12-Management 20of 20Life 1

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Copyright 2008 Society of Critical Care Medicine

Management of Life-

Threatening Electrolyte andMetabolic Disturbances


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1Copyright 2008 Society of Critical Care Medicine

Objectives

Review the emergent management ofsevere electrolyte disturbances

Recognize manifestations of acuteadrenal insufficiency and initiateappropriate treatmentDescribe the management of severehyperglycemic syndromes


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Case Study

80-year-old woman withhypertension and heart failure

Confusion, lethargy, poor oral intakeand weakness for 3 days

BP 108/70 mm Hg, HR 110/min, R18/min

Nonsustained ventricular tachy-cardia on monitor

What risk factors does this patient

have for electrolyte disturbances?

What electrolyte disorders might

contribute to her presentation?


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Treat the electrolyte change, butsearch for the cause

Clinical manifestations are usuallynot specific to a particular electrolytechangeClinical circumstances determineurgency of treatment rather than

electrolyte concentrationFrequent reassessment of electrolyteabnormalities required

Principles of ElectrolyteDisturbances


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Case Study




Laboratory value: K 2.5 mmol/L

How would you initiate evaluationand treatment of this patient?


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Hypokalemia (K


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Case Study

80-year-old woman withhypertension and heart failureECG

How would you initiate treatment of

this patient?

Laboratory value: K 7.8 mmol/L



Treatment of Hyperkalemia

Calcium for cardiac toxicity (ECGabnormalities)

Redistribute potassium

Insulin and glucose Sodium bicarbonate Inhaled 2-agonistsRemove potassium

Loop diuretic

Sodium polystyrene sulfonate Dialysis



Case Study




Laboratory value: Na 118 mmol/L

How would you initiate evaluation of

this patient to determine the etiology?



Etiology of Hyponatremia

Presence of

Glucose

Proteins or Lipids

Mannitol

AssessVolume Status

Urine Osmolarity (Uosm)

Urine Sodium (UNa)FE Na

Hyponatremia

(Na




Hypovolemia Hypervolemia

Uosm>300 mOsm/L

UNa 20 mmol/L

FE Na >1%

Uosm>300 mOsm/L

UNa




Euvolemia

Uosm 30 mmol/L

Uosm >100 mOsm/L (usually >300)

UNa >30 mmol/L

Polydipsia

Inappropriate Water

Administration to Children

SIADH

Hypothyroidism

Adrenal Insufficiency



HypovolemicHypervolemic

Euvolemic

Restrict free-water intake

Increase free-water loss Replace intravascular volume with

normal saline or hypertonic saline

When would you use hypertonic

saline?How fast would you correct the

sodium concentration?

Management ofHyponatremia



Case Study




Laboratory value: Na 168 mmol/L

How would you treat this patient?



Normal saline if hemodynamicallyunstable

Hypotonic fluid when stable

Intravenous fluids Enteral free water

Quantity H2O deficit (L) =

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

Rate of correction

Treatment of Hypernatremia


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Case Study

34-year-old man with flu-likesyndromeFebrile, tachycardic and hypotensiveAntibiotics and volume initiated

Admitted to floor2 hours later, systolic BP 60 mm HgHypotensive in ICU after 40 mL/kgfluids and norepinephrine 10 g/min

What metabolic disorders may

contribute to the hypotension?What testing is needed?


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Hyperglycemic Syndromes

25 year-old type I diabetic; venous pH7.26, glucose 290 mg/dL, HCO3 16 mmol/L,anion gap 16 mmol/L, urine ketones (+)

51 year-old with no chronic illness; Na 141mmol/L, Cl 98 mmol/L, HCO3 13 mmol/L,glucose 1640 mg/dL, BUN 70 mg/dL, urineketones (+)

Is this diabetic ketoacidosis (DKA) orhyperglycemic hyperosmolar state

(HHS)?


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73 year-old type II diabetic; Na 163mmol/L, Cl 134 mmol/L, HCO3 21 mmol/L,glucose 1282 mg/dL, BUN 62 mg/dL, urineketones (-)

Is this diabetic ketoacidosis (DKA) orhyperglycemic hyperosmolar state

(HHS)?


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Characteristics 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


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Initial Evaluation

Mental statusDegree of dehydration

Presence of infection or otherprecipitating condition

Laboratory studies Glucose Venous or arterial pH

Electrolytes, renal function Urine or serum ketones Complete blood count ECG

M t f


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Fluids

Insulin

Electrolytes

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 but


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Continuous insulin infusionGoal 80-110 mg/dL (4.4-6.1 mmol/L)

140-180 mg/dL (7.8-10 mmol/L)


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Questions


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Key Points

Give KCl through a central venouscatheter for life-threatening hypokalemia

Consider calcium administration forhyperkalemia with ECG changes followedby interventions to shift K intracellularly

Limit the increase in serum Na to 8-12mmol/L in the first 24 h in symptomaticeuvolemic hyponatremia

Patients with hypernatremia andhemodynamic instability should havenormal saline administered


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Key Points

Patients with possible adrenalinsufficiency should have emergenttreatment with a glucocorticoid

Treatment goals for hyperglycemicsyndromes are to restore fluid andelectrolyte balance, provide insulin andidentify precipitants

In DKA, insulin infusion should becontinued until acidosis and ketosishave resolved


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Key Points

Maintain glucose 250-300 mg/dL in HHSuntil plasma osmolality 315 mOsm/kgPotassium should be added to fluids inhyperglycemic syndromes as soon as K

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12-Management 20of 20Life 1