Electrolytes Conference 050512

Fluid and Electrolytes Conference

Tracy Santiago, M.D.Christian Daniel Ang, J.I.

May 5, 2012Heart House

General Data

• Patient: MD• Age/Sex: 19M• Address: Pandacan, Manila• Occupation: Unemployed• Date of Admission: May 3, 2012 (6:00PM)• Informant: Patient• Reliability: Good

Chief Complaint

Weakness of Upper and Lower Extremities

History of Present Illness

2 years PTA

• Sudden weakness of UE and LE upon waking up. • (-) dyspnea, dizziness, change in sensorium, blurring of vision, palpitations• No history of trauma• Still able to perform activities of daily living.• No consult or medications• Symptoms resolved spontaneously

6 mont

hs PTA

• Difficulty walking alone, had to use railings for support. • No consult• Resolution of symptoms

Few hours PTA

• Bilateral lower extremity and upper extremity weakness upon waking up• Symptoms progressed throughout the day• (-) dyspnea, dizziness, change in sensorium, blurring of vision, palpitations,

increase or decrease in urine output• Brought to the ER

Pertinent Medical History

• Current Illnesses: None• Previous Illnesses/Hospitalizations: None• Previous Surgeries: None• Known Allergies: None• Previous Transfusions: None• Immunizations: Unrecalled

Family History• (+) Hypertension – Maternal, Paternal• (+) Colon CA, Thyroid CA - Maternal• (-) DM, asthma • (-) Kidney Disease

Personal History• Diet: Mixed diet• Smoking: 0.2 pack year smoker• Illicit Drug Use: No use of illicit drug• Recent Travel: Laoag City, Baguio City• Medications: no intake of diuretics, herbal supplements,

diet pills, vitamins

Social History• Source of Income: parents• Primary caretaker: parents• Family Relationships: good family relationship• Residence: clean environment, well-ventilated house

Review of Systems

• General:(-) weight loss, (-) fever, (-) headache, (-) loss of consciousness• Integumentary:(-) itchiness, (-) redness, (-) pigmentation, (-) rash• EENT:(-) blurring of vision, (-) redness (-) lacrimation (-) photophobia (-)

ear pain (-) discharge (-) epistaxis• Respiratory:(-) difficulty of breathing, (-) cough• Cardiovascular: (-) dyspnea, (-) orthopnea, (-) PND, (-) palpitations• Gastrointestinal: (-) vomiting, (-) diarrhea, (-) constipation, (-)

hematemesis, (-) melena, (-) dysphagia• Genitourinary: (-) dysuria, (-) hematuria, (-) frequency, (-) urgency, (-)

hesitancy, (-) flank pains• Musculoskeletal: See HPI• Endocrine:(-) polyphagia, (-) polydipsia, (-) polyuria, (-) nocturia (-) heat

or cold intolerance• Hematopoietic:(-) easy bruising, (-) gum bleeding• Neurologic:(-) memory lapses, (-)seizures• Psychiatric: (-) anxiety, (-) depression

Physical Examination on Admission

• General Survey: Conscious, coherent, hypersthenic, wheelchair-borne, irritable, not in cardiorespiratory distress

• Vital Signs: BP : 130/90 mm Hg (supine), PR : 68, reg, RR 17, Temp: 36.6°C, O2 sat : 98%

• Wt: 90kg. Ht: 5’8” BMI: 31.14• Skin: Warm, moist skin, no active dermatoses, no jaundice,

brownish striae on the abdomen, whitish striae on the knees• Eyes: pink palpebral conjunctivae, anicteric sclera, pupils 2-3 mm

ERTL, EOM full and equal• Ears: no aural discharge, no tragal tenderness, non-hyperemic

EAC• Nose: midline septum, no nasal tenderness and discharge, no alar

flaring


• Mouth: moist buccal mucosa, no oral and palatal lesions, no gum bleeding

• Throat: tonsils not enlarged, non-hyperemic posterior pharyngeal wall

• Neck: supple neck, no supraclavicular retractions, no enlarged lymph nodes, no anterior neck mass, no thyroid enlargement, trachea midline, no buffalo hump

• Respiratory: No chest wall deformities, symmetrical chest expansion, no retractions, equal tactile and vocal fremiti, clear breath sounds


• Cardiovascular: JVP 3.0 at 30°, CAP rapid upstroke, gradual downstroke, adynamic precordium, apex beat at 5th LICS AAL, (-) heaves, thrills, and lifts, S1>S2 at the apex and S2>S1 at the base, no murmurs

• Gastrointestinal: Globular abdomen, normoactive bowel sounds, tympanic, soft, non-tender, no masses, no tenderness, Traube’s space not obliterated

• Extremities: no edema, full and equal pulses

Neurological exam• Mental Status: conscious, coherent, wheelchair-borne, oriented, GCS 15 (E4V5M6)

• Cranial Nerves:• CN I – no anosmia• CN II – pupils 2-3mm ERTL• CN III, IV, VI – EOM intact, no ptosis• CN V – face sensory intact, can clench teeth• CN VII – no facial asymmetry, can close eyebrows• CN VIII –hearing intact• CN IX, X – uvula midline on phonation, (+) gag reflex• CN XI – can turn head against resistance• CN XII – tongue midline on protrusion

• Motor: 3/5 both LE, 4/5 both UE• Cerebellum: good finger-to-nose test, alternate pronation-supination test

• Sensory: intact• Reflexes: (++)• Meningeal signs:(-) nuchal rigidity

Laboratory Results

Complete Blood CountMay 3 (12:34PM) Reference Range

HGB 163 120-170

RBC 5.34 4-6

HCT 0.47 0.37-0.54

MCV 88.40 87 +/- 5

MCH 30.60 29 +/- 2

MCHC 34.70 34 +/- 2

RDW 12.90 11.6-14.6

MPV 8.00 7.4-10.4

Platelet 202 150-450

WBC 10.30 4.5-10

Neutrophils 0.52 0.50-0.70

Lymphocytes 0.40 0.20-0.40

Eosinophils 0.05 0.00-0.05

Blood ChemistryTest May 3

(12:20PM)May 4

(2:43AM)May 4

(12:58PM)Reference

Range

Urea Nitrogen 10.03 9-23

Creatinine 0.79 0.5-1.2

Sodium 141.00 143.00 137-147

Potassium 1.79 2.46 3.66 LOW 3.8-5

Chloride 104.20 98-110

Magnesium 2.05 1.6-2.59

Ionized Calcium 1.23 1.12-1.32

How do we approach a patient with HYPOKALEMIA?

Algorithm depicting approach to Hypokalemia


Urine Chemistry Test May 3

(10:50PM)Reference

RangeCreatinine-Urine 82.83 39-259

Sodium - Urine 34.00 LOW 40-220

Potassium - Urine 7.65 LOW 25-125

Urine Osmolality 341.00 LOw 500-800


Remember:Potassium-Urine 7.65 mmol/L

ABGMay 3 (3:30PM)

pH 7.455

pCO2 36.6 mmHg

p02 94.1 mmHg

Temperature 37.0

Fi02 21.0%

BP 755.3 mmHg

May 3 (3:30PM)

HCO3 25.7 mmol/L

02 Sat 97.4%

BE 2.8 mmol/L

TC02 26.8 mmol/L

02CT 20.6 vol%

BB 50.8 mmol/L

SBF 2.5 mmol/L

AaD02 10.8 mmHg

a/A 0.90

R1 0.1


Remember:ABG pH = 7.455

Urinalysis May 3 (9:10PM)

Physical Characteristics Yellow, slightly turbid

Chemical Tests pH 7.0

Specific gravity 1.010

Albumin, Sugar, Leukocytes, Bilirubin,

Nitrite, Ketones

negative

Erythrocytes positive

Urobilinogen normal

Casts Absent

Cells RBC 2-4/hpf (no dysmorphic RBC seen)

Pus Cells 4-6/hpf

Squamous cells, Bacteria, Mucus Threads

Few

Casts Amorphous Urate ++

Capillary Blood Sugar

May 3, 2012At the ER

138 mg/dl

12L ECG

• Findings:– Sinus rhythm– 1o AV block– Inferior Wall Ischemia– Prolonged QT interval

Other Labs requested at the ER:Done:• Na, K, Mg, Cl• CBC with platelets• Urinalysis• Urine K, creatinine, osmolality• 12L ECG• Cardiac Monitoring

NOT Done:• TSH, FT3, FT4• Ultrasound of Kidney

Assessment

Hypokalemia

t/c Hypokalemic Paralysis

Let’s DiscussHYPOKALEMIA!

Hypokalemia

• Plasma K concentration <3.5 mmol/L

• Results from:

I. Decreased Intake

II. Redistribution into cells

III. Increased Loss

I. Decrease Intake

A. Starvation

- diminished intake is seldom the sole cause

- amount of K in the diet almost always exceeds that excreted in the urine

B. Clay ingestion

- binds dietary K and iron

II. Redistribution into CellsA. Acid-Base

Metabolic Alkalosis – occurs as a result K redistribution as well as excessive renal K loss

B. Hormonal

Insulin – stimulation of Na-H antiporter and Na-K-ATPase

B2-Adrenergic agonists – induce cellular uptake of K and promote insulin secretion

C. Anabolic State – K shift into cells (following rapid cell growth)

RBC production

WBC production

Frozen Blood transfusion (lost ½ K during storage)

III. Increased LossA. Non-Renal

Gastrointestinal loss – diarrhea, VIPomas, laxative abuse

Integumentary loss – excessive sweating

B. Renal

Increased Distal flow – diuretics, osmotic diuresis

Increased secretion of potassium – mineralocorticoid excess

- Adrenal adenoma (Conn’s syndrome) and hyperplasia

- Hyperreninemia (renal K wasting seen in renovascular HPN)

Hypokalemia: Clinical Manifestations

• Symptoms occur when plasma K concentration is <3 mmol/L

• Common: Fatigue, myalgia, muscular weakness of LEs

• Severe: progressive weakness, hypoventilation, paralysis

• Increased risk of rhabdomyolysis

• Increased risk of paralytic ileus

Hypokalemia: Clinical Manifestations

• ECG changes:– Flattening/inversion of T-waves– Prominent U-waves– ST-segment depression– Prolonged QU-interval*– Prolonged PR interval– Widening of the QRS complex

*Increased risk of VENTRICULAR ARRHYTMIAS

(especially in patients with MI and LVH)

Hypokalemia: Clinical Manifestations• Acid-Base disturbances

– K depletion results in Intracellular Acidification and an increase in net acid excretion or production of new HCO3

Leads to METABOLIC ALKALOSIS!

– Consequence of:• Enhanced proximal HCO3 reabsorption• Increased renal ammoniagenesis• Increased distal H excretion

What is TTKG?Trans-Tubular Potassium Gradient

• An index reflecting the conservation of K in the CCD• Useful in diagnosing the causes of Hypo/Hypo-K

Only NICE TO KNOW in this

case


What is TTKG?Trans-Tubular Potassium Gradient

• An index reflecting the conservation of K in the CCD• Useful in diagnosing the causes of Hypo/Hypo-K

TTKG = (Urine K x Serum Osm) / (serum K x urine osmol)= (7.65 x 293) / (1.79 x 341)= 2241.45/610.39

TTKG = 3.67

We can NOT use TTKG in our patient! In the algorithm, it is only <2 or >4

Serum Osm = 2Na + (Glucose/18) + (BUN/2.8)= 282 + 7.67 + 3.58

Serum osm = 293

TTKG

Only NICE TO KNOW in this

case


In our Patient, these are our possible diagnoses:- Remote Diuretic Use- Remote Vomiting or Stomach Drainage- Profuse Sweating***

Management

Therapeutic Goals:– Correct the K deficit

Our patient: 1.79 mmol/L

– Minimize on going losses (prevent life-threatening complications)

– Safer to correct thru ORAL route– Plasma K should be monitored regularly

Estimation of Potassium Deficit:- decrement of 1.0 mmol (from 4.0 to 3.0 mmol/L) represents a total body K deficit of 200-400

mmol- patients with plasma levels of <3.0 mmol/L often require 600 mmol of K to correct the deficit

Management

Medications:Potassium Chloride** (Kalium Durule)

- Preparation of choice- More rapid correction and metabolic

alkalosis

Potassium HCO3 and Citrate• More appropriate in hypokalemia associated with

chronic diarrhea or RTA

Management

Medications:Intravenous Potassium Chloride**

- Severe hypokalemia- Unable to take anything by mouth- used judiciously, close observation!

Given to our patient:

(2 bags) IV Potassium Chloride drip

(q8) Kalium Durules

GOOD NEWS!!!

For discharge! (May 5, 2012)

Documents

Electrolytes Conference 050512