electrolyte inbalance
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ELECTROLYTE INBALANCE
Patria Adri Wibhawa
Clinical Rotation Student
Internal Medicine Medical School of
Christian university of Indonesia, jakarta
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HYPONATREMIA
Defined as an abnormally low serum sodium
concentration (135 mEq/L)
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Etiology and classification
I. Pseudohyponatremia
A. Hyperlipidemia High lipid serum and normalosmolality
B. Hyperglicemia Finding hyponatremia andhyperglicemia with normal or elevated serumosmolality
II. Hyponatremia with increased body total sodium
This is a state in which an excess of total bodysodium and an event greater excess of total bodywater Edema, ascites or both. Serum osmolality islow CHF, Cirrhosis hepatic, SN
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III. Hyponatremia with decreased total body
sodium
Condition associated with both sodium and
water depletion are characterized by the
abcense of edema or ascites Symptom and
sign tachycardia, decreased sentral venous
pressure, a high hematocrite elevated serumtotal protein may be present
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A. Decreased Urin sodium concentration (10mEq/L), Ussualy associated with :
a. Decreased chloride concentration
1. GI losses- Vomiting or nasogatric suction or both
- Diarrhea
2. Exessive respiration with replacement of waterbut not of the sodium losses
3. Volume depletion without replacemennt of lossfluid and electrolyte after diuretic therapy
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B. Increaesd urin sodium concentration (10
mEq/L)
Causes include adenocortical insufficiency and
salt losing nephropathy
4. Hyponatremia with normal Total body sodium
The disorders include in this category are not
associated with edema or volume depletionA. Hypothyroidism or glucocorticoid deficiency may be
associated with euvolemic hyponatremia
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B. SIADH
This condition may be idiopathic or may associated
with one of the following disorder, diseases of the
central nervous system (Stroke, meningitis),Pulmonary diseases ( TBC, pneumonia), drugs
(Chlorpropamide, narcotics, barbiturates, vincristine,
antidepressants and clofibrate).
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1.Criteria for diagnosis :
a. Hypotonicity of the body fluids
b. Urin osmolality greater than 100 mOsm/kg of water
c. Normal renal, adrenal, and thyroid functiond. Increased urinary excretion of sodium (30mEq/L)
e. Elevated serum concentration of ADH
f. Reversal of the syndrome by adequate fluid restriction
2. CommentWhen a steady state is reached, some of the
abnormality described may not be present
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Diagnostic approach
Once the diagnosis of hyponatremia is made,
the serum sodium lever should be rhececked
and the serumm osmolality determined
1. If the serum osmolality is normal or high in
the presence of confirm hyponatremia, the
possibility of hyperlipidemia or hyperglicemia,
or both should be investigated
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2. If the serum osmolality is low, confirming the diagnosis oftrue hyponatremia, The satus of the extracelluler fluidvolume should be assesed.
A. The presence of edema, ascites, rales, and S3 gallop, or
increaed jugular venous pressure indicate an excess oftotal body sodium.
B. Postural pulse and BP changes, decreased skin turgor, drymucous membranes or decreased JVP indicate decreased
total body sodiumC. In the absence of signs of either increased or decreased
total body sodium TSH and cortisol should be checkedbefore entertaining the diagnose of SIADH
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Therapeutics
A. Total Body Water ( Hypovolemia)
1. If Volume depleted, use NaCL 0,9 % (154 mEq/L)
2. Calculate sodium deficit :
- Target sodium = 125-135 mEq/L (130 mEq/L)
- Sodium deficite = 0,6 x weght in Kg ( desired Na actualNa)
- Correct at a rate not > 0,5 mEq/L/hours
Give the patient 50% of calculated amount of sodium inthe first 8 hours and the other 50% in the next 16 hours
- Use normal saline, do not give hypotonic fluids untilserum sodium is more than 125 mg/L
3. Correct potassium deficit also
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Hypokalemia
Definition
As an abnormality low serum potassium
concentration (3,5 mEq/L)
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Etiology
I. Non renal causes
A. Decreased pottasium intake
B. GI Losses of pottasium
1. Associated with alcalosis and volume depletiona. Gastric suctioning and vomiting
b. Chronic laxative abuse ( maybe associated with
acidosis or normal PH as well)
2. Associated with acidosis
a. Diarrheal states ( including villous adenoma or
Zollinger-Ellison)
b. Ureterosigmoidostomy
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II. Renal causes
A. Pottasium wasting associated with metabolic
acidosis
1. Renal tubular acidosis
2. Postobstructive uropathy
3. Diuretic phase of acute tubular necrosis4. Chronic pyelonephritis
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B. Pottasium wasting associated with metabnolic
akalosis
1. Diuretic therapy ( Furosemide, ethacrynic acid,
thiazides)
2. Disorder with increased aldosteron secretion and
hipertension ( Primary aldosteronism, renovascular
hypertension, essensial hypertension with vomitingand diarrhea, diuretic therapy, oral contraception,
steroid therapy)
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3. Disorder with increased aldosteron without
hypertension
(Salt losing nephropathy, juxtaglomerular
hyperplasia)
4. Disorder with normal or decreased aldosteron
and hypertension ( Cushing syndrom )
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Symptom and sign
1. Most symptom are non specific
anorexia, nausea, vomiting, abdominal
distension, ileus, weakness, decreased deep
reflexes, and depressed sensorium.
2. The ECG finding include lowering, flattening,
notching, or inversion of the T wave, prominent
U, depression of the S-T segment and arrhytmia.3. Nephrogenic diabetes insipidus, rhabdomyolysis,
and aggravation of hepatic coma may also occur
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Diagnosis approach
I. Patient with hypokalemia require a through
investigation to determine whether the pottasium loss
is the result of renal or extra renal mechanism.
II. Renal origin 24 hours urinary excretion of
Pottasium should be measured while the patient is on
a reguler salt intake
20 mEq/24 hours especially 60 mEq/24 hoursSuggestive of renal pottasium wasting
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III. In patient with both metabolic alcalosis and
pottasium wasting, volume depletion may
cause the abnormal state to persist.
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Therapy
1. Oral ruoteOral pottasium should be given
preferably asdiluted liquid with or after meals or as
tablet, which must be swallowed and not allowed
to
dissolve in the mouth.
Oral Kalium 0,75 gm (10mEq) 2-3 days
Oral KCL solution 15-30 cc
(1gm KCL = 14 mEq k+)
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2. Intravenous route
Max : 10-20 mEq/Hours.
Higher rate of infusion may be administered ifthe clinical situation warrants a more rapid
correction of the hypocalemia.
20-40 mEq in 1 L of saline or dextrose
solution
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Hypocalsemia
Definition
Hypocalsemia exists when the total serumcalcium value is less than 8,5 mg/100mL.
Approximately 50% of calcium in blood is boundmainly to albumin and globulins
The ionized calcium concentration is 5 mg/dL
and this fraction is biologically active Concurrent measurement of albumin is
indicated in order to show total serum calcium
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ETIOLOGY
The most common cause of hypocalcemia is
surgically induced hypoparathyroidism.
Therefore, if a thyroidectomy scar is present,
the diagnosis is usually obvious.
A history of antecedent illness, past GI
surgery, or known underlying renal disease
may elucidate the cause in other case.
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I. Hypoparathyroidism
A. Surgically induced, partial or complete
Most common
B. Idopathic
C. Transient hypoparathyridism of infancy
(newborn) Usually partial
D. Bioinactive parathyroid hormon (PTH)
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II. Reduction in serum albumin
A. Malabsorption states
B. Short bowel syndromeC. Chronic liver disease and liver failure
D. Nephrotic syndrom
E. Malnutrition III. Pancreatitis
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IV. Renal disease
A. Renal tubular dysfunction
B. Acute tubular necrosisC. Chronic renal failure
V. Rickets and osteomalasia
VI. Pseudohyparathyroidism, types I and II
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VII. Hypoparathyroidism in association withother disease states, which may be familial
A. Addisons disease
B. Pernicious anemiaC. Candidiasis
VIII. Medullary carcinoma of the thyroid,
sporadic, familial, or in men IX. Hyperphosphatemia
X. Other vitamin D-related disorders
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Symptoms
Usually occur when the total serum calcium
value is below 7,5 mg/ 100mL, but they
sometimes occur at higher levels when there
has been a rapid decrease in the serumcalcium concentration.
The symptomps are generally those of
neuromuscular irritability.
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Symptoms
I. Numbness and tingling of the face, hand, andfeet
II. Muscle cramps in the arms, hands, abdomen,legs and feet
III. Increased number of stools or diarrhea
IV. Headaches, usually frontal, irritability, anxiety
V. Difficulty in breathing, particularly noisy
breathing during exercise or sleepVI. Seizures, which are common, in infants this maybe the only complaint
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VII. Decreased vision
VIII. Nail growth abnormalities and infections,delay in cutting teeth
IX. Dry skin, often infectedX. Weight problem
A. Weight loss in association with chronicsystemic disease
B. difficulity in losing weight inpseudohypoparathyroidism
XI. Bone growth abnormalities or pain (rickets
and osteomalacia)
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Sign
Sign of neuromuscular irritability occur mostoften.
The following findings may be noted on physical
examination:1. Thyroidectomy scar
2. Dry skin
3. Abormal or infected nails
4. Cataracts
5. Chovsteks sign
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6. Trousseaus sign
7. Crowing noises during sleep
8. Seizure disordermay be the finding in infants
9. Hypotension10. Bone pain or bone abnormalities, including
abnormal growth, bowing and brachydactylia
11. Goiter if present may suggest medullarycarcinoma of the thyroid, chronic thyroiditis orgraves disease
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Diagnostic Approach Hypocalcemia
Initial Investigation
The most common
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THERAPY
Medication : Is to correct the deficiencys with
IV calcium ( Ca.Gluconas/ Chloride 10%) or
peroral (Ca.Gluconas/Carbonate); Can give
with vit D in a higher dose
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