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ELECTROLYTE DISORDERS CRISBERT I. CUALTEROS, MD http://crisbertcualteros.page.tl
HYPONATREMIA <ul><li>Plasma concentration < 135 meq/L </li></ul>
Generation of Hyponatremia <ul><li>Plasma Na = Na + K/ TBW </li></ul>
Sign and Symptoms <ul><li>Lethargy, Apathy </li></ul><ul><li>Disorientation </li></ul><ul><li>Muscle cramps </li></ul><ul>...
Sign and Symptoms <ul><li>Abnormal sensorium </li></ul><ul><li>Depressed deep tendon reflexes </li></ul><ul><li>Cheyne-Sto...
Diagnostic Approach Hyponatremia Na and Water Deficit Water Excess Na and Water Excess Hypervolemia Hypovolemia Euvolemia
Diagnostic Approach Hyponatremia Hypovolemia Euvolemia Hypervolemia Renal Losses Diuretic excess Mineralcorticoid Deficien...
Diagnostic Approach Hyponatremia Hypovolemia Euvolemia Hypervolemia Glucocorticoid Deficiency Hypothyroidism Pain Emotiona...
Diagnostic Approach Hyponatremia Hypovolemia Euvolemia Hypervolemia Nephrotic Syndrome Cardiac Failure Cirrhosis ARF CRF U...
Treatment <ul><li>Na deficit = 0.5 x wt (kg) x (D Na – A Na ) </li></ul><ul><li>Calculation of Desired Negative Water Bala...
Rate of Correction <ul><li>First 24 hours = 10 -12 mEq/day </li></ul><ul><li>Seizure and Neurologic symptoms </li></ul><ul...
Central Demyelinating Lesion <ul><li>Paraparesis </li></ul><ul><li>Quadriparesis </li></ul><ul><li>Dysarthria </li></ul><u...
Risk Factor for Demyelination <ul><li>More than 25 mEq/L elevation of Na within the first 48 hours </li></ul><ul><li>Overc...
HYPERNATREMIA <ul><li>Plasma Na > 150 mEq/L </li></ul>
Generation of Hypernatremia <ul><li>Plasma Na = Na + K/TBW </li></ul>
Sign and Symptoms <ul><li>Lethargy </li></ul><ul><li>Weakness </li></ul><ul><li>Irritability </li></ul><ul><li>Twitching <...
Diagnostic Approach Hypernatremia Na and H2O Deficits H2O losses Na Addition Excess Hypovolemia Euvolemia Hypervolemia
Diagnostic Approach Hypernatremia Hypovolemia Euvolemia Hypervolemia Renal losses Osmotic and loop diuretics Post obstruct...
Diagnostic Approach Hypernatremia Hypovolemia Euvolemia Hypervolemia Renal Losses Nephrogenic DI Central DI Extrarenal Los...
Hypernatremia Hypovolemia Euvolemia Hypervolemia Primary Hyperaldoteronism Cushing’s Syndrome Hypertonic Dialysis Hyperton...
Treatment <ul><li>Correction of ECF Volume Depletion </li></ul><ul><ul><li>Isotonic Saline Until the ECF volume is achieve...
Treatment <ul><li>Correction of ECF Volume Expansion </li></ul><ul><ul><li>Diuretics or Dialysis </li></ul></ul>
Water Replacement <ul><li>Computation </li></ul><ul><ul><li>TBW = Wt (Kg) x 0.6 </li></ul></ul><ul><ul><li>Actual plasma N...
HYPOKALEMIA <ul><li>Plasma K < 3.0 mEq/L </li></ul>
Sign and Symptoms <ul><li>Cardiac </li></ul><ul><ul><li>Atrial and ventricular ectopic beats </li></ul></ul><ul><ul><li>Ab...
Sign and Symptoms <ul><li>Neuromuscular </li></ul><ul><ul><li>Constipation, Ileus </li></ul></ul><ul><ul><li>Weakness, par...
Sign and Symptoms <ul><li>Renal </li></ul><ul><ul><li>Impaired concentrating ability (polyuria, polydipsia) </li></ul></ul...
Causes <ul><li>Hypokalemia due to Redistribution </li></ul><ul><ul><li>Alkalosis </li></ul></ul><ul><ul><li>Insulin excess...
Causes <ul><li>Extrarenal Loss </li></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>GI fistula </li></ul></ul><ul><ul...
Causes <ul><li>Renal Loss </li></ul><ul><ul><li>Hypertensive Disorder </li></ul></ul><ul><ul><ul><li>Malignant hypertensio...
Causes <ul><li>Renal Loss </li></ul><ul><ul><li>Normotensive </li></ul></ul><ul><ul><ul><li>RTA </li></ul></ul></ul><ul><u...
Diagnostic Approach Hypokalemia Redistribution Extrarenal U K <20 Renal loss U K >20 Metabolic acidosis Diarrhea GI fistul...
Diagnostic Approach Hypokalemia Redistribution Extrarenal Loss U K <20 Renal Loss U K >20 Hypertensive High Plasma Renin M...
Diagnostic Approach Hypokalemia Redistribution Extrarenal Loss U K <20 Renal Loss U K >20 Normotensive Metabolic Alkalosis...
Diagnostic Approach Hypokalemia Redistribution Extrarenal Loss U K <20 Renal Loss U K >20 Normotensive Metabolic acidosis ...
Treatment <ul><li>Potassium Deficit </li></ul><ul><ul><li>4.0 to 3.0 mEq/L = loss of 200 to 400 mEq/L </li></ul></ul><ul><...
Treatment <ul><li>Rate of Repletion </li></ul><ul><ul><li>3.0 – 3.5 mEq/L = oral KCL 60-80 mEq/day </li></ul></ul><ul><ul>...
HYPERKALEMIA <ul><li>Plasma K > 5.0 mEq/L </li></ul>
Etiology of Hyperkalemia <ul><li>Movement from cells to ECF </li></ul><ul><ul><li>Metabolic acidosis </li></ul></ul><ul><u...
Etiology of Hyperkalemia <ul><li>Decrease Urinary Excretion </li></ul><ul><ul><li>Renal failure </li></ul></ul><ul><ul><li...
Etiology of Hyperkalemia <ul><li>Hypoaldosteronism </li></ul><ul><ul><li>NSAID </li></ul></ul><ul><ul><li>Converting enzym...
Sign and Symptoms <ul><li>Cardiac </li></ul><ul><ul><li>5.0 – 6.5 = peak T wave </li></ul></ul><ul><ul><li>6.5 – 8.0= flat...
Treatment <ul><li>Antagonism of Membrane </li></ul><ul><ul><li>Calcium gluconate = 10 – 20 ml  </li></ul></ul><ul><ul><ul>...
Treatment <ul><li>Increase K entry into the cells </li></ul><ul><li>Glucose–Insulin solution ( 10 u in 50 ml D50W) </li></...
Treatment <ul><li>Removal of Excess K </li></ul><ul><ul><li>Diuretics </li></ul></ul><ul><ul><li>Cation exchange resin </l...
 
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ELECTROLYTE DISORDERS

ELECTROLYTE DISORDERS

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ELECTROLYTE DISORDERS

  1. 1. ELECTROLYTE DISORDERS CRISBERT I. CUALTEROS, MD http://crisbertcualteros.page.tl
  2. 2. HYPONATREMIA <ul><li>Plasma concentration < 135 meq/L </li></ul>
  3. 3. Generation of Hyponatremia <ul><li>Plasma Na = Na + K/ TBW </li></ul>
  4. 4. Sign and Symptoms <ul><li>Lethargy, Apathy </li></ul><ul><li>Disorientation </li></ul><ul><li>Muscle cramps </li></ul><ul><li>Anorexia </li></ul><ul><li>Nausea </li></ul><ul><li>Agitation </li></ul>
  5. 5. Sign and Symptoms <ul><li>Abnormal sensorium </li></ul><ul><li>Depressed deep tendon reflexes </li></ul><ul><li>Cheyne-Stokes respiration </li></ul><ul><li>Hypothermia </li></ul><ul><li>Seizures </li></ul>
  6. 6. Diagnostic Approach Hyponatremia Na and Water Deficit Water Excess Na and Water Excess Hypervolemia Hypovolemia Euvolemia
  7. 7. Diagnostic Approach Hyponatremia Hypovolemia Euvolemia Hypervolemia Renal Losses Diuretic excess Mineralcorticoid Deficiency Salt losing nephritis RTA Extrarenal Losses Vomiting Diarrhea Burn Pancreatitis Peritonitis Urine Na >20 Urine Na<10
  8. 8. Diagnostic Approach Hyponatremia Hypovolemia Euvolemia Hypervolemia Glucocorticoid Deficiency Hypothyroidism Pain Emotional Stress Drugs SIADH Urine Na >20
  9. 9. Diagnostic Approach Hyponatremia Hypovolemia Euvolemia Hypervolemia Nephrotic Syndrome Cardiac Failure Cirrhosis ARF CRF Urine Na <10 Urine Na >20
  10. 10. Treatment <ul><li>Na deficit = 0.5 x wt (kg) x (D Na – A Na ) </li></ul><ul><li>Calculation of Desired Negative Water Balance </li></ul><ul><li>TBW = Wt (kg) x 0.6 </li></ul><ul><li>Actual plasma Na x TBW </li></ul><ul><li>Desired plasma Na </li></ul><ul><li>TBW-Desired TBW = fluid to be removed </li></ul>
  11. 11. Rate of Correction <ul><li>First 24 hours = 10 -12 mEq/day </li></ul><ul><li>Seizure and Neurologic symptoms </li></ul><ul><ul><li>1.5 – 2 mEq/L/h for 3 to 4 hours </li></ul></ul>
  12. 12. Central Demyelinating Lesion <ul><li>Paraparesis </li></ul><ul><li>Quadriparesis </li></ul><ul><li>Dysarthria </li></ul><ul><li>Dysphagia </li></ul><ul><li>Coma </li></ul>
  13. 13. Risk Factor for Demyelination <ul><li>More than 25 mEq/L elevation of Na within the first 48 hours </li></ul><ul><li>Overcorrection of plasma Na above 140 mEq/L </li></ul>
  14. 14. HYPERNATREMIA <ul><li>Plasma Na > 150 mEq/L </li></ul>
  15. 15. Generation of Hypernatremia <ul><li>Plasma Na = Na + K/TBW </li></ul>
  16. 16. Sign and Symptoms <ul><li>Lethargy </li></ul><ul><li>Weakness </li></ul><ul><li>Irritability </li></ul><ul><li>Twitching </li></ul><ul><li>Seizures </li></ul><ul><li>Coma </li></ul><ul><li>Death </li></ul>
  17. 17. Diagnostic Approach Hypernatremia Na and H2O Deficits H2O losses Na Addition Excess Hypovolemia Euvolemia Hypervolemia
  18. 18. Diagnostic Approach Hypernatremia Hypovolemia Euvolemia Hypervolemia Renal losses Osmotic and loop diuretics Post obstruction Extrarenal Losses Sweating Burns Diarrhea Urine Na >20 Urine Na <10
  19. 19. Diagnostic Approach Hypernatremia Hypovolemia Euvolemia Hypervolemia Renal Losses Nephrogenic DI Central DI Extrarenal Losses Respiratory and Dermal Incensible Losses Urine Na = Variable Urine Na = Variable
  20. 20. Hypernatremia Hypovolemia Euvolemia Hypervolemia Primary Hyperaldoteronism Cushing’s Syndrome Hypertonic Dialysis Hypertonic NaHCO3 NaCl tablets Urine Na >20 mEq/L
  21. 21. Treatment <ul><li>Correction of ECF Volume Depletion </li></ul><ul><ul><li>Isotonic Saline Until the ECF volume is achieved </li></ul></ul><ul><ul><li>Followed by Hypotonic NaCl or 5% glucose solution </li></ul></ul>
  22. 22. Treatment <ul><li>Correction of ECF Volume Expansion </li></ul><ul><ul><li>Diuretics or Dialysis </li></ul></ul>
  23. 23. Water Replacement <ul><li>Computation </li></ul><ul><ul><li>TBW = Wt (Kg) x 0.6 </li></ul></ul><ul><ul><li>Actual plasma Na x TBW </li></ul></ul><ul><ul><li>Desired plasma Na </li></ul></ul>
  24. 24. HYPOKALEMIA <ul><li>Plasma K < 3.0 mEq/L </li></ul>
  25. 25. Sign and Symptoms <ul><li>Cardiac </li></ul><ul><ul><li>Atrial and ventricular ectopic beats </li></ul></ul><ul><ul><li>Abnormal EKG </li></ul></ul><ul><ul><ul><li>Flat T mave </li></ul></ul></ul><ul><ul><ul><li>Prominent U wave </li></ul></ul></ul>
  26. 26. Sign and Symptoms <ul><li>Neuromuscular </li></ul><ul><ul><li>Constipation, Ileus </li></ul></ul><ul><ul><li>Weakness, paralysis </li></ul></ul><ul><ul><li>Respiratory paralysis </li></ul></ul><ul><ul><li>Rhabdomyolysis </li></ul></ul>
  27. 27. Sign and Symptoms <ul><li>Renal </li></ul><ul><ul><li>Impaired concentrating ability (polyuria, polydipsia) </li></ul></ul><ul><ul><li>Increase renal NH3 production </li></ul></ul><ul><ul><li>Impaired urinary acidification </li></ul></ul><ul><ul><li>Metabolic alkalosis </li></ul></ul>
  28. 28. Causes <ul><li>Hypokalemia due to Redistribution </li></ul><ul><ul><li>Alkalosis </li></ul></ul><ul><ul><li>Insulin excess </li></ul></ul><ul><ul><li>Beta-adrenergic agonist </li></ul></ul><ul><ul><li>Hypokalemic periodic paralysis </li></ul></ul>
  29. 29. Causes <ul><li>Extrarenal Loss </li></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>GI fistula </li></ul></ul><ul><ul><li>Laxative abuse </li></ul></ul><ul><ul><li>Profuse sweating </li></ul></ul>
  30. 30. Causes <ul><li>Renal Loss </li></ul><ul><ul><li>Hypertensive Disorder </li></ul></ul><ul><ul><ul><li>Malignant hypertension </li></ul></ul></ul><ul><ul><ul><li>Renovascular hypertension </li></ul></ul></ul><ul><ul><ul><li>Renal secreting tumors </li></ul></ul></ul><ul><ul><ul><li>Primary Aldosteronism </li></ul></ul></ul><ul><ul><ul><li>Cushing’s Syndrome </li></ul></ul></ul><ul><ul><ul><li>Congenital adrenal hyperplasia </li></ul></ul></ul>
  31. 31. Causes <ul><li>Renal Loss </li></ul><ul><ul><li>Normotensive </li></ul></ul><ul><ul><ul><li>RTA </li></ul></ul></ul><ul><ul><ul><li>Vomiting </li></ul></ul></ul><ul><ul><ul><li>Diuretics </li></ul></ul></ul><ul><ul><ul><li>Mg depletion </li></ul></ul></ul><ul><ul><ul><li>Barter’s syndrome </li></ul></ul></ul><ul><ul><ul><li>Gittleman’s syndrome </li></ul></ul></ul>
  32. 32. Diagnostic Approach Hypokalemia Redistribution Extrarenal U K <20 Renal loss U K >20 Metabolic acidosis Diarrhea GI fistulas Laxative abuse Normal Acid-Base Profuse sweating Laxative abuse Gastric fistula Previous vomiting
  33. 33. Diagnostic Approach Hypokalemia Redistribution Extrarenal Loss U K <20 Renal Loss U K >20 Hypertensive High Plasma Renin Malignant HPN Renovascular HPN Renin secreting tumors Low Plasma Renin Primary Aldosteronism Cushing’s Syndrome Adrenal hyperplasia
  34. 34. Diagnostic Approach Hypokalemia Redistribution Extrarenal Loss U K <20 Renal Loss U K >20 Normotensive Metabolic Alkalosis U Cl <10 Vomiting U Cl >10 Diuretics Mg Depletion Barter syndrome Gittleman syndrome
  35. 35. Diagnostic Approach Hypokalemia Redistribution Extrarenal Loss U K <20 Renal Loss U K >20 Normotensive Metabolic acidosis Normal Anion Gap RTA Increase Anion Gap Diabetic Ketoacidosis Ethylene Glycol
  36. 36. Treatment <ul><li>Potassium Deficit </li></ul><ul><ul><li>4.0 to 3.0 mEq/L = loss of 200 to 400 mEq/L </li></ul></ul><ul><ul><li>3.0 to 2.0 mEq/L = additional 200 to 400 mEq/L loss </li></ul></ul>
  37. 37. Treatment <ul><li>Rate of Repletion </li></ul><ul><ul><li>3.0 – 3.5 mEq/L = oral KCL 60-80 mEq/day </li></ul></ul><ul><ul><li><2.5 mEq/L = 10-20 mEq/hour IV </li></ul></ul>
  38. 38. HYPERKALEMIA <ul><li>Plasma K > 5.0 mEq/L </li></ul>
  39. 39. Etiology of Hyperkalemia <ul><li>Movement from cells to ECF </li></ul><ul><ul><li>Metabolic acidosis </li></ul></ul><ul><ul><li>Insulin deficiency and hyperosmolarity (DM) </li></ul></ul><ul><ul><li>Tissue catabolism </li></ul></ul><ul><ul><li>B adrenergic blockade </li></ul></ul><ul><ul><li>Severe exercise </li></ul></ul><ul><ul><li>Digitalis overdose </li></ul></ul><ul><ul><li>Periodic paralysis – hyperkalemic form </li></ul></ul>
  40. 40. Etiology of Hyperkalemia <ul><li>Decrease Urinary Excretion </li></ul><ul><ul><li>Renal failure </li></ul></ul><ul><ul><li>Effective circulating volume depletion </li></ul></ul><ul><ul><li>RTA – hyperkalemic form </li></ul></ul><ul><ul><li>Hypoaldosteronism </li></ul></ul>
  41. 41. Etiology of Hyperkalemia <ul><li>Hypoaldosteronism </li></ul><ul><ul><li>NSAID </li></ul></ul><ul><ul><li>Converting enzyme inhibitors </li></ul></ul><ul><ul><li>Cyclosporine </li></ul></ul><ul><ul><li>K sparing diuretics </li></ul></ul><ul><ul><li>Primary adrenal insufficiency </li></ul></ul>
  42. 42. Sign and Symptoms <ul><li>Cardiac </li></ul><ul><ul><li>5.0 – 6.5 = peak T wave </li></ul></ul><ul><ul><li>6.5 – 8.0= flattening of P wave, prolongation of PR interval, widening of QRS complex </li></ul></ul><ul><ul><li>>8.0 = sine wave pattern, V fibrillation or cardiac arrest </li></ul></ul>
  43. 43. Treatment <ul><li>Antagonism of Membrane </li></ul><ul><ul><li>Calcium gluconate = 10 – 20 ml </li></ul></ul><ul><ul><ul><li>Peak effect = 5 minutes </li></ul></ul></ul>
  44. 44. Treatment <ul><li>Increase K entry into the cells </li></ul><ul><li>Glucose–Insulin solution ( 10 u in 50 ml D50W) </li></ul><ul><li>Sodium Bicarbonate </li></ul><ul><li>B adrenergic agonist </li></ul>
  45. 45. Treatment <ul><li>Removal of Excess K </li></ul><ul><ul><li>Diuretics </li></ul></ul><ul><ul><li>Cation exchange resin </li></ul></ul><ul><ul><li>Hemodialysis or Peritoneal Dialysis </li></ul></ul>

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