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
Normal (135-145 meql) Hypernatremia
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
NaCl 450 mM 3 840 mOsm
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
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
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)
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
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
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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
Normal (135-145 meql) Hypernatremia
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
NaCl 450 mM 3 840 mOsm
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
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
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)
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
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
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
3
Regulation of Sodium It is affected by hormones
Aldosterone Reninangiotensin Atrial Natriuretic Peptide (ANP) ADH
Serum sodium
Normal (135-145 meql) Hypernatremia
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
NaCl 450 mM 3 840 mOsm
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
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
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)
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
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
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Serum sodium
Normal (135-145 meql) Hypernatremia
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
NaCl 450 mM 3 840 mOsm
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
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
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)
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
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
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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
NaCl 450 mM 3 840 mOsm
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
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
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)
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
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
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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
NaCl 450 mM 3 840 mOsm
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
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
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)
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
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
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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
NaCl 450 mM 3 840 mOsm
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
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
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)
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
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
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Major Intravenous Solutions
Name Contents Distribution
Half-NormalSaline
NaCl 75 mM 045 140 mOsm
ICF ECF 1 2
HypertonicSaline
NaCl 450 mM 3 840 mOsm
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
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
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)
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
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
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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
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
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)
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
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
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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
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
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)
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
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
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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
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)
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
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
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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)
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
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
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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
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
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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)
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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 deficiency
bull Drug interference as ACEI and K+ sparing diuretics
D- FactitiousHaemolysis of blood sample
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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)
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Antagonism of membrane actionIntravenous calcium
Intracellular shiftInsulin (Dextrose)NaHCO3szlig-2 agonists
RemovalDiureticsCationexchange resinDialysis
Treatment of Hyperkalemia
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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
Labs Serum Na 136 (135-142)Serum K 74 (35-55)Serum creatinine 23 (08-12)
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
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
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
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
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
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
Thanks
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