S LECTURE 3/3

l
i This lecture will bring together your knowledge from
d lectures 1 and 2!
SOM 216:
e
CORE COURSE IN LABORATORY MEDICINE

“Electrolytes
1 and Acid-Base Balance” Time to review.
April 8, 2011
11:00 AM – 11:50 AM
David N. Bailey, M.D.
1

S Neonates have lower bicarbonate ref range

REVIEW OF INDIVIDUAL SERUM
l because of crying and hyperventilation.
ELECTROLYTES: BICARBONATE
i Reference range, 22 – 28 mmol/L (neonates lower –
WHY?)
d Increased in:

e Respiratory acidosis -
Hypoventilation (COPD, cardiac
disease, CNS depression, airway obstruction)
Renal compensation to eliminate H+
2 (sodium-hydrogen ion exchange,
bicarbonate reclamation, ammonia formation,
hydrogen phosphate formation)

S REVIEW OF INDIVIDUAL SERUM Hyperadrenalismexcess cortisol;

l ELECTROLYTES: BICARBONATE mineralocorticoid effect. Lose potassium and
i (cont.) hydrogen into urine.
Increased in:
d Metabolic alkalosis -
e Loss of acid from stomach Compensate with hypoventilation
Excessive drainage of stomach
Hyperadrenalism; excessive
3 cortisone or ACTH; diuretics (loss of
hydrogen and potassium ion into
urine)
Pulmonary compensation (hypoventilation)
(major)
Renal compensation to retain H+ (minor)
3
S REVIEW OF INDIVIDUAL SERUM Salicylate poisoning. Salicylates(aspirin) can
l ELECTROLYTES: BICARBONATE cause a hypothalamic effect that drives
i (cont.) hyperventilation.
d Decreased in:
e Respiratory alkalosis –
Hyperventilation (high altitudes,
4 fever, early salicylate poisoning,
hysteria)
Renal compensation to retain H+

S REVIEW OF INDIVIDUAL SERUM Bicarbonate is also decreased in metabolic

l ELECTROLYTES: BICARBONATE acidosis.
i (cont.)
d Decreased in: Diarrhea contains bicarbonate, GI fistula lose
Metabolic acidosis – bicarb, lower GI drainage leads to loss of
e Ketoacidosis, lactic acidosis
Retention of H+ (renal failure,
bicarb
renal tubular acidosis)
5 Loss of base (diarrhea, GI fistula) Upper GI drainage causes H+ loss instead.
Pulmonary compensation
(hyperventilation) (major)
Renal compensation to eliminate H+
(minor)
5

S Remember you don't need to memorize ref

REVIEW OF INDIVIDUAL SERUM
l ranges! On the quiz, they will be provided.
ELECTROLYTES: CHLORIDE
i
Reference range, 97-107 mmol/L
d (hemolysis lowers chloride)
Chloride is Increased in
e Increased in: Dehydration
Dehydration Loss of HCO3-
Loss of HCO3- (e.g., diarrhea),
6 with compensatory increase in Cl-
Remember the Anion Gap graphic!
Hyperventilation with loss of CO2 and
decrease of HCO3-, resulting in Bulk electroneutrality must remain unchanged!
compensatory increase in Cl- Changes in Bicarb affect Cl because both are
anions and the Cl-/bicarbonate exchanger is in
6
several cells.
S Diabetic ketosis hyperosmolality causes a
REVIEW OF INDIVIDUAL SERUM
l dilutional effect lowering apparent Cl- and Na+.
ELECTROLYTES: CHLORIDE (cont.)
i  Decreased in: (This isn’t a true change in total Cl- or Na+)
Overhydration
d Hypoventilation; CNS depression;
e COPD (CO2 retention, HCO3- increase, Inadequate Aldosterone causes Cl- to be lost
and compensatory decrease in Cl-) along with Na+.
Chronic renal disease (renal loss of Cl- with Na+)
Diabetic ketosis (dilutional due to hyperosmolality)
7 Adrenal insufficiency (Cl- lost with Na+)
In hyperadrenalism , Cl- is lost along with K+.
Hyperadrenalism; overdosage with ACTH
or cortisone (Cl- lost with K+)
Metabolic alkalosis (increased HCO3- with
compensatory decrease in Cl-)
Vomiting; GI fistula (loss of HCl, increase in HCO3-,
and compensatory decrease in Cl-) 7

S REVIEW OF INDIVIDUAL Sodium Imbalances

l SERUM ELECTROLYTES:
i SODIUM Hemolysis lowers both Na+ and Cl- because of
d Reference range, 135 – 145 mmol/L addition of cellular compartment water to
e (hemolysis lowers sodium) serum which causes another dilutional effect.
Increased in: Cells are low in Na+ and Cl- but rich in K+ and
Dehydration protein
8
Diarrhea (water loss)
Hyperadrenalism
Hyperaldosteronism (primary)
8

S REVIEW OF INDIVIDUAL Addison's disease (hypodrenalism) = lack of

l SERUM ELECTROLYTES: Aldosterone therefore no Na+ retention.
i SODIUM (cont.)
d
Decreased in: Diabetic ketoacids grab Na+ as counter ion
Overhydration
e Diarrhea (sodium loss) Therefore Na+ may be lost to urine
GI fistulas
Hypoadrenalism
Renal disease (sodium loss) For every 100 mg/dL increase of glucose there
9 Diabetes (sodium lost with ketoacids
is an apparent Na+ decrease by 1.6mmol/L
in urine)
Dilutional (due to hyperosmolality – decrease of Because of dilution.
1. 6 mmol/L sodium for every 100 mg/dL
increase in glucose above normal)
Syndrome of inappropriate ADH
9
S REVIEW OF INDIVIDUAL Conditions that cause edema.
l SERUM ELECTROLYTES: Congestive heart failure
i SODIUM (cont.) Na is retained to compensate for apparent -
d
Decreased but with INCREASED total body sodium: dilutional loss. This is driven by Renin-
Congestive heart failure
e Nephrotic syndrome Angiotensin-Aldosterone System (RAAS)
Protein deficiency
Renal insufficiency
Cirrhosis Remember this is driven by Juxtaglomerular
1 (FOR ALL: Sodium and water retention resulting in cells that sense low Na+. They detect Na+
edema – dilutional hyponatremia – leading to
0 increased renin – leading to increased aldosterone – flow over time. Therefore J-G cell Na+
leading to more sodium and water retention)
detection depends on GFR and serum Na+
10
concentration.

S REVIEW OF INDIVIDUAL
l SERUM ELECTROLYTES:
i POTASSIUM
d Reference range, 3.5 – 5.0 mmol/L
(hemolysis increases potassium)
e Increased in:
Tissue damage
Impaired renal clearance of K+
1 Shock (decreased GFR)
Diabetic ketoacidosis with tissue
1 breakdown
Dehydration
Adrenal insufficiency
11

S REVIEW OF INDIVIDUAL Diuretics, particularly thiazide diuretics, cause

l SERUM ELECTROLYTES: K+ loss.
i POTASSIUM (cont.)
d  Decreased in: Familial periodic paralysis: a condition that
Malnutrition
e Prolonged IV glucose or sodium (K+ into RBC)
causes excess K+ to go into muscle tissue.
Vomiting (potassium loss with hydrogen ion)
GI fistulas (potassium loss with hydrogen ion)
Diarrhea (potassium loss) An intestinal mucus producing adenoma also
1 Diuretics/laxatives (potassium)
causes K+ loss (it effectively acts as a laxative
Familial periodic paralysis (potassium into muscle)
2 Excessive ACTH or cortisone (potassium into urine) and causes diarrhea)
Hyperadrenalism (potassium into urine)
Hyperaldosteronism (potassium into urine)
Intestinal adenomas (mucus-producing; diarrhea)
12
S
DISCUSSION OF CLINICAL
l CASES #4, 5, AND 6
i
d
e

1
3

13

S
l QUESTIONS?
i
d
e

1
4

14

S 14yo boy post paralytic polio is taken off

l respirator during recovery.
i
d Hypoventilation from residual polio paralysis or
e
post respirator weakness of diaphragm
muscles.
1 Total C02 on lab value print out is bicarbonate
5 and dissolved C02.
1. Chronic Respiratory Acidosis +renal
compensation
Lose H+ ion to urine in kidney.

Evidence of renal compensation Bicarb is

increased. To 35 pC02 70 this is 30 above
40(normal) and for every 10 above
Bicarbonate moves 3.5 up 10.5 from
 24(normal) to 35.

As bicarbonate increases Cl- decreases to

preserve bulk Electro neutrality. Think Cl-
/bicarbonate exchange.

S 8YO girl w/4 day history of diarrhea.

l
i Severe Dehydration causes hypovolemic
d tachycardia.
e
Respiration is rapid because a metabolic
acidosis causes respiratory compensation.
1 Loss of bicarbonate in diarrhea has caused
6 metabolic acidosis.

Why is potassium not a good indicator in acid

base? Because it rapidly shifts across red cell
membranes.

Cl- is increased to balance bicarbonate loss

and because of volume contraction.
S 21 yo woman
l
i Diabetic ketoacidosis
d Hint Coma on presentation and Hyperglycemia
e
w/ ketones strongly positive.

IV insulin.
1
7 Metabolic acidosis driven by ketoacid
formation.

Low serum Na+ because of dilutional effects of

glucose on hyperosmotic serum.

GFR is decreased which causes increased

passive reabsorption of urea nitrogen