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2. A 5 years old child admitted with loose motion for 2 days and abdominal distension for 6 hours. The Child was severely dehydrated, floppy, lethargic. How to Diagnose and manage the child?

3. Common Problem ???

4. Management of Dyselectrolytemia at our situation.
Presented by
Dr. Abdullah Al Mamun
Dr. Azizur Rahman
Dr. Shahana ferdous

5. Sodium Dominant cation of ECF.
Principal determinant of extracellular osmolality.
>40% total body Na+ is in Bone.
Remainders in interstitial & intravascular space.
Daily requirement 2-3 mEq/Kg
Normal serum value mEq/L.

6. Function: Principal determinant of extracellular osmolality.
Maintain neuromuscular conductivity.
Maintain cardiac rhythmicity & contractility.
Forms Alkali reserve of the body.

7. Absorption
Throughout the gut mostly by diffusion. Mineralocorticoid increase absorption.
Glucose enhance by Na-Glucose co-transport.

8. Excretion Multifactorial & is the determinant of Na balance.
Excreted through Kidney, stool & sweat.
Regulated by effective plasma volume which determines the Na+ in Urine.
99% filtered Na reabsorbed in kidney.
Increase sweat Na+ in cystic fibrosis, aldosterone defc., pseudo aldosteronism.

9. Hyponatremia
Very common electrolyte abnormality in Hospitalized patient.
Serum Na+ conc. <135 mEq/L
Ratio of H2O to Na increases.

10. Causes Pseudohyponatremia Hyperosmolality Hyperglycemia Mannitol
Water moves
from ICF to ECF

11. Hypovolemic Hypohyponatremia
Extrarenal losses:
GIT
Skin

12. 2. Renal losses: Loop diuretics Osmotic diuresis
Postobstructive diuresis
Polyuric phase of ATN
AR PCKD
Tubulointerstitial nephritis
Obstructive uropathy
Cerebral salt wasting
RTA ( Type 2 )
Lack of Aldosterone

13. 3. Euvolemic Hyponatremia
SIADH
Desmopressin Acetate
Glucocorticoid defc.
Hypothyroidism.
Water intoxication

14. 4. Hypervolemic Hyponatremia:
CCF
Cirrhosis NS RF
Sepsis
Hypoalbuminemia due to GIT disease.

15. Clinical Manifestations
Chronic hyponatremia even with Na+ 110 mEq/L may be asymptomatic.
Acute hyponatremia in serum conc. From 140 to 125 mEq/L may cause seizure.
Muscle cramp & weakness.
More manifestation of dehydration.

16. Clinical Manifestations (con…)
Symptoms occur due to brain cell swelling
Anorexia, vomiting, nausea,
diminish reflexes
agitation, lethargy, confusion
headache
seizure
coma.
Acute severe hyponatremia may cause brainstem herniation & Apnea.

17. Diagnosis History & physical examination Investigations:
Find out causes
Degree of dehydration.
Investigations:
Serum Electrolytes
Osmolality
Urinary Na+
Non Renal <10 mEq/L
Renal >20 mEq/L

18. Correction of Hyponatremia
Treatment depends on :
- Etiology and types of hyponatremia.
- Clinical condition.
- Serum Na+ level.
- Ongoing loss.

19. Level of Hyponatremia Usually correction not needed at 135-140 mmol/L
Mild : < mmol/L
Moderate : < mmol/L
Severe : < 115 mmol/L
( Ref: Harrison)

20. Formula of correction
mmol Na+ needed to correct the deficit = 0.6 X Wt X [ Des-Mes]
( Ref: Nelson )

21. Flow Chart of management of hyponatremia
Hypovolumia
Yes No
Shock
No Shock
Correction of
the
cause then
correction of Na+.
Follow Steps
of Protocol 3
Follow steps
of protocol 1
Follow steps
of protocol 2
( Ref: Nelson )

22. Steps of Protocol 1: Correction of Hypovolumic hyponatremia.
Step 1: If associated with Shock Replace intravascular volume with
NS 20ml/Kg over 20 min.
May Repeat if needed.
Step 2: Rapid volume repletion with NS 20ml/Kg over 2 hr.
Step 3: Calculate 24 hr fluid needs: Maintenance + Deficit

23. cont...
Step 4: Subtract Isotonic fluid already administered from 24 hr fluid need.
Step 5: Administer remaining fluid over 24 hr using D1/2 NS + 20 meq/L KCl
Step 6 : Replace ongoing loss as they occur.
( Ref: Nelson )

24. Protocol 2: for correction of Hyponatremia.
Step 1: Calculate the deficit using formula.
Step 2: Assess the level of deficit
( Mild/Moderate/Severe)
Step 3 : Calculate the maintenance and
ongoing loss.
Step 4 : Choose the Drug
Step 5 : Choose the route
Step 6 : Check for co-morbidity and conditions.
( Ref: Nelson )

25. Steps of Protocol 3: Isovolumic Hyponatremia: - Water restriction.
- Diuretics
- May need to follow Protocol 2.
- Treatment of the specific cause.
- Conivaptan (newer drug, V 2 receptor antagonist in renal tubule) may be used in SIADH.
( Ref: Nelson )

26. Cont... Hypervolumic Hyponatremia. - Water and Na+ restriction.
- Diuretics may help.
- Treatment of the cause.
( Ref: Nelson )

27. Correction Of going loss
Steps:
- Calculate the volume loss of stool or emesis matter.
- Volume X Na+ content of the fluid lost.
- Add this amount with the deficit value and maintenance value.
Total = Deficit + Maintenance + On going loss.

28. Mild Hyponatremia Usually asymptomatic.
Oral correction with Table salt or ORS solution should be used.
- 1 tsf table salt = 5 gm = 85 mmol
- 1 gm = 17 mmol
- 1 tsf ORS solution = 0.3 mmol
- Give correction over 24 hours.

29. Example: A 6 year old boy weighing 20 kg , S. Na+ is 128 mmol/L
Example: A 6 year old boy weighing 20 kg , S. Na+ is 128 mmol/L. How to correct?
Deficit = 0.6 X 20 X [ ]
= 14.4 mmol.
Maintenance = 3 X 20 = 60 mmol
Total = 74.4 mmol + Ongoing loss if present.
So, 248 tsf = 1240 ml ORS Solution should be given over 24 hrs + Ongoing loss.

30. Moderate Hyponatremia
Usually symptomatic
Correction not more than 0.5mmol/L/hr = 12 mmol/L/24 hr
So calculate the total duration.
Use Na+ containing fluid with 20 meq/L KCl.
Usually < 10 kg child should get
D1/4 NS and > 10 Kg child should get
D ½ NS. ( Ref: Nelson )

31. Example: A 5 year old boy weighing 16 kg ,S. Na+ is 116 mmol/L
Example: A 5 year old boy weighing 16 kg ,S. Na+ is 116 mmol/L. How to correct?
Correction time 48 hrs.
Deficit = 0.6 X 16 X [ ]
= mmol
Maintenance = 3 X 16 = 48 mmol/ 24 hrs
Total = mmol
IV fluid maintenance = 1300ml/24hrs
= 2600ml/48hrs.
So, 5% DNS 1000ml = 133 mmol
5% D1/2 NS 1000ml = 77 mmol
5% DA ml = 0 mmol with 1 amp KCl/L Fluid 55 μdrops/min over 48 hrs will correct the condition.

32. Severe Hyponatremia Usually neurological signs present.
Slow correction is the choice in chronic cases.
Acute hyponatremia can be corrected rapidly.
Rapid correction may cause Central Pontine Myelinolysis ( CPM )
So, calculate the total duration of correction.
Acute neurological signs such as seizure can be corrected by using IV 3% NaCl 4 ml/Kg over 4 hrs.
( Ref: Nelson )

33. CPM
Hypernatremia causes generation of Idiogenic Osmole production in neuron. So when hypotonic fluid is present in ECF cerebral edema and myelin breakdown occurs which is called Central Pontine Myelinolysis. It is a grave condition and mortality is high.
C/F: - Confusion
- Agitation.
- Flaccid or spastic quadriplegia and death.
Treatment : Rapid IV 3% NaCl 4 ml/Kg over 4 hrs.

34. Example: A 5 year old boy with convulsion weighing 16 kg , S
Example: A 5 year old boy with convulsion weighing 16 kg , S. Na+ is 108 mmol/L. How to correct?
Duration : = 27/10 = 2.7 days.
Acute correction: 4ml/Kg IV 3% NaCl over 4 hrs = 64 ml . It corrects = 4 mmol
Usually 1ml/Kg 3%NaCl corrects serum Na+ 1 mmol/L
Daily correction 10 mmol/L
Rest 6 mmol correction needed = 0.6X16X6 = 57.6 mmol Na+
Daily maintenance = 3X16=48 mmol

35. Cont… Total = 105.6 mmol 1 ml 3% NaCl= 0.514 mmol
So 3% NaCl needed=205.4 ml
So 1st Day = Inf 3% NaCl 16 μdrops/min for 4 hours then 10 μdrops/min over next 20 hours.
Then 11 μdrops/min continue for next 36 hrs.
Correction may be done with NS or ORS solution from 2nd day.

36. Hypernatremia Serum Na+ conc. > 145 mEq/L (>150 mEq/L).
Mild hypernatremia fairly common in children.
Hypernatremia in hospitalized pt. may be iatrogenic.

37. Causes of Hypernatremia
1. Excessive Sodium:
Improperly mixed formula
Excess NaHCO3
Ingestion of sea water
IV hypertonic Saline
Hyperaldosteronism

38. Causes of Hypernatremia (con….)
2. Water deficit
Diabetes Insipidus
Increased insensible loss
Inadequate intake
3. Water & sodium deficit
GIT loss
Diarrhea
Emesis/NG suction
Lactulose

39. Causes of Hypernatremia (con….)
Cutaneous losses
Burn
Excess sweating.
Renal losses
Osmotic Diuretics DM
Chr. Kidney disease
Polyuric phase of ATN
Post obstructive Diuresis.

40. Clinical Manifestations
Dehydration is common
Pts are irritable, thirsty, weak & lethargic.
High pitched cry, fever.
Skin is doughy.
Seizure & coma due to brain Hmrg.
Thrombotic complications.

41. Diagnosis History. Physical Examination. Investigations
S. Electrolytes
Blood & Urine Osmolality
H2O Deprivation test
Urinary Na+

42. Correction of Hypernatremia
Acute hypernatremia can be corrected rapidly
Chronic hypernatremia should be corrected slowly. Not lowering serum Na+ level > 12 mmol/L/24 hrs that is not >0.5mmol/L/hr.
(Ref: Nelson)

43. Principles of correction
Rehydrate slowly ( Over hrs)
Oral Rehydration is preferable to IV
Serum Na+ should not drop by more than mmol/L/24 hrs
Treat other co-morbidities
Continue breast feeding if age < 2 yrs.
(Ref: icddr’b)

44. Some Notes
If severe dehydration : NS 20 ml/Kg over 20 mins should be given. May be repeated.
Do not use hypotonic fluid to correct hyponatremic dehydration.
Time Frame for correction of dehydration: meq/L hrs
meq/L hrs
meq/L hrs
meq/L hrs
Typical fluid for correction is D1/2 NS or
D ¼ NS with 20 meq KCl /L.
Typical rate times of maintenance.

45. Cont...
2 IV line with D1/2 NS in one channel and D1/4 NS in another channel helps better adjustment.
Close F/U of Serum Na+ value.
- If Na+ is decreasing slowly:
 Conc. of Na+
or  rate of IV fluid.
- If Na+ is decreasing rapidly:
 Conc. of Na+
or  rate of IV fluid.
ORS solution over hrs can be used to correct hyponatremic dehydration.
(Ref: Nelson)

46. Diagnostic Criteria of SIADH
1. Absence of
Renal, adrenal, thyroid insufficiency.
CCF, NS, Cirrhosis.
Dehydration.
Diuretic ingestion.
2. Urine Osmolality > 100 ( > Plasma )
3. Serum osmolality <280
4. Serum Na+ < 135
5. Urine Na+ > 25

47. Potassium The principal Intra Cellular Cation
About 30 times higher in ICF
Majority in Muscle
<1% in Plasma
Plasma conc. Does not reflex total body K+ content
Normal value in serum mEq/L
Daily requirement 1-2 mEq/Kg/day

48. Functions Main intracellular cation
Maintain membrane potential of all irritable cells
Influence the activity of cardiac muscles
Essential in conducting nerve impulse.

49. Absorption
About 90% of ingested K+ is absorbed mostly in small intestine
Small amount secreted from Colon.

50. Excretion Mostly excreted by Kidneys
About 10-15% filtered K+ is excreted
90% reabsorption in PT
In DCT & CT secretion in exchange of Na+ (Aldosterone mediated)

51. Hyperkalemia Serum K+ >5.5 mEq/L.
Most alarming electrolytes abnormality.
Potential for lethal arrythmia.

52. Causes of Hyperkalemia
Spurious lab value:
Haemolysis
Tissue ischaemia
Thrombocytosis
Leukocytosis
Increased intake:
Oral/IV BT

53. Causes of Hyperkalemia (con…)
Transcellular shift
Acidosis
Rhabdomyolosis
Tumour lysis syndrome
Haemolysis/GI bleeding
Exercise
Insulin defc.
β-adrenergic blocker
Hyperkalemic periodic paralysis

54. Causes of Hyperkalemia (con…)
Decreased excretion:
Renal failure
Primary Adrenal disease
RTA
Medications
ACE inhibitors
K+ sparing diuretics

55. Clinical Manifestations
Cardiac arrythmia may occur without other symptoms.
Skeletal muscle-weakness, tingling, paraesthesia,fasciculation, paralysis.

56. Diagnosis History & physical exam. Investigations:
S. Electrolytes
ECG
Blood gas analysis
TTKG (normal 5-15)
<8 indicates defect in renal excretion.
transtubular potassium gradient (TTKG)

57. ECG Change Serum K+ ECG Change 6-7.5 mEq/L Tall peak T wave 8.0 mEq/L
Prolonged PR
Wide QRS
9.0 mEq/L
ST depression
Further widening QRS
10.0 mEq/L
Bradycardia
Sine wave
Ventricular arrythmia
Asystole

59. Hypokalemia
Serum K+ <3.5 mEq/L

60. Causes of Hypokalemia Spurious: Trascellular shift: Decreased uptake:
High WBC count (if stored in room temp.)
Trascellular shift:
Alkalemia
Insulin
β-adrenergic agonist
Hypokalemic periodic paralysis.
Decreased uptake:
PEM

61. Causes of Hypokalemia (con…)
Renal loss
RTA (Type 1 & 2)
DKA with metabolic alkalosis
Emesis/NG suction
Chloride loosing diarrhoea
Cystic fibrosis
Loop & Thiazide diuretics
Adrenal adenoma/hyperplasia
Cushing syndrome
Glucocorticoid
Renovascular disease

62. Clinical Manifestations
Heart & skeletal muscle most vulnerable
Heart-Ectopic beats, atrial & ventricular tachycardia/Arrest.
SK. Muscle-Weakness, cramp, paralysis, resp. paralysis.
Smooth muscle-paralytic ileus, urinary retention
Kidney (if chronic)-
Polyuria
Polydipsia
Decrease conc. Ability
Stimulates renal NH3 production may worsen hepatic encephalopathy.

63. Diagnosis History & physical exam. Investigations: S. Electrolytes
Blood pH
Acidosis (RTA, Diarrhoea)
Alkalosis (Emesis, Diuretics, Aldosterone)

64. Diagnosis (con…) ECG Changes occur usually if < 2.5 mEq/L.
Flattened T wave
ST depression
Appearance of U wave
Ventricular fibrillation.

66. Principles of management
Treatment of the cause
Correction of deficit/Excess
Ensure maintenance
Correction of ongoing loss/Excess
(Ref: Nelson)

67. Principles of Assessment of the patient
How severe the clinical condition is?
Level of consciousness.
Oral intake possible or not?
Is he getting any fluid?
Associated morbidity.
Current Serum electrolyte level.
How severe is the deficit/Excess?
(Ref: Nelson)

68. Correction of HypoKalemia
Treatment depends on:
- Serum K+ level
- Clinical symptoms
- Renal function
- Ongoing loss
- Ability to tolerate oral potassium
(Ref: Nelson)

69. Formula for correction of K+
Required K+ mmol
= 0.3 X Wt X [ Des-Mes]
Des = Desired level
Mes = Measured level

70. Protocol of correction
Mild Hypokalemia = ( k mmol/L)
Moderate Hypokalemia = (K mmol/L)
Severe Hypokalemia = ( k+ <2 mmol/L)
(Ref: Nelson)

71. Cont... Oral correction: - Asymptomatic patient - Can take orally
- Mild or Moderate Hypokalemia
(Ref: Harrison)

72. Cont... Indication of IV correction: - Symptomatic patient
- Can not take orally
- Severe Hypokalemia
(Ref: Harrison)

73. Steps of Correction Step: 1 = Calculate the deficit
Step: 2 = Calculate the maintenance
Step : 3= Choose the route of administration of drug
Step : 4 = Choose the Drug
Step : 5 = Choose the Fluid if needed.
Step: 6 = Consider other morbidity.

74. Example: A 3 year old unconscious child weighing 10 kg have severe dehydration and Serum K+ is 2.1mmol/L. How to correct?
Step 1 : Deficit= 0.3X10X[4-2.1]=5.7mmol
Step 2: Maintenance= 2X10=20 mmol/L
K+ and 1000 ml fluid
Step 3: Route= IV
Step 4: Drug= KCl IV Solution
Step 5: Fluid getting=Cholera saline ( 13 mmol/L )
Step 6: Correction of severe dehydration over 3 hours (1000 ml fluid needed).

75. Cont... Total KCl needed = 25.7 mmol Cholera saline gives = 13 mmol
Rest = = mmol
1 ml KCl = 2 mmol, so 6.35 ml KCl is needed.
Total Fluid = = 2000ml

76. Cont...
Correction of severe dehydration corrects almost 50% of K+ & water deficit in this patient over 3 hours.
So, 6.35 ml KCl in 1000ml D1/4NS after correction of Severe dehydration is the choice.
That is, Inj KCl 6.35 ml in Infusion D1/4NS μdrops/min over 21 hours.
1st hour correction = 5.72 mmol
(0.5 mmol/Kg)

77. Easy Process (Ref:icddr’b)
Serum K + Level
KCl needed
Serum K + >3 mmol/L
Inj KCl 1 ml in each 100 ml fluid
Serum K+ >2-3mmol/L
Inj KCl 1.5 ml in each 100 ml Fluid.
Serum K+ <2 mmol/L
Inj KCl 2 ml in each 100 ml Fluid.

78. Some important notes:
1 mmol/L change of serum K+ indicates change of mmol of Total body K+.(Ref:Harrison)
Total Body K+ = 55mmol/Kg ( Ref:Journal )
So, Oral correction should be continued for 5-7 days after acute phase management.(Ref:CPDT)
Rate of correction: 0.5 mmol/Kg for 1st hour then 0.25 mmol/Kg/hr for next hours.(Ref: CPDT)
Not > 40 mmol/L of fluid in IV and > 60 mmol/L in CV line. (Ref: Nelson)
IV correction should be avoided unless strictly needed.
Hypokalemia + Metabolic Acidosis = Correction by KHCO3/ K+acetate/K+citrate

79. Cont...  Hypokalemia + Metabolic Alkalosis = Correction by KCl
Hypokalemia+Metabolic Alkalosis / Hypovolumia usually responds to volume correction. (Ref: Harrison)
IV KCl should be given only after being ensured that urine output is normal.
Lack of response to KCl therapy suggest associated Hypomagnesemia and should measure S. Mg level and correct by Inj 50% MgSO4 0.1ml/Kg IM daily for 3-7 days.
(Ref: R N Srivastava.)

80. Cont… K+ rich food: Banana, Citrus fruit, milk, chocolate.
< 3.5 mmol/L serum K+ is usually symptomatic and < 2 mmol/L causes Paralytic Ileus.
Inj KCl should be given in Glucose-free fluid as glucose causes rapid entry of K+ and therefore delays serum K+ correction. (Ref: Harrison)
If glucose free fluid have to give over long time , IV bolus doses of 5 ml/Kg 10% DA should be given intermittently to maintain blood glucose level.
ECG monitoring and hourly (Daily at our situation) electrolyte measurement is needed.
K+ rich food: Banana, Citrus fruit, milk, chocolate.

81. About KCl Oral Syrup 5 ml = 6.7 mmol Inj 1 ml = 2 mmol, 1 amp = 10ml
Trade name : KT, Electro K
Adverse effect of Oral KCl:
- GIT irritation
- Esophageal and small intestinal erosion and stricture.

82. Correction of Hyperkalemia
Hyperkalemia is more dangerous than Hypokalemia
Hyperkalemia with ECG changes is a medical emergency.
(Ref: Harrison)

83. Treatment of Hyperkalemia
Treatment depends on
- Serum K+ level
- Clinical symptoms
- Renal function
- Other morbidity.

84. Principles of management
Mild to Moderate: K+ 6-7 mmol/L
- Goal is to enhance excretion of K+
- Place on Cardiac monitor
- Eliminate K+ from diet / IV fluid.
(Ref: Harrison)

85. Cont… Severe : K+ >7 mmol/L - Goal is to protect the heart.
- Decrease serum K+ level at once.
- Elimination of K+ from body.
- Consider Dialysis if S. K+ > 8 mmol/L.
(Ref: Harrison)

86. Drug treatment of Hyperkalemia (Ref: R N Srivastava)SL
Drug
Dose
Onset of action
Duration
Mechanism of action 1
10%
Cal-gluconate
0.5 ml/Kg IV slowly
1-3 min
30 min
Cardio protective. Threshold for depolarization of cardiac muscle 2
NaHCO3
1-2 meq/Kg IV
10-30 min
2 hour
 Cellular uptake of K+ 3
Insulin +
glucose
U/Kg ê gm/Kg glucose IV
20-30 min
2-4 hour Do

87. Excretetion of K+ from gut in exchange of Na+
Cont… SL
Drug
Dose
Onset of action
Duration
Mechanism of action 4
Salbutamol
5-10 mg Nebulization
30 min
4-6 hour
 Cellular uptake of K+ 5
Kayexalate
1gm/Kg/dose oral/
enema
4 hours
6-8 hour
Excretetion of K+ from gut in exchange of Na+ 6
Dialysis

88. Some Notes Mild to Moderate Hyperkalemia: - K+ restriction
+ - Kayexalate is sufficient.
Severe Hyperkalemia >7.5 mmol/L should be managed by using
- Inj 10% Cal-gluconate
+ - Insulin with glucose (1st Choice)
/ Salbutamol (2nd Choice))
/ Inj NaHCO3 (3rd Choice)
Kayexalate.
(Ref: Harrison)

89. Cont… There is no cut off level of starting or stopping the drug.
Drug of choice differ from patient to patient.
- Hyperkalemia + Metabolic Acidosis =
May use Inj NaHCO3
- Hyperkalemia + Hyperglycemia =
May Use Inj Insulin.
NB: 1 ml Inj SODIBICARB ~ 1 meq NaHCO3.
(Ref: Harrison)

90. Cont… How to use Kayexalate :
-- 1 gm/Kg mixed with 100ml 20% Sorbitol orally – 6 hourly. 1 gm binds 1 mmol of K+ and generally reduces Serum K mmol/L within 1-2 hr.
-- Enema: 1 gm/Kg mixed with 50 ml of 70% Sorbitol ml of tape water– per ractally.
(Ref: Harrison)

91. Calcium Calcium is an important cation in plasma.
99% Body Ca+ is in Bone.
The normal range 2.2 to 2.6 mmol/L.
Appox. 40% of plasma ca++ is bound to plasma proteins, primarily albumin.

92. Functions Controls physiological process – Blood coagulation
Muscular contraction
Nerve conduction
Cardiac contraction

93. Absorption

94. Excretion

95. Hypocalcemia The ionized Ca concentration is low in true Hypocalcemia.
May give rise to severe symptoms, so needs to be identified & treated expeditiously.

96. Causes of Hypocalcemia
Specific causes in Neonates:
Early Neonatal Hypocalcemia
Late Neonatal Hypocalcemia
Maternal Hypercalcemia
2. Hypoparathyroidism
3. Lack of response to PTH
4. Vitamin D deficiency.

97. Causes of Hypocalcemia (con…)
5. Redistribution of Plasma Ca+:
Hypophosphatemia
Rhabdomyolosis
Tumor lysis syndrome
Blood transfusion
Acute pancreatitis
Osteopetrosis

98. Causes of Hypocalcemia (con…)
6. Inadequate Ca intake
7. Unknown:
Septic shock
Critical illness

99. Clinical Manifestations:
Mostly due to neuromuscular irritability
Tetany is the classic manifestation.
Symptoms may include carpopedal spasm, laryngospasm, seizure.
Patients usually not loss consciousness between seizures.
Consequence of long standing hypocalcemia depends on etiology.
Chvostek & Trousseau’s signs may be elicited.

100. Diagnosis History Physical examination Investigations:
Serum Ca, Phosphorus, alkaline phosphatase, Mg, PTH, BUN & Creatinine.
Vitamin D level

101. Correction of Hypocalcemia
Inj Cal-gluconate ml/Kg IV slowly over 30mins – 6-8 hourly.
Orally : mg daily is equally effective .
Tab CaCO mg = 10 mmol
Vitamin D3 Supplementation may be needed.
Ca++ rich diet such as milk, cheese, meat, fish/animal bones may play additive role.
(Ref: Nelson + CPDT)

102. Hypercalcemia
Frequently discovered incidentally on a routine chemistry profile.
Uncommon electrolyte imbalance.

103. Causes of Hypercalcemia:
Excess parathyroid hormone
Excess Vitamin D
Excess Ca intake
Excess renal reabsorption
Release from bone:
Thyrotoxicosis
Hypervitaminosis A
Malignancy
Immobilization

104. Clinical Manifestations
GIT
Nausea & vomiting
Poor feeding
Failure to thrive
Constipation
Abdominal pain
Pancreatitis
Peptic Ulcer

105. Clinical Manifestations (con…)
Cardiac
Hypertension
Decrease QT interval
Arrythmias
CNS:
Lethargy
Hypotonia
Psychiatric disorder
Coma

106. Clinical Manifestations (con…)
Kidney:
Polyuria & dehydration
Hypernatremia
Renal failure
Nephrolithiasis

107. Diagnosis History Investigations: Electrolytes BUN Creatinine
Phosphorus
PTH
Urinary Ca, P, Creatinine, Vitamin D level

108. Correction of Hypercalcemia
Restrict Ca++ containing foods.
Vigorous hydration with NS
Force Ca++ diuresis by Frusemide
1 mg/Kg– 6 hourly.
If inadequate response Glucocorticoides or
Calcitonin may be helpful.
(Ref: Nelson + CPDT)

109. Magnesium Mg is the 4th most common cation of body 50-60% is in bone
Most intracellular Mg bound to protein
Mostly present in muscle & liver.

110. Functions Mg is necessary cofactor for hundreds of Enzymes
Important for membrane stabilization & Nerve conduction
ATP & GTP need associated Mg when they are used by ATPases, cyclases & kinases.

111. Absorption 30-50% dietary Mg absorbed in small intestine.
There is a passive absorption which is poorly understood
Absorption diminished in the presence of substances that bind with Mg.

112. Excretion Renal excretion is the principal regulator of Mg balance
PTH may increase tubular absorption
5-10% filtered Mg is resorbed in in distal tubule.

113. Hypomagnesemia Relatively common in hospitalized pts.
Mg is not measured in most basic metabolic panels.

114. Causes of Hypomagnesemia
Gastrointestinal Disorders:
Diarrhoea
NG suction/Emesis
IBD
Celiac disease
Cystic fibrosis
Pancreatitis
Protein-calorie malnutrition

115. Causes of Hypomagnesemia (con…)
2. Renal disorders:
Medications ( amphotericin, cisplatin, cyclosporin, loop diuretics, mannitol, pentamidin, aminoglycosides, thiazide diuretics)
Diabetes
ATN (recovery phase)
Postobstructive nephropathy
Hypercalcemia
Chronic kidney disease
IV fluids
Prim. aldosteronism

116. Causes of Hypomagnesemia (con…)
3. Other causes:
Poor intake
Insulin
Pancreatitis
IUGR
Infants of Diabetic mother
Exchange transfusion

117. Clinical Menifestations:
Most cases are asymptomatic
Causes secondary hypocalcemia by impairing PTH release
Dominant features due to hypocalcemia

118. Diagnosis History Physical exam. Evaluation of urinary Mg losses ECG:
Flattening of T wave
Lengthening of ST segment
Arrythmias

119. Correction of Hypomagnesemia
Encourage Mg++ containing foods such as Apple juice,vegetables, cereals, nuts.
Inj 50% MgSO ml/Kg/ in IV drip over 24 hours or IM daily.
Lower doses for a child with renal insufficiency.
Oral correction for chronic cases by Mg salt tablet may be done.
(Ref: Nelson + CPDT)

120. Hypermagnesemia Almost always secondary to excessive intake
It is unusual except in neonates born to mother receiving IV Mg
May be due to excessive use of laxatives
May occur in CRF

121. Clinical Manifestations
Asymptomatic until plasma level >4.5 mg/dl
Inhibits acetylcholine release , producing
Hypotonia
Hyporeflexia
Weakness
Lethargy & sleepiness
Hypotension & flushing

122. Diagnosis History ECG changes: Prolonged PR, QRS, & QT intervals
Complete Heart block & cardiac arrest.

123. Correction of Hypermagnesemia
Restrict Mg++ containing foods.
Diuretics-Frusemide.
Inj Cal-gluconate 1 ml/Kg may give transient benefit.
Dialysis may be needed for severe cases.
(Ref: Nelson + CPDT)