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Electrolyte Imbalance
Management
Syafruddin Gaus
Dept. of Anesthesiology, Intensive Care and Pain ManagementFaculty of Medicine Hasanuddin University
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Introduction
Common in critically ill & injured emergencypatients
Alter physiologic function and contribute tomorbidity & mortality
The most common electrolytedisturbance in emergency patients are:disturbance in K and Na levels
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Objectives
Review causes and clinical manifestations
of electrolyte disturbances
Outline emergent management of
electrolyte disturbances
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Principles of Electrolyte Disturbances
Management
Implies an underlying disease process.
Treat the electrolyte change, but seek the
cause.
Clinical manifestations usually not specific
to a particular electrolyte change, e.g.,
seizures, arrhythmias.
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Principles of Electrolyte Disturbances
Management
Clinical manifestations determine urgency
of treatment, not laboratory values
Speed and magnitude of correctiondependent on clinical circumstances
Frequent reassessment of electrolytes
required
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MONITORING OF FLUID &ELECTROLYTE THERAPY
Serum electrolytes do not need to be measured pre-operativelyin healthy children prior to elective surgery where IV fluids areto be given.
Serum electrolytes need to be measured pre-operatively in allchildren presenting for elective or emergency surgery who
require IV fluid to be administered prior to surgery. Serum electrolytes should be measured every 24 hours in all
children on IV fluids or more frequently if abnormal.
Children should be weighed prior to fluids being prescribedand given.
Although ideally children should be weighed daily while on IVfluids, practically this is difficult in older children, or those whohave undergone major surgery. Use of a fluid input/outputchart will help with fluid management.
Association of Pediatric Anesthetists Consensus Guideline on Perioperative FluidManagement in Children, September 2007.
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Electrolyte Disturbances
Potassium: hypo- & hyperkalemia
Sodium : hypo- & hypernatremia
Others:
Calcium : hypo- & hypercalcemia
Phosphate : hypo- & hyperphosphatemia
Magnesium : hypo- & hypermagnesemia
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Potassium (K)
The main intracellular cation.
Normal serum concentration: 3.5 - 5 mEq/L.
Concentration in cell is maintained by the
membrane sodium-potassium adenosinetriphosphate (Na+, K+-ATPase) pump.
Essential for maintenance of the electricalmembrane potential.
Alteration of K primarily effect the CV,neuromuscular, and GI systems, effect onmyocardial cells are the most prominentand severe.
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Hypokalemia
Plasma [K+] < 3.5 mEq/L (< 3.5 mmol/L)
Can occur as a result from:
1.increased K loss (renal or extrarenallosses)
2.intercompartmental shift / transcellularshift of K
3.inadequate or decreased K intake
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Disorders of Potassium Balance
HYPOKALEMIA
- Inadequate intake- GI losses: vomiting, diarrhea, continuous gastric aspiration, removal
of GI contents
- Renal losses: diuretics, steroids, renal tubular acidosis
- Bartters syndrome
Causes of hypokalemia
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The consequences of hypokalemia are
related to the effects on muscle cells:
- Abdominal distention & diminished bowel
motility
- Cardiac effect much greater concern
Clinical manifestation:
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Mosby items and derived items 2005, 2002 by Mosby, Inc.
Symptoms of hypokalemia.
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Hypokalemia
ECG may be a better measure of serious
imbalance than the serum [K]
ECG changes:
- Depressed ST segment
- Flattened T wave
- Higher U wave
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Due to delayed ventricular repolarization: T wave flattening and inversion
Prominent U wave
ST segment depression
Increased P wave amplitude
Prolongation of the PR interval
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Treatment (1)
Stop offending drugs (if possible)
Correct other electrolyte disturbances
Correct alkalosis
Treatment is aimed:
Correcting the underlying cause
Administering potassium
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Treatment (2)
K replacement
KCl should given very slowly (over 1 h):
< 0.5 mEq/kg/hr
Rapid IV administration may cause fatal
arrhythmias and cardiac arrest may
result
Ford DM. Fluid, Electrolyte, and Acid-Base Disorders and Therapy. In: Current Pediatric Diagnosis
& Treatment, 18th Ed.
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Lund GJ. Fluid and electrolyte. The Harriet Lane Handbook. 8th Ed, 2009
K+ deficit (mEq/L) =
fluid deficit (L) x proportion from ICF x K+
concentration (mEq/L) in ICF
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Monitoring
Continuous ECG monitoring is necessa-
ry (during parenteral administration of
high concentration of KCl)
Serum K levels must be monitored at
frequent interval during repletion (every
4-6 hrs during initial replacement until
correction is achieved)
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Hyperkalemia
Serum K level > 6.5 mEq/L (> 6.5 mmol/L)
Most often results from renal dysfunction
Occurs in approximately 50% of infantwhose birth weight < 1000 g and
especially common in infant with low urine
output in the first hours of life
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Disorders of Potassium Balance
HYPERKALEMIA
- Excessive intake
- Impaired excretion: renal failure, congenital adrenal hyperplasia
- Movement of potassium out of cells: catabolic states, acidosis of
any origin
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Clinical manifestation
Heart:
arrhythmias (heart block, bradycardia, dimi-
nished conduction and contraction)
ECG abnormalities (diffuse peaked T waves,
PR prolongation, QRS widening, diminished P
waves, sine waves)
Muscle: muscle weakness, paralysis, pares-thesias, and hypoactive reflexes
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ECG change:
Peaked T-wave Widening of QRS complex PR prolongation Loss of P wave Loss of R wave amplitude ST depression (occationally elevation) Sine wave Ventricular fibrillation and asystole
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Treatment (1)
Recognition & treatment of underlying diseases
Removal of offending drugs (digoxin, propanolol,phenyllephrine)
Limitation of potassium intake
Correction of acidemia or electrolyte abnorma-lities
Any serum potassium level > 6 mEq/L should beaddressed, but the urgency of treatment
depends on clinical manifestation The presence of ECG changes mandates
immediate therapy
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Treatment (2)
Several temporary measures can be taken:
- to antagonize the effect of hyperkalemia on the
myocardium: 10% calcium gluconate (0.5-1ml/kg, IV, over 5-10 min, if ECG changes persistmay be repeated after 5 min)
- to raise the blood pH and increase K influx into
cells: Na bicarbonate (1-2 mEq/kg, IV)
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Treatment (3)
- to try to increase cellular uptake of K:
* 2-agonists: albuterol or salbutamol (aerosol) 10-
20 mg
* infusion of glucose and insulin (0.5-1 g/kg glucose
and 4 g of glucose to 1 IU of insulin) over 2 h
with monitoring of the serum glucose level every
15 min
- to increase renal excretion: Furosemide (1-2 mg/kg,
IV)- to increase intestinal excretion: a potassium-binding
resin, Kayexalate (1 g/kg, by rectum or by mouth)
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Treatment (4)
Refractory hyperkalemia:If the serum [K] continues to rise and exceeds 8
mEq/L:
- Peritoneal dialysis, or hemofiltration and
hemodialysis
- Exchange blood transfusion (to avoid a high
blood K level):
* Mixture of washed red blood cells (RBCs) &
* Fresh-frozen plasma
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Monitoring
Should be monitored duringevaluation and treatment:
Repeat serum K levels (every 1-2 h)
Continuous cardiac monitoring
and serial ECG tracings
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Sodium
The main extracellular ion
Normal serum [Na] 130 150 mEq/L
More than 90% of the total amount ofsolutes in the extracellular space
Absorbed in both the small intestine and
the colon, large amount is absorbed in
the jejenum
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Sodium
Primary functions:
determinant of osmolality in the body involved in the regulation of extracellular
volume
Abnormalities in circulating Na primarily
effect neuronal and neuromuscularfunction.
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Hyponatremia
A serum Na level < 130 mEq/L Caused by retention of water relative to Na
When the serum Na concentration decrease serum osmolality decline, water moves into cells
increased water content in the brain causesthe signs and symptoms of hyponatremia:
- vomiting
- lethargy
- apnea- seizures & coma
(if serum Na concentration < 115 mEq/L)
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Disorders of Sodium Balance
HYPONATREMIA
Early:
- Perinatal asphyxia
- RDS
- Diuretics
- Nebulization associated with nasal continuous positve airway pressure
- Hypotonic fluid administered to mother during labor
Late:
- Very low birth weight infant fed human milk or standard formula- With overhydration: CHF, renal failure
- With dehydration: adrenal insufficiency, vomiting, diarrhea, peritonitis
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Clinical manifestation
CNS: disorientation, decreased mentation,
irritability, seizures, lethargy, coma,
nausea and vomiting
Muscle: weakness & CNS-driven
respiratory arrest
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Treatment (1)
Treating the underlying disease
Removing offending drugs
Improving the circulating Na level
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Treatment (2)
The amount of Na needed to correct a low
serum Na level can be calculated according to
the standard formula:
Na to be given (mEq/L) = 0.6 x weight (kg) x(desired serum Na - actual serum Na)
Target serum Na concentration: 135 mEq/L.
Usually is made over several hours.
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Treatment (3)
Shock is present or impending:- Normal saline IV 10-20 ml/kg over 20-30 minute,
repeated until BP is normal
Symptomatic hyponatremia (almost always occurs onlywhen the serum Na level < 115 mEq/L):
- Hypertonic saline IV.- Initial correction: lower than normal serum Na
concentration (120-125 mEq/L).
- An abrupt or a large increase in osmolality carries the
risk of intracranial hemorrhage and CHF. Asymptomatic hyponatremia:
- Hypertonic saline is used if serum Na is < 120 mEq/L
to prevent symptoms
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Example:
A 10-kg child is lethargic and found to
have a plasma [Na+] of 110 mEq/L. How muchNaCl must be given to raise her plasma [Na+] to
130 mEq/L?
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[Na+] to be given = TBW x (130-110)
TBW is approximately 60% of body weight in
children:[Na+] to be given = 10 x 0.6 x (130-110)
= 120 mEq
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Normal saline contains 154 mEq/L, the patient
should receive 120 mEq : 154 mEq/L = 779
mL of normal saline.
This amount of saline should be given over 24hours (32.5 mL/h)
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Hypernatremia
Serum N level > 150 mEq/L (> 150
mmol/L)
Indicates intracellular volume depletionwith a loss of free water, which exceeds
Na loss
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Disorders of Sodium Balance
HYPERNATREMIA
With Dehydrat ion :
- Vomiting, diarrhea with inadequate fluid replecement
- Osmotic diuresis (hyperglycemia, mannitol)
- Radiant warmers
With Overhydrat ion:
- Excessive administration of sodium bicarbonate (NaHCO3)- Errors in administration of sodium chloride (NaCl)
Causes of hypernatremia
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Clinical manifestation
CNS: altered mental, lethargy, seizures,
coma
Muscle function: muscle weakness
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Treatment (1)
Centers on correcting the underlying cause
of hypernatremia
Should not be corrected rapidly
Goal: decrease the serum Na by
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Example:
A 10-kg child is found to have a plasma
[Na+] of 160 mEq/L. What is his water
deficit?
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Greenbaum LA. Electrolyte and acid-base disorders. In: Textbook of Pediatrics. 18th Ed, 2007.
Water deficit (L)= body weight (kg) x 0.6(1-145/[current sodium])
Water deficit = 10 x 0.6 (1-145/[160])= 6 x (1 - 0.90625)
= 6 x 0.09375 = 0.5625 L
= 562.5 mL
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To replace this deficit over 48 hours, one
would give 5% Dextrose in water IV,
562.5 mL over 48 hours, or 11.8 mL/h
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TERIMAKASIH