacological basis Indications contraindications
Correct dehydration Prevention and treatment
of dehydration
Neurosurgical
procedures, cerebral
edema
Supply energy (170
Kcal/L)
Pre-post op fluid
replacement
Prevention of ketosis in
starvation, vomiting,
diarrhea
Hypovolemic shock
Not for volume
expansion
Correct hypernatremia
IV administration of
various drugs
Blood transfusion –
clumping, hemolysis if
used same iv line
Adequate glucose infusion
protects liver against toxic
Hyponatremia, water
intoxication
13. Pharmacological basis Indications contraindications
Most physiological fluid Severe hypovolemia Severe CHF
Rapid expand iv volume Replacing fluids in post
op pt, burns
Addison’s disease
Provide buffering
capacity
DKA by provide water,
correct metabolic
acidosis and supplies
potassium
Liver disease, severe
hypoxia and shock
Maintaining normal ECF
and electrolyte balance
Vomiting or NG tube
induced alkalosis
14. • It is LMW substances that remain in the intravascular
compartment to generate oncotic pressure.
• 3 times more potent.
• 1 mL blood loss = 1 mL colloids = 3 mL crystalloids
17. Indications Advantages Adverse effects
Rapid plasma volume
expansion in
hypovolemic shock
Don’t interfere with
coagulation, blood
grouping
Shouldn’t mixed with
citrated blood
Volume pre-loading in GA Remain in blood 4-5
hours
Hypersensitive reaction
Priming of heart lung
machines
Infusion of 1L expands
plasma volume by 300-
350 mL
• Sterile, pyogen free 3.5% solution.
• Polymer of degraded gelatin with electrolytes.
• 2 types
Succinylated gelatin (modified fluid gelatin)
Urea cross linked gelatin (polygeline)
18. • Crystalloids is recommended as the initial fluid of choice
in resuscitating patients from hemodynamic shock.
(Svensen et al 1999)
• No evidence that resuscitation with colloids reduces the
risk of death, compared with crystalloids in patients with
trauma or burns or post-surgical.
(Robert et al 2004)
19. 1. Urine Output: at least 0.5 ml/kg/hr
2. Vital Signs: BP and HR normal
3. Physical Assessment: Skin and mucous
membranes not dry, no thirst in an awake
patient
4. Laboratory tests: periodic monitoring of
hemoglobin and hematocrit, electrolytes and
ABG.
22. • Maintain body fluid volume and osmolarity
• Distribute body water between fluid compartments
• Regulate acid-base balance.
23. • Sodium is predominant extracellular cation.
• Controls and regulates volume of body fluids.
• For generation and transmission of nerve.
• Eliminated primarily by kidneys, smaller in stools and
perspiration.
• Normal serum level is 135-145 mmol/L
• Daily requirement is 1-2 mmol/L.
• Disorder of sodium concentration usually results from
relative excesses or deficits of water.
24. • Indicates absolute or relative water deficits
• Associated with hyperosmolarity.
• Causes:
1. Water deficiency:
Inadequate intake
Excessive loss :
Renal : DI, osmotic diuresis (mannitol)
Extrarenal : sweat, fever, diarrhea
2. Excess Na :
Increase intake : hypertonic saline infusion
Inadequate excretion : renal failure, primary hyperaldosteronism
25. • Hypernatremia results in contraction of brain cells as
water shifts to attenuate the rising ECF osmolality.
• The major symptom is thirst.
• The most severe symptoms of hypernatremia are
neurologic, including altered mental status, weakness,
neuromuscular irritability, focal neurologic deficits and,
occasionally, coma or seizures.
• The presence of encephalopathy is a poor prognostic
sign in hypernatremia, and carries a mortality rate as high
as 50%
Clinical presentations
26. • Target fall in serum Na concentration of 10 mmol/L per day,
except those whom hypernatraemia developed over a period
of hours.
• If patient with long-standing hypernatraemia is infused with
hypotonic fluids, there is danger of cerebral oedema.
• It is essential to lower extracellular hypertonicity slowly in
hypertonically-dehydrated patients, e.g. 0.5 mmol/hr
• If patient is able to tolerate orally, give water orally.
• If not, set up an IV infusion of D5% or 0.45% NaCl.
• Volume and rate of infusion may be calculated as follows:-
• Change in serum Na = Infusate Na – serum Na
Total body water + 1
27. • 1st we need to know how much Na there is in IV fluids.
• 1L of 0.9% NaCl will provide 150 mmol of Na.
• 1g of table salt = 17 mmol Na
Fluids Amount of sodium
3% NaCl (hypertonic
saline)
513 mmol per litre
0.9% NaCl (normal saline) 150 mmol per litre
0.45% (half saline) 77 mmol per litre
28. 1. Total body water (TBW) = body weight X
fraction
Fraction of body water:
0.6 in men, 0.5 in elderly men
0.5 in women, 0.45 in elderly women
2. Change in serum Na = Infusate Na – serum Na
Total body water + 1
If you use 3% saline to correct the
hypernatraemia, that means that infusate Na
value is 513 mmol.
29. • 60 kg female hypovolemic pt presented with Na level of
165 mmol/L
Change in serum Na = Infusate Na – serum Na
Total body water + 1
• Desired correction : 10 mmol/L over 24H
• 1L 0.45% NaCl reduce Na concentration by:
(77-165) ÷ (30 + 1) = 2.8 mmol/L
• Aim to decrease 10 mmol/L = (10 ÷ 2.8) = 3.6 L / 24H
30. • Most common due to excess water retention due to
inability to excrete ingested water. (dilutional
hyponatremia)
• Requirements for water excretion:
1. Adequate GFR
2. Functional tubules
3. Hypertonic medulla
4. Presence or absence of ADH
31. • Acute hyponatraemia
• Features related to osmotic water shift that leads to increased ICF
volume and brain cell swelling.
• Mild hyponatraemia – usually asymptomatic
• Serum Na+ 120 mmol/L may be associated with
disturbed mental status, restlessness, confusion and
irritability
• As Na approaches 110 mmol/l, seizures and coma may
occur.
33. 1) Hypovolaemic hyponatremia
Low blood volume due to fluid loss
Occurs in patients taking thiazide diuretics, and
after severe vomiting or diarrhoea.
34. 2) Hypervolaemic hyponatremia
High blood volume due to fluid retention
Occurs in people with liver cirrhosis, heart disease, or nephrotic
syndrome.
Edema often develops with fluid retention.
3) Euvolaemic hyponatremia
Increase in total body water
Occurs in people with hypothyroidism, adrenal gland disorder, and
disorders that increase the release of the antidiuretic hormone
(ADH), such as tuberculosis, pneumonia, and brain trauma.
35. • Assess the following:-
1. Fluid status
2. Osmolality
3. Sodium correction (if hyperglycaemia)
4. Urinary sodium
38. • Measured serum Na in pts with hyperglycaemia
can be corrected by:
Adding approximately 1.6 mmol/l for every 5.5
mmol/l rise in glucose over 5.5 mmol/l.
In marked hyperglycemia, ECF osmolality rises and
exceeds that of ICF, since glucose not absorbed in the
absence of insulin, resulting in movement of water out
of cells into the ECF.
This condition has been called translational
hyponatremia because no net change in total body
water (TBW) has occurred.
Na concentration will return to normal once the plasma
glucose concentration is lowered.
39. • Urine Na combined with clinical assessment
of fluid status may help determine
underlying cause:
Volume depletion from extra-renal cause with intact renal Na-
conserving mechanism – have low urinary Na concentration (<
10 mmol/L)
Pts with isovolaemic hyponatraemia generally have urinary Na
> 20 mmol/L. Eg: SIADH.
Dehydration with high urinary Na (> 20 mmol/L) suggests
inappropriate renal-salt wasting.
Fluid overload with low urine Na (< 10 mmol/L) is seen in
conditions such as CCF or cirrhosis
40. Confirm the patient truly has a hypo-osmolar state by checking serum osmolality
Assess for serious signs or symptoms suggesting cerebral edema
Determine the duration of development of hyponatremia (less or more than 48 hours)
Assess the patient’s extracellular fluid volume status using clinical examination and
laboratory testing (spot urine sodium)
Check the urine osmolality to see if the urine is appropriately dilute (< 100 mOsm/kg)
or inappropriately concentrated (≥ 100 mOsm/kg)
Assess for underlying causes of hyponatremia that may correct rapidly with treatment
(e.g. hyponatremia induced by thiazide diuretics)
Assess the patient’s medications (intravenous antibiotics, infusions) and nutritional
intake (total parenteral nutrition, tube-feeding) for sources of water
Look for drugs the patient is taking that potentiate antidiuretic hormone action (ie,
selective serotonin uptake inhibitors)
41. • Acute drop in the serum osmolality
neuronal cell swelling occurs due to the water
shift from the extracellular space to the
intracellular space .
• Swelling of the brain cells elicits the following
2 osmoregulatory responses:
• It inhibits both arginine vasopressin secretion from
neurons in the hypothalamus and hypothalamic
thirst center. This leads to excess water elimination
as dilute urine.
• There is an immediate cellular adaptation with loss
of electrolytes, and over the next few days, there is
a more gradual loss of organic intracellular
osmolytes.
42. Effects of hyponatremia on
the brain.
Minutes after the development
of hyponatremia, the
decreased osmolality causes
swelling of the brain. Rapid
adaption occurs within hours
as a result of the cellular loss
of electrolytes. Slow adaption
occurs over several days
through the loss of organic
osmolytes from brain cells to
normalize brain volume.
Aggressive correction of
hyponatremia may lead to
irreversible brain damage
(osmotic demyelination);
however, proper correction of
hyponatremia reestablishes
normal osmolality without the
risk of brain damage.
From Adrogue HJ, Madias NE:
Hyponatremia. N Engl J Med
342:1581–
1589, 2000; reprinted with
permission.
43. • IMPORTANT! Correction of hyponatremia must
take into account the chronicity of the condition.
• Correction of serum sodium that is too rapid can
precipitate severe neurologic complications –
osmotic demyelination.
44. • Degree of brain edema and consequent neurologic
symptoms depends on the rate and duration of
hypotonicity.
• Clinical manifestations are typically delayed for 2 to 6
days after the correction of plasma sodium
concentration.
• Symptoms: headache, nausea, vomiting, muscle
cramps, restlessness, disorientation, depressed reflexes,
dysarthria, dysphagia, paraparesis or quadreparesis,
lethargy and coma.
• Seizures may also be seen but less common.
• Some symptoms may be irreversible or partially
reversible.
45.
46. • In general, serum Na should not be increased:
• By > 10 mmol/l in asymptomatic patient
• By > 12 mmol/l in symptomatic patient
• In a 24-hour period.
• If plasma Na is > 120 mmol/l, aggressive treatment is not
necessary.
• Gradually correct with either water restriction or administration of
normal saline.
• If plasma Na < 110 mmol/l, or patient is severely
symptomatic, urgent treatment is required with a more
rapid rate of increase of 1-2 mmol/L/hr for the 1st 3 – 4
hours.
47. • 60 kg isovolemic 40 years old male pt presented with
grand mal seizure with level of Na of 111 mmol/L
• TBW: 60 x 0.6 = 36 L
• Desired correction : 3 mmol/L in first 3H
• Based on formula:
Change in serum Na = Infusate Na – serum Na
Total body water + 1
• 1L of 3% NaCl increase Na = (513 – 111) ÷ (36 + 1)
=10.9 mmol/L
• Aim for 3 mmol elevation = 3 ÷10.9 = 0.275 L over 3H
48. • Potassium is predominant intracellular cation with
concentration 150 mmol/L (90%).
• The more K, the less Na and vice versa.
• Vital role in transmission of impulses, cellular building
and maintainance of cellular metabolism and excitation.
• Excreted primarily by the kidneys.
• Extracellularly, potassium concentration is 3.5-5.0
mmol/L
• Daily requirement : 1-2 mmol/kg/d
49. • Severe hyperkalemia is considered if serum K > 7
mmol/L and/or presence of ECG changes.
• Causes :
1. Increase intake :
Use of K supplement, potassium containing medications
Stored or irradiated blood tranfusion
2. Decrease excretion :
Mineralocorticosteroid deficiency
Drugs : Potassium sparing diuretic
50. 3. Increased release from
cells
• Shift of K out of cells –
Acidosis
– Insulin deficiency e.g.
DKA
– Aldosterone deficiency
• Tissue breakdown
– Severe intravascular
haemolysis e.g. severe
malaria
– Rhabdomyolysis
– Tumour lysis syndrome
– Tissue necrosis/ crush
injury
– Vigorous exercise
4. Pseudohyperkalaemia
• Increased in vitro release
from abnormal cells
– Thrombocytosis
– Leucocytosis
• Haemolysis of sample
(commonly encountered)
52. • 1st ECG sign of hyperkalemia is peaked T waves (K ≥ 6
mmol/l)
• 2nd sign: prolonged PR interval (K ≥ 7 mmol/l)
• 3rd sign: absent P waves and widen QRS – a VERY
DANGEROUS SIGN! (K between 8 – 9 mmol/l) *Atrial
activity is lost and the stage is set for ventricular
tachycardia/ fibrillation
• If continue to ignore the changes above, ventricular
tachycardia/ fibrillation will ensue.
53. 1. To protect the heart from effects of potassium by
antagonizing its effects on cardiac conduction (calcium)
2. To shift potassium from ECF to ICF (Na bicarb, insulin
and glucose)
3. To reduce total body potassium (resins, dialysis)
*Urgent treatment if K > 6.5 mmol/l or ECG shows changes
of hyperkalemia
54. Mild-moderate hyperkalaemia (K 5.5 – 6.5 mmol/l) with no
ECG changes
• Low potassium diet
• Stop drugs which may cause hyperkalemia
• Cation - exchange resins
• Correction of acidosis in patients with metabolic acidosis
• +/- glucose and insulin infusion
55. Lytic cocktail with continuous ECG monitoring
• 10 ml 10% IV calcium gluconate slow infusion for cardiac
protection, second dose may be given if no ECG changes
after 5 minutes.
*Effect within minutes, lasts for 1 hour
• Rapid acting insulin 10 U with 50 ml of dextrose 50% infused
slowly for 30-60 minutes. In patient with renal failure, need
higher dose of glucose (100-150 ml).
*Onset within 30 – 60 minutes, lasts for several hours
*Can be repeated 6 – 8 hrly.
• Arrange for urgent dialysis
56. Beta agonist therapy
• IV salbutamol 0.5 mg IV in 15 mins or 10 mg nebulization
(with or without glucose and insulin infusion) has been
shown to be effective in reducing K level (IV preferred in
patient with ESRD)
• If effective, plasma K will fall by 0.5 – 1.5 mmol/l in 15-30
mins and effect will last for several hours.
*However, beware of tachycardia.
57. Cation-exchange resins (Kalimate)
• Binds potassium in exchange for another cation in GI
tract, thereby removing K from body
• Usually given orally Kalimate (calcium polystyrene
sulphonate) 5-10g TDS
• Can be given as enemas (Kalimate 30g in 100 mls 3-4
times/d)
58. Sodium bicarbonate infusion :
• IV infusion of bicarbonate 100 – 200 mmol/l over 30 mins
produces metabolic alkalosis which lowers K in ECF.
• Onset of action occurs within 30 mins and lasts for 1-2
hours.
• Less effective in patients with renal failure and may
worsen sodium overload leading to pulmonary edema.
• Don’t give in the same line with IV Calcium gluconate
(can precipitate calcium)
59. • Can result from:
– Poor potassium intake
– Increased translocation into cells
– Increased losses in urine or GI tract (most common)
• Kidney can lower excretion to a minimum of 5 mmol per
day to 10 mmol per day in the presence of decreased
potassium intake.
– Poor intake without excessive potassium loss is a rare
cause of hypokalaemia.
60. • Excessive loss of potassium – common cause.
• Most common mechanisms:
– Increased urinary losses due to increased sodium
delivery to the distal nephron (e.g. with diuretics)
– Mineralocorticoid excess (e.g. Conn’s syndrome)
– Increased urine flow (e.g. osmotic diuresis)
61. • Rare hereditary defects of renal salt transporters
• Hypomagnasemia
– direct effect of low cytosolic magnesium on potassium
channels and enhanced potassium secretion
• Diabetic ketoacidosis
– Obligate loss of potassium from kidney as a cationic
partner to the negatively charged ketone and β-
hydroxybutyrate
63. Symptoms usually appear when K < 2.5 mmol/l
– Malaise, fatigue
– Neuromuscular disturbance: weakness, hyporeflexia,
paraesthesias, cramps, restless leg syndrome,
rhabdomyolysis, paralysis
– GI: constipation, ileus
– Polyuria, polydipsia, metabolic alkalosis
64. – Flat or inverted T waves – Prominent U waves –
Depressed ST segments
– Arrhythmias: 1st and 2nd degree heart blocks, atrial
fibrillaIon, ventricular tachycardia, ventricular fibrillaIon
65. • Oral therapy: method of choice for mild-to-moderate
hypokalaemia (K > 2.5 mmol/l)
• Can also be given as slow release K (slow K, 1
tablet 600 mg = 8 mmol) or liquid forms (mist KCL 10
ml = 1g = 14 mmol)
• Slow K less efficacious in correcting more severe
degrees of hypokalemia (slow release), also shown
to be associated with gastric erosions
• 40 – 200 mmol daily of KCl may be required over
periods of days or weeks e.g. 20 – 40 mmol for 2 – 4
x daily depending on severity of depletion (as
frequent as 2 – 4 hrly may be required)
66. • 1g of KCL contains 14 mmol of potassium
• If K level is < 3 mmol/l, potassium supplements should be
given.
• In patient with hypokalemia with low urinary K excretion
(< 20 mmol/l), hypokalemia of extra- renal origin should
be suspected (i.e. GI loss).
• In asymptomatic patient with K between 3 -4 mmol/l,
who are vulnerable to cardiac arrhythmias e.g. CCF,
digoxin, history of MI/ IHD, potassium supplements are
recommended.
67. • IV therapy is method of choice in:
– Severe hypokalaemia (K < 2.5 mmol/l)
– With ECG changes
– Patient not able to take orally
– Symptomatic e.g. cardiac arrhythmias with rapid
ventricular response, familial periodic paralysis, severe
myopathy
68. • In asymptomatic patients without ECG changes, K should
be given as follows :
– At a concentration of < 40 mmol/l (< 3g KCL per liter) in
normal saline (avoid dextrose fluid)
– Given at a rate of < 20 mmol/hr (10 mmol/hr
recommended) e.g. 2 g KCL in 1 pint over 3 hour.
– Monitor plasma K regularly, ECG monitoring advised.
69. • In emergency e.g cardiac arrhythmias, severe myopathy,
K can be given:
1. At rates up to 40 mmol/l per hour (i.e. KCL 3g/hr)
2. In concentrations of 200 – 400 mmol/l (by mixing 20 –
40 mmol/l or 1.5 – 3.0g KCl in 100 mls NS)
3. IV administration of K at a rate of > 10 mmol/hr
requires continuous ECG monitoring.
As soon as ECG changes normalize, cardiac rhythm
returns to normal or respiratory muscle strength is restored,
gradually taper IV infusion and discontinued. Then, initiate
oral KCL.
70. • Most important potential risk of IV K administration =
acute hyperkalaemia (most likely in pts with renal
insufficiency)
• Use large central vein: femoral venous infusion is
preferable than upper body central vein to avoid
deleterious effects on cardiac conduction.
• Concentration of > 60 mmol/l should not be given through
peripheral vein.
71. • 99% in bone and teeth.
• High Ca, low Po4
• For nerve impulses transmission, blood clotting, for vitamin B12 absorption. Most
in ECF
• Regulated by:
1. Parathyroid hormone
↑Blood Ca by stimulating osteoclasts
↑GI absorption and renal retention
2. Calcitonin from the thyroid gland
Promotes bone formation
↑ renal excretion
• Albumin bound = 40-60%
• Excreted in urine, faeces, bile, digestive secretions and perspiration.
• Normal value: 8.5-10.5 mmol/L
Corrected Ca = 4 - serum albumin x 0.8 + serum Ca
72.
73.
74. 1. Correct underlying causes
2. Monitor serum Ca and correction of deficit
3. Check albumin
4. Acute symptomatic:
• IV Calcium gluconate 2-3 g
• Continuous cardiac monitoring.
5. Chronic hypocalcemia: high calcium diet or oral calcium
salts
6. Mild symptoms : give calcium 5 mmol/6H with daily
plasma Ca level
7. In severe symptoms : give IV 10% calcium gluconate
over 30 mins, repeat as necessary.
8. In CKD : may require alfacalcidol
9. Encourage careful ambulation to min bone resorption.
75. • If Ca >3.5 and symptomatic:
1. Correct hydration with NS
2. Bisophosphonates prevent bone resorption by inhibiting
osteolast
3. Furosemide- used once fully hydrated. It promoted
renal excretion of Ca.
76. • If Ca >3.5 and symptomatic:
1. Correct hydration with NS
2. Bisophosphonates prevent bone resorption by inhibiting
osteolast
3. Furosemide- used once fully hydrated. It promoted
renal excretion of Ca.
77. • Mostly found within body cells: heart, bone, nerve and
muscles.
• Second most important cation ICF.
• For protein and DNA synthesis, transcription and
translation.
• Absorbed in intestines and excreted by kidneys
• Normal value : 1.5-2.5 mmol/L
78.
79. 1. Recognition risk factors, signs and symptoms.
2. If hypokalemia doesn’t respond to potassium
replacement, hypomagnesemia should be suspected.
3. Continuous cardiac monitoring.
4. Mild or chronic (1-1.5 mmol/L, asymptomatic)
• Magnesium oxide 240 mg od-bd
5. Severe <1mmol/L
• Iv magnesium sulfate comes in 49.3% 5ml solution.
• IV magnesium sulfate 1-2g over 15 min – 2H
6. Frequent mg level
80.
81. 1. Mild symptoms and normal renal function
• Observe
• Withold any magnesium-containing meds
2. Moderate symptoms
• Iv NS and Frusemide
• Watch K
3. Severe symptoms
• Iv 10% calcium gluconate 10-20mL bolus over 10 mins
(antagonizes membrane effects of Mg and reverses respiratory
depression)
82. • Hypophosphatemia causes include Vit D deficiency,
alcohol withdrawal. S & S include muscle weakness or
rhabdomyolysis, red cell and white cell and platelet
dysfunction and cardiac arrest or arrthymias. Tx by oral
or parenteral phosphate supplementation.
• Hyperphosphatemia most commonly due to CKD, when
it is treated with phosphate binder. Also catabolic state
such as tumor lysis syndrome. Tx treatment in patients
with renal failure is reduction of intake of PO4 and PO4-
binding drugs taken with meals
84. A. Compensatory intravascular volume expansion:
Compensate for the vasodilatation and cardiac
depression caused by anesthetic drugs
B. Pre-existing deficits:
Due to fasting or pre-operative loses
Should be replaced properly
85. C. Normal maintainance requirements:
• If patients need IV fluids for routine maintenance alone, restrict
the initial prescription to:
25–30 ml/kg/day of water
~ 1 mmol/kg/day of potassium, sodium and chloride
~ 50–100 g/day of glucose to limit starvation ketosis.
• For patients who are obese, adjust the IV fluid prescription to
their ideal body weight. Use lower range volumes per kg
(patients rarely need more than a total of 3 litres of fluid per
day)
• Do not exceed 30 ml/kg/day for routine fluid maintenance
• Consider prescribing less fluid (25 ml/kg/day fluid) for patients
who:
older or frail
have renal impairment or cardiac failure.
• When prescribing for routine maintenance alone, consider
using 25–30 ml/kg/day sodium chloride 0.9% alternate with
5% dextrose.
86. • Fluid therapy is critically important during the
perioperative period.
• The most important goal is to maintain hemodynamic
stability and protect vital organs from hypoperfusion
(heart, liver, brain, kidneys).
• All sources of fluid losses must be accounted for.
• Good fluid management goes a long way toward
preventing problems.
Editor's Notes
-Barrter syndrome – Defect in sodium transport in loop of Henle – Associated with hypercalciuria
Gitelman syndrome – Impairment of thiazide-sensiIve sodium-chloride co-
transporter in the distal tubule – Associated with hypocalciuria and hypomagnesemia.