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Electrolyte Disturbances

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Title: Electrolyte Disturbances


1
  • Electrolyte Disturbances

Pediatric Critical Care Medicine Emory
University Childrens Healthcare of Atlanta
2
Objectives
  • Recognize common fluid and electrolyte disorders
  • Clinical presentations
  • Management

3
Basic Metabolic Panel
  • Na Cl- BUN Ca
  • Glu Mg
  • K CO3-- Cr Phos--

4
Basic Metabolic Panel
  • Na Cl- BUN Ca
  • Glu Mg
  • K CO3-- Cr Phos--

5
Sodium (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

6
Sodium (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

7
Sodium (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

8
Sodium (Na)
  • Hypernatremia Causes
  • Excessive intake
  • Improperly mixed formula
  • Exogenous bicarb, hypertonic saline, seawater
  • Water deficit
  • Central nephrogenic DI
  • Increased insensible loss
  • Inadequate intake

9
Sodium (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

10
Sodium (Na)
  • Hypernatremia Clinical presentation
  • Dehydration
  • Doughy feel to skin
  • Irritability, lethargy, weakness
  • Intracranial hemorrhage
  • Thrombosis renal vein, dura sinus

11
Sodium (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

12
Sodium (Na)
  • Hyponatremia
  • Nalt135
  • Seizure threshold 125
  • lt120 life threatening

13
Sodium (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

14
Sodium (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

-
15
Sodium (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

16
Sodium (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

17
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
18
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
19
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
20
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
21
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
22
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
23
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
24
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
25
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
26
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
27
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
28
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
29
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
30
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
31
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
32
Sodium (Na)
  • Fill in the blanks

Urine Output SerumNa UrineNa Serum Osm UrineOsm
DI
SIADH
CSW
33
Basic Metabolic Panel
  • Na Cl- BUN Ca
  • Glu Mg
  • K CO3-- Cr Phos--

34
Potassium (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

35
Potassium (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

36
Potassium (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

37
Potassium (K)
  • Hyperkalemia
  • gt6.5 life threatening
  • Potential lethal arrhythmias

38
Potassium (K)
  • Hyperkalemia Causes
  • Spurious
  • Difficult blood draw ? hemolysis ? false reading
  • Increase intake
  • Iatrogenic IV or oral
  • Blood transfusions

39
Potassium (K)
  • Hyperkalemia Causes
  • Decrease excretion
  • Renal failure
  • Adrenal insufficiency or CAH
  • Hypoaldosteronism
  • Urinary tract obstruction
  • Renal tubular disease
  • ACE inhibitors
  • Potassium sparing diuretics

40
Potassium (K)
  • Hyperkalemia Causes
  • Trans-cellular shifts
  • Acidemia
  • Rhadomyolysis Tumor lysis syndrome Tissue
    necrosis
  • Succinylcholine
  • Malignant hyperthermia

41
Potassium (K)
  • Hyperkalemia Clinical presentation
  • Neuromuscular effects
  • Delayed repolarization, faster depolarization,
    slowing of conduction velocity
  • Paresthesias ? weakness ? flaccid paralysis

42
Potassium (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

43
Potassium (K)
44
Potassium (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

45
Potassium (K)
  • Hyperkalemia Treatment
  • Increase elimination
  • Hemodialysis or hemofiltration
  • Kayexalate via feces
  • Furosemide via urine

46
Potassium (K)
  • Hypokalemia
  • lt2.5 life threatening
  • Common in severe gastroenteritis

47
Potassium (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

48
Potassium (K)
  • Hypokalemia Causes
  • Renal losses
  • DKA
  • Diuretics thiazide, loop diuretics
  • Drugs amphotericin B, Cisplastin
  • Hypomagnesemia
  • Alkalosis
  • Hyperaldosteronism
  • Licorice ingestion
  • Gitelman Bartter syndrome

49
Potassium (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

50
Potassium (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

51
Potassium (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

52
Basic Metabolic Panel
  • Na Cl- BUN Ca
  • Glu Mg
  • K HCO3-- Cr Phos--

53
Bicarb (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

54
Bicarb (HCO3--)
  • Metabolic acidosis
  • Anion gap Na (Cl bicarb)
  • Normal range 12 /- 2

55
Bicarb (HCO3--)
  • Metabolic acidosis causes for increase anion gap
  • M
  • U
  • D
  • P
  • I
  • L
  • E
  • S

56
Bicarb (HCO3--)
  • Metabolic acidosis causes for increase anion
    gap
  • Methanol
  • Uremia
  • DKA
  • Paraldehyde or propylene glycol
  • Isoniazid
  • Lactic acidosis
  • Ethylene glycol
  • Salicylates

57
Bicarb (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

58
Bicarb (HCO3--)
  • Metabolic acidosis Clinical presentation
  • Chest pain, palpitation
  • Kussmaul respirations
  • Hyperkalemia
  • Neuro lethargy, stupor, coma, seizures
  • Cardiac arrhythmias, decreased response to
    Epinephrine, hypotension

59
Bicarb (HCO3--)
  • Metabolic acidosis Treatment
  • pHlt7.1, risk of arrhythmias
  • IV bicarb
  • Dialysis

60
Bicarb (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

61
Basic Metabolic Panel
  • Na Cl- BUN Ca
  • Glu Mg
  • K CO3-- Cr Phos--

62
Glucose
  • Hypoglycemia Causes
  • Complication of DM therapies
  • Hyperinsulinemia
  • Inborn errors of metabolism
  • Alcohol
  • Starvations
  • Infections, organ failure

63
Glucose
  • 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

64
Glucose
  • 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)

65
Basic Metabolic Panel
  • Na Cl- BUN Ca
  • Glu Mg
  • K CO3-- Cr Phos--

66
Calcium
  • 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)

67
Calcium
  • Roles
  • Coagulation
  • Cellular signals
  • Muscle contraction
  • Neuromuscular transmission
  • Controlled by parathyroid hormone and vitamin D

68
Calcium
  • 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

69
Calcium
  • 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

70
Calcium
  • Hypercalcemia Treatments
  • Fluid diuretics
  • Forced diuresis
  • Loop diuretic
  • Oral supplement biphosphate or calcitonine
  • Glucocorticoids
  • Dialysis

71
Calcium
  • 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

72
Calcium
  • 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

73
Calcium
  • Hypocalcemia Treatments
  • Supplements
  • IV gluconate or chloride with EKG change
  • Oral calcium with vitamin D

74
Basic Metabolic Panel
  • Na Cl- BUN Ca
  • Glu Mg
  • K CO3-- Cr Phos--

75
Magnesium
  • Normal range 1.5-2.3
  • 60 stored in bone
  • 1 in extracellular space
  • Necessary cofactor for many enzymes
  • Renal excretion is primary regulation

76
Magnesium
  • Hypermagnesemia Causes
  • Hemolysis
  • Renal insuficiency
  • DKA, adrenal insufficiency, hyperparathyroidism,
    lithium intoxication

77
Magnesium
  • 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

78
Magnesium
  • Hypermagnesemia Treatments
  • Calcium infusion
  • Diuretics
  • Dialysis

79
Magnesium
  • 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

80
Magnesium
  • 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

81
Magnesium
  • Hypomagnesemia Treatments
  • Oral or IV supplement
  • Correct on going loss

82
Basic Metabolic Panel
  • Na Cl- BUN Ca
  • Glu Mg
  • K CO3-- Cr Phos--

83
Phosphorus
  • 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

84
Phosphorus
  • Hyperphosphatemia
  • Causes
  • Hypoparathyroidism
  • Chronic renal failure
  • Osteomalacia
  • Presentations
  • Ectopic calcification
  • Renal osteodystrophy
  • Treatments
  • Dietary restriction
  • Phosphate binder

85
Phosphorus
  • Hypophosphatemia Causes
  • Re-feeding syndrome
  • Respiratory alkalosis
  • Alcohol abuse
  • Malabsorption

86
Phosphorus
  • Hypophosphatemia
  • Clinical presentation
  • Muscle dysfunction and weakness diploplia, low
    CO, dysphagia, respiratory depression
  • AMS
  • WBC dysfunction
  • Instability of cell membrane ? rhabdomyolysis
  • Treatments
  • supplementation
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