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Objectives
Review the emergent management of severe electrolyte disturbances Recognize manifestations of acute adrenal insufficiency and initiate appropriate treatment Describe the management of severe hyperglycemic syndromes
Case Study
80-year-old woman with hypertension and heart failure Confusion, lethargy, poor oral intake and weakness for 3 days BP 108/70 mm Hg, HR 110/min, R 18/min Nonsustained ventricular tachycardia on monitor risk factorsdisorders does this might patient What electrolyte have for electrolyte disturbances? contribute to her presentation?
Copyright 2008 Society of Critical Care Medicine
Case Study
80-year-old woman with hypertension and heart failure Confusion, lethargy, poor oral intake and weakness for 3 days Nonsustained ventricular tachycardia on monitor Laboratory value: K 2.5 mmol/L How would you initiate evaluation and treatment of this patient?
Copyright 2008 Society of Critical Care Medicine
Treatment of Hypokalemia
Hypokalemia (K<3.5 mmol/L) K2.5 mmol/L (<3 mmol/L if on Digoxin) K<3.5 but >2.5 mmol/L and No Symptoms Enteral replacement KCl 20-40 mmol every 4-6 h
Life-Threatening Symptoms
Enteral replacement KCl 20-40 mmol every 2-4 h and/or IV KCl 10 mmol/h
Copyright 2008 Society of Critical Care Medicine
Case Study
80-year-old woman with hypertension and heart failure ECG
Laboratory value: K 7.8 mmol/L How would you initiate treatment of this patient?
Copyright 2008 Society of Critical Care Medicine
Treatment of Hyperkalemia
Calcium for cardiac toxicity (ECG abnormalities) Redistribute potassium Insulin and glucose Sodium bicarbonate Inhaled 2-agonists Remove potassium Loop diuretic Sodium polystyrene sulfonate Dialysis
Copyright 2008 Society of Critical Care Medicine
Case Study
80-year-old woman with hypertension and heart failure Confusion, lethargy, poor oral intake and weakness for 3 days Nonsustained ventricular tachycardia on monitor Laboratory value: Na 118 mmol/L How would you initiate evaluation of this patient to determine the etiology?
Copyright 2008 Society of Critical Care Medicine
Etiology of Hyponatremia
Hyponatremia (Na<135 mmol/L) Presence of Glucose Proteins or Lipids Mannitol No Hypo-osmolar Hyponatremia
Yes
Etiology of Hyponatremia
Hypovolemia Hypervolemia Uosm>300 mOsm/L UNa <10-20 mmol/L FE Na <1% Congestive Heart Failure Cirrhosis Renal Failure With/Without Nephrosis
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Etiology of Hyponatremia
Euvolemia
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Management of Hyponatremia
Hypovolemic Hypervolemic Euvolemic Restrict free-water intake Increase free-water loss Replace intravascular volume with normal saline or hypertonic saline
When would you use hypertonic How fast would you correct the saline? concentration? sodium
Copyright 2008 Society of Critical Care Medicine
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Case Study
80-year-old woman with hypertension and heart failure Confusion, lethargy, poor oral intake and weakness for 3 days Nonsustained ventricular tachycardia on monitor Laboratory value: Na 168 mmol/L
How would you treat this patient?
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Treatment of Hypernatremia
Normal saline if hemodynamically unstable Hypotonic fluid when stable Intravenous fluids Enteral free water Quantity H2O deficit (L) = [0.6 wt (kg) ] [Measured Na - 1] 140 Rate of correction
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Case Study
34-year-old man with flu-like syndrome Febrile, tachycardic and hypotensive Antibiotics and volume initiated Admitted to floor 2 hours later, systolic BP 60 mm Hg Hypotensive in ICU after 40 mL/kg fluids and norepinephrine 10 g/min What metabolic disorders may What testing is needed? contribute to the hypotension?
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Hyperglycemic Syndromes
Is this diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS)?
25 year-old type I diabetic; venous pH 7.26, glucose 290 mg/dL, HCO3 16 mmol/L, anion gap 16 mmol/L, urine ketones (+) 51 year-old with no chronic illness; Na 141 mmol/L, Cl 98 mmol/L, HCO3 13 mmol/L, glucose 1640 mg/dL, BUN 70 mg/dL, urine ketones (+)
Copyright 2008 Society of Critical Care Medicine
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Hyperglycemic Syndromes
Is this diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS)?
73 year-old type II diabetic; Na 163 mmol/L, Cl 134 mmol/L, HCO3 21 mmol/L, glucose 1282 mg/dL, BUN 62 mg/dL, urine ketones (-)
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Hyperglycemic Syndromes
Characteristics of Hyperglycemic Syndromes DKA HHS
Glucose
Arterial/venous pH Anion gap Serum osmolarity
Negative or small
Increased
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Initial Evaluation
Mental status Degree of dehydration Presence of infection or other precipitating condition Laboratory studies Glucose Venous or arterial pH Electrolytes, renal function Urine or serum ketones Complete blood count ECG
Copyright 2008 Society of Critical Care Medicine
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Insulin
Electrolytes If K <3.3 mmol/L hold insulin and replace K Add K to fluids if K >3.3 but <5 mmol/L
Copyright 2008 Society of Critical Care Medicine
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Questions
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Key Points
Give KCl through a central venous catheter for life-threatening hypokalemia Consider calcium administration for hyperkalemia with ECG changes followed by interventions to shift K intracellularly Limit the increase in serum Na to 8-12 mmol/L in the first 24 h in symptomatic euvolemic hyponatremia Patients with hypernatremia and hemodynamic instability should have normal saline administered
Copyright 2008 Society of Critical Care Medicine
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Key Points
Patients with possible adrenal insufficiency should have emergent treatment with a glucocorticoid Treatment goals for hyperglycemic syndromes are to restore fluid and electrolyte balance, provide insulin and identify precipitants In DKA, insulin infusion should be continued until acidosis and ketosis have resolved
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Key Points
Maintain glucose 250-300 mg/dL in HHS until plasma osmolality 315 mOsm/kg Potassium should be added to fluids in hyperglycemic syndromes as soon as K <5 mmol/L and urine output is adequate A protocol for glycemic control should be chosen to avoid hyperglycemia and minimize hypoglycemia in critically ill patients
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