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Copyright 2008 Society of Critical Care Medicine
Management of Life-
Threatening Electrolyte andMetabolic Disturbances
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Objectives
Review the emergent management ofsevere electrolyte disturbances
Recognize manifestations of acuteadrenal insufficiency and initiateappropriate treatmentDescribe the management of severehyperglycemic syndromes
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Case Study
80-year-old woman withhypertension and heart failure
Confusion, lethargy, poor oral intakeand weakness for 3 days
BP 108/70 mm Hg, HR 110/min, R18/min
Nonsustained ventricular tachy-cardia on monitor
What risk factors does this patient
have for electrolyte disturbances?
What electrolyte disorders might
contribute to her presentation?
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Treat the electrolyte change, butsearch for the cause
Clinical manifestations are usuallynot specific to a particular electrolytechangeClinical circumstances determineurgency of treatment rather than
electrolyte concentrationFrequent reassessment of electrolyteabnormalities required
Principles of ElectrolyteDisturbances
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Case Study
80-year-old woman withhypertension and heart failure
Confusion, lethargy, poor oral intakeand weakness for 3 days
Nonsustained ventricular tachy-cardia on monitor
Laboratory value: K 2.5 mmol/L
How would you initiate evaluationand treatment of this patient?
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Hypokalemia (K
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Case Study
80-year-old woman withhypertension and heart failureECG
How would you initiate treatment of
this patient?
Laboratory value: K 7.8 mmol/L
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Treatment of Hyperkalemia
Calcium for cardiac toxicity (ECGabnormalities)
Redistribute potassium
Insulin and glucose Sodium bicarbonate Inhaled 2-agonistsRemove potassium
Loop diuretic
Sodium polystyrene sulfonate Dialysis
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Case Study
80-year-old woman withhypertension and heart failure
Confusion, lethargy, poor oral intakeand weakness for 3 days
Nonsustained ventricular tachy-cardia on monitor
Laboratory value: Na 118 mmol/L
How would you initiate evaluation of
this patient to determine the etiology?
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Etiology of Hyponatremia
Presence of
Glucose
Proteins or Lipids
Mannitol
AssessVolume Status
Urine Osmolarity (Uosm)
Urine Sodium (UNa)FE Na
Hyponatremia
(Na
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Etiology of Hyponatremia
Hypovolemia Hypervolemia
Uosm>300 mOsm/L
UNa 20 mmol/L
FE Na >1%
Uosm>300 mOsm/L
UNa
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Etiology of Hyponatremia
Euvolemia
Uosm 30 mmol/L
Uosm >100 mOsm/L (usually >300)
UNa >30 mmol/L
Polydipsia
Inappropriate Water
Administration to Children
SIADH
Hypothyroidism
Adrenal Insufficiency
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HypovolemicHypervolemic
Euvolemic
Restrict free-water intake
Increase free-water loss Replace intravascular volume with
normal saline or hypertonic saline
When would you use hypertonic
saline?How fast would you correct the
sodium concentration?
Management ofHyponatremia
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Case Study
80-year-old woman withhypertension and heart failure
Confusion, lethargy, poor oral intakeand weakness for 3 days
Nonsustained ventricular tachy-cardia on monitor
Laboratory value: Na 168 mmol/L
How would you treat this patient?
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Normal saline if hemodynamicallyunstable
Hypotonic fluid when stable
Intravenous fluids Enteral free water
Quantity H2O deficit (L) =
[0.6 wt (kg) ] [Measured Na - 1]140
Rate of correction
Treatment of Hypernatremia
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Case Study
34-year-old man with flu-likesyndromeFebrile, tachycardic and hypotensiveAntibiotics and volume initiated
Admitted to floor2 hours later, systolic BP 60 mm HgHypotensive in ICU after 40 mL/kgfluids and norepinephrine 10 g/min
What metabolic disorders may
contribute to the hypotension?What testing is needed?
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Hyperglycemic Syndromes
25 year-old type I diabetic; venous pH7.26, glucose 290 mg/dL, HCO3 16 mmol/L,anion gap 16 mmol/L, urine ketones (+)
51 year-old with no chronic illness; Na 141mmol/L, Cl 98 mmol/L, HCO3 13 mmol/L,glucose 1640 mg/dL, BUN 70 mg/dL, urineketones (+)
Is this diabetic ketoacidosis (DKA) orhyperglycemic hyperosmolar state
(HHS)?
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Hyperglycemic Syndromes
73 year-old type II diabetic; Na 163mmol/L, Cl 134 mmol/L, HCO3 21 mmol/L,glucose 1282 mg/dL, BUN 62 mg/dL, urineketones (-)
Is this diabetic ketoacidosis (DKA) orhyperglycemic hyperosmolar state
(HHS)?
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Hyperglycemic Syndromes
Characteristics of Hyperglycemic Syndromes
DKA HHS
Glucose > 250 mg/dL > 600 mg/dL
Arterial/venous pH 7.3 > 7.3
Anion gap Increased Variable
Serum/urine ketones Positive Negative or small
Serum osmolarity Normal Increased
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Initial Evaluation
Mental statusDegree of dehydration
Presence of infection or otherprecipitating condition
Laboratory studies Glucose Venous or arterial pH
Electrolytes, renal function Urine or serum ketones Complete blood count ECG
M t f
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Fluids
Insulin
Electrolytes
CrystalloidsAdd glucose to fluids when
glucose 250-300 mg/dL
Regular insulin loading dose
(0.1-0.15 U/kg)Regular insulin infusion (0.1
U/kg/h)
If K 3.3 but
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Continuous insulin infusionGoal 80-110 mg/dL (4.4-6.1 mmol/L)
140-180 mg/dL (7.8-10 mmol/L)
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Questions
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Key Points
Give KCl through a central venouscatheter for life-threatening hypokalemia
Consider calcium administration forhyperkalemia with ECG changes followedby interventions to shift K intracellularly
Limit the increase in serum Na to 8-12mmol/L in the first 24 h in symptomaticeuvolemic hyponatremia
Patients with hypernatremia andhemodynamic instability should havenormal saline administered
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Key Points
Patients with possible adrenalinsufficiency should have emergenttreatment with a glucocorticoid
Treatment goals for hyperglycemicsyndromes are to restore fluid andelectrolyte balance, provide insulin andidentify precipitants
In DKA, insulin infusion should becontinued until acidosis and ketosishave resolved
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Key Points
Maintain glucose 250-300 mg/dL in HHSuntil plasma osmolality 315 mOsm/kgPotassium should be added to fluids inhyperglycemic syndromes as soon as K