7/28/2019 Kuliah Water&Electr Imbalance 2010
1/78
FLUID & ELECTROLYTEIMBALANCET.Haryanto S. dr SpPK
7/28/2019 Kuliah Water&Electr Imbalance 2010
2/78
FLUID & ELECTROLYTE IMBALANCE
Fluid and electrolyte disorders refer to an imbalance inthe mixture of water and electrolytes ---needed for
normal body function.
Necessary salts contain sodium, potassium, calcium,
bicarbonate, and phosphate.
All body parts--even hard bone -- are bathed in a
precise blend of water and natural salts.
7/28/2019 Kuliah Water&Electr Imbalance 2010
3/78
APPROPRIATE HEALTH CARE INCLUDES:1. Physician's monitoring of general condition and
medications.
2. Self-care after diagnosis of a minor imbalance/ as soon as
possible
3. Hospitalization for intravenous fluids and treatment of a
serious imbalance, including the underlying cause.
4. Especially important in infants. Dehydration with fluidand electrolyte imbalance can be life-threatening in the very
young.
7/28/2019 Kuliah Water&Electr Imbalance 2010
4/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
5/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
6/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
7/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
8/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
9/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
10/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
11/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
12/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
13/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
14/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
15/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
16/78
CONDITION CAUSE FLUID IMBALANCE:
*SEVERAL DAYS AFTER SURGERY ---- CAUSING SWELLING OF THE
BODY
*IN HEART FAILURE, FLUID COLLECTS IN THE LUNGS, LIVER,BLOOD
VESSELS, AND BODY TISSUES BECAUSE THE HEART DOES A POOR JOB
OF PUMPING IT TO THE KIDNEYS WHERE IT CAN BE ELIMINATED
*WHEN THE KIDNEYS DO NOT WORK WELL BECAUSE OF CHRONIC
KIDNEY DISEASE, THE BODY CANNOT GET RID OF UNNEEDED FLUIDS*DIARRHEA, VOMITING, EXCESSIVE BLOOD LOSS, OR HIGH FEVER
*OFTEN ASSOCIATED WITH IMBALANCES OF ELECTROLYTE
7/28/2019 Kuliah Water&Electr Imbalance 2010
17/78
SIGNS & SYMPTOMS
Depends on whether water or salts are out of proportion.
The following may indicate either imbalance problem:
Dry mouth.Wrinkled skin.
Increased, decreased, or absent urination.
Fatigue.
Puffy legs, hands, face, or abdomen.
Lung congestion.Weakness and confusion.
Heartbeat irregularities.
Volume depletion : water and salt are lost : weight loss, excessive thirst, dry
mucous membrane
Dehydration : lost especially water : resting tachycardia, orthostatic
hypotension and shock
7/28/2019 Kuliah Water&Electr Imbalance 2010
18/78
CAUSESFluid and salts may be lost by:
Vomiting.
Diarrhea.
Heavy perspiration.Some medications, such as diuretics.
Fluid and salts may accumulate from:
Congestive heart failure.
Excess intravenous fluids.Acute or chronic kidney failure.
Adrenal disease.
Chronic lung disease.
Use of cortisone drugs, female hormones, or sodium bicarbonate.
RISK FACTORSFever; kidney disease; diabetes mellitus; heart disease; anorexia nervosa
or bulimia; use of diuretics; infancy and early childhood -- infants and
young children lose fluid very quickly when sick; alcoholism.
7/28/2019 Kuliah Water&Electr Imbalance 2010
19/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
20/78
DIABETES INSIPIDUS
ETIOLOGI :
1.Abnormality of ADH production from hypothalamus
2.ADH action in kidneyADH insufficiency : produce large amount of urine
Type of Diabetes Insipidus :
1.Central DI : insufficiency ADH released in response to physiologic stimuli.
Cause : Acquired ( head trauma, neoplastic or inflammatory condition
affecting
posterior pituitary ) , Congenital, Idiopathic
2.Gestational DI : increase metab of plasma ADH by an amino peptidase
produced by the placenta leads to deficiency of ADH during pregnancy
3. Primary polydipsia results in secondary insufficiencies of ADH due to
inhibition of ADH secretion by excessive fluid intake4. Nephrogenic DI : genetic or acquired from drug exposure ( lithium,
demeclocycline etc), metabolic condition (hypercalcemia) or renal damage
7/28/2019 Kuliah Water&Electr Imbalance 2010
21/78
SYMPTOMS:
Polyuria, polydipsia ( urine out put > 50 ml/Kg BW/Day , urine osmolality 20 mmol/L
Treatment :
Fluid intake restricted ( less 500 ml than urinary out put)
If Severe symptoms : Infused hypertonic saline ( 3 %) at 24-48 hours and if corrected rapidly
Another drug : Demeclocycline and fludrocortisone in case chronic SIADH
7/28/2019 Kuliah Water&Electr Imbalance 2010
23/78
EDEMA
7/28/2019 Kuliah Water&Electr Imbalance 2010
24/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
25/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
26/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
27/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
28/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
29/78
ELECTROLYTE DISTURBANCE / IMBALANCE
T.HARYANTO S. dr SpPK
7/28/2019 Kuliah Water&Electr Imbalance 2010
30/78
ELECTROLYTE DISTURBANCE / IMBALANCE
Electrolytes are chemicals in the body that regulate important physiologicalfunctions-----help to regulate myocardial and neurological function, fluid balance,
oxygen delivery, acid-base balance .
ELECTROLYTE include sodium, chloride, magnesium, potassium and calcium.
When dissolved in water, electrolytes separate into positively and negativelycharged ions.
Nerve and muscle function are dependent upon the proper exchange of these
ions in and out of the cells.
Electrolytes must exist in the body within a narrow concentration range in order to
effectively serve a variety of critical functions .
7/28/2019 Kuliah Water&Electr Imbalance 2010
31/78
The most serious electrolyte disturbances involve abnormalities in
the levels ofsodium, potassium, and/or calcium.
Other electrolyte imbalances are less common, and often occur in
conjunction with major electrolyte changes.
Chronic laxative abuse or severe diarrhea or vomiting can lead to
electrolyte disturbances alone or with dehydration.
People suffering from bulimia or anorexia are at especially high
risk for an electrolyte imbalance.
http://en.wikipedia.org/wiki/Laxativehttp://en.wikipedia.org/wiki/Diarrheahttp://en.wikipedia.org/wiki/Vomitinghttp://en.wikipedia.org/wiki/Dehydrationhttp://en.wikipedia.org/wiki/Dehydrationhttp://en.wikipedia.org/wiki/Vomitinghttp://en.wikipedia.org/wiki/Diarrheahttp://en.wikipedia.org/wiki/Laxativehttp://en.wikipedia.org/wiki/Dehydrationhttp://en.wikipedia.org/wiki/Vomitinghttp://en.wikipedia.org/wiki/Diarrheahttp://en.wikipedia.org/wiki/Laxative7/28/2019 Kuliah Water&Electr Imbalance 2010
32/78
Causes electrolyte imbalance
Electrolyte imbalance is commonly caused by1. loss of body fluids through prolonged vomiting, diarrhea,
sweating, or high fever.
2.side effects of chemotherapy treatment.
3. renal failure.The kidneys play a critical role in regulating electrolytes.
They control the levels of chloride in the blood and flush out
potassium, magnesium and sodium.
Therefore, a disturbance in blood levels of these electrolytes
may be related to kidney function.
7/28/2019 Kuliah Water&Electr Imbalance 2010
33/78
Symptoms of electrolyte imbalanceSymptoms depend on
WHICH ELECTROLYTE IS OUT OF BALANCETHE LEVEL ELECTROLYTE IS TOO HIGH OR TOO LOW.
Altered potassium, magnesium, sodium or calcium levels, can lead one or more of the
following symptoms:
Muscle spasm
Bone disorders
Weakness
Blood pressure changes
Twitching
Irregular heartbeat
Numbness
Nervous system disorders
Confusion
Convulsions
Lethargy
Seizures etc
7/28/2019 Kuliah Water&Electr Imbalance 2010
34/78
Electrolyte
Calcium
Chlorida
Potassium
Magnesium
Sodium
Functions in the body Necessary for muscle
contraction, nervefunction, blood clotting,cell division, healthybones and teeth
Maintains fluid balancein the body
Regulates heart
contraction, helpsmaintain fluid balance
Necessary for musclecontraction, nervefunction, heart rhythm,bone strength,generating energy andbuilding protein
Maintains fluid balanceand necessary formuscle contraction andnerve function
Normal adult range*
4.5-5.5 mEq/L
97-107 mEq/L
3.5-5.3 mEq/L
1.5-2.5 mEq/L
136-145 mEq/L
7/28/2019 Kuliah Water&Electr Imbalance 2010
35/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
36/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
37/78
HYPERNATREMIASymptoms :
thirst , orthostatic hypotension , dry mouth and mucous
membranes
concentrated urineloss of elasticity in the skin
irregular heartbeat (tachycardia)
irritability
fatigue
lethargymuscle twitching and/or seizures
7/28/2019 Kuliah Water&Electr Imbalance 2010
38/78
Hypernatremia is high sodium in the blood that occurs with
excessive fluid loss.
- Inadequate water intake
- Excessive fluid loss ( diabetes insipidus, kidney disease, severe
burns, and prolonged vomiting or diarrhea)
- Sodium retention (caused by excessive sodium intake or
aldosteronism).- Certain drugs, including loop diuretics, corticosteroids, and
antihypertensive medications may cause elevated sodium levels.
7/28/2019 Kuliah Water&Electr Imbalance 2010
39/78
Diagnose
By measuring the sodium levels in a blood sample.
Normal blood sodium levels are 136 to 145 milliequivalents per liter
(mEq/L) Hypernatremia : blood sodium level higher than 145 mEq/L.
Important: to look for any underlying causes of hypernatremia, such as
diabetes insipidus or other disorders.
Treatment
Principle : replacing the lost fluids.
Mild cases---drinking electrolyte replacement fluids.
Severe cases--- fluids are given intravenously . The fluid is given slowly,
and the blood sodium levels are constantly monitored so thesodium/water levels are brought to the proper balance.
Unless brain function has been affected, most people make a full recovery
from hypernatremia.
7/28/2019 Kuliah Water&Electr Imbalance 2010
40/78
Who gets it?
1. Eldery : who may not recognize that they are thirsty
or are unable to get themselves something to drink.
2.Diuretic user : which cause the kidneys to excrete
more water
3.Patientdiabetes insipidus or diseases of the
hypothalamus or pituitary gland, which can alsointerfere with normal kidney function
7/28/2019 Kuliah Water&Electr Imbalance 2010
41/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
42/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
43/78
SymptomsMost patients with chronic water intoxication are asymptomatic, but may have
symptoms related to the underlying cause.
Severe hyponatremia may cause osmotic shift of water from the plasma into the
braincells. Typical symptoms include nausea, vomiting, abdominal cramping,
edema (swelling) headache and malaise.
Since nausea is, itself, a stimulus for the release ofADH, which promotes the
retention of water, a positive feedback loop may be created and the potential for
a vicious circle of hyponatremia and its symptoms exists.
As the hyponatremia worsens, confusion, diminished reflexes, convulsions,stuporor comamay occur.
http://en.wikipedia.org/wiki/Symptomhttp://en.wikipedia.org/wiki/Osmosishttp://en.wikipedia.org/wiki/Brainhttp://en.wikipedia.org/wiki/Cell_(biology)http://en.wikipedia.org/wiki/Headachehttp://en.wikipedia.org/wiki/Malaisehttp://en.wikipedia.org/wiki/Vasopressinhttp://en.wikipedia.org/wiki/Positive_feedback_loophttp://en.wikipedia.org/wiki/Reflexhttp://en.wikipedia.org/wiki/Convulsionhttp://en.wikipedia.org/wiki/Stuporhttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Stuporhttp://en.wikipedia.org/wiki/Convulsionhttp://en.wikipedia.org/wiki/Reflexhttp://en.wikipedia.org/wiki/Positive_feedback_loophttp://en.wikipedia.org/wiki/Vasopressinhttp://en.wikipedia.org/wiki/Malaisehttp://en.wikipedia.org/wiki/Headachehttp://en.wikipedia.org/wiki/Cell_(biology)http://en.wikipedia.org/wiki/Brainhttp://en.wikipedia.org/wiki/Osmosishttp://en.wikipedia.org/wiki/Symptomhttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Stuporhttp://en.wikipedia.org/wiki/Convulsionhttp://en.wikipedia.org/wiki/Reflexhttp://en.wikipedia.org/wiki/Positive_feedback_loophttp://en.wikipedia.org/wiki/Vasopressinhttp://en.wikipedia.org/wiki/Malaisehttp://en.wikipedia.org/wiki/Headachehttp://en.wikipedia.org/wiki/Cell_(biology)http://en.wikipedia.org/wiki/Brainhttp://en.wikipedia.org/wiki/Osmosishttp://en.wikipedia.org/wiki/Symptom7/28/2019 Kuliah Water&Electr Imbalance 2010
44/78
Causes
Hyponatremia is caused by conditions such as water retention and renal failure that result
in a low sodium level in the blood.
Pseudohyponatremia occurs when too much water is drawn into the blood; it is
commonly seen in people with hypoglycemia (low blood sugar).
Psychogenic polydipsia occurs in people who compulsively drink more than four gallons
of water a day.
Hypovolemic hyponatremia (with low blood volume due to fluid loss) occurs in
dehydrated people who rehydrate (drink a lot of water) too quickly, in patients taking
thiazide diuretics, and after severe vomiting or diarrhea.
Hypervolemic hyponatremia (high blood volume due to fluid retention) occurs in people
with liver cirrhosis, heart disease, or nephrotic syndrome. Edema (swelling) often
develops with fluid retention.
Euvolemic hyponatremia (decrease in total body water) occurs in people with
hypothyroidism, adrenal gland disorder, and disorders that increase the release of theantidiuretic hormone (ADH), such as tuberculosis, pneumonia, and brain trauma.
7/28/2019 Kuliah Water&Electr Imbalance 2010
45/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
46/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
47/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
48/78
HYPERKALEMIA
Hyperkalemia may be caused by ketoacidosis (diabetic coma), myocardial
infarction (heart attack), severe burns, kidney failure, fasting, bulimia nervosa,gastrointestinal bleeding, adrenal insufficiency, or Addison's disease. Diuretic
drugs, cyclosporin, lithium, heparin, ACE inhibitors, beta blockers, and
trimethoprim can increase serum potassium levels, as can heavy exercise. The
condition may also be secondary to hypernatremia (low serum concentrations
of sodium).
7/28/2019 Kuliah Water&Electr Imbalance 2010
49/78
SYMPTOMS
Nonspecific and generally include malaise, palpitations and muscle weakness;
Mild hyperventilation may indicate a compensatory response to metabolic
acidosis, which is one of the possible causes of hyperkalemia.
Detected hyperkalemia
*during screening blood tests for a medical disorder,
* detected after complications have developed, such as cardiac arrhythmia
or sudden death.
*during the medical history taking, a physician will dwell on kidney disease
and medication use ( as these are the main causes) .
http://en.wikipedia.org/wiki/Malaisehttp://en.wikipedia.org/wiki/Palpitationshttp://en.wikipedia.org/wiki/Muscle_weaknesshttp://en.wikipedia.org/wiki/Metabolic_acidosishttp://en.wikipedia.org/wiki/Metabolic_acidosishttp://en.wikipedia.org/wiki/Blood_testhttp://en.wikipedia.org/wiki/Cardiac_arrhythmiahttp://en.wikipedia.org/wiki/Cardiac_arresthttp://en.wikipedia.org/wiki/Nephrologyhttp://en.wikipedia.org/wiki/Medicationhttp://en.wikipedia.org/wiki/Medicationhttp://en.wikipedia.org/wiki/Nephrologyhttp://en.wikipedia.org/wiki/Cardiac_arresthttp://en.wikipedia.org/wiki/Cardiac_arrhythmiahttp://en.wikipedia.org/wiki/Blood_testhttp://en.wikipedia.org/wiki/Metabolic_acidosishttp://en.wikipedia.org/wiki/Metabolic_acidosishttp://en.wikipedia.org/wiki/Muscle_weaknesshttp://en.wikipedia.org/wiki/Palpitationshttp://en.wikipedia.org/wiki/Malaisehttp://en.wikipedia.org/wiki/Medicationhttp://en.wikipedia.org/wiki/Nephrologyhttp://en.wikipedia.org/wiki/Cardiac_arresthttp://en.wikipedia.org/wiki/Cardiac_arrhythmiahttp://en.wikipedia.org/wiki/Blood_testhttp://en.wikipedia.org/wiki/Metabolic_acidosishttp://en.wikipedia.org/wiki/Metabolic_acidosishttp://en.wikipedia.org/wiki/Muscle_weaknesshttp://en.wikipedia.org/wiki/Palpitationshttp://en.wikipedia.org/wiki/Malaise7/28/2019 Kuliah Water&Electr Imbalance 2010
50/78
Diagnosis
Attention : Result increase K in serum can be due to hemolysis in the
sample.
The normal serum level of potassium is 3.5 to 5,3 mEq/L.
Generally, blood tests for renal function (creatinine, blood urea nitrogen),glucose and occasionally creatine kinase and cortisol will be performed.
In many cases, renal ultrasound will be performed, since hyperkalemia is highly
suggestive of renal failure.
Also, electrocardiography (EKG/ECG) may be performed to determine if there is asignificant risk of cardiac arrhythmias (see ECG/EKG Findings, below).
http://en.wikipedia.org/wiki/Hemolysishttp://en.wikipedia.org/wiki/Renal_functionhttp://en.wikipedia.org/wiki/Creatininehttp://en.wikipedia.org/wiki/Blood_urea_nitrogenhttp://en.wikipedia.org/wiki/Glucosehttp://en.wikipedia.org/wiki/Creatine_kinasehttp://en.wikipedia.org/wiki/Cortisolhttp://en.wikipedia.org/wiki/Medical_ultrasonographyhttp://en.wikipedia.org/wiki/Electrocardiographyhttp://en.wikipedia.org/wiki/Arrhythmiashttp://en.wikipedia.org/wiki/Hyperkalemiahttp://en.wikipedia.org/wiki/Hyperkalemiahttp://en.wikipedia.org/wiki/Arrhythmiashttp://en.wikipedia.org/wiki/Electrocardiographyhttp://en.wikipedia.org/wiki/Medical_ultrasonographyhttp://en.wikipedia.org/wiki/Cortisolhttp://en.wikipedia.org/wiki/Creatine_kinasehttp://en.wikipedia.org/wiki/Creatine_kinasehttp://en.wikipedia.org/wiki/Creatine_kinasehttp://en.wikipedia.org/wiki/Glucosehttp://en.wikipedia.org/wiki/Blood_urea_nitrogenhttp://en.wikipedia.org/wiki/Creatininehttp://en.wikipedia.org/wiki/Renal_functionhttp://en.wikipedia.org/wiki/Hemolysishttp://en.wikipedia.org/wiki/Hyperkalemiahttp://en.wikipedia.org/wiki/Arrhythmiashttp://en.wikipedia.org/wiki/Electrocardiographyhttp://en.wikipedia.org/wiki/Medical_ultrasonographyhttp://en.wikipedia.org/wiki/Cortisolhttp://en.wikipedia.org/wiki/Creatine_kinasehttp://en.wikipedia.org/wiki/Creatine_kinasehttp://en.wikipedia.org/wiki/Creatine_kinasehttp://en.wikipedia.org/wiki/Glucosehttp://en.wikipedia.org/wiki/Blood_urea_nitrogenhttp://en.wikipedia.org/wiki/Creatininehttp://en.wikipedia.org/wiki/Renal_functionhttp://en.wikipedia.org/wiki/Hemolysis7/28/2019 Kuliah Water&Electr Imbalance 2010
51/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
52/78
2.Excessive release from cells
Rhabdomyolysis, burns or any cause of rapid tissue necrosis, including tumor lysissyndrome
Massive blood transfusion or massive hemolysis
Shifts/transport out of cells caused by acidosis, low insulin levels, beta-blocker
therapy, digoxin overdose, or the paralyzing anesthetic succinylcholine
3. Excessive intakeIntoxication with salt-substitute, potassium-containing dietary supplements, or
potassium chloride (KCl) infusion. Note that for a person with normal kidney
function and nothing interfering with normal elimination (see above),
hyperkalemia by potassium intoxication would be seen only with large infusions of
KCl or massive doses of oral KCl supplements.
4.Lethal injection
Hyperkalemia is intentionally brought about in an execution by lethal injection,
with potassium chloride being the third and last of the three drugs administered to
cause death..
http://en.wikipedia.org/wiki/Rhabdomyolysishttp://en.wikipedia.org/wiki/Burn_(injury)http://en.wikipedia.org/wiki/Necrosishttp://en.wikipedia.org/wiki/Tumor_lysis_syndromehttp://en.wikipedia.org/wiki/Tumor_lysis_syndromehttp://en.wikipedia.org/wiki/Blood_transfusionhttp://en.wikipedia.org/wiki/Hemolysishttp://en.wikipedia.org/wiki/Acidosishttp://en.wikipedia.org/wiki/Insulinhttp://en.wikipedia.org/wiki/Beta-blockerhttp://en.wikipedia.org/wiki/Digoxinhttp://en.wikipedia.org/wiki/Succinylcholinehttp://en.wikipedia.org/wiki/Intoxicationhttp://en.wikipedia.org/wiki/Potassium_chloridehttp://en.wikipedia.org/wiki/Capital_punishmenthttp://en.wikipedia.org/wiki/Lethal_injectionhttp://en.wikipedia.org/wiki/Potassium_chloridehttp://en.wikipedia.org/wiki/Potassium_chloridehttp://en.wikipedia.org/wiki/Lethal_injectionhttp://en.wikipedia.org/wiki/Capital_punishmenthttp://en.wikipedia.org/wiki/Potassium_chloridehttp://en.wikipedia.org/wiki/Intoxicationhttp://en.wikipedia.org/wiki/Succinylcholinehttp://en.wikipedia.org/wiki/Digoxinhttp://en.wikipedia.org/wiki/Beta-blockerhttp://en.wikipedia.org/wiki/Insulinhttp://en.wikipedia.org/wiki/Acidosishttp://en.wikipedia.org/wiki/Hemolysishttp://en.wikipedia.org/wiki/Blood_transfusionhttp://en.wikipedia.org/wiki/Tumor_lysis_syndromehttp://en.wikipedia.org/wiki/Tumor_lysis_syndromehttp://en.wikipedia.org/wiki/Tumor_lysis_syndromehttp://en.wikipedia.org/wiki/Tumor_lysis_syndromehttp://en.wikipedia.org/wiki/Necrosishttp://en.wikipedia.org/wiki/Burn_(injury)http://en.wikipedia.org/wiki/Rhabdomyolysishttp://en.wikipedia.org/wiki/Potassium_chloridehttp://en.wikipedia.org/wiki/Lethal_injectionhttp://en.wikipedia.org/wiki/Capital_punishmenthttp://en.wikipedia.org/wiki/Potassium_chloridehttp://en.wikipedia.org/wiki/Intoxicationhttp://en.wikipedia.org/wiki/Succinylcholinehttp://en.wikipedia.org/wiki/Digoxinhttp://en.wikipedia.org/wiki/Beta-blockerhttp://en.wikipedia.org/wiki/Beta-blockerhttp://en.wikipedia.org/wiki/Beta-blockerhttp://en.wikipedia.org/wiki/Insulinhttp://en.wikipedia.org/wiki/Acidosishttp://en.wikipedia.org/wiki/Hemolysishttp://en.wikipedia.org/wiki/Blood_transfusionhttp://en.wikipedia.org/wiki/Tumor_lysis_syndromehttp://en.wikipedia.org/wiki/Tumor_lysis_syndromehttp://en.wikipedia.org/wiki/Tumor_lysis_syndromehttp://en.wikipedia.org/wiki/Tumor_lysis_syndromehttp://en.wikipedia.org/wiki/Necrosishttp://en.wikipedia.org/wiki/Burn_(injury)http://en.wikipedia.org/wiki/Rhabdomyolysis7/28/2019 Kuliah Water&Electr Imbalance 2010
53/78
Pseudohyperkalemia
Pseudohyperkalemia is a rise in the amount of potassium that occurs
due to excessive leakage of potassium from cells, during or after
blood is drawn.
Pseudohyperkalemia is typically caused by hemolysis during
venipuncture(by either excessive vacuum of the blood draw or by a
collection needle that is of too fine a gauge); excessive tournequet
time or fist clenching during phlebotomy (which presumably leads toefflux of potassium from the muscle cells into the bloodstream); or
by a delay in the processing of the blood specimen.
It can also occur in specimens from patients with abnormally high
numbers ofplatelets (>1,000,000/mm), leukocytes (> 10 000/mm),or erythrocytes (hematocrit > 55%). People with "leakier" cell
membranes have been found, whose blood must be separated
immediately to avoid pseudohyperkalemia.
http://en.wikipedia.org/wiki/Hemolysishttp://en.wikipedia.org/wiki/Venipuncturehttp://en.wikipedia.org/wiki/Platelethttp://en.wikipedia.org/wiki/Leukocytehttp://en.wikipedia.org/wiki/Erythrocytehttp://en.wikipedia.org/wiki/Cell_membranehttp://en.wikipedia.org/wiki/Cell_membranehttp://en.wikipedia.org/wiki/Cell_membranehttp://en.wikipedia.org/wiki/Cell_membranehttp://en.wikipedia.org/wiki/Erythrocytehttp://en.wikipedia.org/wiki/Leukocytehttp://en.wikipedia.org/wiki/Platelethttp://en.wikipedia.org/wiki/Venipuncturehttp://en.wikipedia.org/wiki/Hemolysishttp://en.wikipedia.org/wiki/Cell_membranehttp://en.wikipedia.org/wiki/Cell_membranehttp://en.wikipedia.org/wiki/Erythrocytehttp://en.wikipedia.org/wiki/Leukocytehttp://en.wikipedia.org/wiki/Platelethttp://en.wikipedia.org/wiki/Venipuncturehttp://en.wikipedia.org/wiki/Hemolysis7/28/2019 Kuliah Water&Electr Imbalance 2010
54/78
PATHO PHYSIOLOGY
Potassium is the most abundant intracellular cation. I
Important for many physiologic processes, including maintenanceof cellular membrane potential, homeostasis of cell volume, and
transmission ofaction potentials in nerve cells.
Main dietary sources are vegetables (tomato and potato), fruits
(orange and banana) and meat.
Elimination is through the gastrointestinal tract and the kidney.
The renal elimination of potassium is passive (through the
glomeruli), and resorption is active in the proximal tubule and the
ascending limb of the loop of Henle.There is active excretion of potassium in the distal tubule and the
collecting duct; both are controlled by aldosterone.
http://en.wikipedia.org/wiki/Membrane_potentialhttp://en.wikipedia.org/wiki/Homeostasishttp://en.wikipedia.org/wiki/Action_potentialhttp://en.wikipedia.org/wiki/Nerve_cellhttp://en.wikipedia.org/wiki/Vegetablehttp://en.wikipedia.org/wiki/Tomatohttp://en.wikipedia.org/wiki/Potatohttp://en.wikipedia.org/wiki/Orange_(fruit)http://en.wikipedia.org/wiki/Bananahttp://en.wikipedia.org/wiki/Meathttp://en.wikipedia.org/wiki/Gastrointestinal_tracthttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Glomerulihttp://en.wikipedia.org/wiki/Proximal_tubulehttp://en.wikipedia.org/wiki/Loop_of_Henlehttp://en.wikipedia.org/wiki/Distal_tubulehttp://en.wikipedia.org/wiki/Collecting_ducthttp://en.wikipedia.org/wiki/Aldosteronehttp://en.wikipedia.org/wiki/Aldosteronehttp://en.wikipedia.org/wiki/Collecting_ducthttp://en.wikipedia.org/wiki/Distal_tubulehttp://en.wikipedia.org/wiki/Loop_of_Henlehttp://en.wikipedia.org/wiki/Loop_of_Henlehttp://en.wikipedia.org/wiki/Proximal_tubulehttp://en.wikipedia.org/wiki/Glomerulihttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Gastrointestinal_tracthttp://en.wikipedia.org/wiki/Meathttp://en.wikipedia.org/wiki/Bananahttp://en.wikipedia.org/wiki/Orange_(fruit)http://en.wikipedia.org/wiki/Potatohttp://en.wikipedia.org/wiki/Tomatohttp://en.wikipedia.org/wiki/Vegetablehttp://en.wikipedia.org/wiki/Nerve_cellhttp://en.wikipedia.org/wiki/Action_potentialhttp://en.wikipedia.org/wiki/Homeostasishttp://en.wikipedia.org/wiki/Membrane_potentialhttp://en.wikipedia.org/wiki/Aldosteronehttp://en.wikipedia.org/wiki/Collecting_ducthttp://en.wikipedia.org/wiki/Distal_tubulehttp://en.wikipedia.org/wiki/Loop_of_Henlehttp://en.wikipedia.org/wiki/Loop_of_Henlehttp://en.wikipedia.org/wiki/Proximal_tubulehttp://en.wikipedia.org/wiki/Glomerulihttp://en.wikipedia.org/wiki/Kidneyhttp://en.wikipedia.org/wiki/Gastrointestinal_tracthttp://en.wikipedia.org/wiki/Meathttp://en.wikipedia.org/wiki/Bananahttp://en.wikipedia.org/wiki/Orange_(fruit)http://en.wikipedia.org/wiki/Potatohttp://en.wikipedia.org/wiki/Tomatohttp://en.wikipedia.org/wiki/Vegetablehttp://en.wikipedia.org/wiki/Nerve_cellhttp://en.wikipedia.org/wiki/Action_potentialhttp://en.wikipedia.org/wiki/Homeostasishttp://en.wikipedia.org/wiki/Membrane_potential7/28/2019 Kuliah Water&Electr Imbalance 2010
55/78
Treatment
Acute:When arrhythmias occur, or when potassium levels exceed 6.5 mmol/l--- EMERGENCY
Several agents are used to lower K levels.
Calcium supplementation (calcium gluconate 10% (10ml), preferably through a central
venous catheter , does not lowering potassium but decreases myocardial excitability,
protecting against life threatening arrhythmias.
Insulin(e.g. intravenous injection of 10-15u of regular insulin will lead to a shift ofpotassium ions into cells, secondary to increased activity of the sodium-potassium
ATPase.
Bicarbonate therapy is effective in cases of metabolic acidosis. The bicarbonate ion will
stimulate an exchange of cellular H+ for Na+, thus leading to stimulation of the sodium-
potassium ATPase.
Salbutamol (albuterol, Ventolin) is a 2-selective catecholamine that is administered bynebulizer (e.g. 10-20 mg). This drug promotes movement of K into cells, lowering the
plasmalevels.
Dialysis in refractory or severe cases may need to remove the potassium from the
circulation.
http://en.wikipedia.org/wiki/Central_venous_catheterhttp://en.wikipedia.org/wiki/Central_venous_catheterhttp://en.wikipedia.org/wiki/Myocardiumhttp://en.wikipedia.org/wiki/Arrhythmiashttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Arrhythmiashttp://en.wikipedia.org/wiki/Myocardiumhttp://en.wikipedia.org/wiki/Central_venous_catheterhttp://en.wikipedia.org/wiki/Central_venous_catheterhttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Sodium-potassium_ATPasehttp://en.wikipedia.org/wiki/Arrhythmiashttp://en.wikipedia.org/wiki/Myocardiumhttp://en.wikipedia.org/wiki/Central_venous_catheterhttp://en.wikipedia.org/wiki/Central_venous_catheter7/28/2019 Kuliah Water&Electr Imbalance 2010
56/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
57/78
Principal causes of potassium depletion.
1. Deficient dietary intake2.Excessive losses
A.Gastrointestinal
a.Protracted vomiting
b.Diarrheac.Fistula
d.Laxative abuse
B..Renal
a. metabolic alkalosis
b.Diuretics
c.Aldosteronism
d.Tubular dysfunction
7/28/2019 Kuliah Water&Electr Imbalance 2010
58/78
A major cause ofpotassium depletion is diuretic use.Diuretics that block sodium reabsorption in the renal tubule at site proximal
to where sodium potassium exchange occurs.
There fore more sodium is delivered to these sites for exchange.
Furthermore, because of ECV depletion from the saline diuresis ,aldostreron is stimulated enhancing potassium secretion
The symptoms and signs of potassium depletion usually do
not appear until deficiency is marked.
7/28/2019 Kuliah Water&Electr Imbalance 2010
59/78
Determination of plasma potassium is the most valuable aid in
the diagnosis of potassium depletion .
When hypokalemia is present and before any therapy is given,
the urinary potassium concentration is helpful in defining the
etiology of depletion.
If the urine potassium is less than 10 mEq/L , non renal losses
should be defining the etiology of depletion .When urine potassium concentrations exceeds 10 mEq/L,
depletion is probably secondary to renal losses.
In summary , potassium depletion may be suggested by :
1.Recognition of causative events.2.Symptoms and signs of neuromuscular dysfunction
3.electrocardiographic changes.
7/28/2019 Kuliah Water&Electr Imbalance 2010
60/78
SYMPTOMS
Irregular heartbeat, which can range from mild to severe.Severe cases can result in cardiac arrest and paralysis of thelungs.
Other symptoms muscle weakness, cramping, or flaccid
paralysis (limpness); leg discomfort; extreme thirst; frequent
urination; and confusion.
Infants and young children with gastrointestinal
illnesses that cause prolonged vomiting and diarrhea
can die from cardiac arrest when potassium levels
become dangerously low.
7/28/2019 Kuliah Water&Electr Imbalance 2010
61/78
DIAGNOSE
Hypokalemia is diagnosed by measuring the
potassium levels in a blood sample.
Normal blood potassium :3.5 to 5.3 (mEq/L)To determine the cause of hypokalemia, --- also
check potassium levels in a urine sample----also
order test electrocardiogram (ECG or EKG).
EKG : prominent u waves with flat T
7/28/2019 Kuliah Water&Electr Imbalance 2010
62/78
TREATMENT
In most cases /mild and moderate case treated by increasing the amounts of
potassium-rich foods in the diet, drinking electrolyte replacement fluids during
intense exercise or for severe vomiting or diarrhea, or by taking a potassium
supplement .
Severe hypokalemia is treated in a hospital with intravenous (IV) potassium.
It is important to have the potassium levels in the blood checked regularly if
taking diuretics or conditions.
It is difficult to predict if hypokalemia will occur with vomiting and diarrhea or
with diuretic use.
7/28/2019 Kuliah Water&Electr Imbalance 2010
63/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
64/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
65/78
HYPERCALCEMIA
Blood calcium levels may be elevated
*IN CASES OF HYPO THYROID calcitonin decreaserenal excretionand bone formation decrease .
*HYPER PARATHYROID (adenoma, carcinoma) stimulating
osteoclast and increasing absorption in GIT & renal retention
* TUMOR PROMOTE BONE BREAK DONE OR CA RELEASE FROM
BONE :Multiple myeloma, metastatic cancer in bone , multiplebone fractures, and Paget's disease.
*EXCESSIVE USE OF CALCIUM-CONTAINING SUPPLEMENTS AND
MEDICATIONS (i.e., antacids) may also cause hypercalcemia.
*IN INFANTS, lesser known causes may include blue diaper
syndrome, Williams syndrome, secondary hyperparathyroidism
from maternal hypocalcemia, and dietary phosphate deficiency.
*GFR DECREASE /renal disease : ca retention
*MILK ALKALI SYNDROME : massive Ca ingestion in GIT
7/28/2019 Kuliah Water&Electr Imbalance 2010
66/78
Symptoms :fatigue
constipation
depression
confusionmuscle pain
nausea and vomiting
dehydration
increased urination
irregular heartbeat (arrhythmia)/severe case
7/28/2019 Kuliah Water&Electr Imbalance 2010
67/78
TREATMENT:
IF THE CALCIUM LEVEL IS VERY HIGH, RAPID TREATMENT IS NEEDED. GIVING
FLUIDS INTRAVENOUSLY, Often, drugs such as calcitonin and bisphosphonatesmust be given intravenously--- These drugs decrease the amount of bone being
broken down and thus the amount of calcium released into the bloodstream.
When the cause is cancer or Paget's disease, bisphosphonates are often taken
by mouth indefinitely.
When the cause is a tumor in the parathyroid gland, surgery to remove the
tumor or part of the parathyroid gland may be done.
7/28/2019 Kuliah Water&Electr Imbalance 2010
68/78
7/28/2019 Kuliah Water&Electr Imbalance 2010
69/78
SYMPTOMS :
WEAKNUMBNESS IN THE HANDS OR FEET.
MUSCLE CRAMPS AND SPASMS
TETANY AND/OR CONVULSIONS
MOOD CHANGES (DEPRESSION, IRRITABILITY)DRY SKIN
BRITTLE NAILS
FACIAL TWITCHING
TREATMENT :
INVOLVES TAKING CALCIUM SUPPLEMENTS BY MOUTH.
IF A DISORDER IS THE CAUSE, IT SHOULD BE TREATED.
7/28/2019 Kuliah Water&Electr Imbalance 2010
70/78
HYPERMAGNESEMIAExcessive magnesium levels may occur with
end-stage renal disease, Addison's disease, or
an overdose of magnesium salts.Hypermagnesemia is characterized by:
lethargy
hypotension
decreased heart and respiratory rate
muscle weakness
diminished tendon reflexes
7/28/2019 Kuliah Water&Electr Imbalance 2010
71/78
HYPOMAGNESEMIA
CAUSES
Common cause : Inadequate dietary intake , often caused by
chronic alcoholism or malnutrition.
Other causes include malabsorption syndromes, pancreatitis,
aldosteronism, burns, hyperparathyroidism, digestive system
disorders, and diuretic use.Symptoms :
leg and foot cramps
weight loss
vomitingmuscle spasms, twitching, and tremors
seizures
muscle weakness
arrthymia
7/28/2019 Kuliah Water&Electr Imbalance 2010
72/78
HYPERCHLOREMIA
Severe dehydration, kidney failure, hemodialysis, traumatic
brain injury, and aldosteronism can also cause hyperchloremia.
Drugs such as boric acid and ammonium chloride and the
intravenous (IV) infusion of sodium chloride can also boost
chloride levels, resulting in hyperchloremic metabolic acidosis.Symptoms include:
weakness
headache
nauseacardiac arrest
7/28/2019 Kuliah Water&Electr Imbalance 2010
73/78
HYPOCHLOREMIA
Hypochloremia usually occurs as a result of sodium and potassium
depletion (i.e., hyponatremia, hypokalemia). Severe depletion of
serum chloride levels causes metabolic alkalosis.
Symptoms include:
mental confusion
slowed breathing
paralysis
muscle tension or spasm
7/28/2019 Kuliah Water&Electr Imbalance 2010
74/78
HYPERPHOSPHATEMIA
Skeletal fractures or disease, kidney failure,hypoparathyroidism, hemodialysis, diabetic ketoacidosis,
acromegaly, systemic infection, and intestinal obstruction can
all cause phosphate retention and build-up in the blood. The
disorder occurs concurrently with hypocalcemia.mild hyperphosphatemia : asymptomatic
severe hyperphosphatemia include :
tingling in hands and fingers
muscle spasms and crampsconvulsions
cardiac arrest
7/28/2019 Kuliah Water&Electr Imbalance 2010
75/78
HYPOPHOSPHATEMIA
Serum phosphate levels of 2 mg/dL or below may be
caused by hypomagnesemia and hypokalemia. Severe
burns, alcoholism, diabetic ketoacidosis, kidney disease,
hyperparathyroidism, hypothyroidism, Cushing'ssyndrome, malnutrition, hemodialysis, vitamin D
deficiency, and prolonged diuretic therapy can also
diminish blood phosphate levels.
Symptoms of severe hypophosphatemia include:muscle weakness
weight loss
bone deformities (osteomalacia)
7/28/2019 Kuliah Water&Electr Imbalance 2010
76/78
THE END
7/28/2019 Kuliah Water&Electr Imbalance 2010
77/78
Bicarbonate
The bicarbonate ion acts as a buffer to maintain the normal levels of acidity (pH) in
blood and other fluids in the body.
Bicarbonate levels are measured to monitor the acidity of the blood and body
fluids.
The acidity is affected by foods or medications that we ingest and the function ofthe kidneys and lungs.
The chemical notation for bicarbonate on most lab reports is HCO3- or
represented as the concentration of carbon dioxide (CO2). The normal serum
range for bicarbonate is 22-30 mmol/L.
The bicarbonate test is usually performed along with tests for other blood
electrolytes.
Disruptions in the normal bicarbonate level may be due to diseases that interfere
with respiratory function, kidney diseases, metabolic conditions, or other causes.
7/28/2019 Kuliah Water&Electr Imbalance 2010
78/78
ADDISON DISEASE :
caused by destruction or dy;sfunction of adreno coritices . Chronic
deff cortisol, aldosteron, adrenal androgens
Acute Adrenal Insufficiency primary
--- insuff cortisol
Adrenal crisis may occur :
1Following stress : trauma, surgery, infection
2.following sudden with drawal of adrenocortic hormon