Title: Electrolyte Disturbances
1Pediatric Critical Care Medicine Emory
University Childrens Healthcare of Atlanta
2Objectives
- Recognize common fluid and electrolyte disorders
- Clinical presentations
- Management
3Basic Metabolic Panel
-
- Na Cl- BUN Ca
- Glu Mg
- K CO3-- Cr Phos--
4Basic Metabolic Panel
-
- Na Cl- BUN Ca
- Glu Mg
- K CO3-- Cr Phos--
5Sodium (Na)
- Bulk cation of extracellular fluid ? change in
SNa reflects change in total body Na - Principle active solute for the maintenance of
intravascular interstitial volume - Absorption throughout the GI system via active
Na,K-ATPase system - Excretion urine, sweat feces
- Kidneys are the principal regulator
6Sodium (Na)
- Kidneys are the principal regulator
- 2/3 of filtered Na is reabsorbed by the proximal
convoluted tubule, increase with contraction of
extracellular fluid - Countercurrent system at the Loop of Henle is
responsible for Na (descending) water
(ascending) balance active transport with Cl- - Aldosterone stimulates further Na re-absorption
at the distal convoluted tubules the collecting
ducts - lt1 of filtered Na is normally excreted but can
vary up to 10 if necessary
7Sodium (Na)
- Normal SNa 135-145
- Major component of serum osmolality
- Sosm (2 x Na) (BUN / 2.8) (Glu / 18)
- Normal 285-295
- Alterations in SNa reflect an abnormal water
regulation
8Sodium (Na)
- Hypernatremia Causes
- Excessive intake
- Improperly mixed formula
- Exogenous bicarb, hypertonic saline, seawater
- Water deficit
- Central nephrogenic DI
- Increased insensible loss
- Inadequate intake
9Sodium (Na)
- Hypernatremia Causes
- Water and sodium deficit
- GI losses
- Cutaneous losses
- Renal losses
- Osmotic diuresis mannitol, diabetes mellitus
- Chronic kidney disease
- Polyuric ATN
- Post-obstructive diuresis
10Sodium (Na)
- Hypernatremia Clinical presentation
- Dehydration
- Doughy feel to skin
- Irritability, lethargy, weakness
- Intracranial hemorrhage
- Thrombosis renal vein, dura sinus
11Sodium (Na)
- Hypernatremia Treatment
- Rate of correction for Na 1-2 mEq/L/hr
- Calculate water deficit
- Water deficit 0.6 x wt (kg) x (current
Na/140) 1 - Rate of correction for calculated water deficit
- 50 first 12-24 hrs
- Remaining next 24 hrs
12Sodium (Na)
- Hyponatremia
- Nalt135
- Seizure threshold 125
- lt120 life threatening
13Sodium (Na)
- Hyponatremia Etiology
- Hypervolemic
- CHF Cirrhosis
- Nephrotic syndrome Hypoalbuminemia
- Septic capillary leak
- Hypovolemic
- Renal losses Cerebral salt wasting
- Extra-renal losses aldosterone effect
- GI losses
- Third spacing
14Sodium (Na)
- Hyponatremia Etiology
- Euvolemic hyponatremia
- SIADH
- Glucocorticoid deficiency
- Hypothyroidism
- Water intoxication
- Psychogenic polydipsia
- Diluted formula
- Beer potomania
- Pseudo-hyponatremia
- Hyperglycemia
- SNa decreased by 1.6/100 glucose over 100
-
15Sodium (Na)
- Hyponatremia Clinical presentation
- Cellular swelling due to water shifts into cells
- Anorexia, nausea, emesis, malaise, lethargy,
confusion, agitation, headache, seizures, coma - Chronic hyponatremia better tolerated
16Sodium (Na)
- Hyponatremia Treatment
- Rapid correction ? central pontine myelinolysis
- Goal 12 mEq/L/day
- Fluid restriction with SIADH
- Hyponatremic seizures
- Poorly responsive to anti-convulsants
- Hypertonic saline
- Need to bring Na to above seizure threshold
17Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
18Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
19Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
20Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
21Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
22Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
23Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
24Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
25Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
26Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
27Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
28Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
29Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
30Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
31Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
32Sodium (Na)
Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
33Basic Metabolic Panel
-
- Na Cl- BUN Ca
- Glu Mg
- K CO3-- Cr Phos--
34Potassium (K)
- Normal range 3.5-4.5
- Largely contained intra-cellular ? SK does not
reflect total body K - Important roles contractility of muscle cells,
electrical responsiveness - Principal regulator kidneys
35Potassium (K)
- Daily requirement 1-2 mEq/kg
- Complete absorption in the upper GI tract
- Kidneys regulate balance
- 10-15 filtered is excreted
- Aldosterone increase K decrease Na excretion
- Mineralocorticoid glucocorticoid ? increase K
decrease Na excretion in stool
36Potassium (K)
- Solvent drag
- Increase in Sosmo ? water moves out of cells ? K
follows - 0.6 SK / 10 of Sosmo
- Evidence of solvent drag in diabetic ketoacidosis
- Acidosis
- Low pH ? shifts K out of cells (into serum)
- Hi pH ? shifts K into cells
- 0.3-1.3 mEq/L K change / 0.1 unit change in pH
in the opposite direction
37Potassium (K)
- Hyperkalemia
- gt6.5 life threatening
- Potential lethal arrhythmias
38Potassium (K)
- Hyperkalemia Causes
- Spurious
- Difficult blood draw ? hemolysis ? false reading
- Increase intake
- Iatrogenic IV or oral
- Blood transfusions
39Potassium (K)
- Hyperkalemia Causes
- Decrease excretion
- Renal failure
- Adrenal insufficiency or CAH
- Hypoaldosteronism
- Urinary tract obstruction
- Renal tubular disease
- ACE inhibitors
- Potassium sparing diuretics
40Potassium (K)
- Hyperkalemia Causes
- Trans-cellular shifts
- Acidemia
- Rhadomyolysis Tumor lysis syndrome Tissue
necrosis - Succinylcholine
- Malignant hyperthermia
41Potassium (K)
- Hyperkalemia Clinical presentation
- Neuromuscular effects
- Delayed repolarization, faster depolarization,
slowing of conduction velocity - Paresthesias ? weakness ? flaccid paralysis
42Potassium (K)
- Hyperkalemia Clinical presentation
- EKG changes
- 6 peak T waves
- 7 increased PR interval
- 8-9 absent P wave with widening QRS complex
- Ventricular fibrillation
- Asystole
43Potassium (K)
44Potassium (K)
- Hyperkalemia Treatment
- Lower K temporarily
- Calcium gluconate 100mg/kg IV
- Bicarb 1-2 mEq/kg IV
- Insulin glucose
- Insulin 0.05 u/kg IV D10W 2ml/kg then
- Insulin 0.1 u/kg/hr D10W 2-4 ml/kg/hr
- Salbutamol (ß2 selective agonist) nebulizer
45Potassium (K)
- Hyperkalemia Treatment
- Increase elimination
- Hemodialysis or hemofiltration
- Kayexalate via feces
- Furosemide via urine
46Potassium (K)
- Hypokalemia
- lt2.5 life threatening
- Common in severe gastroenteritis
47Potassium (K)
- Hypokalemia Causes
- Distribution from ECF
- Hypokalemic periodic paralysis
- Insulin, ?-agonists, catecholamines, xanthine
- Decrease intake
- Extra-renal losses
- Diarrhea
- Laxative abuse
- Perspiration
- Excessive colas consumption
48Potassium (K)
- Hypokalemia Causes
- Renal losses
- DKA
- Diuretics thiazide, loop diuretics
- Drugs amphotericin B, Cisplastin
- Hypomagnesemia
- Alkalosis
- Hyperaldosteronism
- Licorice ingestion
- Gitelman Bartter syndrome
49Potassium (K)
- Hypokalemia Presentation
- Usually asymptomatic
- Skeletal muscle weakness cramps respiratory
failure - Flaccid paralysis hyporeflexia
- Smooth muscle constipation, urinary retention
- ECG changes
- Flattened or inverted T-wave
- U wave prolonged repolarization of the Purkinje
fibers - Depressed ST segment and widen PR interval
- Ventricular fibrillation can happen
50Potassium (K)
- Hypokalemia
- - Flattened or inverted T-wave
- - U wave prolonged repolarization of the
Purkinje fibers - - Depressed ST segment and widen PR interval
- - Ventricular fibrillation can happen
51Potassium (K)
- Hypokalemia Treatment
- Address the causes underlying condition
- Dietary supplements leafy green vegetables,
tomatoes, citrus fruits, oranges or bananas - Oral K replacement preferred
- IV KCl 0.5-1 mEq/kg over 1 hr (rate of 10
mEq/hr) - K Acetate or K Phos as alternative
- Add K sparing diuretics
- Correct hypomagnesemia
52Basic Metabolic Panel
-
- Na Cl- BUN Ca
- Glu Mg
- K HCO3-- Cr Phos--
53Bicarb (HCO3--)
- Normal range 25-35
- Important buffer system in acid-base homeostasis
- Increased in metabolic alkalosis or compensated
respiratory acidosis - Decreased in metabolic acidosis or compensated
respiratory alkalosis - 0.15 pH change/10 change in bicarb in
uncompensated conditions
54Bicarb (HCO3--)
- Metabolic acidosis
- Anion gap Na (Cl bicarb)
- Normal range 12 /- 2
55Bicarb (HCO3--)
- Metabolic acidosis causes for increase anion gap
- M
- U
- D
- P
- I
- L
- E
- S
56Bicarb (HCO3--)
- Metabolic acidosis causes for increase anion
gap - Methanol
- Uremia
- DKA
- Paraldehyde or propylene glycol
- Isoniazid
- Lactic acidosis
- Ethylene glycol
- Salicylates
57Bicarb (HCO3--)
- Metabolic acidosis causes for normal anion gap
- Diarrhea
- Pancreatic fistula
- Renal tubular acidosis or renal failure
- Intoxication ammonium chloride, Acetazolamide,
bile acid sequestrants, isopropyl alcohol - Glue sniffing
- Toluene
58Bicarb (HCO3--)
- Metabolic acidosis Clinical presentation
- Chest pain, palpitation
- Kussmaul respirations
- Hyperkalemia
- Neuro lethargy, stupor, coma, seizures
- Cardiac arrhythmias, decreased response to
Epinephrine, hypotension
59Bicarb (HCO3--)
- Metabolic acidosis Treatment
- pHlt7.1, risk of arrhythmias
- IV bicarb
- Dialysis
60Bicarb (HCO3--)
- Metabolic alkalosis Causes
- Chloride responsive
- Compensated respiratory acidosis
- Diuretics ? contraction alkalosis
- Vomiting
- Chloride resistant
- Retention of bicarb, shift hydrogen ion into IC
space - Alkalotic agents
- Hyperaldosteronism
61Basic Metabolic Panel
-
- Na Cl- BUN Ca
- Glu Mg
- K CO3-- Cr Phos--
62Glucose
- Hypoglycemia Causes
- Complication of DM therapies
- Hyperinsulinemia
- Inborn errors of metabolism
- Alcohol
- Starvations
- Infections, organ failure
63Glucose
- Hypoglycemia Clinical presentation
- Adrenergic
- Shakiness, anxiety, nervousness, palpitations,
tachycardia - Sweating, pallor, coldness, clamminess
- Glucagon
- Hunger, borborygmus, nausea, vomiting, abd.
Discomfort - Headache
- Neuroglycopenic
- AMS, fatigue, weakness, lethargy, confusion,
amnesia. - Ataxia, incoordination, slurred speech
64Glucose
- Hypoglycemia Treatments
- 0.5-1 g/kg of dextrose
- 5-10 ml/kg of D10W
- 2-4 ml/kg of D25W
- Max 1 amp (50 g)
65Basic Metabolic Panel
-
- Na Cl- BUN Ca
- Glu Mg
- K CO3-- Cr Phos--
66Calcium
- Normal range 8.8-10.1 with half bound to albumin
- Ionized (free or active)calcium 4.4-5.4
relevant for cell function - Majority is stored in bone
- Hypoalbuminemia ? falsely decreased calcium
- Cac Cam 0.8 x (Albn Alb m)
67Calcium
- Roles
- Coagulation
- Cellular signals
- Muscle contraction
- Neuromuscular transmission
- Controlled by parathyroid hormone and vitamin D
68Calcium
- Hypercalcemia Causes
- Excess parathyroid hormone, lithium use
- Excess vitamin D
- Malignancy
- Renal failure
- High bone turn over
- Prolonged immobilization
- Hyperthyroidism
- Thiazide use, vitamin A toxicity
- Pagets disease
- Multiple myeloma
69Calcium
- Hypercalcemia Clinical presentation
- Groans constipation
- Moans psychic moans (fatigue, lethargy,
depression) - Bones bone pain
- Stones kidney stones
- Psychiatric overtones depression confusion
- Fatigue, anorexia, nausea, vomiting, pancreatitis
- ECG short QT interval, widened T wave
70Calcium
- Hypercalcemia Treatments
- Fluid diuretics
- Forced diuresis
- Loop diuretic
- Oral supplement biphosphate or calcitonine
- Glucocorticoids
- Dialysis
71Calcium
- Hypocalcemia Causes
- Eating disorder
- Hungry bone syndrome
- Ingestion mercury , excessive Mg
- Chelation therapy EDTA
- Absent of PTH
- Ineffective PTH CRF, absent or ineffective
vitamin D, pseudohypoparathyroidism - Deficient in PTH acute hyperphos TLS, ARF,
Rhabdo - Blood transfusions
72Calcium
- Hypocalcemia Clinical presentation
- Neuromuscular irritability
- Paresthesias oral, perioral and acral, tingling
or pin needles - Tetany (Chvostek Trousseau signs)
- Hyperreflexia
- Laryngospasm
- Jittery, poor feedings or vomiting in newborns
- ECG changes prolonged QT intervals
73Calcium
- Hypocalcemia Treatments
- Supplements
- IV gluconate or chloride with EKG change
- Oral calcium with vitamin D
74Basic Metabolic Panel
-
- Na Cl- BUN Ca
- Glu Mg
- K CO3-- Cr Phos--
75Magnesium
- Normal range 1.5-2.3
- 60 stored in bone
- 1 in extracellular space
- Necessary cofactor for many enzymes
- Renal excretion is primary regulation
76Magnesium
- Hypermagnesemia Causes
- Hemolysis
- Renal insuficiency
- DKA, adrenal insufficiency, hyperparathyroidism,
lithium intoxication
77Magnesium
- Hypermagnesemia Clinical presentation
- Weakness, nausea, vomiting
- Hypotension, hypocalcemia
- Arrhythmia and asystole
- 4.0 mEq/L hyporeflexia
- gt5 prolonged AV conduction
- gt10 complete heart block
- gt13 cardiac arrest
78Magnesium
- Hypermagnesemia Treatments
- Calcium infusion
- Diuretics
- Dialysis
79Magnesium
- Hypomagnesemia Causes
- Alcoholism malnutrition diarrhea Thiamine
deficiency - GI causes Crohns, UC, Whipples disease, celiac
sprue - Renal loss Bartters syndrome, postobstructive
diuresis, ATN, kidney transplant - DKA
- Drugs
- Loop and thiazide diuretics
- Abx aminoglycoside, ampho B, pentamidine, gent,
tobra - PPI
- Others digitalis, adrenergic, cisplastin,
ciclosporine
80Magnesium
- Hypomagnesemia Clinical presentation
- Weakness, muscle cramps
- Cardiac arrhythmias
- Prolonged PR, QRS QT
- Torsade de pointes
- Complete heart block cardiac arrest with level
gt15 - CNS irritability, tremor, athetosis, jerking,
nystagmus - Hallucination, depression, epileptic fits, HTN,
tachycardia, tetany
81Magnesium
- Hypomagnesemia Treatments
- Oral or IV supplement
- Correct on going loss
82Basic Metabolic Panel
-
- Na Cl- BUN Ca
- Glu Mg
- K CO3-- Cr Phos--
83Phosphorus
- Normal range 2.3 - 4.8
- Most store in bone or intracellular space
- lt1 in plasma
- Intracellular major anion, most in ATP
- Concentration varies with age, higher during
early childhood - Necessary for cellular energy metabolism
84Phosphorus
- Hyperphosphatemia
- Causes
- Hypoparathyroidism
- Chronic renal failure
- Osteomalacia
- Presentations
- Ectopic calcification
- Renal osteodystrophy
- Treatments
- Dietary restriction
- Phosphate binder
85Phosphorus
- Hypophosphatemia Causes
- Re-feeding syndrome
- Respiratory alkalosis
- Alcohol abuse
- Malabsorption
86Phosphorus
- Hypophosphatemia
- Clinical presentation
- Muscle dysfunction and weakness diploplia, low
CO, dysphagia, respiratory depression - AMS
- WBC dysfunction
- Instability of cell membrane ? rhabdomyolysis
- Treatments
- supplementation