electrolyte inbalance

8/8/2019 Electrolyte Inbalance

1/34

ELECTROLYTE INBALANCE

Patria Adri Wibhawa

Clinical Rotation Student

Internal Medicine Medical School of

Christian university of Indonesia, jakarta


2/34

HYPONATREMIA

Defined as an abnormally low serum sodium

concentration (135 mEq/L)


3/34

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


4/34

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


5/34

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


6/34

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


7/34

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).


8/34

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


9/34

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


10/34

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


11/34

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


12/34

Hypokalemia

Definition

As an abnormality low serum potassium

concentration (3,5 mEq/L)


13/34

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


14/34

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


15/34

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)


16/34

3. Disorder with increased aldosteron without

hypertension

(Salt losing nephropathy, juxtaglomerular

hyperplasia)

4. Disorder with normal or decreased aldosteron

and hypertension ( Cushing syndrom )


17/34

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


18/34

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


19/34

III. In patient with both metabolic alcalosis and

pottasium wasting, volume depletion may

cause the abnormal state to persist.


20/34

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+)


21/34

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


22/34

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


23/34

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.


24/34

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)


25/34

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


26/34

IV. Renal disease

A. Renal tubular dysfunction

B. Acute tubular necrosisC. Chronic renal failure

V. Rickets and osteomalasia

VI. Pseudohyparathyroidism, types I and II


27/34

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


28/34

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.


29/34

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


30/34

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)


31/34

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


32/34

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


33/34

Diagnostic Approach Hypocalcemia

Initial Investigation

The most common


34/34

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

electrolyte inbalance

Documents