ELECTROLYTES MAED PATHWAY by JVRosano, OD MACT RN

Electrolytes

Substance responsible for:

Blood volume regulation Nerve impulse transmission Muscle contractility, bone and teeth formation Acid and base balance, buffer system Plasma osmolality Energy storage and nutrients metabolism
2

Key Points!

Major source: food intake, SUPPLEMENTS Excretion: kidneys, GIT, sweat, Imbalance is usually associated with diseases:
DM, DI, SIADH, BURNS, CRF, CHF, DIARRHEA, CUSHINGS, ADDISONS, ACIDOSIS DRUGS: laxatives, diuretics

FOUND in the water compartment

3

Electrolyte Imbalance

Electrolyte Imbalance

Types of Ions

CATIONS OR POSITIVE CHARGE 1. Na 2. K 3. Ca 4. Mg 5. H

ANIONS OR NEGATIVE CHARGE 1. Cl 2. PO4 3. HCO3

Sodium

Positively charged ion (cation) MAJOR EXTRACELLULAR CATION Maintains plasma osmolality Important for nerve impulse transmission Normal value: 135-145 meq/L RDA: 0.5 2.7gm/day up to 6 gm/day Source: cooked foods, canned foods, cheese, ketchup Regulated by Aldosterone

Hypernatremia

Cause: hyperaldosteronism or FVD S/sx: Na=increased brain activity H2O=FVD or FVE Hypokalemia Mgt: restrict Na and H2O

Hyponatremia

Cause: hypoaldosteronism or FVE S/sx: Na=decreased brain activity H2O=FVE or FVD Hyperkalemia Mgt: restrict H2O and give Na oral and IV (NaCl)
9

Potassium

Positively charged ion (cation)

MAJOR INTRACELLULAR CATION

Inhibits cardiac excitability Normal value: 3.5-5.0 meq/L Source: banana, orange, potato or any fresh fruits and raw vegetables Mainly excreted by the kidneys

10

Hyperkalemia

Cause: RF most common, Hypoaldosteronism S/sx: Heart=bradycardia and peaked T wave GIT=diarrhea Muscle=flaccidity to weakness Mgt: kayexalate, insulin and DIALYSIS calcium gluconate to improve heart contraction
11

Hypokalemia

Cause: diuretics and laxatives or hyperaldosteronism S/sx: Heart=tachycadia and inverted T wave, U wave prominent appearance GIT=constipation Muscle=spasticity to weakness Mgt: oral, tablet and KCl IV
12

Calcium

Positively charged ion (cation) 99% are stored in the bones and teeth Aids in muscle contraction Helps in blood coagulation Normal value: 8.5-10.5 mg/dL RDA: 800 1200 mg/day Source: dairy products (milk, cheese, yogurt) BINDS with albumin Requires vitamin D for intestinal Ca absorption Regulated by parathormone

13

Vitamin D
VITAMIN D INTAKE SMALL INTESTINE BILE and FATS VITAMIN D IS ABSORBED SKIN SUNLIGHT FOR SYNTHESIS KIDNEYS ACTIVE VITAMIN D 1,25 DIHYDROXYCHOLECALCIFEROL

CALCIUM INTAKE SMALL INTESTINE VITAMIN D CALCIUM ABSORPTION 99% BONES AND TEETH 1% BLOOD

14

Parathormone
LOW SERUM CALCIUM TRIGGERS PTG PARATHORMONE EFFECTS 1. GIT CALCIUM ABSORPTION 2. KIDNEYS CALCIUM REABSORPTION PO4 EXCRETION 3. BONES OSTEOCLAST ACTIVITY SERUM CALCIUM

HIGH SERUM CALCIUM EFFECTS ARE OPPOSITE

15

Hypercalcemia

Cause: hyperparathyhroidism S/sx: deep bone pain lithiasis formation (calcium stones) HYPOPHOSPHATEMIA (low energy store) Mgt: parathyroidectomy, hydration, prevent fracture reduce Ca intake, DIALYSIS

16

Hypocalcemia

Cause: hypoparathyroidism S/sx: TETANY=tingling, Trousseau, Chvosteks and laryngeal spasm HYPERPHOSPHATEMIA (calcification) Mgt: oral, tablet and calcium gluconate IV respiratory support for laryngeal spasm

17

Phosphate

Negatively charged ion (anion) Hydrogen buffer Energy formation ATP, metabolizes nutrients 2,3 DPG diphosphoglycerate (delivers O2) Normal value: 1.8-2.6 meq/L Source: same with Calcium Regulated by Calcitonin
18

Calcitonin
LOW LEVEL OF PHOSPHATE TRIGGERS THYROID GLAND CALCITONIN EFFECTS GIT: PO4 ABSORPTION KIDNEYS: PO4 REABSORPTION CALCIUM EXCRETION
19

Magnesium

Positively charged ion (cation) Aids in nerve impulse transmission Plays a role for nutrients metabolism Normal value: 1.5-2.6 meq/L Source: chocolates, dry beans, meats, nuts, seafoods Regulated by Parathormone
20

Hypermagnesemia

Cause: RF most common S/sx: DTRs decrease decrease RR sensorium changes HYPERCALCEMIA Mgt: laxatives, diuretics, DIALYSIS
21

Hypomagnesemia

Cause: alcoholism S/sx: (inverse to brain activity) DTRs increase increase RR change in level of sensorium HYPOCALCEMIA Mgt: oral tablet of MgSO4 or parenteral
22

Comparatively
Hypomag S/sx: DTR +++, ++++ BB spastic incontinence, Decreased VC BRAIN seizures HYPOCALCEMIA Hypermag S/sx: DTR 0, + BB flaccid distention, Decreased VC BRAIN dec LOC HYPERCALCEMIA

23

Chloride

Relative to Na and H ion Acid by nature Found chiefly in the GIT High level = acidosis Low level = alkalosis Inverse to HCO3
24

Chloride Pathways
level level

metabolic acidosis
H : HCO3 blood pH acidemia CO2 expulsion RR H excretion acidic urine K, Ca, Mg move inside causing a high level of these in the blood blood vessels will dilate O2 supply to vital organs

metabolic alkalosis
HCO3 : H blood pH alkalinemia CO2 expulsion RR HCO3 excretion alkali urine K, Ca, Mg move outside causing a low level of these in the blood blood vessels will spasm O2 supply to vital organs
25

Acid Base Regulation

During Acidosis and Alkalosis Body will try to compensate Buffer System
HCO3:H2CO3 (20:1) ratio Phosphate Protein

Lungs = retention of CO2 or expulsion Kidneys = excrete or reabsorb HC03 and H ions
26

Acid Base Regulation

1. Buffer System 2. Respiratory Center 3. Kidneys

27

1. Buffer System

NaBICARBONATE-CARBONIC ACID HCO3:H2CO3 (20:1 ratio) Example: HCl + NaHCO3 H2CO3 + NaCl H2CO3 H2O + CO2 THE PHOSPHATE SYSTEM NaH2PO4 and Na2HPO4 Example: HCl + Na2HPO4 NaH2PO4 + NaCl NaOH + NaH2PO4 Na2HPO4 + H2O
28

1. Buffer System

THE PROTEIN BUFFER SYSTEM HCl + NaNH3 NH4 + NaCl THE HEMOGLOBIN SYSTEM SECOND LEVEL OF BUFFER most important buffer

29

2. Respiratory System
H ions and CO2 (blood) Stimulates the Medulla Oblongata RR Hyperventilation H ions and CO2 (blood) H ions and CO2 (blood) Stimulates the Medulla Oblongata RR Hypoventilation H ions and CO2 (blood)

30

2. Respiratory System

CO2 + H2O H2CO3 H + HCO3

31

3. Renal Regulation
H ions and HCO3 (blood) H tubular excretion HCO3 tubular excretion Acidic urine Or H tubular reabsorption HCO3 tubular reabsorption H ions and HCO3 (blood) H ions and HCO3 (blood) H tubular excretion HCO3 tubular excretion Alkali urine Or H tubular reabsorption HCO3 tubular reabsorption H ions and HCO3 (blood)

32

How to obtain blood sample?

Allens test - evaluate patency of radial and ulnar artery Heparinized syringe and container Pressure dressing, no activity at the site and check 5 ps distal to the site of punctured artery Note if patient is under O2 therapy Label the sample and send immediately to the laboratory

33

ABG Responsibilities

Arterial blood Radial or ulnar artery Allens test Prepare Heparinized (Syringe, specimen container) Note: 02 therapy, FIO2, temp Bring specimen to the LAB (ice)
34

After injection Maintain extension position, no activity 8H Apply pressure 5-15 min Observe the site Distal, 5 ps
35

5 Ps Pulselessness Pain Paresthesia Poikilothermia Pallor

36

Handling of Specimen

Expel all air bubbles immediately Do not agitate the syringe Discard frothy specimen 1:1000 U/ml HEPARIN Place sample in ice Cool sample to 5 C if it can not be analyzed quickly
37

ABG Interpretation

pH potential hydrogen or power of hydrogen

Normal value: 7.35-7.45 H ion reflection:

H=pH H=pH

Low pH indicates ACIDOSIS High pH indicates ALKALOSIS

Example:
7.33 = ACIDOSIS 7.47 = ALKALOSIS Note: pH change is dependent to CO2 and HCO3 level in the blood
38

HCO3 bicarbonate
Normal value: 22-26 meq/L By nature its alkali same Example:
20 = Metabolic Acidosis = H=pH 28 = Metabolic Alkalosis = H=pH

39

CO2 carbon dioxide

Normal value: 35-45 mm Hg By nature its acid opposite to pH and HCO3 Example:
48 = Respiratory Acidosis = H=pH 33 = Respiratory Alkalosis = H=pH

40

Pa O2
Normal value = 80-100 mmHg Below 80 is hypoxemia

70-79 mild 60-69 moderate 50-59 severe

Above 100 is hyperoxemia

FIO2 fraction of inspired oxygen

By percent above 20% Mech vent, venturi, high or low flow
41

DRILL
pH = 7.33 HCO3 = 20 PaCO2 = 40 Metabolic Acidosis pH = 7.47 HCO3 = 28 PaCO2 = 40 Metabolic Alkalosis pH = 7.33 HCO3 = 24 PaCO2 = 48 Respiratory Acidosis pH = 7.47 HCO3 = 24 PaCO2 = 32 Respiratory Alkalosis

42

DRILL
pH = 7.33 HCO3 = 20 PaCO2 = 48 Mixed Acidosis pH = 7.40 HCO3 = 28 PaCO2 = 32 Mixed Alkalosis pH = 7.33 PaCO2 = 48 HCO3 = 20 Mixed Acidosis pH = 7.40 PaCO2 = 32 HCO3 = 28 Mixed Alkalosis

43

DRILL
pH = 7.33 HCO3 = 20 PaCO2 = 32 Uncompensated Metabolic Acidosis pH = 7.47 HCO3 = 28 PaCO2 = 48 Uncompensated Metabolic Alkalosis pH = 7.33 HCO3 = 28 PaCO2 = 48 Uncompensated Respiratory Acidosis pH = 7.47 HCO3 = 20 PaCO2 = 32 Uncompensated Respiratory Alkalosis

44

DRILL
pH = 7.40 HCO3 = 18 PaCO2 = 32 Compensated Metabolic Acidosis pH = 7.35 HCO3 = 30 PaCO2 = 48 Compensated Metabolic Alkalosis pH = 7.40 HCO3 = 28 PaCO2 = 48 Compensated Respiratory Acidosis pH = 7.44 HCO3 = 20 PaCO2 = 32 Compensated Respiratory Alkalosis

45

comparatively

pH = 7.33 HCO3 = 20 PaCO2 = 32 Uncompensated Metabolic Acidosis

pH = 7.35 HCO3 = 30 PaCO2 = 48 Compensated Metabolic Alkalosis
46

DRILL
pH = 7.40 HCO3 = 18 PaCO2 = 32 Fully Compensated Metabolic Acidosis pH = 7.35 HCO3 = 30 PaCO2 = 48 Partially Compensated Metabolic Alkalosis pH = 7.40 HCO3 = 28 PaCO2 = 48 Fully Compensated Respiratory Acidosis pH = 7.44 HCO3 = 20 PaCO2 = 32 Partially Compensated Respiratory Alkalosis

47

pH = 7.45 HCO3 = 23 PaCO2 = 34 Simple Respiratory Alkalosis

48

pH = 7.34 HCO3 = 21 PaCO2 = 43 Metabolic Acidosis

49

pH = 7.48 HCO3 = 27 PaCO2 = 34 Mixed Alkalosis

50

pH = 7.32 HCO3 = 29 PaCO2 = 48 Uncompensated Respiratory Acidosis

51

pH = 7.33 HCO3 = 29 PaCO2 = 48 Pa O2 = 65 Uncompensated Respiratory Acidosis With Moderate Hypoxemia

52

pH = 7.48 HCO3 = 28 PaCO2 = 48 Pa O2 = 50 Uncompensated Metabolic Alkalosis With Severe Hypoxemia

53

tnk u po!
54