ELECTROLYTE DISORDERS

CRISBERT I.
CUALTEROS, MD
http://crisbertcualtero
s.page.tl
HYPONATREMIA

 Plasma concentration < 135 meq/L

Generation of Hyponatremia

 Plasma Na = Na + K/ TBW
Sign and Symptoms

 Lethargy, Apathy
 Disorientation
 Muscle cramps
 Anorexia
 Nausea
 Agitation
Sign and Symptoms

 Abnormal sensorium
 Depressed deep tendon reflexes
 Cheyne-Stokes respiration
 Hypothermia
 Seizures
Diagnostic Approach

Hyponatremia

Na and Water Deficit Water Excess Na and Water Excess

Hypovolemia Euvolemia Hypervolemia

Diagnostic Approach

Hyponatremia

Hypovolemia Euvolemia Hypervolemia

Extrarenal Losses
Renal Losses
Vomiting
Diuretic excess
Diarrhea
Mineralcorticoid Deficiency
Burn
Salt losing nephritis
Pancreatitis
RTA
Peritonitis

Urine Na >20 Urine Na<10

Diagnostic Approach

Hyponatremia

Hypovolemia Euvolemia Hypervolemia

Glucocorticoid Deficiency
Hypothyroidism
Pain
Emotional Stress
Drugs
SIADH

Urine Na >20
Diagnostic Approach

Hyponatremia

Hypovolemia Euvolemia Hypervolemia

Nephrotic Syndrome
ARF
Cardiac Failure
CRF
Cirrhosis

Urine Na <10 Urine Na >20

Treatment

 Na deficit = 0.5 x wt (kg) x (D Na – A Na )

 Calculation of Desired Negative Water

Balance
 TBW = Wt (kg) x 0.6
Actual plasma Na x TBW
Desired plasma Na
TBW-Desired TBW = fluid to be removed
Rate of Correction

 First 24 hours = 10 -12 mEq/day

 Seizure and Neurologic symptoms

1.5 – 2 mEq/L/h for 3 to 4 hours
Central Demyelinating Lesion

 Paraparesis
 Quadriparesis
 Dysarthria
 Dysphagia
 Coma
Risk Factor for Demyelination

 More than 25 mEq/L elevation of Na within

the first 48 hours

 Overcorrection of plasma Na above 140

mEq/L
HYPERNATREMIA

 Plasma Na > 150 mEq/L

Generation of Hypernatremia

 Plasma Na = Na + K/TBW
Sign and Symptoms

 Lethargy
 Weakness
 Irritability
 Twitching
 Seizures
 Coma
 Death
Diagnostic Approach

Hypernatremia

Na and H2O Deficits H2O losses Na Addition Excess

Hypovolemia Euvolemia Hypervolemia

Diagnostic Approach

Hypernatremia

Hypovolemia Euvolemia Hypervolemia

Extrarenal Losses
Renal losses
Sweating
Osmotic and loop diuretics
Burns
Post obstruction
Diarrhea

Urine Na >20 Urine Na <10

Diagnostic Approach

Hypernatremia

Hypovolemia Euvolemia Hypervolemia

Renal Losses Extrarenal Losses

Nephrogenic DI Respiratory and Dermal
Central DI Incensible Losses

Urine Na = Variable Urine Na = Variable

 Hypernatremia

Hypovolemia Euvolemia Hypervolemia

Primary Hyperaldoteronism
Cushing’s Syndrome
Hypertonic Dialysis
Hypertonic NaHCO3
NaCl tablets

Urine Na >20 mEq/L

Treatment

 Correction of ECF Volume Depletion

– Isotonic Saline Until the ECF volume is achieved
– Followed by Hypotonic NaCl or 5% glucose
solution
Treatment

 Correction of ECF Volume Expansion

– Diuretics or Dialysis
Water Replacement

 Computation

TBW = Wt (Kg) x 0.6

Actual plasma Na x TBW

Desired plasma Na
HYPOKALEMIA

 Plasma K < 3.0 mEq/L

Sign and Symptoms

 Cardiac
– Atrial and ventricular ectopic beats
– Abnormal EKG
 Flat T mave
 Prominent U wave
Sign and Symptoms

 Neuromuscular
– Constipation, Ileus
– Weakness, paralysis
– Respiratory paralysis
– Rhabdomyolysis
Sign and Symptoms

 Renal
– Impaired concentrating ability (polyuria,
polydipsia)
– Increase renal NH3 production
– Impaired urinary acidification
– Metabolic alkalosis
Causes

 Hypokalemia due to Redistribution

– Alkalosis
– Insulin excess
– Beta-adrenergic agonist
– Hypokalemic periodic paralysis
Causes

 Extrarenal Loss
– Diarrhea
– GI fistula
– Laxative abuse
– Profuse sweating
Causes

 Renal Loss
– Hypertensive Disorder
 Malignant hypertension
 Renovascular hypertension
 Renal secreting tumors
 Primary Aldosteronism
 Cushing’s Syndrome
 Congenital adrenal hyperplasia
Causes

 Renal Loss
– Normotensive
 RTA
 Vomiting
 Diuretics
 Mg depletion
 Barter’s syndrome
 Gittleman’s syndrome
Diagnostic Approach

Hypokalemia

Extrarenal Renal loss

Redistribution
U K <20 U K >20

Metabolic acidosis
Laxative abuse
Diarrhea Normal Acid-Base
Gastric fistula
GI fistulas Profuse sweating
Previous vomiting
Laxative abuse
Diagnostic Approach

Hypokalemia

Extrarenal Loss Renal Loss

Redistribution
U K <20 U K >20

Hypertensive

High Plasma Renin Low Plasma Renin

Malignant HPN Primary Aldosteronism

Renovascular HPN Cushing’s Syndrome
Renin secreting tumors Adrenal hyperplasia
Diagnostic Approach

Hypokalemia

Extrarenal Loss Renal Loss

Redistribution
U K <20 U K >20

Normotensive

Metabolic Alkalosis

U Cl >10

U Cl <10 Diuretics
Vomiting Mg Depletion
Barter syndrome
Gittleman syndrome
Diagnostic Approach

Hypokalemia

Extrarenal Loss Renal Loss

Redistribution
U K <20 U K >20

Normotensive

Metabolic acidosis

Normal Anion Gap Increase Anion Gap

Diabetic Ketoacidosis
RTA Ethylene Glycol
Treatment

 Potassium Deficit
– 4.0 to 3.0 mEq/L = loss of 200 to 400 mEq/L
– 3.0 to 2.0 mEq/L = additional 200 to 400 mEq/L
loss
Treatment

 Rate of Repletion
– 3.0 – 3.5 mEq/L = oral KCL 60-80 mEq/day
– <2.5 mEq/L = 10-20 mEq/hour IV
HYPERKALEMIA

 Plasma K > 5.0 mEq/L

Etiology of Hyperkalemia

 Movement from cells to ECF

– Metabolic acidosis
– Insulin deficiency and hyperosmolarity (DM)
– Tissue catabolism
– B adrenergic blockade
– Severe exercise
– Digitalis overdose
– Periodic paralysis – hyperkalemic form
Etiology of Hyperkalemia

 Decrease Urinary Excretion

– Renal failure
– Effective circulating volume depletion
– RTA – hyperkalemic form
– Hypoaldosteronism
Etiology of Hyperkalemia

 Hypoaldosteronism
– NSAID
– Converting enzyme inhibitors
– Cyclosporine
– K sparing diuretics
– Primary adrenal insufficiency
Sign and Symptoms

 Cardiac
– 5.0 – 6.5 = peak T wave
– 6.5 – 8.0= flattening of P wave, prolongation of
PR interval, widening of QRS complex
– >8.0 = sine wave pattern, V fibrillation or cardiac
arrest
Treatment

 Antagonism of Membrane
– Calcium gluconate = 10 – 20 ml
 Peak effect = 5 minutes
Treatment

 Increase K entry into the cells

 Glucose–Insulin solution ( 10 u in 50 ml
D50W)
 Sodium Bicarbonate
 B adrenergic agonist
Treatment

 Removal of Excess K
– Diuretics
– Cation exchange resin
– Hemodialysis or Peritoneal Dialysis