Objectives Review causes and clinical manifestations of severe electrolyte disturbances Outline emergent management of electrolyte disturbances Recognize acute adrenal insufficiency and appropriate treatment Describe management of severe hyperglycemic syndromes Review causes and clinical manifestations of severe electrolyte disturbances Outline emergent management of electrolyte disturbances Recognize acute adrenal insufficiency and appropriate treatment Describe management of severe hyperglycemic syndromes

Principles of Electrolyte Disturbances Implies an underlying disease process Treat the electrolyte change, but seek the cause Clinical manifestations usually not specific to a particular electrolyte change, e.g., seizures, arrhythmias Implies an underlying disease process Treat the electrolyte change, but seek the cause Clinical manifestations usually not specific to a particular electrolyte change, e.g., seizures, arrhythmias

Principles of Electrolyte Disturbances Clinical manifestations determine urgency of treatment, not laboratory values Speed and magnitude of correction dependent on clinical circumstances Frequent reassessment of electrolytes required Clinical manifestations determine urgency of treatment, not laboratory values Speed and magnitude of correction dependent on clinical circumstances Frequent reassessment of electrolytes required

Hypokalemia Neuromuscular manifestations (weakness, fatigue, paralysis, respiratory dysfunction) GI (constipation, ileus) Nephrogenic DI ECG changes (U waves, flattened T waves) Arrhythmias

Hypokalemia Spurious hypokalemia  Marked leukocytosis  A dose of insulin right before the blood draw Redistribution hypokalemia  Alkalosis (K decreases.3 for every.1 increase in pH)  Increased Beta 2 adrenergic activity  Theophylline toxicity  Familial

Hypokalemia Extrarenal depletion  diarrhea  laxative abuse  sweat losses  fasting or inadequate intake

Hypokalemia Renal potassium depletion  urine potassium > 20 mEq/24 hrs  spot urine with > 20 mEq K/gram creatinine  classified whether they occur with a metabolic alkalosis vomiting/NG suction diuretic tx Mineralocorticoid excess syndromes

Hypokalemia Renal losses  metabolic acidosis RTA Type I and II DKA Carbonic anhydrase inhibitor therapy Ureterosigmoidostomy  No acid-base disorder Mg deficiency Drugs

Hyperkalemia Severe hyperkalemia is a medical emergency Neuromuscular signs (weakness, ascending paralysis, respiratory failure) Progressive ECG changes (peaked T waves, flattened P waves, prolonged PR interval, idioventricular rhythm and widened QRS complex, “sine wave” pattern, V fib)

Hyperkalemia Etiology – renal failure, transcellular shifts, cell death, drugs, pseudohyperkalemia Manifestations – cardiac, neuromuscular Etiology – renal failure, transcellular shifts, cell death, drugs, pseudohyperkalemia Manifestations – cardiac, neuromuscular

Hyperkalemia Impaired potassium secretion  Aldosterone deficiency adrenal failure Syndrome of hyporeninemic hypoaldosteronism (SHH) tubular unresponsiveness  Renal failure GFR < % of normal

Hyperkalemia Treatment  Stop potassium!  Get and ECG  Hyperkalemia with ECG changes is a medical emergency

Hyperkalemia Treatment  First phase is emergency treatment to counteract the effects of hyperkalemia IV Calcium  Temporizing treatment to drive the potassium into the cells glucose plus insulin Beta 2 agonist NaHCO 3

Hyperkalemia Treatment  Therapy directed at actual removal of potassium from the body sodium polystyrene sulfonate (Kayexalate) dialysis  Determine and correct the underlying cause

Body Fluid Distribution Water[Na] [K] (L)(mmol/L) (mmol/L) ECF Vascular31405 Interstitial ICF Intracellular TOTAL42