2CASE 1Mr. B. is a patient in the intensive care unit with ARF whose arms are observed to flex in intermittent involuntary tonic contractions. Urea and electrolyte results revealed the following (normal value)Sodium mmol/L ( )Potassium mmol/L ( )Calcium mmol/L ( )Phosphate mmol/L ( )Urea mmol/L ( )Creatinine μmol/L (50-120)Question:What is the cause of this condition and how should it be treated?
3CASE 2Mr D has been admitted to an intensive care unit with ARF which developed following a routine cholecystectomy . his electrolyte picture shows the followingSodium mmol/L ( )Potassium mmol/L (3.5-5)Urea mmol/L (3-6.5)Bicarbonate 19 mmol/L (22-31)Creatinine μmol/L (50-120)pH ( )
4CASE 2the patient was connected to an ECG monitor and the resultant trace indicated absent p-wave and a broad QRS complex.Question:Explain the biochemistry and ECG abnormalities and indicate what therapeutic measures must be implemented.
5Answer of case 1 Convulsion is due to electrolyte disturbance Treatment:Correction of electrolytes (ca- gluconate , phosphate binder)Anticonvulsant and hemodialysis
6Answer of case 2Hyperkalemia is one of the principal problems encountered in patients with renal failure.The increased levels of k arise from failure of the excretory pathway &also from intracellular release of k. attention should also be paid to pharmacological or pharmaceutical processes that might lead to k elevation “k-supplement, ACE I “. The acidosis noted in this patient, which is common in ARF, also aggravates hyperkalemia by promoting leakage of k from cells. Serum k level greater than 7 m mol\L indicates that emergency ttt is required as the patient risk-life-threatening ventricular arrhythmia &asystolic cardiac arrest if EEG changes are present as in this case emergency ttt should be initiated when serum k rise above 6.5 m mol\L .
7Answer of case 2 The emergency ttt should include the following: 1-Stabilization of the myocardium by I.V administration of ml ca.gluconate 10% over 5-10 min the effect is temporary but the dose can be repeated.2-I.V adm. Of units of soluble insulin with 50 ml of 50% glucose to stimulate cellular k uptake the dose may be repeated. The blood glucose should be monitored for at least 6 hr to avoid hyperglycemia.
8Answer of case 23-I.V salbutamol 0.5 mg in 100ml 5%dextrose over 15 min has been used to stimulate the cellular sod-k-atpase pump & thus drive k into cells. This may cause disturbing muscle tremors at the doses required to reduce serum k levels.4-Acidosis may be corrected with I.V dose ml of NaHCO3 8.4% correction of acidosis stimulates cellular k –uptake. Hypertonic HCO3 soln(8.4%)can cause volume expansion & should be used with extreme caution.