Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Electrolytes
Disturbances
Daniela Filipescu
Prof. of Anaesthesia & Intensive Care
Medicine
Interstitial fluid
Between cells
Cerebrospinal fluid
Intraocular fluid
Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Newborn
About 80% of total body weight
Childhood
60% to 65% of total body weight
Rinichi
Cutanat
8 ml/kg/24 ore
Plmn
Scaun
ml/kg/ora
ml/kg/zi
1-10
120-150
11-20
50-100
> 20
25-40
> 40
25-40
Cl-
Plasma
(albumina)
140
NaCl 0,9 %
K+
Mg++
Ca++
Tampon
pH
102 3.7
0.8.
1.2
HCO324
7,4
154
154 -
5,7
Sterofundin
iso
145
127 4.5
2.5
Acetat
24
5.15.9
Ringer lactat
131
109 5
Lactat
28
6,4
Solutie
gelatina
Gelofusin
154
120 -
7,17,7
Solutie
gelatina
Gelaspan
151
103 4
Acetat
24
Soluii de
amidon
154
154
4-7
Membrane Permeability
Most cell membranes are relatively
highly permeable to water
Membranes are semi-permeable to
certain anions and cations
Difference in permeability between
water and dissolved solutes
Lichid
intracelular
Sodiu (mmol/l)
140
145
10
Potasiu (mmol/l)
3,7
3,8
155
1,2
1,2
<0,01
Magneziu (mmol/l)
0,8
0,8
10
Fosfat (mmol/l)
1,1
1,0
105
Clor (mmol/l)
102
115
Bicarbonat (mmol/l)
28
30
10
Cationi
Anioni
Diffusion
Due to constant motion of atoms,
molecules, ions in solution
Passive process
Moves particles from area of higher
concentration to area of lower
concentration
Concentration gradient
Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Starling equation
Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Osmosis
Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Electrolyte Balance
Potassium is the chief intracellular cation
and sodium the chief extracellular cation
Because the osmotic pressure of the
interstitial space and the ICF are
generally equal, water typically does not
enter or leave the cell
Na+
K+
Electrolyte Balance
Click to see
animation
H2O Na+
Na
H2O
Na
K+
H2O
Na+
H2O
H2O
K+
H2
K
O
H2O
K+
H2O
Plasma osmolality
(2 x Na + G/18 + U/2,8) =
290 mOsm/kg H2O
Tonicity = (2 x Na + G/18 ) =
285 mOsm/kg H2O
Solutions
Hypertonic solution
Hypotonic solution
Isotonic solution
Hyponatremia
Definition
Epidemiology
Physiology
Pathophysiology
Types
Clinical Manifestations
Diagnosis
Treatment
Hyponatremia
Definition:
serum sodium concentration <135 mmol/L
represents a relative excess of water in relation to sodium.
Hyponatremia
We define mild hyponatraemia as a biochemical
finding of a serum sodium concentration between 130
and 135 mmol/L as measured by ion specific electrode.
We define moderate hyponatraemia as a biochemical
finding of a serum sodium concentration between 125
and 129 mmol/L as measured by ion specific electrode.
We define profound hyponatraemia as a biochemical
finding of a serum sodium concentration<125 mmol/L
as measured by ion specific electrode.
Hyponatremia
We define acute hyponatraemia as
hyponatraemia that is documented to exist
< 48 h.
We define chronic hyponatraemia as
hyponatraemia that is documented to exist
for at least 48 h.
If the hyponatraemia cannot be classified,
we consider it being chronic, unless there
is clinical or anamnestic evidence of the
contrary
Spasovski G et al. ICM 2014:320
Hyponatremia
We define moderately symptomatic
hyponatraemia as any biochemical
degree of hyponatraemia in the presence
of moderately severe symptoms of
hyponatraemia
We define severely symptomatic
hyponatraemia as any biochemical
degree of hyponatraemia in the presence
of severe symptoms of hyponatraemia
Spasovski G et al. ICM 2014:320
Symptoms
Moderately severe
Nausea without vomiting
Confusion
Headache
Severe
Vomiting
Cardio-respiratory distress
Abnormal and deep somnolence
Seizures
Coma (Glasgow Coma Scale < 8)
Spasovski G et al. ICM 2014:320
Hyponatremia
Epidemiology:
Frequency
Hyponatremia is the most common
electrolyte disorder
incidence of approximately 1%
surgical ward, approximately 4.4%
30% of patients treated in the intensive care
unit
Hyponatremia
Types
Hypovolemic hyponatremia
Euvolemic hyponatremia
Hypervolemic hyponatremia
Redistributive hyponatremia
Pseudohyponatremia
Redistributive
hyponatremia
Water shifts from the intracellular to the
extracellular compartment, with a
resultant dilution of sodium
The TBW and total body sodium are
unchanged
this condition occurs with hyperglycemia
administration of mannitol
Pseudohyponatremia
Hypovolemic
hyponatremia
develops as sodium and
free water are lost and/or
replaced by
inappropriately hypotonic
fluids
Sodium can be lost
through renal or nonrenal routes
www.grouptrails.com/.../0-Beat-Dehydration.jpg
Hypovolemic
hyponatremia
Nonrenal loss
GI losses
Vomiting, Diarrhea, fistulas, pancreatitis
Excessive sweating
Third spacing of fluids
www.jupiterimages.com
Volum
ml/zi
Sodiu
mmol/l
Potasiu
mmol/l
Clor
mmol/l
Bicarbonat
mmol/l
Suc gastric
10002500
60-100
10-20
100-130
Suc pancreatic
300-800 135-145
5-10
70-90
40-120
Bila
300-600
140
5-10
90-130
30-70
Lichid jejunal
20004000
120-140
5-10
90-140
30-40
Lichid ileal
10002000
80-150
2-8
45-140
30
60
30
40
5002000
2-30
20-30
8-35
0-30
Lichid colonic
Saliva
Hypovolemic
hyponatremia
Renal Loss
Diuretics
www.ct-angiogram.com/images/renalCTangiogram2.jpg
Euvolemic hyponatremia
Normal sodium stores and a total body
excess of free water
psychogenic polydipsia, often in psychiatric patients
administration of hypotonic intravenous or irrigation
fluids in the immediate postoperative period
Infants who may have been given inappropriate
amounts of free water
bowel preparation before colonoscopy or colorectal
surgery
SIADH
SIADH
Caused by various etiologies
CNS disease tumor, infection, CVA, SAH
Pulmonary disease TB, pneumonia, sarcoidosis,
PPV
Cancer Lung, pancreas, thymoma, ovary,
lymphoma
Drugs NSAIDs, SSRIs, antipsychotics, diuretics,
opiates
Surgery - Postoperative
Idiopathic most common
SIADH
essential criteria
Serum osmolality <275 mOsm/kg
Clinical euvolemia
Absence of adrenal, thyroid, pituitary or renal
insufficiency
No recent use of diuretic agents
Urine osmolality greater than 100 mOsm/kg
though generally greater than 400-500 mOsm/kg
in setting of low serum osmolality (inappropriate)
Urine sodium concentration > 30 mmol/L with
normal dietary salt and water intake
Supplemental criteria
Serum uric acid<0.24 mmol/L (<4
mg/dL)
Serum urea<3.6 mmol/L (<21.6 mg/dL)
Failure to correct hyponatraemia after
0.9 % saline infusion
Fractional sodium excretion> 0.5 %
Fractional urea excretion> 55 %
Fractional uric acid excretion> 12 %
Correction of hyponatraemia through
fluid restriction
Hypervolemic
hyponatremia
Total body sodium increases, and
TBW increases to a greater extent
Can be renal or non-renal
acute or chronic renal failure
dysfunctional kidneys are unable to excrete
the ingested sodium load
Prognostic implications
of hyponatremia in HF
142 pts
72.1 11.6 years
Worsening HF NYHA III-IV
Na (mEq/l)
136
135131
130
In hospital mortality
1.8
(%)
3.4
6.4
7.2
13.7
60 day
27.2
29.1
39.3
rehospitalization (%) Vaitsis J et al. Crit Care 2009: abstr 456
Hyponatremia
Clinical manifestations
- Fluid deficit or excess
- Altered mental status
Oliguria
Concentrated urine
Postural hypotension
Weak, rapid, heart rate
Flattened neck veins
Increased temperature
Decreased central venous pressure
Hypervolemia
Hypovolemia
peripheral and
presacral edema
pulmonary edema
jugular venous
distension
hypertension
decr. hct,
decr. serum prot
decr. bun/cr
UNa no help
Cerebral symptoms of
hyponatremia
Nausea and vomiting
Headache
Decreased consciousness
Lethargy
Confusion
Coma
Seizures
Muscle weakness, cramps or spasms
Respiratory distress // arrest
Death (5-50%)
Overgaard-Steenson C. Acta Anesthesiol Scand 2010:1-10
Adrogue HJ & Madias NE. NEJM 2000;342:1581-1589
Clinical manifestations
Hyponatremia 126-134 mmol/L
Alterations of cognitive function
Gait stability
Falls
Osteoporosis
Fractures and inpatient mortality
Sterns RH et al. Curr Opin Nephrol Hypertens 2010:493
Treatment of
hyponatremia
Treatment is based on symptoms
Severe symptoms = Hypertonic Saline
Mild or no symptoms = Fluid restriction
Hyponatremia
Symptomatic
1st step is to calculate the total body water
total body water (TBW) = 0.6 body weight
Sodium deficit = TBW x (desired Na actual Na)
Here comes the Math!!!
estimate SNa change on the basis of the amount of
Na in the infusate
SNa = {[Na + K]inf SNa} (TBW + 1)
OH MY GOD!!!!!!!!!!!!!!!!!!
Hyponatremia
IV Fluids
Hyponatraemia with
moderately severe symptoms
Hyponatremia
SIADH
Water restriction
0.5-1 liter/day
Demeclocycline
Inhibits the effects of ADH
Onset of action may require up to one week
Vasopressin receptor
antagonists
AQUARETICS
Excretion of electrolyte-free water
Beneficial impact on serum Na
Lack of evidence on long term beneficial
effects
Absence of disease-modifying properties
Risk of overcorrection
Cost
Kazory A. Clin Cardiol 2010:322-329
Practical therapeutic
approach
to hyponatremia in HF
Establish the diagnosis
Limit Na-free fluid intake
Prescribe iv.loop diuretics saline solution
Prescribe vasopressin receptor antagonist
Institute UF/renal replacement therapy
Practical therapeutic
approach to symptomatic
hyponatremia in HF
Saline solution - Hypertonic?
No worsening of pulmonary congestion
Increase in urine output
Reduction in serum blood urea nitrogen
No change in HF functional class
Lower readmission rate
Lower hospital mortality
Kazory A. Clin Cardiol 2010:322-329
ULTRAFILTRATION
Summary of Hyponatremia
Hyponatremia has variety of causes
Treatment is based on symptoms
Severe symptoms = Hypertonic Saline
Mild or no symptoms = Fluid restriction
Hypernatremia
Normal range for blood levels of sodium
is
135 - 145 mmol/liter
Hypernatremia refers to an elevated
serum sodium level (145 -150
mmol/liter)
Na+
CAUSES OF
HYPERNATREMIA
Most
cases are due to water deficit
due to loss or inadequate intake
1) Water loss
Insensible and sweat losses
GI losses
Diabetes Insipidus (both central and nephrogenic)
Osmotic diuresis
Hypothalamic lesions which affect thirst function
tumors, granulomatous diseases or vascular
disease
CAUSES OF
HYPERNATREMIA
2) Sodium ion overload
Hypernatremia
Pathophysiology
- Fluid deprivation in patients who cannot
perceive, respond to, or communicate
their thirst
- Most often affects very old, very young,
and cognitively impaired patients
- Infants without access to water or
increased insensible water loss can be
very susceptible to hypernatremia
CNS reaction to
hypernatremia
As the result of an osmotic gradient,
water shifts from the interstitium and
cells of the brain and enters the
capillaries
The brain tends to shrink and the
capillaries dilate and possibly
rupture
Result is focal intracerebral &
subarachnoid hemorrhages,
hemorrhages blood
clots, and neurological dysfunction
H2
O
Symptoms of
hypernatremia
Initial symptoms include lethargy, weakness and
irritability
Can progress to twitching, seizures, obtundation
or coma
Resulting decrease in brain volume can lead to
rupture of cerebral veins leading to hemorrhage
Severe symptoms usually occur with rapid
increase to sodium concentration of 158 mmol/l
or more
CNS protective
mechanisms
H2
O
Pathogenesis of
hypernatremia
Normal-Volume Hypernatremia
Conditions associated with a loss of electrolyte free fluids
(loss of pure water)
High-Volume Hypernatremia
Conditions associated with ingestion or administration of
sodium containing hypertonic solutions
Low-Volume Hypernatremia
Conditions associated with the loss of hypotonic fluids
(fluids containing more water than sodium)
Normal-volume
hypernatremia
Pure Water Loss
Renal Loss
Central diabetes insipidus
Nephrogenic diabetes
insipidus
Idiopathic (?autoimmune)
Neurosurgery or trauma
CNS tumors
Infiltrative disorders (e.g., CNS sarcoidosis)
Others (e.g., hypoxic encephalopathy, bleeding,
infection)
Nephrogenic Diabetes
Insipidus
Impairmentinurinaryconcentrationduetoinabilityof
collectingducttorespondtoADH
Diagnosis of
hypernatremia
Same labs as workup for hyponatremia:
Serum osmolality, urine osmolality and urine
sodium
Urine sodium should be lower than 25 mmol/L
if water and volume loss are cause. It can be
greater than 100 mmol/L when hypertonic
solutions are infused or ingested
If urine osmolality is lower than serum
osmolality then DI is present
Administration of DDAVP will differentiate
Low-volume
hypernatremia
Clinical manifestations
Thirst
Dry, swollen tongue
Sticky mucous membranes
Flushed skin
Postural hypotension
Low-volume
hypernatremia
Treatment
Re-hydration is the primary objective in most
cases
Treatment is best handled by giving
slow infusions of glucose solutions
Low-volume
hypernatremia
Treatment
If hypotensive: then 5% of total body weight
(kg) is needed as isotonic fluids initially
Give free H2O (D5W or p.o. water to correct
hypernatremia - only after plasma (and ECF)
volume is re-expanded
Treatment of Hypernatremia
First, calculate water deficit
TBW present = current body water
assumed to be 50% of body weight in
men and 40% in women
So lets do a sample calculation:
60 kg man with 168 mEq/L
How much water will it take to reduce
his sodium to 140 mEq/L
Calculation continued
Water deficit = 0.5 x 60 (1-[140/168]) approx
5L
But how fast should I correct it?
Same as hyponatremia, sodium should not be
lowered by more than 10-12 mmol/L in 24
hours
Overcorrection can lead to cerebral edema which
can lead to encephalopathy, seizures or death
High-volume
hypernatremia Treatment
Diuretics
remove Na+ and water
Replacement of water losses from
diuretic
Dialysis if concurrent renal failure
Summary of Hypernatremia
Loss of thirst usually has to occur to
produce hypernatremia
Rate of correction same as hyponatremia
D5 water infusion is typically used to
lower sodium level
Same diagnostic labs used: Serum
osmolality, Urine osmolality and Urine
sodium
Beware of overcorrection as cerebral
edema may develop
Hypokalemia
Serum Potassium below 3.5 mmol/L
Causes:
diarrhea, diuretics, poor K intake,
stress, steroid administration, renal
disease
Intracellular movement
Beta-stimulation
Alcalosis
Hypotermia
Insulin
48-50 mmol/kg
Intracelular
120-160 mmol/l
Extracelular
55-70 mmol
Interstiial/intravascular
3,14,2 mmol/l.
Saliv
15-20 mmol/l
Transpiraie
5-20 mmol/l
Lichid gastric
10-15 mmol/l
Scaun normal
5-10 mmol/l
Bila
5-10 mmol/l
Suc pancreatic
5-10 mmol/l
Urina
30-150 mmol/l
Lichid de cecostomie
8 - 10 mmol/l
Lichid de transversostomie
70 mmol/l
Lichid de sigmoidostomie
130 mmol/l
Diaree
75 mmol/l
Hypokalemia
Clinical manifestations:
malaise, muscle weakness, fatigue,
decreased reflexes,
faint heart sounds,
hypotension,
cardiac arrhythmias,
increased sensitivity to digitalis
EKG changes
Hypokalemia
Administering IV Potassium
- Should be administered only after
adequate urine flow has been established
- Decrease in urine volume to less than 20
mL/h for 2 hours is an indication to stop
the potassium infusion
Principii de tratament in
hKaliemie
1. Corectarea cauzelor care produc translocare
intracelular de potasiu
2. nlocuirea deficitului de potasiu
Hyperkalemia
Serum Potassium greater than 5.5 mEq/L
- More dangerous than hypokalemia because
cardiac arrest is frequently associated with
high serum K+ levels
Hyperkalemia
Causes:
- Decreased renal potassium excretion as
seen with renal failure and oliguria
- High potassium intake
- Hypoaldosteronism
- Shift of potassium out
of the cell as seen in
acidosis, burns, crush injuries,
infections
Tacrolimus
Digital
Pentamidina
Diuretice antialdosteronice
Penicilina potasic
Heparina
Trimetoprim-sulfametoxazol
Succinilcolina
Hyperkalemia
Clinical manifestations:
- Skeletal muscle weakness/paralysis
- Irritability
- Abdominal distension
- EKG changes such as peaked T waves,
widened QRS complexes
- Heart block
Principii de tratament in
HKaliemie
1. Oprirea oricrui aport de potasiu
2. Reversarea efectelor membranare
glucoza 50 g + insulina 20 U
agonisti beta-adrenergici
4. Inlturarea din organism
diuretice de ansa
epurare extrarenal