hyponatremia and other critical electrolyte abnormalities
DESCRIPTION
Hyponatremia and Other Critical Electrolyte Abnormalities . Phillip D. Levy, MD, MPH, FACEP Associate Professor and Associate Director of Clinical Research Department of Emergency Medicine Assistant Director of Clinical Research Cardiovascular Research Institute - PowerPoint PPT PresentationTRANSCRIPT
Hyponatremia and Other Critical
Electrolyte Abnormalities
Phillip D. Levy, MD, MPH, FACEPAssociate Professor and Associate Director of Clinical Research
Department of Emergency MedicineAssistant Director of Clinical Research
Cardiovascular Research InstituteWayne State University School of Medicine
Disclosures• None relevant to this presentation
Objectives• To provide a brief review of
common electrolyte abnormalities encountered in the ED and discuss basic treatment
• To take a closer look at hyponatremia and evolving approaches to management
Potassium• Hyperkalemia
- Most common life-threatening electrolyte abnormality
- Three stage approach to treatment• Membrane stabilization• Shift potassium into cells• Remove potassium from the body
Common Causes
Pfenning et al. Critical Decisions in Emergency Medicine 2011;10;2-11.
Potassium• Hyperkalemia
- Most common life-threatening electrolyte abnormality
- Three stage approach to treatment• Membrane stabilization• Shift potassium into cells• Remove potassium from the body
Typical ECG Changes
Pfenning et al. Critical Decisions in Emergency Medicine 2011;10;2-11.
Potassium• Hyperkalemia
- Most common life-threatening electrolyte abnormality
- Three stage approach to treatment• Membrane stabilization• Shift potassium into cells• Remove potassium from the body
Potassium• Hyperkalemia
- Most common life-threatening electrolyte abnormality
- Three stage approach to treatment• Membrane stabilization• Shift potassium into cells• Remove potassium from the body
Potassium• Hypokalemia
- Often coupled with hypomagnesemia- Frequently asymptomatic
• Cramps, weakness- Classic ECG findings
Common Causes
Pfenning et al. Critical Decisions in Emergency Medicine 2011;10;2-11.
Potassium• Hypokalemia
- Often coupled with hypomagnesemia- Frequently asymptomatic
• Cramps, weakness- Classic ECG findings
Potassium• Hypokalemia
- Often coupled with hypomagnesemia- Frequently asymptomatic
• Cramps, weakness- Classic ECG findings
Potassium• Hypokalemia
- Replete orally for mild to moderate decreases
• Each 0.3 mEq < normal = 100 mEq deficit- Prolonged therapy may be needed for
severe cases- Requires concurrent magnesium to
move intracellularly
Potassium• Hypokalemia
- Replete orally for mild to moderate decreases
• Each 0.3 mEq < normal = 100 mEq deficit- Prolonged therapy may be needed for
severe cases- Requires concurrent magnesium to
move intracellularly
Potassium• Hypokalemia
- Replete orally for mild to moderate decreases
• Each 0.3 mEq < normal = 100 mEq deficit- Prolonged therapy may be needed for
severe cases- Requires concurrent magnesium to
move intracellularly
Calcium• Hypercalcemia
– Most often caused by parathyroid disease and malignancy
– “Bones, moans, groans and stones”• Arrhythmias with concomitant electrolyte
abnormalities– Primary treatment is normal saline
• Furosemide can help with associated diuresis but no longer routinely recommended
• Bisphosphonates = definitive therapy
Common Causes
Pfenning et al. Critical Decisions in Emergency Medicine 2011;10;2-11.
Calcium• Hypercalcemia
– Most often caused by parathyroid disease and malignancy
– “Bones, moans, groans and stones”• Arrhythmias with concomitant electrolyte
abnormalities– Primary treatment is normal saline
• Furosemide can help with associated diuresis but no longer routinely recommended
• Bisphosphonates = definitive therapy
Calcium• Hypercalcemia
– Most often caused by parathyroid disease and malignancy
– “Bones, moans, groans and stones”• Arrhythmias with concomitant electrolyte
abnormalities– Primary treatment is normal saline
• Furosemide can help with associated diuresis but no longer routinely recommended
• Bisphosphonates = definitive therapy
Calcium• Hypocalcemia
– Typically caused by hypoalbuminemia– Muscle cramping, paresthesias
• Chvostek sign• Trousseau sign
– Oral repletion for mild cases, IV for more significant deficits• Ionized calcium level more accurate than
total
Calcium• Hypocalcemia
– Typically caused by hypoalbuminemia– Muscle cramping, paresthesias
• Chvostek sign• Trousseau sign
– Oral repletion for mild cases, IV for more significant deficits• Ionized calcium level more accurate than
total
Calcium• Hypocalcemia
– Typically caused by hypoalbuminemia– Muscle cramping, paresthesias
• Chvostek sign• Trousseau sign
– Oral repletion for mild cases, IV for more significant deficits• Ionized calcium level more accurate than
total
Magenesium• Hypomagnesemia
– Typically caused by insufficient dietary intake, GI disorders, and medication effects
– Symptoms relatively non-specific– Treatment generally IV
• 0.5-2 gm/h• Watch for loss of deep tendon reflexes and
development of respiratory depression
Magenesium• Hypomagnesemia
– Typically caused by insufficient dietary intake, GI disorders, and medication effects
– Symptoms relatively non-specific– Treatment generally IV
• 0.5-2 gm/h• Watch for loss of deep tendon reflexes and
development of respiratory depression
Magenesium• Hypomagnesemia
– Typically caused by insufficient dietary intake, GI disorders, and medication effects
– Symptoms relatively non-specific– Treatment generally IV
• 0.5-2 gm/h• Watch for loss of deep tendon reflexes and
development of respiratory depression
Sodium• Hypernatremia
- Hypovolemia most common cause- Also consider diabetes insipidus
• Central (deficient production of AVP)• Nephrogenic (diminished response to AVP)
Sodium• Hypernatremia
- Hypovolemia most common cause- Also consider diabetes insipidus
• Central (deficient production of AVP)• Nephrogenic (diminished response to AVP)
Sodium• Hypernatremia
- Hypovolemic: replace free water deficit• TBW = 0.6 x current weight (kg)• Desired TBW = measured Na x current
TBW / normal Na• Body water deficit = desired TBW – current
TBW- Diabetes insipidus
• Central: DDAVP• Nephrogenic: thiazide diuretic
Sodium• Hypernatremia
- Hypovolemic: replace free water deficit• TBW = 0.6 x current weight (kg)• Desired TBW = measured Na x current
TBW / normal Na• Body water deficit = desired TBW – current
TBW- Diabetes insipidus
• Central: DDAVP• Nephrogenic: thiazide diuretic
Hyponatremia• Most common electrolyte
abonormality• Classified by volume status
– Hypovolemic hyponatremia• Decrease in total body water with greater
decrease in total body sodium– Euvolemic hyponatremia
• Normal body sodium with increase in total body water
– Hypervolemic hyponatremia• Increase in total body sodium with greater
increase in total body water
Hyponatremia• Most common electrolyte
abonormality• Classified by volume status
– Hypovolemic hyponatremia• Decrease in total body water with greater
decrease in total body sodium– Euvolemic hyponatremia
• Normal body sodium with increase in total body water
– Hypervolemic hyponatremia• Increase in total body sodium with greater
increase in total body water
Hyponatremia• Most common electrolyte
abonormality• Classified by volume status
– Hypovolemic hyponatremia• Decrease in total body water with greater
decrease in total body sodium– Euvolemic hyponatremia
• Normal body sodium with increase in total body water
– Hypervolemic hyponatremia• Increase in total body sodium with greater
increase in total body water
Hyponatremia• Most common electrolyte
abonormality• Classified by volume status
– Hypovolemic hyponatremia• Decrease in total body water with greater
decrease in total body sodium– Euvolemic hyponatremia
• Normal body sodium with increase in total body water
– Hypervolemic hyponatremia• Increase in total body sodium with greater
increase in total body water
Hyponatremia• Most common electrolyte
abonormality• Classified by volume status
– Hypovolemic hyponatremia• Decrease in total body water with greater
decrease in total body sodium– Euvolemic hyponatremia
• Normal body sodium with increase in total body water
– Hypervolemic hyponatremia• Increase in total body sodium with greater
increase in total body water
Hyponatremia• Critical diagnostic tests
– Urine osmolality– Serum osmolality– Urine sodium concentration
Hyponatremia• Subclassified by effective serum
osmolality– Hypertonic
• Pseudohypernatremia– Isotonic
• High protein or lipid concentration– Hypotonic
• < 280 mOsm/kg
Hyponatremia• Subclassified by effective serum
osmolality– Hypertonic
• Pseudohypernatremia– Isotonic
• High protein or lipid concentration– Hypotonic
• < 280 mOsm/kg
Hyponatremia• Subclassified by effective serum
osmolality– Hypertonic
• Pseudohypernatremia– Isotonic
• High protein or lipid concentration– Hypotonic
• < 280 mOsm/kg
Hyponatremia• Subclassified by effective serum
osmolality– Hypertonic
• Pseudohypernatremia– Isotonic
• High protein or lipid concentration– Hypotonic
• < 280 mOsm/kg
Hypotonic Hyponatremia• Hypovolemic
– Caused by GI loss, renal loss , or 3rd spacing• Non-renal: urine sodium < 20 mEq/L• Renal: urine sodium > 20 mEq/L
– Treat with IV normal saline
Hypotonic Hyponatremia• Hypovolemic
– Caused by GI loss, renal loss , or 3rd spacing• Non-renal: urine sodium < 20 mEq/L• Renal: urine sodium > 20 mEq/L
– Treat with IV normal saline
Hypotonic Hyponatremia• Isovolemic
– Glucocorticoid insufficiency– Hypothyroidism– Psychogenic polydipsia– Medications
• Amitriptyline, carbamazepine– Diuretic use with potassium depletion– SIADH
• Urine sodium > 20 mEq/L• Urine osmolality > 200 mOsm/kg
Hypotonic Hyponatremia• Hypervolemic
– Heart failure– Liver disease– CKD– Nephrotic syndrome
Hypotonic Hyponatremia• Treatment considerations
– Acute vs. chronic– Degree of sodium depletion
• Mild: 130-134 mEq/L• Moderate: 120-130 mEq/L• Severe: < 120 mEq/L
– Symptoms• Neurologic
– Underlying cause
Hypotonic Hyponatremia• Treatment considerations
– Acute vs. chronic– Degree of sodium depletion
• Mild: 130-134 mEq/L• Moderate: 120-130 mEq/L• Severe: < 120 mEq/L
– Symptoms• Neurologic
– Underlying cause
Hypotonic Hyponatremia• Treatment considerations
– Acute vs. chronic– Degree of sodium depletion
• Mild: 130-134 mEq/L• Moderate: 120-130 mEq/L• Severe: < 120 mEq/L
– Symptoms• Neurologic
– Underlying cause
Hypotonic Hyponatremia• Treatment considerations
– Acute vs. chronic– Degree of sodium depletion
• Mild: 130-134 mEq/L• Moderate: 120-130 mEq/L• Severe: < 120 mEq/L
– Symptoms• Neurologic
– Underlying cause
Hyponatremia and HF
Gheorghiade et al. Eur Heart J 2007;28:980-88.
45.0
40.0
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
(Day
s) o
r (%
)
6.4 5.5 6.03.2
12.4
7.1
42.5
34.8
P < .0001
Na < 135 mEq/LNa ≥ 135 mEq/L
Length of In-hospital Post-discharge Death or stay (days) mortality (%) mortality (%) rehospitalization
since discharge (%)
Vasopressin
Non-osmotic stimulation of AVP secretion
H20 retention Intravascular volume
Dilutional hyponatremia
Sympathetic activity
Vasoconstriction
Fibrosis Myocardial &
vascular hypertrophy
Aortic/ carotid sinus baroreceptors stimulation
Goldsmith and Gheorghiade JACC 2005;46:1785-91
Vasopressin Mediated
Maisel et al. Circ Heart Fail. 2011;4:613-20.
Hypotonic Hyponatremia• Treatment options
– Hypertonic saline (3% soln)• Reserved for acute, severe cases• Bolus 100 mL over 10 min q 1 hr x 2 doses• Infusion of 1-2 mL/kg/hr• Target correction: 0.5 mEq/L/hr
– Fluid restriction– Medication withdrawal– Diuresis– Democlocycline
Central Pontine Myelinolysis
Hypotonic Hyponatremia• Treatment options
– Hypertonic saline (3% soln)• Reserved for acute, severe cases• Bolus 100 mL over 10 min q 1 hr x 2 doses• Infusion of 1-2 mL/kg/hr• Target correction: 0.5 mEq/L/hr
– Fluid restriction– Medication withdrawal– Diuresis– Democlocycline
Vasopressin Antagonists• Conivaptan
– Dual V1/V2 receptor antagonist• Tolvaptan
– V2 receptor antagonist >>V1• Lixivaptan
– V2 receptor antagonist >>>V1
Cassagnol et al. J Pharm Practice 2011;24:391-9.
Cassagnol et al. J Pharm Practice 2011;24:391-9.
Improves Sodium But…
Konstam et al. JAMA 2007; 297:1319-31.
No Effect On “Outcomes”
Konstam et al. JAMA 2007; 297:1319-31.
Elhassan and Schrier. Expert Opin. Investig. Drugs 2011;20:373-80.
Final Thoughts• Obtain ECGs early with suspected or
confirmed electrolyte abnormalities– Irritable cardiomyocytes need attention
• Little has changed in therapeutic approach for most – Think normal saline for hyper-anything– Deficiencies tend to comingle
• Don’t ignore those low sodiums!– Especially in HF…