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Electrolyte Disorders
Dom Colao, DO
November 2011
Review of Electrolyte disorders
• HypoNatremia
• Hypernatremia
• HypoKalemia
• HyperKalemia
• Calcium
• Magnesium
• Phosphorus
Overview of Disorders
• The differential for any lab abnormality:– Lab error
• Lab error– Lab error
– Polypharmacy– Iatrogenic– Real disease
• In that order!
Always consider the potential for a confounding variable
• Was the blood drawn above a running IV?
• Did it sit too long before the test was run?
• Is it your patients blood?
• Is there a pattern of abnormalities in numerous patients on the same day?
Over view of Sodium Disorders
• Pseudo-hyponatremia– Due to high concentrations of other solutes
in the blood - Mannitol in a pt with cerebral edema, Glucose in a diabetic.
• Then look at the patient’s volume status
• Hypervolemic/Euvolemic/Hypovolemic
Hyponatremia
• Hypervolemic:
• HypOvolemic:
• Euvolemic:
Hyponatremia
• Hypervolemic:– CHF, – Cirrhosis, – Pregnancy, – Nephrotic syndrome– In these conditions, total body sodium is up, but
total body WATER is up even more.– Due to reduced Effective Arterial Blood Volume,
(EABV) leading to increased ADH secretion.
Hyponatremia
• Hypervolemic:– CHF, Cirrhosis, Pregnancy, Nephrotic syndrome
• HypOvolemic:– GI losses (diarrhea, Vomiting, NG suction)– Renal Losses (diuretics, Salt wasting nephropathy,
recovery phase from ATN or obstruction).– Due to true depletion of water and sodium, leading
to increased secretion of Aldosterone AND ADH
Hyponatremia
• Hypervolemic:– CHF, Cirrhosis, Pregnancy, Nephrotic syndrome
• HypOvolemic:– GI losses (diarrhea, Vomiting, NG suction)– Renal Losses (diuretics, Salt wasting nephropathy,
recovery phase from ATN or obstruction).
• Euvolemic:– Medication effects, Endocrine syndromes,
Excessive water intake, reset osmostat, SIADH
Hyponatremia
• Euvolemic:– Medication effects
• ACE/ ARB/Tekturna/Spironolactone/HCTZ• Antidepressant and antipsychotic meds• NSAID’s
– Endocrine syndromes• Hyper and Hypo thyroid, • Adrenal insufficiency and excess (addison’s / Cushings)
– Excessive water intake, • Psychogenic polydipsia, beer potomania
– reset osmostat, • Seen in conditions which stimulate tonic ADH secretion from tissues
which have Neuroectoderm (brain and Lung)
– SIADH
Hyponatremia
• Euvolemic:– reset osmostat,
• Seen in conditions which stimulate tonic ADH secretion from tissues which have Neuroectoderm (brain and Lung)
• Pneumonia, COPD, stroke, brain hemorrhage.• These conditions result in a stable low level of sodium, around
which water and sodium regulation are functioning normally, but at a new lower setting.
• Confirmed by water loading test.
– SIADH - Persistant high production of ADH which does not suppress in the face of water load, usually due to a tumor such as small cell lung carcinoma or brain tumor.
Case 1, Hyponatremia
Case 1b Hyponatremia
Case 1c, Hyponatremia
Pieces of metal in abdominal wall
Can you guess what she swallowed?
Case 2a Hypernatremia
Case 2b Hypernatremia
Case 3a Hypokalemia
Case 3a Hypokalemia
Case 3 b, Hypokalemia
Case 3 b, Hypokalemia
Case 4 Hyperkalemia
Case 4 Hyperkalemia
Case 4 Hyperkalemia
Case 5, Hypercalcemia
Case 6 Hypocalcemia
Case 6 Hypocalcemia
Case 7, Hypomagnesemia
Case 7, Hypomagnesemia
Case 8 Hypermagnesemia
• Hypermagnesemia is seen only in patients with renal failure who are supplemented,
• or in cases where large amounts of magnesium are infused.
Case 9, Hypophosphatemia
Case 9 Hyperphosphatemia• Classic presentation of Hypophosphatemic
rhabdomyolysis.• Prolonged NPO status/starvation• Resp failure requiring reintubation after extubation
or surgery. Due to resp muscle weakness.• Phos goes very low, then suddenly climbs without
any supplementation. Associated with high K and Low calcium.
• Creatinine climbs more than 1.0 mg/dl/day, suggesting increased creatinine production
Reference
• Narins. Fluid and Electrolyte Disorders: Am journal of Medicine, 1982