ELECTROLYTE ELECTROLYTE ABNORMALITIESABNORMALITIES

BY: Anthony M. Letizio D.O.BY: Anthony M. Letizio D.O.

HyponatremiaHyponatremiaDefn: plasma sodium concentrationDefn: plasma sodium concentration

less than 134mEq/L.less than 134mEq/L.

Clinical Manifestations: vary with the degree Clinical Manifestations: vary with the degree of hyponatremia, and the rapidity of onset. of hyponatremia, and the rapidity of onset. Moderate or gradual onset causes Moderate or gradual onset causes confusion, muscle cramps, lethary, confusion, muscle cramps, lethary, anorexia, and nausea. Severe or rapid anorexia, and nausea. Severe or rapid onset can cause seizures and/or coma.onset can cause seizures and/or coma.

Etiology and ClassificationsEtiology and Classifications

Hypotonic HyponatremiaHypotonic Hyponatremia

1) Euvolemic – SIADH, water intoxication, 1) Euvolemic – SIADH, water intoxication, renal failure, glucocorticoid deficiency, renal failure, glucocorticoid deficiency, hypothryoidism, thiazide diuretics, NSAIDs, hypothryoidism, thiazide diuretics, NSAIDs, carbamazepine, amitriptyline, thioridazine, carbamazepine, amitriptyline, thioridazine, vincristine, cyclophosphamide, colchicine, vincristine, cyclophosphamide, colchicine, tolbutamide, chlorpropamide, Ace tolbutamide, chlorpropamide, Ace inhibitors, clofibrate, oxytocin, SSRI’s, and inhibitors, clofibrate, oxytocin, SSRI’s, and amiodarone.amiodarone.

Hypotonic HyponatremiaHypotonic Hyponatremia

2) Hypovolemic – Renal Losses 2) Hypovolemic – Renal Losses (diuretics, partial urinary tract (diuretics, partial urinary tract obstruction, salt-losing renal obstruction, salt-losing renal disease), Extrarenal losses: disease), Extrarenal losses: gastrointestinal (vomiting, diarrhea), gastrointestinal (vomiting, diarrhea), extensive burns, third spacing extensive burns, third spacing (peritonitis, pancreatitis, ileus), and (peritonitis, pancreatitis, ileus), and adrenal insufficiency.adrenal insufficiency.

Hypotonic HyponatremiaHypotonic Hyponatremia

3) Hypervolemic – CHF, nephrotic 3) Hypervolemic – CHF, nephrotic syndrome, cirrhosis, and pregnancysyndrome, cirrhosis, and pregnancy

Isotonic Hyponatremia (normal Isotonic Hyponatremia (normal serum osmolality)serum osmolality)

1) Pseudohyponatremia (increased 1) Pseudohyponatremia (increased serum lipids and serum proteins).serum lipids and serum proteins).

2) Isotonic infusion (glucose, 2) Isotonic infusion (glucose, mannitol).mannitol).

Hypertonic HyponatremiaHypertonic Hyponatremia

1) Hyperglycemia - each 100 mg/dL 1) Hyperglycemia - each 100 mg/dL increment in blood sugar level above increment in blood sugar level above normal decreases plasma sodium normal decreases plasma sodium concentration by 1.6 mEq/L.concentration by 1.6 mEq/L.

2) Hypertonic infusions – (glucose, 2) Hypertonic infusions – (glucose, mannitol)mannitol)

Diagnostic ApproachDiagnostic ApproachUseful lab tests: serum electrolytes, Useful lab tests: serum electrolytes, glucose, BUN, creatinine, urine sodium, glucose, BUN, creatinine, urine sodium, serum and urine osmolality, uric acid, and serum and urine osmolality, uric acid, and TSH.TSH.Urine sodium determines the source. It Urine sodium determines the source. It will be low in patients with GI losses or will be low in patients with GI losses or third spacing. It will be high in patients third spacing. It will be high in patients taking diuretics. Pseudohyponatremia taking diuretics. Pseudohyponatremia should be suspected when the measured should be suspected when the measured and the calculated osmolarities are and the calculated osmolarities are mismatchedmismatched

TreatmentTreatmentEuvolemic – SIADH fluid restriction unless Euvolemic – SIADH fluid restriction unless acutely symptomatic which you can give acutely symptomatic which you can give hypertonic saline infusions.hypertonic saline infusions.

The serum sodium concentration should The serum sodium concentration should be corrected only halfway to normal in the be corrected only halfway to normal in the initial 24 hours, but not faster than 1 initial 24 hours, but not faster than 1 mEq/hr to prevent cerebral edema, mEq/hr to prevent cerebral edema, myelinolysis, and seizures.myelinolysis, and seizures.

TreatmentTreatment

Hypovolemic – give normal saline Hypovolemic – give normal saline infusioninfusion

Hypervolemic – strict fliud and Hypervolemic – strict fliud and sodium restiction.sodium restiction.

HypernatremiaHypernatremia

Defn: Plasma sodium concentration Defn: Plasma sodium concentration greater than 144 mEq/L.greater than 144 mEq/L.

Clinical Manifestations: Vary with Clinical Manifestations: Vary with degree of hypernatremia and rapidity degree of hypernatremia and rapidity of onset: they range from confusion of onset: they range from confusion and lethargy to seizures and coma.and lethargy to seizures and coma.

Isovolemic HypernatremiaIsovolemic Hypernatremia

(decreased total body water, normal (decreased total body water, normal total body sodium, and extracellular total body sodium, and extracellular fluid.fluid.

Causes include diabetes insipidus Causes include diabetes insipidus both neurogenic and nephrogenic, both neurogenic and nephrogenic, and skin loss (hyperhemia), and skin loss (hyperhemia), iatrogenic, reset osmostatiatrogenic, reset osmostat

Hypervolemic HypernatremiaHypervolemic Hypernatremia

(increased total body water, (increased total body water, markedly increased total body markedly increased total body sodium and extracellular fluid)sodium and extracellular fluid)

Causes include iatrogenic Causes include iatrogenic (administration of hypernatremic (administration of hypernatremic solutions), mineralocorticoid excess solutions), mineralocorticoid excess (Conn’s syndrome, Cushing’s (Conn’s syndrome, Cushing’s syndrome) and salt ingestion syndrome) and salt ingestion

Hypovolemic HypernatremiaHypovolemic Hypernatremia

Loss of water and sodium. (water Loss of water and sodium. (water loss is greater than sodium loss)loss is greater than sodium loss)

Causes include renal losses (diuretics Causes include renal losses (diuretics and glycosuria), Gastrointestinal, and glycosuria), Gastrointestinal, respiratory, skin losses, inadequate respiratory, skin losses, inadequate access to water in the disabled or access to water in the disabled or elderly, and adrenal deficiencies.elderly, and adrenal deficiencies.

TreatmentTreatment

Isovolemic – Replace fliud with Isovolemic – Replace fliud with dextrose in water D5W. Correct half dextrose in water D5W. Correct half of the estimated water deficit in the of the estimated water deficit in the first 24 hours. The correction rate first 24 hours. The correction rate should not exceed 1 mEq/L/hr in should not exceed 1 mEq/L/hr in acute cases, and 0.5mEq/L/hr in acute cases, and 0.5mEq/L/hr in chronic cases.chronic cases.

TreatmentTreatment

Hypovolemic – Replace fluid with Hypovolemic – Replace fluid with isotonic saline initially until it is felt isotonic saline initially until it is felt that the person is becomes that the person is becomes euvolemic. This often occurs before euvolemic. This often occurs before the sodium concentration is the sodium concentration is completely corrected. Then switch to completely corrected. Then switch to ½ normal saline or D5W. The rate of ½ normal saline or D5W. The rate of correction should not exceed 2 correction should not exceed 2 mEq/kg/hrmEq/kg/hr

TreatmentTreatment

Hypervolemic – Replace fluid with Hypervolemic – Replace fluid with D5W after loop diuretics are used to D5W after loop diuretics are used to increase excretion of sodium. increase excretion of sodium. Recommended to monitor Recommended to monitor electrolytes q8-12 hours during this. electrolytes q8-12 hours during this.

HypokalemiaHypokalemia

Defn: plasma potassium Defn: plasma potassium concentration less than 3.3 mEq/Lconcentration less than 3.3 mEq/L

Clinical Manifestations: Mild muscle Clinical Manifestations: Mild muscle weakness to overt paralysis weakness to overt paralysis (including respiratory paralysis), and (including respiratory paralysis), and rhabdomyolysis. Atrial and rhabdomyolysis. Atrial and ventricular arrhythmias may develop ventricular arrhythmias may develop and ECG changes.and ECG changes.

HypokalemiaHypokalemia

Mild causes flattening of T waves, ST-Mild causes flattening of T waves, ST-segment depression, PVC’s, segment depression, PVC’s, prolonged QT intervals.prolonged QT intervals.

Severe causes prominent U waves, Severe causes prominent U waves, atrioventricular conduction atrioventricular conduction disturbances, and V-Tach, Fib.disturbances, and V-Tach, Fib.

HypokalemiaHypokalemia

Causes of HypokalemiaCauses of HypokalemiaAlkalosis (each 0.1 increase in pH Alkalosis (each 0.1 increase in pH decreases serum potassium by 0.4 to decreases serum potassium by 0.4 to 0.6 mEq/L0.6 mEq/LInsulin administrationInsulin administrationVitamin B12 therapy for Vitamin B12 therapy for megaloblastic anemias, acute megaloblastic anemias, acute leukemiasleukemiasHypokalemic periodic paralysis which Hypokalemic periodic paralysis which is a rare familial disorderis a rare familial disorder

Causes of HypokalemiaCauses of HypokalemiaBeta-Adrenergic agonist (terbutaline), Beta-Adrenergic agonist (terbutaline), decongestants, bronchodilators, decongestants, bronchodilators, theophylline, and caffeine.theophylline, and caffeine.Barium poisoning, toluene, verapamil, and Barium poisoning, toluene, verapamil, and chloroquine intoxication.chloroquine intoxication.Correction of digoxin intoxication with Correction of digoxin intoxication with digoxin antibody fragments (digibind)digoxin antibody fragments (digibind)Increased renal excretion due to drugs Increased renal excretion due to drugs including the diuretic carbonic anhydrase including the diuretic carbonic anhydrase inhibitors such as acetazolamideinhibitors such as acetazolamide

Causes of HypokalemiaCauses of Hypokalemia

Amphotericin BAmphotericin B

High-dose sodium penicillin, nafcillin, High-dose sodium penicillin, nafcillin, ampicillin, or carbenicillinampicillin, or carbenicillin

CisplatinCisplatin

AminoglycosidesAminoglycosides

Corticosteroids, mineralcorticoidsCorticosteroids, mineralcorticoids

Foscarnet sodiumFoscarnet sodium

Causes of HypokalemiaCauses of HypokalemiaRenal tubular acidosis distal type 1 or Renal tubular acidosis distal type 1 or proximal type 2proximal type 2

Diabetic ketoacidosisDiabetic ketoacidosis

Magnesium deficiencyMagnesium deficiency

Postobstruction diuresis, diuretic phase of Postobstruction diuresis, diuretic phase of acute tubular necrosisacute tubular necrosis

Osmotic diuresis such as mannitolOsmotic diuresis such as mannitol

Bartter’s syndrome which is hyperplasis of Bartter’s syndrome which is hyperplasis of the juxtaglomerular cellsthe juxtaglomerular cells

Causes of HypokalemiaCauses of HypokalemiaIncreased mineralocorticoid activity both Increased mineralocorticoid activity both primary and secondary aldosteronism, primary and secondary aldosteronism, Cushings syndrome, or physiological Cushings syndrome, or physiological increases in mineralocorticoid activity increases in mineralocorticoid activity during dehydration.during dehydration.Chronic metabolic alkalosis from loss of Chronic metabolic alkalosis from loss of gastric fluidgastric fluidGI losses including vomiting, nasogartic GI losses including vomiting, nasogartic suctioning, diarrhea, laxative abuse villous suctioning, diarrhea, laxative abuse villous adenomas and fistulasadenomas and fistulasInadequate dietary intake seen in people Inadequate dietary intake seen in people with anorexia nervosawith anorexia nervosa

Causes of HypokalemiaCauses of Hypokalemia

Cutaneous losses such as sweatingCutaneous losses such as sweating

High dietary sodium intake, High dietary sodium intake, excessive use of licoriceexcessive use of licorice

HypomagnesemiaHypomagnesemia

TreatmentTreatmentReplace potassium either IV or oral Replace potassium either IV or oral or both. Oral increases the or both. Oral increases the potassium more quickly than IV potassium more quickly than IV because you have to give IV slowly.because you have to give IV slowly.Each 10 meq should raise the Each 10 meq should raise the potassium level 0.1 mmol/Lpotassium level 0.1 mmol/L

May have to adjust patients diuretics May have to adjust patients diuretics or other drugs such as amphotericin or other drugs such as amphotericin which decrease the potassiumwhich decrease the potassium

TreatmentTreatment

Check a magnesium level which has Check a magnesium level which has to be normal for maintainence of to be normal for maintainence of serum potassium levels.serum potassium levels.

Advice patients to eat foods that are Advice patients to eat foods that are high in potassium such as fruits.high in potassium such as fruits.

HyperkalemiaHyperkalemia

Defn: plasma potassium Defn: plasma potassium concentration greater than 4.9 mEq/Lconcentration greater than 4.9 mEq/L

Clinical Manifestations include Clinical Manifestations include generalized weakness, irritability, generalized weakness, irritability, paresthesias, decreased deep tendon paresthesias, decreased deep tendon reflexes, flaccid paralysis, cardiac reflexes, flaccid paralysis, cardiac arrhythmias, and ileusarrhythmias, and ileus

HyperkalemiaHyperkalemia

Mild causes peaking of T waves, and Mild causes peaking of T waves, and PVC’sPVC’s

Severe causes peaking of T waves, Severe causes peaking of T waves, widening of QRS complex, depressed widening of QRS complex, depressed ST segments, prolongation of PR ST segments, prolongation of PR interval, sinus arrest, deep S waves, interval, sinus arrest, deep S waves, PVC’s, V-Tach, Fib, and cardiac arrestPVC’s, V-Tach, Fib, and cardiac arrest

HyperkalemiaHyperkalemia

Causes of HyperkalemiaCauses of HyperkalemiaPseudohyperkalemia – Hemolyzed specimen, Pseudohyperkalemia – Hemolyzed specimen, severe thrombocytosis (platelet count of less than severe thrombocytosis (platelet count of less than 10 x 6/ml), severe leukocytosis (wbc less than 10 10 x 6/ml), severe leukocytosis (wbc less than 10 x 5/ml, fist clenching during phlebotomy, and x 5/ml, fist clenching during phlebotomy, and drawing blood from a limb into which potassium drawing blood from a limb into which potassium is being infused.is being infused.Excessive potassium intake Excessive potassium intake Decreased renal excretion from potassium Decreased renal excretion from potassium sparing diuretics, insufficiency, tubular sparing diuretics, insufficiency, tubular unresponsiveness, type 4 RTA, ACE inhibitors, unresponsiveness, type 4 RTA, ACE inhibitors, heparin administration, NSAIDs, TMP-SMX, B-heparin administration, NSAIDs, TMP-SMX, B-Blockers, and pentamidine.Blockers, and pentamidine.

Causes of HyperkalemiaCauses of HyperkalemiaAcidemia (each 0.1 decrease in pH Acidemia (each 0.1 decrease in pH increases the serum potassium by increases the serum potassium by 0.4 to 0.6 mEq/L. 0.4 to 0.6 mEq/L. Insulin deficiencyInsulin deficiencyDrugs such as succinycholine, Drugs such as succinycholine, markedly increased digitalis levels, markedly increased digitalis levels, arginine, and B-adrenergic blockersarginine, and B-adrenergic blockersHypertonicity, hemolysis, tissue Hypertonicity, hemolysis, tissue necrosis, rhabdomyolysis, burnsnecrosis, rhabdomyolysis, burns

TreatmentTreatmentIV calcium gluconate helps stabilize the IV calcium gluconate helps stabilize the myocardial cell membranes, it does not myocardial cell membranes, it does not lower the potassium.lower the potassium.Give glucose and insulin which will lower Give glucose and insulin which will lower plasma potassium transiently for 4 to 6 plasma potassium transiently for 4 to 6 hours.hours.Sodium bicarbonate can be used.Sodium bicarbonate can be used.Kayexalate orally or per rectum.Kayexalate orally or per rectum.Remove the cause and patients may need Remove the cause and patients may need dialysis.dialysis.

HypomagnesemiaHypomagnesemia

Defn: plasma magnesium Defn: plasma magnesium concentration less than 1.8mg/dLconcentration less than 1.8mg/dL

Clinical Manifestations: Clinical Manifestations: Neuromuscular weakness, Neuromuscular weakness, hyperreflexia, fasciculations, hyperreflexia, fasciculations, tremors, convulsions, delirium, and tremors, convulsions, delirium, and comacoma

Causes of HypomagnesemiaCauses of HypomagnesemiaDefective absorption (malabsorption)Defective absorption (malabsorption)Inadequate dietary intake (alcoholics)Inadequate dietary intake (alcoholics)Parenteral therapy without magnesiumParenteral therapy without magnesiumChronic diarrhea, villous adenoma, prolonged Chronic diarrhea, villous adenoma, prolonged nasogastric suction, and fistulasnasogastric suction, and fistulasDiuretic usageDiuretic usageRenal tubular acidosisRenal tubular acidosisEndocrine disturbances such as diabetic Endocrine disturbances such as diabetic ketoacidosis, hyperaldosteronism, ketoacidosis, hyperaldosteronism, hyperthyroidism, hyperparathryroidism, SIADH, hyperthyroidism, hyperparathryroidism, SIADH, bartter’s syndrome, hypercalciuria, and bartter’s syndrome, hypercalciuria, and hypokalemiahypokalemia

Causes of HypomagnesemiaCauses of HypomagnesemiaCisplatin, alcohol, cyclosporine, digoxin, Cisplatin, alcohol, cyclosporine, digoxin, pentamidine, mannitol, amphotericin B, pentamidine, mannitol, amphotericin B, foscarnet, and methotrexatefoscarnet, and methotrexate

Gentamicin, ticarcillin, carbenicillinGentamicin, ticarcillin, carbenicillin

Hypoalbuminemia, cirrhosis, insulin and Hypoalbuminemia, cirrhosis, insulin and glucose, theophylline, epinephrine, acute glucose, theophylline, epinephrine, acute pancreatitis, CABG, sweating, burns, pancreatitis, CABG, sweating, burns, prolonged exercise, lactation, hungry-prolonged exercise, lactation, hungry-bones disease.bones disease.

EKG ManifestationsEKG Manifestations

Prolonged QT interval, T-wave Prolonged QT interval, T-wave flattening, prolonged PR interval, A-flattening, prolonged PR interval, A-Fib, torsades de pointesFib, torsades de pointes

Lab Manifestations of Lab Manifestations of HypomagnesemiaHypomagnesemia

Hypokalemia refractory to potassium Hypokalemia refractory to potassium replacementreplacement

Hypocalcemia refractory to calcium Hypocalcemia refractory to calcium replacementreplacement

Treatment HypomagnesemiaTreatment HypomagnesemiaCorrect the magnesium deficiencyCorrect the magnesium deficiencyMild – Oral magnesium Mild – Oral magnesium Moderate – IV magnesium sulfate Moderate – IV magnesium sulfate over 6 hour periodsover 6 hour periodsSevere – serum mag of less than 1 Severe – serum mag of less than 1 mg/dL give 2grams magnesium in mg/dL give 2grams magnesium in over 1 hour periodover 1 hour periodMonitor ECG, blood pressure, pulse, Monitor ECG, blood pressure, pulse, respiration, DTR’s, and urine outputrespiration, DTR’s, and urine output

HypermagnesemiaHypermagnesemiaDefn: plasma magnesium Defn: plasma magnesium concentration greater than 2.3 mg/dLconcentration greater than 2.3 mg/dLClinical Manifestations: Paresthesias, Clinical Manifestations: Paresthesias, hypotension, confusion, decreased hypotension, confusion, decreased DTR’s paralysis, coma, apneaDTR’s paralysis, coma, apneaAcute hypermagnesemia suppresses Acute hypermagnesemia suppresses parathyroid hormone secretion parathyroid hormone secretion causing hypocalcemiacausing hypocalcemia

Causes of HypermagnesemiaCauses of HypermagnesemiaRenal failure due to a decreased GFRRenal failure due to a decreased GFRDecreased renal excretion due to salt Decreased renal excretion due to salt

depletiondepletionAbuse of antacids and laxatives which Abuse of antacids and laxatives which

contain magnesiumcontain magnesiumEndocrinopathies including Endocrinopathies including

mineralocorticoid and thyroid mineralocorticoid and thyroid horomonehoromone

RhabdomyolysisRhabdomyolysis

Causes of HypermagnesemiaCauses of Hypermagnesemia

Acute diabetic ketoacidosisAcute diabetic ketoacidosis

PheochromocytomaPheochromocytoma

Lithium, volume depletion, familial Lithium, volume depletion, familial hypocalciuric hypercalcemiahypocalciuric hypercalcemia

EKG ManifestationsEKG Manifestations

Shortened PR interval, heart block, Shortened PR interval, heart block, peaked T-waves, and increased QRS peaked T-waves, and increased QRS durationduration

Treatment for HypermagnesemiaTreatment for Hypermagnesemia

Identify and correct the underlying Identify and correct the underlying disorderdisorder

Dialysis is needed for severe Dialysis is needed for severe hypermagnesiumhypermagnesium

HypophosphatemiaHypophosphatemiaDefn: plasma phosphate concentration Defn: plasma phosphate concentration less than 2.5 mg/dLless than 2.5 mg/dLClinical Manifestations: Proximal muscle Clinical Manifestations: Proximal muscle weakness, waddling gait, bone pain, weakness, waddling gait, bone pain, myalgias, osteopenia, apprehension, myalgias, osteopenia, apprehension, paresthesia, seizures, coma, ataxia, paresthesia, seizures, coma, ataxia, encephalopathy, hemolytic anemia, encephalopathy, hemolytic anemia, leukocyte and platelet dysfunction, leukocyte and platelet dysfunction, rhabdomyolysis, ventilator dependence, rhabdomyolysis, ventilator dependence, respiratory failure, dysrhythmias, respiratory failure, dysrhythmias, hypotension, cardiomyopathy, decreased hypotension, cardiomyopathy, decreased contractility, CHF, and metabolic acidosiscontractility, CHF, and metabolic acidosis

Causes of HypophosphatemiaCauses of HypophosphatemiaDecreased intakeDecreased intake

Malabsorption, vomiting, diarrheaMalabsorption, vomiting, diarrhea

Phosphate-binding antacidsPhosphate-binding antacids

Renal loss including RTA, Met acidosis, Renal loss including RTA, Met acidosis, Fanconi’s syndrome, vitamine D- resistant Fanconi’s syndrome, vitamine D- resistant rickets, ATN, hyperparathyroidism, familial rickets, ATN, hyperparathyroidism, familial hypophosphatemia, acute volume hypophosphatemia, acute volume expansion, glycosuria, acetazolmide, and expansion, glycosuria, acetazolmide, and kidney transplantationkidney transplantation

Causes of HypophosphatemiaCauses of HypophosphatemiaTranscellular – caused by withdrawal Transcellular – caused by withdrawal of alcohol, DKA, glucose, insulin of alcohol, DKA, glucose, insulin and/or catecholamine infusion, and/or catecholamine infusion, anabolic steriods, and other anabolic steriods, and other hormones such as insulin, glucagon, hormones such as insulin, glucagon, epinephrine and dopamine. Total epinephrine and dopamine. Total parenteral nutrition, theophylline parenteral nutrition, theophylline overdose, severe hyperthermia, overdose, severe hyperthermia, acute leukemias and Burkitt’s acute leukemias and Burkitt’s lymphoma.lymphoma.

TreatmentTreatment

Mild to moderate can be oral Mild to moderate can be oral replaced daily.replaced daily.

Severe cases require IV phosphate Severe cases require IV phosphate salts until serum phosphate is salts until serum phosphate is greater than 1.5 mg/dLgreater than 1.5 mg/dL

HyperphosphatemiaHyperphosphatemia

Defn: plasma phosphate Defn: plasma phosphate concentration greater than 5mg/dLconcentration greater than 5mg/dL

Clinical Manifestations: Soft tissue Clinical Manifestations: Soft tissue calcifications in the kidney, cornea, calcifications in the kidney, cornea, lung, blood vessels, and skin.lung, blood vessels, and skin.

TreatmentTreatmentRenagel (Sevelamer) is the agent of Renagel (Sevelamer) is the agent of choice. It is an oral agent given TID choice. It is an oral agent given TID with meals. It binds phosphate in the with meals. It binds phosphate in the gut and prevents its absorption.gut and prevents its absorption.May also use insulin and glucose May also use insulin and glucose infusion to prompt cell phosphate infusion to prompt cell phosphate uptake when rapid phosphate uptake when rapid phosphate decreases are needed.decreases are needed.May also need dialysis.May also need dialysis.

HypercalcemiaHypercalcemiaSymptoms – constipation, anorexia, Symptoms – constipation, anorexia, nausea, vomiting, pancreatitis, ulcers, nausea, vomiting, pancreatitis, ulcers, confusion, obtundation, pyschosis, confusion, obtundation, pyschosis, lassitude, depression, coma, lassitude, depression, coma, nephrolithiasis, renal insufficiency, nephrolithiasis, renal insufficiency, polyuria, decreased urine-concentrating polyuria, decreased urine-concentrating ability, nocturia, nephrocalcinosis, ability, nocturia, nephrocalcinosis, myopathy, weakness, osteoporosis, myopathy, weakness, osteoporosis, pseudogout, bone pain, HTN, metastatic pseudogout, bone pain, HTN, metastatic calcifications, pruritiscalcifications, pruritis

EKG changesEKG changesShortening of the Shortening of the QT intervalQT interval

TreatmentsTreatments

Vigorous IV hydration, Vigorous IV hydration, bisphosphonates, loop diuretics, bisphosphonates, loop diuretics, phosphate repletion, calcitonin, phosphate repletion, calcitonin, mithramycin, glucocorticoids, and mithramycin, glucocorticoids, and indomethacinindomethacin

HypocalcemiaHypocalcemia

Symptoms – neuromuscular Symptoms – neuromuscular irritability with the Chvostek’s and irritability with the Chvostek’s and Trousseau’s sign, tetany, Trousseau’s sign, tetany, paresthesias, myopathy, seizures, paresthesias, myopathy, seizures, muscle spasm or weakness, soft muscle spasm or weakness, soft tissue calcifications, ocular cataracts, tissue calcifications, ocular cataracts, arrhythmias, CHFarrhythmias, CHF

ECG changesECG changesIncreases QT Increases QT intervalinterval

TreatmentTreatment

IV calcium gluconate, improve IV calcium gluconate, improve nutritional status, replace calcium nutritional status, replace calcium orally, treat underlying diseases.orally, treat underlying diseases.