Copyright 2008 Society of Critical Care Medicine Management of Life- Threatening Electrolyte and...

Copyright 2008 Society of Critical Care Medicine

Management of Life-Threatening Electrolyte and Metabolic Disturbances

2 Copyright 2008 Society of Critical Care Medicine

Objectives

Review the emergent management of severe electrolyte disturbancesRecognize manifestations of acute adrenal insufficiency and initiate appropriate treatmentDescribe the management of severe hyperglycemic syndromes


Case Study80-year-old woman with hypertension and heart failureConfusion, lethargy, poor oral intake and weakness for 3 daysBP 108/70 mm Hg, HR 110/min, R 18/minNonsustained ventricular tachy-cardia on monitor

What risk factors does this patient What risk factors does this patient have for electrolyte disturbances?have for electrolyte disturbances?What electrolyte disorders might What electrolyte disorders might contribute to her presentation?contribute to her presentation?


Treat the electrolyte change, but search for the causeClinical manifestations are usually not specific to a particular electrolyte changeClinical circumstances determine urgency of treatment rather than electrolyte concentrationFrequent reassessment of electrolyte abnormalities required

Principles of Electrolyte Disturbances


Case Study80-year-old woman with hypertension and heart failureConfusion, lethargy, poor oral intake and weakness for 3 daysNonsustained ventricular tachy-cardia on monitorLaboratory value: K 2.5 mmol/L

How would you initiate evaluation How would you initiate evaluation and treatment of this patient?and treatment of this patient?


Hypokalemia (K<3.5 mmol/L)Hypokalemia (K<3.5 mmol/L)

K<3.5 but >2.5 mmol/L K<3.5 but >2.5 mmol/L and No Symptomsand No Symptoms

Enteral replacementEnteral replacementKCl 20-40 mmol KCl 20-40 mmol every 4-6 hevery 4-6 h

KK2.5 mmol/L (<3 mmol/L if 2.5 mmol/L (<3 mmol/L if on Digoxin)on Digoxin)

Life-ThreateningLife-ThreateningSymptomsSymptoms

Non-Life Non-Life Threatening or Threatening or No SymptomsNo Symptoms

IV KCl 20-30 IV KCl 20-30 mmol/h via mmol/h via Central CatheterCentral Catheter

Enteral replacement Enteral replacement KCl 20-40 mmol every KCl 20-40 mmol every 2-4 h and/or IV KCl 10 2-4 h and/or IV KCl 10 mmol/hmmol/h

Treatment of Hypokalemia


Case Study80-year-old woman with hypertension and heart failureECG

How would you initiate treatment of How would you initiate treatment of this patient?this patient?

Laboratory value: K 7.8 mmol/L


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


Case Study80-year-old woman with hypertension and heart failureConfusion, lethargy, poor oral intake and weakness for 3 daysNonsustained ventricular tachy-cardia on monitorLaboratory value: Na 118 mmol/L

How would you initiate evaluation of How would you initiate evaluation of this patient to determine the etiology?this patient to determine the etiology?


Etiology of Hyponatremia

Presence ofPresence of↑ ↑ GlucoseGlucose

↑ ↑ Proteins or LipidsProteins or LipidsMannitolMannitol

AssessAssessVolume StatusVolume Status

Urine Osmolarity (UUrine Osmolarity (Uosmosm))

Urine Sodium (UUrine Sodium (UNaNa))

FE NaFE Na

Hyponatremia(Na<135 mmol/L)

Hypo-osmolar Hyponatremia

Consider Hyperosmolar Hyponatremia

Pseudohyponatremia

Yes

No


Etiology of Hyponatremia

HypovolemiaHypovolemia HypervolemiaHypervolemia

UUosmosm>300 mOsm/L>300 mOsm/L

UUNaNa <20 mmol/L <20 mmol/L

FE Na <1%FE Na <1%


UUNaNa >20 mmol/L >20 mmol/L

FE Na >1%FE Na >1%


UUNaNa <10-20 mmol/L <10-20 mmol/L

FE Na <1%FE Na <1%

VomitingVomitingDiarrheaDiarrheaThird-SpaceThird-Space Fluid LossFluid Loss

DiureticsDiureticsAldosteroneAldosterone

DeficiencyDeficiencyRenal TubularRenal Tubular

DysfunctionDysfunction

Congestive Heart FailureCongestive Heart FailureCirrhosisCirrhosisRenal Failure Renal Failure With/Without NephrosisWith/Without Nephrosis


Etiology of HyponatremiaEuvolemiaEuvolemia

UUosmosm <100 mOsm/L <100 mOsm/L


UUosm osm >100 mOsm/L (usually >300)>100 mOsm/L (usually >300)


PolydipsiaPolydipsiaInappropriate WaterInappropriate Water Administration to ChildrenAdministration to Children

SIADHSIADHHypothyroidismHypothyroidismAdrenal InsufficiencyAdrenal Insufficiency


HypovolemicHypervolemicEuvolemic Restrict free-water intake Increase free-water loss Replace intravascular volume with

normal saline or hypertonic saline

When would you use hypertonic When would you use hypertonic saline?saline?How fast would you correct the How fast would you correct the sodium concentration?sodium concentration?

Management of Hyponatremia


Case Study

80-year-old woman with hypertension and heart failureConfusion, lethargy, poor oral intake and weakness for 3 daysNonsustained ventricular tachy-cardia on monitorLaboratory value: Na 168 mmol/L

How would you treat this patient?How would you treat this patient?


Normal saline if hemodynamically unstableHypotonic fluid when stable Intravenous fluids Enteral free waterQuantity H2O deficit (L) =

[0.6 wt (kg) ] [Measured Na - 1] 140

Rate of correction

Treatment of Hypernatremia


Case Study34-year-old man with flu-like syndromeFebrile, tachycardic and hypotensiveAntibiotics and volume initiatedAdmitted to floor2 hours later, systolic BP 60 mm HgHypotensive in ICU after 40 mL/kg fluids and norepinephrine 10 g/min

What metabolic disorders may What metabolic disorders may contribute to the hypotension?contribute to the hypotension?What testing is needed?What testing is needed?


Support blood pressure with fluids and vasopressorsTreat precipitating conditionsPerform a short ACTH stimulation test if indicatedAdminister IV hydrocortisone 200-300 mg/24 hoursConsider fludrocortisoneTreat until critical illness resolves

Treatment for Acute Adrenal Insufficiency


Hyperglycemic Syndromes

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 (+)

Is this diabetic ketoacidosis (DKA) or Is this diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state hyperglycemic hyperosmolar state (HHS)?(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 (-)

Is this diabetic ketoacidosis (DKA) or Is this diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state hyperglycemic hyperosmolar state (HHS)?(HHS)?



Characteristics of Hyperglycemic SyndromesCharacteristics of Hyperglycemic Syndromes

DKA HHS

Glucose > 250 mg/dL > 600 mg/dL

Arterial/venous pH ≤ 7.3 > 7.3

Anion gap Increased Variable

Serum/urine ketones Positive Negative or small

Serum osmolarity Normal Increased


Initial EvaluationMental statusDegree of dehydrationPresence of infection or other precipitating conditionLaboratory studies Glucose Venous or arterial pH Electrolytes, renal function Urine or serum ketones Complete blood count ECG


CrystalloidsAdd glucose to fluids when

glucose 250-300 mg/dL

Regular insulin loading dose (0.1-0.15 U/kg)

Regular insulin infusion (0.1 U/kg/h)

If K <3.3 mmol/L hold insulin and replace K

Add K to fluids if K >3.3 but <5 mmol/L

Management of Hyperglycemic Syndromes


Continuous insulin infusionGoal 80-110 mg/dL (4.4-6.1 mmol/L) 140-180 mg/dL (7.8-10 mmol/L) <150 mg/dL (8.3 mmol/L)Patient selectionProtocol important to optimal outcomes

Hyperglycemia of Critical Illness


Questions Questions


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


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


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

Copyright 2008 Society of Critical Care Medicine Management of Life- Threatening Electrolyte and...

Documents

Transcript of Copyright 2008 Society of Critical Care Medicine Management of Life- Threatening Electrolyte and...