Fluid & Electrolyte Abnormalities - Clin Med

What does this refer to

• Normal Values 135 – 145 mEq/L

Sodium (Na+)

What does this refer to

• Normal Values 3.5 – 5.0 mEq/L

Potassium (K+)

What does this refer to

• Normal Values 8.4 – 10.2 mg/dL

Calcium (Ca+)

What does this refer to

• Normal Values 1.5-2.0mg/dL

Magnesium (Mg+)

What type of IV fluid does this refer to

• “– same concentration of solutes as blood plasma”

What type of IV fluid does this refer to

• “– lesser concentration of solutes as blood plasma”

Hypotonic

What type of IV fluid does this refer to

• “– greater concentration of solutes as blood plasma”

Hypertonic

What does this refer to

• Most IV fluids are _______

• _______ solutions expand intracellular and extracellular spaces equally

Isotonic

What does this refer to

• Sodium Chloride (NS or NaCl)

  • 0.9%

  • 0.45% (hypotonic)

• Lactated Ringers or Ringers Lactate (LR)

• Dextrose 5% in water (D5W)

IV fluids

What does this refer to

• Contains water + sodium (154 mEq/L) + chloride (154 mEq/L)

• Indications

  • Hypovolemia

  • Burns

  • Trauma

• Contraindications

  • Conditions that cause sodium retention

• Use with great caution in heart failure/pulmonary edema and severe CKD

0.9% Normal saline (NS 0.9%)

What does this refer to

• “Half normal saline”

• Hypotonic

• Indications

  • Hypovolemic patient with hypernatremia

0.45% Normal saline (NS 0.45%)

What does this refer to

• Crystalloid, isotonic solution

• Indications

  • Dehydration

  • Burns/Trauma

  • Metabolic acidosis

• Composition

  • Na+ 130mEq/L

  • K+ 4 mEq/L

  • Ca2+ 3mEq/L

  • Cl- 109mEq/L

  • Trace bicarbonate precursors prevent acidosis

Lactate Ringers (LR)

What does this refer to

• Crystalloid, isotonic fluid

• Contains 50g of dextrose/liter

• Indications

  • Nutritional support to patients NPO

• Contraindications

  • Hyperglycemia

  • ↑ ICP

Dextrose 5% in water (D5W)

What does this refer to

• Most often caused by a loss of bodily fluids

  • Prolonged vomiting, diarrhea, or sweating

  • Other causes of hypovolemia

• Multi-organ problem

  • Kidneys

  • Muscles

  • Heart

Fluid-electrolyte abnormalities

What does this refer to

• Edema (↑ fluid)

  • Swelling and pain in the face, arms, legs, hands and feet.

• Dehydration (body loses more fluids than it consumes)

  • Thirst

  • Weakness

  • Light-headedness/fainting

  • Decreases in urine output or increases in its concentration (darker colored urine).

Fluid-electrolyte imbalance

What does this refer to

• Sodium less than 135mEq/L

• Types of hyponatremia

  • Hypertonic

  • Isotonic

  • Hypotonic

Hyponatremia

What does this refer to

• Due to hyperglycemia or Mannitol infusion

HypertonicHyponatremia

What does this refer to

• Usually due to hyperproteinemia or hypertriglyceridemia

IsotonicHyponatremia

What does this refer to

EtiologyHyponatremia

What does this refer to

• Headache

• Muscle spasm/twitch

• ↓ UOP

• Weakness

• ↓ DTR (Deep tendon reflex)

• ↑ Bowel motility

• Shallow respirations

• Orthostatic hypotension

• ↑ Temp, ↓ BP, ↑ Pulse

Clinical presentation of hyponatremia

What does this refer to

• Hypervolemic

  • Edema

    • Peripheral

    • JVD

  • HTN

• Hypovolemic

  • Poor skin turgor

  • DMM

  • Flat neck veins

  • Hypotension

Physical examHyponatremia

What does this refer to

• CMP to obtain serum sodium (Na) level

• Obtain serum osmolality

• Volume status of patient

WorkupHyponatremia

What does this refer to

• Depends on source for hyponatremia

• Level of Hyponatremia

  • Mild (130-134mEq/L)

  • Moderate (120-129mEq/L)

  • Severe (<120mEq/L)

• Address/treat the underlying cause

• What if the patient is asx?

• Moderate hyponatremia

  • IVF normal saline +/- loop diuretcs

• Severe hyponatremia

  • IVF 3% Hypertonic saline + Furosemide

TreatmentHyponatremia

What does this refer to

• Serum sodium > 145 mEq/L

• Due to increased free water loss, hypotonic fluid loss or hypertonic sodium gain

Hypernatremia

What does this refer to

• ↓ H2O

• Diabetes Insipidus

• Heatstroke

• Hypertonic IVF

• Sea Water

• Watery diarrhea

• Osmotic diuresis

EtiologyHypernatremia

What does this refer to

• ↑ Thirst

• ↑ Temp

• Lethargy

• ↑ BP

• ↑ Pulse

• Restless

• Weakness

• Swollen tongue

Clinical presentationHypernatremia

What does this refer to

• Goals of management

  • Early sx recognition

  • Identification of the underlying cause(s)

  • Correction of volume disturbances

  • Correction of hypertonicity

• Hypotonic fluids

  • Water

  • D5W

  • 0.45% NS

  • 0.2% NS

TreatmentHypernatremia

What does this refer to

• Serum potassium (K+) less than 3.5mEq/L

Hypokalemia

What does this refer to

• Vomiting/Diarrhea

• Dehydration

• Hyperglycemia/ ↑ insulin

• Gastric suction

• Hyperaldosteronism

• Bulimia

• Osmotic diuresis

• Alkalosis

• β2 adrenergic agonist

EtiologyHypokalemia

What does this refer to

Co-occuring hypomagnesemia

Clinical Presentation of Hypokalemia

What does this refer to

Hypokalemia

What does this refer to

• 4 components of the treatment of hypokalemia

  • Reduction of potassium losses

  • Replenishment of potassium stores

  • Evaluation for potential toxicities

  • Determination of the cause to prevent future episodes

Treatment goalsHypokalemia

What does this refer to

• Oral K+ preferred

• Treat co-occurring hypomagnesemia

• Give it slow

• Dose

  • 10-20mEq/L/hr

TreatmentHypokalemia

What does this refer to

Potassium replacement protocolHypokalemia

What does this refer to

• Serum K+ levels > 5.0mEq/L

Hyperkalemia

What does this refer to

• Pseudohyperkalemia

• Acute or chronic renal failure

• Rhabdomyolysis

• Oliguric renal failure

• Insulin deficiency

• Metabolic acidosis

• Addison’s disease

• Crush injury/Burns

• Blood transfusions

EtiologyHyperkalemia

What does this refer to

• Muscle weakness

• Dysrhythmias

• Flaccid paralysis/Paresthesia

• Intestinal colic

• Abdominal distention

• Irritability/anxiety

• Leg cramps

• EKG Rhythms & Abnormalities

  • Tall tented T waves * ON EXAM

  • Prolonged PRi & QRS

  • Absent or indiscernable P waves

  • ST elevation

Clinical presentationHyperkalemia

What does this refer to

Hyperkalemia

What does this refer to

• Hyperkalemic Emergency (> 7mEq/L)

• Calcium gluconate IV

• Insulin & Glucose IV

• Remove excess K+ from the body (Loop diuretics)

  • If renal fxn not impaired

TreatmentHyperkalemia

What does this refer to

• Calcium Gluconate 1000mg OR

• Calcium Chloride 500-1000mg

• Regular Insulin 10-20 units/500mL 10% dextrose

• Furosemide (Lasix) 40mg IV q 12 hours

TreatmentHyperkalemia

What does this refer to

• Serum calcium (Ca+) < 8.4mg/dL OR

• Ionized calcium < 4.4mg/dL

Hypocalcemia

What does this refer to

EtiologyHypocalcemia

What does this refer to

• Numbness/tingling

• Anxiety/Irritability

• ↓ BP

• + Trousseau & Chvostek’s

• Seizures

• Carpopedal spasm

• ↑ DTR

• Bronchospasm

• ↓ Clotting time/Prothrombin time

• EKG Rhythms & Abnormalities

  • Prolonged QTi

  • Lengthened ST

Clinical presentationHypocalcemia

What does this refer to

Hypocalcemia

What does this refer to

• Mild hypocalcemia/Chronic or asx hypocalcemia

  • Oral preferred

    • Calcium citrate

    • Calcium carbonate

    • Vitamin D

  • Thiazides for patients with hypoparathyroidism

• Calcium Gluconate 1-2g IV/50mL NS or 5% dextrose

• Chronic renal failure

  • Phosphate binders (calcium acetate)

  • Oral calcium replacement

    • Calcitrol

TreatmentHypocalcemia

What does this refer to

• Serum Ca+ > 2.2mg/dL OR

• Ionized Ca+ 5.6mg/dL

Hypercalcemia

What does this refer to

• Hyperparathyroidism

• Malignant neoplastic disease

• Prolonged immobilization

• Oliguric renal failure

• Acidosis

• ↑ PTH

EtiologyHypercalcemia

What does this refer to

Clinical presentation of hypercalemia

What does this refer to

Hypocalecemia

What does this refer to

Hypercalcemia

What does this refer to

• IVF 1st line tx

• Furosemide (Lasix)/Loop diuretics

• Isotonic saline 200-300ml/hr titrated to UOP 100-150ml/hr

• Malignancy - Calcitonin then bisphosphonates

  • Denosumab (Prolia) given concurrently with Calcitonin

TreatmentHypercalcemia

What does this refer to

• Serum Mg+ < 1.5mEq/L

Hypomagnesemia

What does this refer to

• ICU patients at high risk

• Nutrition deficit, diuretics, hypoalbuminemia

• Polygenic heritability

• GI loss

  • MC diarrhea

• Renal loss

  • Nephrotoxic drugs

• Endocrine loss

  • Hypoparathyroidism

• Common in Alcoholics/uncontrolled DM

EtiologyHypomagnesemia

What does this refer to

Hypomagnesemia

What does this refer to

• Irritability

• Nystagmus

• ↑ DTR

• Muscle cramps

• + Trousseau and Chvostek’s sign

• Behavioral changes

• Vertigo

• Altered gait – ataxia

• Tachycardia

• Tetany

• Convulsions

Clinical presentationHypomagnesemia

What does this refer to

EKG change sin hypomagnesemia

What does this refer to

Hypomagnesemia symptoms

What does this refer to

• Acute Setting – hemodynamically unstable

  • Magnesium Sulfate 1-2g IV/2-15 mins

• Hemodynamically stable

  • Magnesium Sulfate 1-2g IV/50-100mL 5% dextrose/5-60 mins

• Pediatrics

  • Magnesium Sulfate 25-50mg/kg (Max single dose is 2g)

• Recheck Mg level 6-12 hours after each IV dose

TreatmentHypomagnesemia

What does this refer to

• Serum Mg+ > 2.0mEq/L

DefinitionHypermagnesemia

What does this refer to

• Renal insufficiency

• Magnesium infusion

• Antacids/laxatives

• Dietary supplements

• Lithium

EtiologyHypermagnesemia

What does this refer to

Clinical presentationHypermagnesemia

What does this refer to

ECG Hypermagnesemia

What does this refer to

• Calcium gluconate stabilizes myocardium

• IVF + Furosemide

  • Isotonic saline (0.9%)

TreatmentHypermagnesemia

What does this refer to

• Normal renal fxn

  • Cessation of magnesium therapy

  • Loop diuretics

• Moderate CKD (eGFR 15-45ml/min/1.73m2) & mild AKI

  • NS 0.9% IVF + loop diuretic

  • If not responsive → dialysis

• Severe renal impairment

  • Symptomatic - Calcium 100-200mg elemental Ca/5-10 mins

  • eGFR < 15 = dialysis

TreatmentHypermagnesemia

What does this refer to

• Loss of too much fluid from the body

Dehydration

What does this refer to

• Older adults

• Infants/young children

• People with chronic diseases

• Medications causing increased urination or sweating

• People who exercise or work outdoors during hot weather

Epidemiology/risk factorsDehydration

What does this refer to

• Diarrhea

• Vomiting

• Excessive sweating

• ↑ urination

• Fever

• Inadequate hydration

EtiologyDehydration

What does this refer to

• Feeling very thirsty

• Dry mouth

• Urinating and sweating less than usual

• Dark-colored urine

• Dry skin

• Feeling tired

• Dizziness

Clinical historyDehydration

What dos this refer to

• Dry MM

• Confusion

• Syncope

• Lack of urination

• Tachycardia

• Tachypnea

• Delayed cap refill

• Shock

Physical exam dehydration

What does this refer to

• Dry mouth and tongue

• Crying without tears

• No wet diapers for 3 hours or more

• A high fever

• Being unusually sleepy or drowsy

• Irritability

• Eyes that look sunken

Physical exam - infants/young childrenDehydration

What does this refer to

Signs and symptoms of dehydration

What does this refer to

• Hypoglycemia

• Hyponatremia-hypernatremia

• Anemia

• Thyroid disease

• Parathyroid disease

• GI illness

• SIADH

• Renal failure/AKI

Differential diagnosisDehydration

What does this refer to

• Labs

  • CBC w. diff

  • CMP

  • Urinalysis

  • Cardiac biomarkers/EKG

• Imaging

  • No specific imaging indicated

WorkupDehydration

What does this refer to

• Treat underlying abnormalities

• Oral hydration with water if tolerated

• IVF

  • NS 0.9%

    • 20-30mL/kg/1 hr

  • Pediatrics

    • UOP 1.5mL/kg/hr

• Electrolyte replacement if needed

Clinical interventionDehydration

What does this refer to

• Rehydration

• Oral fluids OR

• IVF

Clinical pharmacotherapeuticsDehydration

What does this refer to

Complementary and alternative therapy

What does this refer to

• Morbidity/complications

  • Most have full recovery if properly treated

• Mortality

  • Untreated – develop life-threatening heat stroke

PrognosisDehydration

What does this refer to

Dehydration