Upload
justina-sherman
View
218
Download
1
Embed Size (px)
Citation preview
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
3 Copyright 2008 Society of Critical Care Medicine
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?
4 Copyright 2008 Society of Critical Care Medicine
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
5 Copyright 2008 Society of Critical Care Medicine
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?
6 Copyright 2008 Society of Critical Care Medicine
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
7 Copyright 2008 Society of Critical Care Medicine
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
8 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
9 Copyright 2008 Society of Critical Care Medicine
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?
10 Copyright 2008 Society of Critical Care Medicine
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
11 Copyright 2008 Society of Critical Care Medicine
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%
UUosmosm>300 mOsm/L>300 mOsm/L
UUNaNa >20 mmol/L >20 mmol/L
FE Na >1%FE Na >1%
UUosmosm>300 mOsm/L>300 mOsm/L
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
12 Copyright 2008 Society of Critical Care Medicine
Etiology of HyponatremiaEuvolemiaEuvolemia
UUosmosm <100 mOsm/L <100 mOsm/L
UUNaNa >30 mmol/L >30 mmol/L
UUosm osm >100 mOsm/L (usually >300)>100 mOsm/L (usually >300)
UUNaNa >30 mmol/L >30 mmol/L
PolydipsiaPolydipsiaInappropriate WaterInappropriate Water Administration to ChildrenAdministration to Children
SIADHSIADHHypothyroidismHypothyroidismAdrenal InsufficiencyAdrenal Insufficiency
13 Copyright 2008 Society of Critical Care Medicine
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
14 Copyright 2008 Society of Critical Care Medicine
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?
15 Copyright 2008 Society of Critical Care Medicine
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
16 Copyright 2008 Society of Critical Care Medicine
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?
17 Copyright 2008 Society of Critical Care Medicine
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
18 Copyright 2008 Society of Critical Care Medicine
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)?
19 Copyright 2008 Society of Critical Care Medicine
Hyperglycemic Syndromes
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)?
20 Copyright 2008 Society of Critical Care Medicine
Hyperglycemic Syndromes
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
21 Copyright 2008 Society of Critical Care Medicine
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
22 Copyright 2008 Society of Critical Care Medicine
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
23 Copyright 2008 Society of Critical Care Medicine
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
24 Copyright 2008 Society of Critical Care Medicine
Questions Questions
25 Copyright 2008 Society of Critical Care Medicine
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
26 Copyright 2008 Society of Critical Care Medicine
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
27 Copyright 2008 Society of Critical Care Medicine
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