Management of LifeThreatening Electrolyte and Metabolic Disturbances

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Objectives
Review the emergent management of severe electrolyte disturbances Recognize manifestations of acute adrenal insufficiency and initiate appropriate treatment Describe the management of severe hyperglycemic syndromes

Copyright 2008 Society of Critical Care Medicine

Case Study
80-year-old woman with hypertension and heart failure Confusion, lethargy, poor oral intake and weakness for 3 days BP 108/70 mm Hg, HR 110/min, R 18/min Nonsustained ventricular tachycardia on monitor risk factorsdisorders does this might patient What electrolyte have for electrolyte disturbances? contribute to her presentation?
Copyright 2008 Society of Critical Care Medicine

Principles of Electrolyte Disturbances

Treat the electrolyte change, but search for the cause Clinical manifestations are usually not specific to a particular electrolyte change Clinical circumstances determine urgency of treatment rather than electrolyte concentration Frequent reassessment of electrolyte abnormalities required
Copyright 2008 Society of Critical Care Medicine

Case Study
80-year-old woman with hypertension and heart failure Confusion, lethargy, poor oral intake and weakness for 3 days Nonsustained ventricular tachycardia on monitor Laboratory value: K 2.5 mmol/L How would you initiate evaluation and treatment of this patient?
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Treatment of Hypokalemia
Hypokalemia (K<3.5 mmol/L) K2.5 mmol/L (<3 mmol/L if on Digoxin) K<3.5 but >2.5 mmol/L and No Symptoms Enteral replacement KCl 20-40 mmol every 4-6 h

Life-Threatening Symptoms

Non-Life Threatening or No Symptoms

IV KCl 20-30 mmol/h via Central Catheter

Enteral replacement KCl 20-40 mmol every 2-4 h and/or IV KCl 10 mmol/h
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Case Study
80-year-old woman with hypertension and heart failure ECG

Laboratory value: K 7.8 mmol/L How would you initiate treatment of this patient?
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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
Copyright 2008 Society of Critical Care Medicine

Case Study
80-year-old woman with hypertension and heart failure Confusion, lethargy, poor oral intake and weakness for 3 days Nonsustained ventricular tachycardia on monitor Laboratory value: Na 118 mmol/L How would you initiate evaluation of this patient to determine the etiology?
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Etiology of Hyponatremia
Hyponatremia (Na<135 mmol/L) Presence of Glucose Proteins or Lipids Mannitol No Hypo-osmolar Hyponatremia

Yes

Consider Hyperosmolar Hyponatremia Pseudohyponatremia

Assess Volume Status Urine Osmolarity (Uosm) Urine Sodium (UNa) FE Na

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Etiology of Hyponatremia
Hypovolemia Hypervolemia Uosm>300 mOsm/L UNa <10-20 mmol/L FE Na <1% Congestive Heart Failure Cirrhosis Renal Failure With/Without Nephrosis

Uosm>300 mOsm/L UNa <20 mmol/L FE Na <1%

Vomiting Diarrhea Third-Space Fluid Loss

Uosm>300 mOsm/L UNa >20 mmol/L FE Na >1%

Diuretics Aldosterone Deficiency Renal Tubular Dysfunction

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Etiology of Hyponatremia
Euvolemia

Uosm <100 mOsm/L UNa >30 mmol/L

Uosm >100 mOsm/L (usually >300) UNa >30 mmol/L

Polydipsia Inappropriate Water Administration to Children

SIADH Hypothyroidism Adrenal Insufficiency

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Management of Hyponatremia
Hypovolemic Hypervolemic Euvolemic Restrict free-water intake Increase free-water loss Replace intravascular volume with normal saline or hypertonic saline
When would you use hypertonic How fast would you correct the saline? concentration? sodium
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Case Study
80-year-old woman with hypertension and heart failure Confusion, lethargy, poor oral intake and weakness for 3 days Nonsustained ventricular tachycardia on monitor Laboratory value: Na 168 mmol/L
How would you treat this patient?

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Treatment of Hypernatremia
Normal saline if hemodynamically unstable Hypotonic fluid when stable Intravenous fluids Enteral free water Quantity H2O deficit (L) = [0.6 wt (kg) ] [Measured Na - 1] 140 Rate of correction
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Case Study
34-year-old man with flu-like syndrome Febrile, tachycardic and hypotensive Antibiotics and volume initiated Admitted to floor 2 hours later, systolic BP 60 mm Hg Hypotensive in ICU after 40 mL/kg fluids and norepinephrine 10 g/min What metabolic disorders may What testing is needed? contribute to the hypotension?
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Treatment for Acute Adrenal Insufficiency

Support blood pressure with fluids and vasopressors Treat precipitating conditions Perform a short ACTH stimulation test if indicated Administer IV hydrocortisone 200300 mg/24 hours Consider fludrocortisone Treat until critical illness resolves
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Hyperglycemic Syndromes
Is this diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS)?
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 (+)
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Hyperglycemic Syndromes
Is this diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS)?
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 (-)

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Hyperglycemic Syndromes
Characteristics of Hyperglycemic Syndromes DKA HHS

Glucose
Arterial/venous pH Anion gap Serum osmolarity

> 250 mg/dL

7.3 Increased Normal

> 600 mg/dL

> 7.3 Variable

Serum/urine ketones Positive

Negative or small
Increased

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Initial Evaluation
Mental status Degree of dehydration Presence of infection or other precipitating condition Laboratory studies Glucose Venous or arterial pH Electrolytes, renal function Urine or serum ketones Complete blood count ECG
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Management of Hyperglycemic Syndromes

Fluids Crystalloids Add 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)

Insulin

Electrolytes If K <3.3 mmol/L hold insulin and replace K Add K to fluids if K >3.3 but <5 mmol/L
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Hyperglycemia of Critical Illness

Continuous insulin infusion Goal 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 selection Protocol important to optimal outcomes

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Questions

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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
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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

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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

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