electrolyte imbalance
TRANSCRIPT
ELECTROLYTE IMBALANCE
Dr. Vignesh kumarAmbedkar hospital
http://www.globalrph.com/index.htm
Composition in body compartments
Electrolyte ECF (mEq/l) ICF (mEq/l)
Sodium 135-150 10-18
Potassium 3.5-5.0 120-145
Calcium 8.5-10.5 mg/dl
Magnesium 1.5-2.4 30-50
Chloride 95-108 2-6
Phosphate 2.5-4.5 mg/dl 25-60
Bailey&Love 26th ed., Schwartz 9th ed.
Composition of GI secretions(mEQ/l) Sodium Potassium Chloride Bicarbonate
Saliva 10 25 10 30
Stomach 60-90 10-30 100-130
Duodenum 140 5 100
Mixed gastric
aspirate
120 10 100
Ileum 140 5 100 30
Colon 60 30 40
Stool 35 3-12 20
Pancreas 140 5 75 115
Bile 140 5 100 35
POTASSIUMPrimary intracellular ionRegulates cell excitabilityRDA : 4700 mg
(0.6-0.8mEq/kg/day)Regulated be renin-angiotensin-
aldosterone axisRelation to acid base
balance(buffer)potassium decreases by 0.3
mEq/l for every 0.1 increase in pH
ETIOLOGY
HYPERKALEMIA HYPOKALEMIA
Increased intake Increased secretion Impaired excretion
Inadequate intakeExcessive excretionGI lossesMisc
Treatment of hypokalemiaCorrection = 0.4× Body weight×
deficitOral / IVHow much to correct?Peripheral/central line?Refractory cases?? Why?Co-existing hypokalemia and
acidosis, what to correct first?
Treatment of hyperkalemiaStop all oral and iv infusions of
potassiumStabilize the heartRole of bicarbonate??Short term measuresPermanent measures
SODIUMPrimary extracellular ionVital for homeostasis and action
potential in the bodyControls water movement in and out
of the vascular systemRegulated by ADHRDA : 2400mg (1-2mEq/kg/day)Serum osmolality
◦2×Na + BUN/2.8 + glucose/18◦2×Na + Bl urea/6 + glucose/18
Hyponatremia Hypotonic/hypertonicEvery 100 gm fall in glucose,
1.6mEq/l fall in na (transient h-na)
Renal/ extra renalVolume statusADH – H-na – osmalilty SIADH
Treatment of hyponatremiaCorrection = 0.6(m)/0.5(f) × deficit × BW
Na <110 or neurological symptoms◦3% NS until Na >120 or symptom free◦Rate of correction 0.25 mEq/l/hr or 8
mEq/l/day◦Seizures are present, correction can be upto
4-5 mEq/l in first hour◦Central pontine myelinosis
Hypovolemia Euvolemia Hypervolemia
Salt and water Water restriction Salt & Water restriction
IV saline Loop diuretics
Hypernatremia Volume statusRenal / extra renalDiabetes insipidusSr.osmalalityRare for a thristy person to end
up with hypernatremia
Treatment of hypernatremiaVolume status
Rate of correction◦Acute – max of1-2 m Eq/l/hr◦Chronic – max of 0.5 mEq/l/hr◦Max of 8 mEq/l/day
Diabetes insipidus
Hypovolemia Euvolemia Hypervolemia
NS/2 and D5 Water or D5 Salt restriction
Loop diuretics with water
CALCIUMRegulated by PTH and CalcitoninVitamin D plays a role in absorptionCoagulation cascade, neuromuscular
functionIonic 50%, protein bound 40%, anion
bound 10%RDA : 1-2gIonic ca = total ca + [0.8×(4.5-albumin)]Relation to acid-base balance
◦Acidosis decreases protein bound ca levels
ETIOLOGY
HYPOCALCEMIA HYPERCALCEMIAPost thyroid and neck
surgeryEndocrineRenal failureHyperphosphatemia Malignant diseaseNutritionalBlood transfusion Inflammatory
conditions
EndocrineRenal dysfunctionMalignant diseaseNutritionalGranulomatous
disease Inherited disorders
Chvostek’s sign
Trosseau’s sign (carpopedal spasm)
Treatment of hypocalcemia
10ml of 10% calcium gluconate(1 gm) f/b calcium infusion if necessary (0.5-1.5mg/kg/hr)
Gluconate preferred over chlorideHyperphosphatemia correctionRefractory cases? Why?Oral supplementation with
vitamin DTeriparatide (synthetic PTH)
HYPERCALCEMIASIGNS AND SYMPTOMS
Treatment of hypercalcemiaTreat the etiology – m/c
parathyroid adenomaStop thiazide diureticsSaline diuresis with furosemideInhibit bone resorption
(biphosphonates)HemodialysisCalcitonin as short term measureOral phosphates
MAGNESIUMNormal levels 1.5-2.4 m Eq/lProtein bound(30%), anion
bound(10%) and free(60%)Calcium channel antagonist and co
factor in ATP powered reactionsPhysiological test to detect tissue H-
MgMg is reabsorbed in Henle’s loop and
DCTRDA : 400mg
Hypomagnesemia40% of hypomagnesemics are
hypokalemic60% of hypokalemics are
hypomagnesemicHypomagnesemia
Slows ATP production
Na+-K+ ATPase
Loss of intracellular potassium
Loss of potassium in urine
Treatment of hypomagnesemia1gm MgSo4 contains 0.1 g of
elemental magnesium8-12g IV over 24 hours f/b 4-6g
IV for the next three daysDose to be adjusted in renal
insufficiencyDeep tendon reflexes, RR, Urine
output to be checked while giving Mg correction
Hypermagnesemia Uncommon in the absence of
renal failureIV overdose are better tolerated
than oral overdoseNeuromuscular blockadeCalcium channel blockade ECG changes
Treatment of hypermagnesemiaStopping Mg in patients with
intact renal function will sufficeCalcium to stabilize the heartSaline diuresis with loop diureticsDialysis for renal failure patients