Na, K imbalance

Electrolyte imbalance

Serum sodium

Normal (135-145 meql) Hypernatremia

gt 145 meql

Hyponatremia

lt135meql

3

Regulation of Sodium It is affected by hormones

Aldosterone Reninangiotensin Atrial Natriuretic Peptide (ANP) ADH

Serum sodium


gt 145 meql

Hyponatremia

lt135meql

Hypovolaemic Hyponatraemic statesbull Diuretic therapybull Mineralocorticoid deficit (Addisons disease)

bull GIT losses (diarrhea or vomiting)bull Fluid loss in third space (peritonitis burn)

Hypervolaemic (oedematous) Hyponatraemic statesbull Liver cirrhosis bull Congestive heart failurebull Nephrotic syndrome bull Renal failure with water overload

Euvolaemic (Normal volume) Hyponatraemic States

bull Hormonal (Myxoedema glucocorticoid deficiency)bull Massive water load (psychogenic polydipsia parenteral fluid)bull Syndrome of inappropriate secretion of ADH (SIADH)

Causes of hyponatremia

Na H2O

H2O

Na H2O

Treatment Modalities

All forms of hyponatremia will respond to water restriction

Primary polydipsiaRenal failure DialysisVolume depletion Normal salineThyroid cortisol replacementSIADH Asymptomaticchronic

AcuteMental Hypertonic saline

Major Intravenous Solutions Name Content Distribution

D5W 5 Dextrose Water 300 mOsm

ICF ECF 2 1

Isotonic (normal) Saline

NaCl 150 mM (09) 280 mOsm

ECF 100

2313

23 D5W 13 Isotonic Saline

ICFECF 1 1 440 550

Major Intravenous Solutions

Name Contents Distribution

Half-NormalSaline

NaCl 75 mM 045 140 mOsm

ICF ECF 1 2

HypertonicSaline


ECF NaCl100Water shiftsfrom ICF

General principle

-Do not exceed 10-12 mEqL rise in PNa in first 24deg and 20 mEqL rise in PNa after 48deg

- If seizures or severe neurological abnormalities present then correct more rapidly initially

Danger of rapid correctionCentral Pontine Myelinolysis (osmotic demyelination)

Strategies for Safe Correction of Hyponatremia

A 56 years old female patient coming to ER complaining from 3 days of persistent watery diarrhea

By examination she was conscious with BP 11070 and heart rate 90min week pulse dry tongue sunken eyes

Serum Na 118 meql (135-142)Serum K 31 meql (35-55) S creatinine 17mgdl (08-13)blood urea 70 mgdl (20-40)

She was treated by Normal saline solution 09







CaseA 71 year old woman presented with fatigue and forgetfulness over last 2 weeks She is known Hypertensive on thiazide diuretics Physical exam Systolic BP drop gt 20mmHg on standing

Serum Na119meql (135-142)Serum potassium 31meql (35-55)Blood urea 55 mgdl (25-40)S creatinine 15 mgdl (08-13)







Case A 65 year old man with history of chronic heavy cigarette smoking He was admitted with unresponsiveness over last two days Physical exam is normal Normal CT brain Normal sugarurea screatinine 13 mgdl PNa+ = 115







Human Anatomy 3rd editionPrentice Hall copy 2001

A Typical Nephron

ADH

Hypertonic saline- dose calculation

Current PNa+ = 115 Target PNa+ = 125

Na+deficit= 10 meqliter

Infusion on 1005 = 20

Total body Na+ deficit= 5 x total body water= 10 x 06 x body wt (75kgs) =500

Amount of 3 NaCl needed (Na=513meqL)= 1000mlRate of infusion=500 20=50mlhour

1048708Decreased free water supply

1048708Water loss1048708Osmotic diuresis DI1048708Osmotic diarrhea

1048708Solute load

Pathogenesis of Hypernatremia

Serum Potassium Normal (35-55 meql)

Hyperkalemia gt 55 meqlHypokalemia lt 35 meql

HyperkalaemiaIt is plasma K+ concentration which is more than 55 mmollitre

A- Increased Potassium Intakebull Dietary excess (Banana citrus fruits)bull Intravenous load with K+ containing fluids

B- Shift of Intracellular K+ to extracellular Compartmentbull Acidosisbull Cell damage (cancer chemotherapy)bull Convulsions myositis

C- Decreased excretion of K+ by the kidneysbull Renal failure bull Mineralocorticoid deficiencybull Drug interference as ACEI and K+ sparing diuretics

D- FactitiousHaemolysis of blood sample

ECG tracing in hyperkalaemia may showbull Tall T wavesbull Prolongation of the PR intervalbull Widening of the QRS complexFinally cardiac arrest in diastolebull

ECG Changes

Note the ldquotentedrdquo or ldquopinchedrdquo shape to Twaves

Code Blue

Antagonism of membrane actionIntravenous calcium

Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists

RemovalDiureticsCationexchange resinDialysis

Treatment of Hyperkalemia

Treatment

A- Immediate correction (Emergency) of hyperkalaemiabull Caclium gluconate slow IV (5ml of 10 solution) It acts as a Physiologic anatagonist of K+ on cardiac cell membrane

middot Correct acidosis with IV NaHCO3 84(25 100ml)middot B adrenergic agonists(eg salbutamol) Shift K+ into cellmiddot 50 ml of IV 50 glucose 20 units soluble insulin every 30 min

B- Increase renal excretion of K+Diuresis with saline and furosemide

C- Potassium exchange resinbull eg sorbosteritbull They will increase faecal K+

D- DialysisPreferably K+ low Dialysate haemodialysis for patients with renal failureThe condition is considered medical emergency if ECG abnormalitiesare present

50 year old male with type 2 DM chronic kidney disease has been prescribed an ACEI (Capotopril) for HTN He presents to the ER with marked flaccid weakness of both lower limbs

Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 20 (08-12)




C- Decreased excretion of K+ by the kidneysbull Renal failure bull Mineralocorticoid deficiency

bull Drug interference as ACEI and K+ sparing diuretics








A 54 years old female with chronic renal failure and stopped hemodialysis for 1 week because of closure of her AV fistula He presents to the ER with marked dyspnea orthopnea and bradycardia 45min




Hemodialysis

45 year old female with type 2 DM and HTN She presents to the ER with marked tachypnea dehydration BP 11060

Labs Random blood glucose 540 mgdlAcetone in urineBlood gases PH 712 pO2 98 pCO2 22 Hco3 90

Serum Na 138 (135-142)Serum K 65 (35-55)Serum creatinine 16 (08-12)

DKA

Hypokalemia-Decrease intake(never alone)

Intracellualar Shift1Treatment with insulin2Alkalosis3szlig-2 stimulation

Increased Excretion1)GI2)Renal3)Hyperaldosteronism4)Diuresis5)Ampho-B6)Hypomagnesemia

Clinical Consequences of hypokalemia

Cardiac arrhythmiasMuscle weaknessRhabdomyolysisRenal dysfunctionGlucose intolerance

Hypokalemia-Treatment

Estimate of deficit is difficult ~100-200 meqfor 1 meqliter

PO therapy usually adequate

IV therapy if severesymptomatic Max conc 40meqliter Max rate 20meqhour Use in saline (not dextrose)

Case

A 58 yr old cirrhotic is admitted with worsening ascites- Meds Lasix40mg bid Lactulose- EKG Unifocal VPCrsquos prominent U waves-Admission labsNa 125 Bl glucose 87 K 22 Urea 40 creat 20

How would you treat her hypokalemia

Thanks

PowerPoint Presentation

Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

A 56 years old female patient coming to ER complaining from 3 days of persistent watery diarrhea By examination she was conscious with BP 11070 and heart rate 90min week pulse dry tongue sunken eyes Serum Na 118 meql (135-142) Serum K 31 meql (35-55) S creatinine 17mgdl (08-13) blood urea 70 mgdl (20-40)

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41

Serum sodium


gt 145 meql

Hyponatremia

lt135meql

3



Serum sodium


gt 145 meql

Hyponatremia

lt135meql







Na H2O

H2O

Na H2O







ICF ECF 2 1



ECF 100

2313


ICFECF 1 1 440 550



Half-NormalSaline


ICF ECF 1 2

HypertonicSaline



General principle































A Typical Nephron

ADH









1048708Solute load










ECG Changes


Code Blue





Treatment
























Hemodialysis




DKA










Case



Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41

3



Serum sodium


gt 145 meql

Hyponatremia

lt135meql







Na H2O

H2O

Na H2O







ICF ECF 2 1



ECF 100

2313


ICFECF 1 1 440 550



Half-NormalSaline


ICF ECF 1 2

HypertonicSaline



General principle































A Typical Nephron

ADH









1048708Solute load










ECG Changes


Code Blue





Treatment
























Hemodialysis




DKA










Case



Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41

Serum sodium


gt 145 meql

Hyponatremia

lt135meql







Na H2O

H2O

Na H2O







ICF ECF 2 1



ECF 100

2313


ICFECF 1 1 440 550



Half-NormalSaline


ICF ECF 1 2

HypertonicSaline



General principle































A Typical Nephron

ADH









1048708Solute load










ECG Changes


Code Blue





Treatment
























Hemodialysis




DKA










Case



Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41







Na H2O

H2O

Na H2O







ICF ECF 2 1



ECF 100

2313


ICFECF 1 1 440 550



Half-NormalSaline


ICF ECF 1 2

HypertonicSaline



General principle































A Typical Nephron

ADH









1048708Solute load










ECG Changes


Code Blue





Treatment
























Hemodialysis




DKA










Case



Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41







ICF ECF 2 1



ECF 100

2313


ICFECF 1 1 440 550



Half-NormalSaline


ICF ECF 1 2

HypertonicSaline



General principle































A Typical Nephron

ADH









1048708Solute load










ECG Changes


Code Blue





Treatment
























Hemodialysis




DKA










Case



Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41



Half-NormalSaline


ICF ECF 1 2

HypertonicSaline



General principle































A Typical Nephron

ADH









1048708Solute load










ECG Changes


Code Blue





Treatment
























Hemodialysis




DKA










Case



Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41

General principle































A Typical Nephron

ADH









1048708Solute load










ECG Changes


Code Blue





Treatment
























Hemodialysis




DKA










Case



Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41



























A Typical Nephron

ADH









1048708Solute load










ECG Changes


Code Blue





Treatment
























Hemodialysis




DKA










Case



Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41









1048708Solute load










ECG Changes


Code Blue





Treatment
























Hemodialysis




DKA










Case



Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41









ECG Changes


Code Blue





Treatment
























Hemodialysis




DKA










Case



Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41

Code Blue





Treatment
























Hemodialysis




DKA










Case



Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41





Treatment
























Hemodialysis




DKA










Case



Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41



















Hemodialysis




DKA










Case



Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41




DKA










Case



Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41










Case



Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41

Thanks


Slide 6

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12


Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

A Typical Nephron

Slide 20

Slide 23

Slide 24

Slide 25

Slide 26

Slide 28

Slide 29

Slide 31

Slide 32

Slide 33

Slide 34

Slide 35

Slide 36

Slide 37

Slide 38

Slide 39

Slide 40

Slide 41

Na, K imbalance

Documents

Transcript of Na, K imbalance