ELECTROLYTE

PROBLEMS
Hyponatremia
• Normal serum Na 135-145 meq/L
• Hyponatremia
• Pseudohyponatremia
• Hyperosmolarity
• Hypovolemia hyponatremia
• Euvolemic hyponatremia
• Hypervolemic hyponatremia
• Clinical manifestations
• Neurologic – anorexia, nausea, vomiting, agitation,
headache, muscle cramps, seizures, sensorial changes
• Cardiovascular – volume depletion, shock
Hyponatremia: Correct deficit or limit
fluids and induce diuresis?
• Correct deficits and add maintenace Na to patients with
losses [eg: GIT losses]
• Limit and induce diuresis in patients with dilutional
hyponatremia [SIADH]
Diarrhea - [ Na ] = 55 mEq/L

[Na] is lower Na than plasma so this can cause

hypernatremia but patient drinks low Na-containing fluid
thus this does not occur

If there is intravascular volume depletion ADH secretion is

stimulated, thus there is renal water retention and
increased PT water reabsorption, so hypernatremia does
not ensue
 SIADH – Syndrome of Inappropriate ADH Secretion

ADH secretion is NOT regulated by increased osmolality or

expanded intravascular volume

• Decreasing urine output

• Dilution of serum Na thus hyponatremic
• No renal failure
 Diagnostic criteria for SIADH
• Absence of : Renal, adrenal or thyroid insufficiency,
Congestive heart failure, nephrotic syndrome or cirrhosis,
Diuretic ingestion, Dehydration
• Urine osmolality >100 mOsm/kg [usually > plasma]
• Serum osmolality <280 mOsm/kg and serum sodium < 135
mEqs/L
• Urine sodium > 30 mEqs/L
• Reversal ofsodium wasting and correction of hyponatremia
with water restriction
 TREATMENT
• When the level of Na is below 120 mmol/L- frequently
serious clinical s/sx are seen [convulsions, shock, lethargy]
• Na Deficit = [Desired-Actual Na] x 0.6 x Wt [kg]
• Na Maintenance = 2 mEqs/kg/day
• Na Requirement = Deficit + Maintenance

• Correcting Solution = IVF + NaCl

• NaCl for incorporation = 2.5 mEqs/ml

• Fluid limitation, diuresis in SIADH

GIT loses, Burns, CSF losses, Renal loses,
Diuretic use…
• Manifestations mostly due to volume deficit
• Replace volume with 0.9 NSS or LRS Rapid correction of Na
not usually needed; May correct within 24 hours with half of
correction in 8 hrs; the rest in the next 16 hours
• Adjust according to patients response
Hyponatremia < 120mmol/L,
symptomatic
• Use desired Na level of 125 mmol/L –
a level at which
syptoms of hyponatremia are relieved
• Hypertonic solution using 3% [513 mmol/L] NaCl at 4 to 6
ml/kg over 4 hours
• At the end of the rapid initial correction, further correction
over 24 to 48 hrs should be continued with serial serum Na
monitoring
• If secondary to SIADH, dilute formula, DDAVP use … fluid
restriction & diuretic
How do you prepare a Hypertonic NaCl
solution?
• Hypertonic solution using 3% NaCl [ Na = 513 mmol/L]
• Using NaCl + Sterile Water
• NaCl 2.5meq + Water 4 ml; Prepare 4-6ml/kg of this
solution and give over 4 to 6 hours; other references: may
give as IV push over 10 mins
HYPERNATREMIA
• Causes
• Water deficit - polyuria [DI,DM], inc insensible water loss,
inadequate intake
• Excessive Sodium - faulty mixture of ORS, bicarb [pontine
myelinosis], hyperaldosteronism
• Water & Na deficits – GIT , Cutaneous, Renal [DM, post
obst]
• CLINICAL FEATURES
• warm & doughy skin; fair turgor & gray color, parched
mucous membrane; sunken eyeballs, [ low BP ]
• Hyperirritable, convulsions, increased muscle tone
• Hyperirritable & convulsions [ brain hge], lethargic, fever,
increased muscle tone
• ECF Volume is preserved at the expense of ICF Volume
• TREATMENT
• Slow correction of imbalance using hypotonic solution,
0.15% NaCl [25 mmol/L] usually over 48 hrs
• Decrease serum Na by less than 12mEq/L or a rate of 0.5
mEq/L/hr

• K incorporation given if with urine output

• Calcium content [hypo Ca]: 1 amp of 10% calcium
gluconate for 500 ml infusate
• Glucose : 2-3% to prevent problems with
hyperglycemia later
What is D5.0.15% NaCl + 20 mEq K ?
• When a hypernatremic patient starts to have adequate UO…
Do not forget to add maintenance KCl in the fluid
• 0.15 NaCl has 25mEqs of Na /L of IVF
• Plus K of 20 mEqs/L of IVF

• D5IMB has 25mEqs of Na /L of IVF and K of 20 mEqs/L of

IVF
• TREATMENT
• Restore intravascular volume
• Determine the time for correction based on the initial
[Na]
• Administer at a constant rate over the time for
correction
• Follow serum Na levels
• Adjust fluid based on clinical status and serum [Na]
• Replace ongoing loses as they occur
• TREATMENT
• Determine the time for correction based on the initial
[Na]

[Na] 145-157 mEq/L : 24 hrs

[Na] 158-170 mEq/L : 48 hrs
[Na] 171-183 mEq/L : 72 hrs
[Na] 184-196 mEq/L : 84 hrs

Why is it this way?

• Change in in serum < 12meq/L/24 hrs
TREATMENT
• Adjust fluid based on clinical status and serum Na
concentration

• Signs of volume depletion : NS [20 ml/kg]

• Priority: Volume precedes tonicity!
• Sodium decreases to rapidly
• Increase Na concentration or Decrease IVF rate
• Sodium decreases too slowly
• Decrease Na concentration or Increase IVF rate
HYPOKALEMIA
• Normal serum K 3.5 - 5 mmol/L
• Causes
• Spurious
• Transcellular shifts – Alkalemia, Insulin, B-adrenergics,
HypoK periodic paralysis
• Extrarenal loses – Diarrhea, Laxatives, Sweating
• Renal loses - Proximal RTA [with acidosis], DKA, Gitelman
syd & Bartters synd [with alkalosis], Renovascular disease
Renal Tubular Acidosis
- Type 1 - Distal RTA Click icon to add picture
- Type 2 - Proximal
RTA
Hypokalemia
Metabolic Acidosis
Normal Anion Gap
Polyuria
Bartters Syndrome
Gitelman’s Syndrome Click icon to add picture
- Hypokalemia
- Metabolic Alkalosis
- High urine chloride
- Normal BP
- Polyuria

- Gitelman’s
Syndrome - has
hypocalciuria
CLINICAL FEATURES
• Polyuria [dec urinary conc & primary polydispsia]
• Neuromuscular - decreased in excitability
• Muscular - skeletal weakness [K <2.5 mEq/L] & cramps,
paralysis
• Smooth - ileus with slow or no bowel sounds [K < 2.5
mEq/L]
• Cardiac - arrhythmia [PE-skip beats, ECG]
• Neurological - lethargy, confusion, tetany
CLINICAL FEATURES
• Cardiac - arrhythmia [PE-skip beats, ECG]
• ECG changes
• flattened T wave
• depressed ST segment
• appearance of U wave & P wave
 TREATMENT
• Depends on severity
• ECG monitoring
• K concentration of IVF
• peripheral vein 40 to 60 mEqs/L
• central line 60 to 80 mEqs/L
• Repair Rate : 0.2 - 0.5 mEqs/kg/hr
• if 0.5 mEqs/kg/hr - ECG Monitoring
• NOT to exceed 20 mEqs/hr

KCl incorporation = 2.0 mEqs/ ml preparation

Correcting solution = IVF + KCl
HYPERKALEMIA
• Causes
• Spurious - hemolysis, thrombocytosis,leukocytosis
• Excessive intake
• Transcellular shifts – TLS
• Renal Failure - decreased excretion
• Low aldosterone - Addison’s Disease, Adrenal Insuf
• Drugs - Spirinolactone [K sparing diuretic]
S/Sx- Cardiac rhythm changes

ECG
• peaked T waves, prolonged PR
• interval, wide QRS complex
• complete heart block
 TREATMENT
• Depends on severity
• Decrease/discontinue intake
• Discontinue Spirinolactone
• Correct acidosis - Na Bicarbonate
• Reverse membrane effects -10% Ca gluconate, 0.5 - 1.0
ml/kg over 2-10 mins
• Transfer K into cells - Na bicarbonate, Glucose - insulin
Drip
• Enhance renal excretion of K -Kayexalate [sodium
polystyrene sulfonate]; NaCl 0.9% - 10-20ml/kg
• Adrenal insufficiency- Steroids
HYPOCALCEMIA
• TREATMENT - if patient is symptomatic
• Calcium gluconate 10% [9.2 elemental Ca/ml]
• Dose: 0.5-1.0 ml/kg IV bolus administered over 3 - 5 mins [2
- 10 mins]
• Cardiac monitoring: STOP if CR < 60/min or if there is a
drop of 20 beats/min
• Maintenance: 100mg Ca/kg/24 hrs added to IVF
HYPOMAGNESEMIA
• Normal serum Mg 1.6-2.2mEq/l
• TREATMENT: Magnesium Sulfate
• Dose IM, IV: 25-50 m/kg/dose or 0.2-0.mEq/kg/dose every 4 to 6
hours for 3 to 4 doses
• Maximum single dose: 2000mg [16mEqs]
• Maintenance IV : 60-120 mg/kg/day or 0.25-0.5mEqs/kg/day
• Preparation 250mg/ml, 10 ml ampul [IV]; 500 mg/ml, 2 ml ampul
[IV]
• Administration: Dilute to a maximum 200mg/ml, infuse over 2-4
hours. Maximum 125mg/kg/hr or 1 mEq/kg/hr