NP14 Nephrology

Electrolyte Disorders/Acid-Base Disorders

2. Shift K+ into Cells

regular insulin (Insulin R) 10-20 units IV, with 1-2 amp D50W (give D50W before insulin)
onset of action 15-30 min, lasts 1-2 h
monitor capillary blood glucose q1h because of risk of hypoglycemia
can repeat every 4-6 h
caution giving D50W before insulin if hyperkalemia is severe as it can cause a serious
arrhythmia
NaHCO3 1-3 ampules (given as 3 ampules of 7.5% or 8.4% NaHCO3 in 1L D5W)
onset of action 15-30 min, transient effect, drives K+ into cells in exchange for H+
more effective if patient has metabolic acidosis
2-agonist (Ventolin) in nebulized form (dose = 2 cc or 10 mg inhaled) or 0.5 mg IV
onset of action 30-90 min, stimulates Na+/K+ ATPase
caution if patient has heart disease as may result in tachycardia
3. Enhance K+ Removal from Body
via urine (preferred approach)
furosemide (40 mg IV), may need IV NS to avoid hypovolemia
fludrocortisone (synthetic mineralocorticoid) if suspect aldosterone deficiency
via gastrointestinal tract
cation-exchange resins: calcium resonium or sodium polystyrene sulfonate (Kayexalate)
increasingly falling out of favor due to risk of colonic necrosis; works by binding Na+ in
exchange for K+, and controversial how much K+ is actually removed
lactulose PO to avoid constipation (must ensure that patient has a bowel movement after
resin is administered main benefit may be the diarrhea caused by lactulose)
Kayexalate enemas with tap water
dialysis (renal failure, life threatening hyperkalemia unresponsive to therapy)

Acid-Base Disorders
acid-base homeostasis influences protein function and can critically affect tissue and organ
function with consequences to cardiovascular, respiratory, metabolic, and CNS function
see Respirology, R5 for more information on respiratory acidosis/alkalosis
normal concentration of HCO3 = 24 mEq/L (range: 22-30)
normal pCO2 = 40 mmHg (range: 36-44)
each acid base disorder has an appropriate compensation
inadequate compensation or overcompensation can indicate the presence of a second
acid-base disorder (e.g. in metabolic acidosis, inadequate compensation means there is also
respiratory acidosis; overcompensation means there is also respiratory alkalosis)
pH

Low (pH <7.35)

Normal

High (pH >7.45)

Acidemia

No Disturbance
or
Mixed Disturbance

Alkalemia

Mixed if pCO2 + HCO3

change in opposite
directions or plasma
AG wide

Low
HCO3

High
pCO2

Metabolic acidosis
i 1 HCO3 = i 1 pCO2

Respiratory acidosis
Acute: h 10 pCO2 = h 1 HCO3
Chronic: h 10 pCO2 = h 3 HCO3

High
HCO3

Metabolic alkalosis
h 10 HCO3 = h 5-7 pCO2

Low
pCO2

Respiratory alkalosis
Acute: i 10 pCO2 = i 2 HCO3
Chronic: i 10 pCO2 = i 5 HCO3

Figure 9. Approach to acid-base disorders

Approach
1. Identify the primary disturbance (see Figure 8)
respiratory acidosis, metabolic acidosis, respiratory alkalosis, metabolic alkalosis

Essential Med Notes 2015