llulds and LlecLrolyLes

Crlucal Care 8oard 8evlew 1uLorlal

2013
Case 1
91 year old woman wlLh dlabeLes melllLus and
lschemlc cardlomyopaLhy on furosemlde,
splronolacLone and poLasslum chlorlde was
noLed Lo have hypokalemla four days ago.
lurosemlde was dlsconunued, oral poLasslum
lncreased and she presenLs Loday Lo Lhe
emergency deparLmenL noung l feel awful".
Case 1
Case 1
!"#$%%$&'
Sodlum (mmol/L) 136
oLasslum (mmol/L) 8.2
Chlorlde (mmol/L) 107
CC2 (mmol/L) 17
8un (mg/dL) 22
Creaunlne (mg/dL) 1.6
Clucose (mg/dL) 146
Case 1
Whlch one of Lhe followlng sLaLemenLs ls
Lrue?
A. Serum poLasslum level predlcLs
elecLrocardlographlc abnormallues
8. 8elease of lnLracellular poLasslum conLrlbuLed Lo
Lhls pauenL's hyperkalemla
C. LecL of lnLravenous calclum on cardlac
conducuon lasLs 30-60 mlnuLes
u. urgenL hemodlalysls ls lndlcaLed
L. 8ebound hyperkalemla ls llkely Lo occur
Case 1
Aer LreaLmenL
Case 1
earls
1here ls noL a ughL correlauon beLween poLasslum level and
conducuon abnormallues.
ueLermlne wheLher poLasslum ls due Lo exogenous load (as ln
Lhls case), Lrans-cellular shl, or ussue ln[ury.
Calclum ls lnlual Lherapy because of rapld onseL, buL durauon ls
relauvely shorL.
1reaLmenL wlLh calclum ls lndlcaLed for conducuon
abnormallues (absenL wave, C8S wldenlng) noL peaked 1
waves.
AgenLs LhaL remove poLasslum Lhrough Lhe Cl LracL or kldney
are adequaLe for modesL poLasslum overload, however dlalysls
may be requlred lf Lhere ls ongolng poLasslum enLry lnLo Lhe
clrculauon (ussue ln[ury).
8ebound hyperkalemla ls nearly unlversal aer hemodlalysls,
and poLasslum levels measured lmmedlaLely aer dlalysls are
noL sLeady sLaLe.
Case 2
47 year old woman ls broughL Lo Lhe
emergency deparLmenL by her daughLers wlLh
a 4 day hlsLory of lncreaslng confuslon, now
wlLh leLhargy and fecal lnconunence. She ls
able Lo provlde her name only, follows slmple
commands lnconslsLenLly. Per medlcauons
lnclude uoxeune and hydrochloroLhlazlde as
needed for edema. C1 of head ls normal.
WelghL ls 100 kg, helghL ls 3 3 ln
!"#$%%$&' ) *&+,% - *&+,% ./ *&+,% /) *&+,%
Sodlum (mmol/L) 109
oLasslum (mmol/L) 2.9
Chlorlde (mmol/L) 81
CC2 (mmol/L) 16
8un (mg/dL) 9
Creaunlne (mg/dL) 0.6
Serum osmolallLy 230
urlne osmolallLy 161
urlne sodlum
(mmol/L)
36
1oLal urlne (L)
1reaLmenL 0.9 sallne
3 sallne
Case 2
Whlch one of Lhe followlng sLaLemenLs ls Lrue?
A. She does noL have cerebral edema
8. 1hls ls acuLe hyponaLremla and should be LreaLed
wlLh a bolus of 3 sallne
C. Cllnlcal semng and urlne sLudles are mosL conslsLenL
wlLh cerebral salL wasung
u. 8apld correcuon of hyponaLremla ls llkely Lo occur
sponLaneously
L. Selzures occur ln mosL pauenLs wlLh osmouc
demyellnauon syndrome
!"#$%%$&' ) *&+,% - *&+,% ./ *&+,% /) *&+,%
Sodlum (mmol/L) 109 118 124 126 123
oLasslum (mmol/L) 2.9
Chlorlde (mmol/L) 81
CC2 (mmol/L) 16
8un (mg/dL) 9
Creaunlne (mg/dL) 0.6
Serum osmolallLy 230
urlne osmolallLy 121
urlne sodlum
(mmol/L)
36
1oLal urlne (L) 2 4 3 6
1reaLmenL 0.9 sallne
3 sallne
Case 2
earls
Cerebral edema ls llfe LhreaLenlng wlLh acuLe hyponaLremla (less Lhan 24
hours, oen less Lhan 6 hours), buL may be presenL and mlld wlLh more
chronlc onseL of hyponaLremla.
SympLomauc acuLe hyponaLremla ls LreaLed wlLh bolus hyperLonlc
sallne, whlle sympLomauc chronlc hyponaLremla ls LreaLed wlLh lnfuslon
of hyperLonlc sallne, wlLh rapld correcuon lnlually, noL Lo exceed 10
mmol/L shl over 24 hours.
Cerebral salL wasung and SlAuP share rlsk facLors (CnS ln[ury) and
slmllar urlne sLudles, dlsungulsh by cllnlcal evldence of hypovolemla ln
cerebral salL wasung.
SponLaneous correcuon may be rapld for several causes of chronlc
hyponaLremla, and should be suspecLed lf low urlne osmolallLy
measured or lncreased urlne ouLpuL observed. lf excesslvely rapld
correcuon ls observed, hypoLonlc uld +/- desmopressln should be used.
Selzures are well descrlbed buL uncommon early ln osmouc
demyellnauon syndrome, and weakness ls usually ldenued beLween 2
and 6 days aer overcorrecuon.
oLasslum replacemenL Lo correcL hypokalemla wlll ralse Lhe sodlum
level
Case 2
lnlual brlef lncrease ln serum sodlum lf 0.9 sallne glven
SoluLe ln 1000 mL of 0.9 sallne (308 mosm) can be excreLed
ln 300 mL of urlne
lree waLer ls reLalned
3 sallne usually lnfused ~20 - 30 mL/hr
300 mL of 3 sallne conLalns 236 mmol sodlum
Wlll correcL a 70 kg pauenL (18W 30 - 40 L) by 6-8 mmol/L
LecL ls Lemporary due Lo excreuon of concenLraLed soluLe
Loop dlureuc or vasopressln anLagonlsL may be needed
Check serum sodlum every 2-3 hours
Change ln Lherapy ls frequenLly requlred
Case 3
74 year old woman wlLh hyperLenslon, end
sLage renal dlsease and breasL cancer
(dlagnosed Lhree years ago) presenLs wlLh
nausea and somnolence, noL Laklng
medlcauons for several days.
!"#$%%$&' / "01% 2034,
Sodlum (mmol/L) 141 140
oLasslum (mmol/L) 4.1 4.9
Chlorlde (mmol/L) 101 101
CC2 (mmol/L) 23 21
8un (mg/dL) 20 28
Creaunlne (mg/dL) 7.2 10.1
1oLal calclum (mg/dL) 13.2 16.3
lonlzed calclum (mmol/L) 1.64
hosphorus (mg/dL) 6.7 9.0
Albumln (g/dL) 3.2
1oLal proLeln (g/dL) 7.1
araLhyrold hormone
level (pg/mL)
990 (10-63)
1,23-vlLamln u 37 (23-66)
Case 3
Whlch one of Lhe followlng sLaLemenLs ls Lrue ln
Lhls case?
A. Sallne and furosemlde can be used for sympLomauc
hypercalcemla
8. Mallgnancy ls a more llkely cause Lhan end sLage
renal dlsease of Lhls pauenL's hypercalcemla
C. Pemodlalysls ls noL eecuve for acuLe LreaLmenL of
hypercalcemla
u. CalclLonln Lherapy ls eecuve wlLhln hours
L. 8lsphosphonaLe Lherapy would be lneecuve for
Lhls pauenL
Case 3
earls
Sallne ls lndlcaLed for sympLomauc hypercalcemla, whlch ls
Lyplcally accompanled by hypovolemla and oen acuLe renal
fallure. ln Lhe case of end sLage renal dlsease, less llkely Lo be
lndlcaLed.
Lnd sLage renal dlsease may be compllcaLed by hypercalcemla
due Lo excesslve replacemenL (calclum and acuve vlLamln u) or
Leruary hyperparaLhyroldlsm (elevaLed 1P dlagnosuc ln Lhls
case).
Can worsen ln hosplLallzed pauenLs due Lo lmmoblllLy,
lnLerrupuon of calclmlmeuc, lnsumclenL dlalysls (all Lhree ln Lhls
case).
CalclLonln works wlLhln hours buL ls eecuve for only 48 hours
(Lachyphylaxls).
8lsphosphonaLes work wlLhln a few days wlLh long lasung
eecL, buL are noL well sLudled and noL recommended ln renal
fallure (Cl8 < 30)
Case 4
23 year old morbldly obese woman ls
admlued Lo Lhe lCu wlLh abrupL onseL of
abdomlnal paln 3 hours aer auempLed L8C
for choledochollLhlasls. She ls LreaLed for
severe pancreauus wlLh acuLe kldney ln[ury
and on day Lwo develops numbness of hands
and face, palnful exlon of her rlghL wrlsL and
lnablllLy Lo open her mouLh or speak. She ls
alerL and anxlous.
!"#$%%$&' /) *,% 56 *,%
Calclum 8.8 6.1 3.3
Albumln 3.3 2.9 2.3
Magneslum 1.6
hosphorus 2.9
CC2 22 17 17
Creaunlne 0.8 2.4 2.1
Amylase 1287 1164
Llpase >1300 >1300
lacLaLe 2.3
pP 7.28
pCC2 46
pC2 73
Case 4
Whlch one of Lhe followlng sLaLemenLs ls Lrue
ln Lhls case?
A. An lonlzed calclum measuremenL ls needed prlor
Lo Lherapy
8. Sodlum blcarbonaLe lnfuslon should be avolded
C. She should be LreaLed wlLh an anxlolyuc
medlcauon
u. She should be evaluaLed for acuLe
hypoparaLhyroldlsm
L. 1reaLmenL wlLh calclum lv bolus ls lndlcaLed
!"#$%%$&' /) *,% 56 *,% )- *,%
78+,,4'39
Calclum 8.8 6.1 3.3
lon Calclum 0.47
Albumln 3.3 2.9 2.3
Magneslum 1.6
hosphorus 2.9
CC2 22 17 17 22
Creaunlne 0.8 2.4 2.1 2.4
Amylase 1287 1164
Llpase >1300 >1300
lacLaLe 2.3
pP 7.28 7.4
pCC2 46 44
pC2 73 71
Case 4
earls
lonlzed calclum levels are more accuraLe ln crlucally lll
pauenLs ln whom albumln and pP shls are acuLe and
slgnlcanL. Powever, Lyplcal ndlngs ln Lhls case (LeLany,
muscle spasm, numbness) wlLh low LoLal calclum should
be LreaLed.
Addluon of alkalosls (resplraLory or meLabollc) can make
hypocalcemla more sympLomauc by decreaslng pP and
lonlzed calclum.
AnxleLy ls presenL buL secondary Lo Lhe above.
She does noL have a rlsk facLor for acuLe
hypoparaLhyroldlsm (neck surgery).
lnLravenous calclum lnfuslon ls Lhe emergenL Lherapy,
however bolus Lherapy ls noL recommended.
Case 3
41 year old woman wlLh poorly conLrolled
asLhma, narcouc dependency and lncreaslng
shorLness of breaLh was found unresponslve
by her famlly. Lmergency responders found
pulseless elecLrlcal acuvlLy and performed
advanced cardlopulmonary resusclLauon for
23 mlnuLes before reLurn of sponLaneous
clrculauon. ln Lhe emergency deparLmenL she
ls unresponslve wlLh puplls 8 mm and
unreacuve Lo llghL.
Case 3
C1 scan was performed aL 18 hours aer
cardlopulmonary arresL.
Case 3
Case 3
!"#$%%$&' ) *&+,% 0:& 8+,,4'3
Sodlum (mmol/L) 143 160
oLasslum (mmol/L) 3.8 3.9 3.8
Chlorlde (mmol/L)
CC2 (mmol/L) 30 29 30
8un (mg/dL) 16 20 21
Creaunlne (mg/dL) 0.9 1.0 1.0
urlne ouLpuL (mL/hr) 30 300 300
WelghL 70 kg, non-obese
Case 3
Whlch one of Lhe followlng sLaLemenLs ls
Lrue?
A. Cerebral salL wasung ls presenL ln Lhls case
8. Per free waLer declL 4 hours ago was 6 llLers
C. 1he currenL serum sodlum level ls ~170 mmol/L
u. Pead C1 ls unllkely Lo demonsLraLe hernlauon
L. uesmopressln wlll noL be eecuve
Case 3
lree waLer replacemenL
= LoLal body waLer x ([serum sodlum/140] - 1)
= LoLal body waLer x (serum sodlum - 140)/140)

1oLal body waLer = lean body welghL x ~0.3
ad[usL for gender and age?
ad[usL for welghL loss wlLh dehydrauon?
AlLernauve formula:
3 mL waLer x kg lean body welghL x mmol sodlum correcuon
LxpecL ~3 mmol/L change ln sodlum for every llLer of free waLer ln
an average slze adulL
Case 3
18W = 70 x 0.3 = 33 L = 33 L
(160-140)/140 = 0.143
33 x 0.143 = 3.0 L
AlLernauve formula:
3 mL waLer x 70 kg x 20 mmol/L sodlum correcuon = 4.2 L

Average slze pauenL
~ 20 mmol/L above normal
one llLer for every 3 mmol/L = ~ 4 L

Case 3
earls
lnLracranlal paLhology ls assoclaLed wlLh SlAuP, cerebral
salL wasung and dlabeLes lnslpldus.
lree waLer declL can be esumaLed qulckly.
Cngolng urlnary losses are easlly measured and wlll
deLermlne Lhe raLe of change ln sodlum level.
ln Lhe case of cerebral edema, dlabeLes lnslpldus ls llkely
Lo be a marker of hernlauon and evolvlng braln deaLh.
uesmopressln and free waLer replacemenL are eecuve
for sodlum correcuon, buL wlll noL lmprove Lhe neurologlc
condluon ln Lhls case (expecL Lo worsen).
8apld lnfuslons of dexLrose soluuons can cause osmouc
dluresls and conunued waLer losses desplLe desmopressln.
Case 6
A 24 year old woman ls broughL Lo Lhe
emergency deparLmenL early ln Lhe mornlng
aer parLylng" and danclng durlng Lhe nlghL.
She ls responslve only Lo paln and her serum
sodlum level ls 110 mmol/L.
Case 6
Whlch one of Lhe followlng sLaLemenLs ls
Lrue?
A. She has Lhe mosL common compllcauon of
recreauonal MuMA (ecsLacy) use
8. urlne osmolallLy wlll be less Lhan 100 mosm/kg
C. lluld resLrlcuon ls Lhe besL lnlual Lherapy
u. She ls mosL llkely Lo have osmouc demyellnauon
syndrome
L. 1reaLmenL wlLh 3 sallne bolus ls lndlcaLed
Case 6
earls
MuMA use ls compllcaLed by hyperpyrexla mosL commonly,
however also sumulaLes LhlrsL and AuP secreuon Lo cause
hyponaLremla.
lf slmple waLer lnLoxlcauon, urlne wlll be maxlmally dlluLe (less
Lhan 100 mosm). lf AuP ls lncreased as ln MuMA use, urlne
osmolallLy wlll be lncreased.
lree waLer resLrlcuon wlll gradually correcL Lhe sodlum as waLer
ls excreLed, however emergenL lncrease ln serum sodlum level
ls lndlcaLed.
Per greaLesL neurologlc rlsk ls hernlauon due Lo unLreaLed
cerebral edema, ln conLrasL Lo Lhe lncreased rlsk of osmouc
demyellnauon wlLh overcorrecuon of chronlc hyponaLremla.
LmergenL LreaLmenL ls hyperLonlc sallne (3) glven as bolus
Lherapy.
Case 7
30 year old man presenLs wlLh Lwo weeks of
progresslve shorLness of breaLh, weakness,
serum poLasslum level of 1.6 mmol/L and Lhe
followlng C1 of Lhe chesL:
Case 7
Whlch one of Lhe followlng sLaLemenLs ls
Lrue?
A. Pls muscle weakness ls due Lo hypercalcemla
8. Pe ls llkely Lo have hyperLhyroldlsm
C. MeasuremenL of Lhe aldosLerone level ls
lndlcaLed
u. 1he urlne poLasslum concenLrauon wlll be low
L. A dlureuc should be lncluded ln Lhe LreaLmenL
Case 7
earls
Lung cancer elecLrolyLe abnormallues: hypercalcemla
(paraLhyrold relaLed pepude) ln squamous cell carclnoma,
hyponaLremla (AuP) and hypokalemla (AC1P) ln small cell
lung cancer.
Conslder weakness due Lo hypokalemla or paraneoplasuc
dlsease (LamberL LaLon myasLhenlc syndrome).
A neck or subsLernal Lhyrold mass (noL shown ln Lhls case)
would suggesL LhyroLoxlcosls as a cause of acuLe
hypokalemla.
AC1P sumulaLes corucosLerold producuon and lncreases
urlnary poLasslum wasung.
oLasslum cannoL be correcLed unless urlnary losses are
decreased (poLasslum sparlng dlureuc/aldosLerone
anLagonlsL).
Case 8
A 67 year old woman wlLh chronlc kldney
dlsease presenLs wlLh weakness and
sympLomauc bradycardla four days aer
beglnnlng a new over-Lhe-counLer reglmen for
consupauon. Per magneslum level ls 8.4 mg/
dL and her phosphorus level ls 6 mg/dL.
Case 8
Whlch one of Lhe followlng sLaLemenLs ls
Lrue?
A. PyperphosphaLemla causes bradycardla
8. Pypermagnesemla causes mlouc puplls
C. lnLravenous calclum ls Lhe besL lnlual Lherapy
u. Chelauon Lherapy ls used for bradycardla
L. Pemodlalysls has llule eecL on serum
magneslum levels
Case 8
earls
Cver Lhe counLer ln anLacld and bowel reglmens oen
conLaln magneslum, especlally dangerous lf lmpalred renal
funcuon (decreased clearance) or bowel dlsease
(lncreased absorpuon).
Pypermagnesemla causes hypoLenslon, bradycardla,
dllaLed puplls, leLhargy
lnLravenous calclum ls Lhe besL emergenL LreaLmenL for
hypermagnesemla (lmmedlaLe reversal).
Pemodlalysls ls eecuve for hypermagnesemla over hours.
Cver Lhe counLer bowel reglmens may also conLaln
phosphaLe, causlng acuLe hyperphosphaLemla and
sympLomauc hypocalcemla.
Case 9
67 year old man ls belng evaluaLed for llver
LransplanL wlLh hepauus b lnfecuon. Pe ls
lnLubaLed for alLered menLal sLaLus, and ls
recelvlng broad specLrum anubloucs and
lacLulose.
CurrenL welghL 100 kg (70 kg when healLhy)
uependenL edema, Lense asclLes

Case 9
;&%<$302 "01
/=
./ *&+,% 2034, /) *&+,% 2034,
Sodlum (mmol/L) 130 134 137
oLasslum (mmol/L) 4.8 4.1 3.4
Chlorlde (mmol/L) 127 129 130
CC2 (mmol/L) 14 16 17
8un (mg/dL) 16 18 18
Creaunlne (mg/dL) 1.0 1.1 1.0
Clucose (mg/dL) 148 190 136
Case 9
Whlch one of Lhe followlng sLaLemenLs ls
Lrue?
A. Pe ls llkely Lo be hypovolemlc
8. Pls free waLer declL calculauon should be
based on hls lean body welghL
C. 1hlrsL plays no role ln hls free waLer balance
u. Csmouc dluresls conLrlbuLes Lo hls waLer losses
L. vasopressln ls a Lherapy for Lhls condluon
Case 9
lree waLer replacemenL
= LoLal body waLer x ([serum sodlum/140] - 1)
= LoLal body waLer x (serum sodlum - 140)/140)

1oLal body waLer = lean body welghL x ~0.3
ad[usL for gender and age?
ad[usL for welghL loss wlLh dehydrauon?
ad[usL for edema?
Case 9
1oLal body waLer
Lean LoLal body waLer = 70 x 0.3 = 33 L
AsclLes and edema = 30 kg = 30 L above lean welghL
1oLal body waLer = 63 L
lree waLer replacemenL
= LoLal body waLer x (130-140)/140
= 63 L x 0.067 = 4.4 L
+ 700 mL + Z
Insensible
losses
Other
losses
Case 9
earls
auenLs presenung from Lhe communlLy wlLh hypernaLremla
are volume depleLed, whlle hosplLallzed pauenLs are usually
noL.
Calculauon of Lhe free waLer declL ln Lhls case ls based upon an
assessmenL of LoLal body waLer.
Slmple calculauon (3 ml/kg/mmol na) noL useful here
Ldema/asclLes ls excess LoLal body waLer and needs Lo be lncluded
noLe LhaL obeslLy does noL aecL free waLer declL calculauon based
upon lean body welghL
Crlucally lll pauenLs can experlence LhlrsL, buL are unable Lo
volunLarlly lncrease free waLer lnLake.
Cngolng losses are lmporLanL when deLermlnlng waLer
replacemenL. LacLulose ls llkely Lo conLrlbuLe Lo gasLrolnLesunal
waLer losses ln Lhls case. Serum glucose ls noL markedly
elevaLed, maklng glycosurla and osmouc urlnary losses unllkely.