Electrolyte Imbalances

Dr Hussain Azhar

Natures Water Balance

Topic Outline
Important Electrolytes
Sodium

Well Discuss:
Main causes of excess
and deficiency

Potassium
Clinical Features
Calcium
Management
Acid Base Disturbances

Water and Electrolyte Balance

Sodium

Hyponatremia

Sodium

Normally, the extracellular-fluid and

intracellular-fluid compartments make up 40
percent and 60 percent of total body water,
respectively

With the syndrome of inappropriate secretion of

antidiuretic hormone, the volumes of extracellular
fluid and intracellular fluid expand

Water retention can lead to hypotonic hyponatremia without the

anticipated hypo-osmolality in patients who have accumulated
ineffective osmoles, such as urea (ARF / CRF)
A shift of water from the intracellular-fluid compartment to
the extracellular-fluid compartment, driven by solutes
confined in the extracellular fluid, results in hypertonic
(translocational) hyponatremia e.g. hyperglycemia
Sodium depletion (and secondary water retention) usually
contracts the volume of extracellular fluid but expands the
intracellular-fluid compartment e.g. diarrhea
Hypotonic hyponatremia in sodium-retentive states involves
expansion of both compartments, but predominantly the
extracellular-fluid compartment e.g. nephrotic syndrome

Hypotonic hyponatremia due to water retention in

association with sodium gain and potassium loss e.g.
CCF treated with diuretics)

N Engl J Med 2000; 342:1581-1589 May 25, 2000

Hyponatremia

UNa> 20
FENa> 1%

Una < 20
FENa< 1%

DIFFERENTIAL DIAGNOSIS OF HYPONATREMIA BASED ON CLINICAL

ASSESSMENT OF EXTRACELLULAR FLUID VOLUME (ECFV)

Hyponatremia
Clinical Features
Asymptomatic
Mild and chronic state:
Headache, nausea, vomiting, muscle cramps,
lethargy, restlessness, disorientation, and
depressed reflexes

Severe and rapidly developing state:

Seizures, coma, permanent brain damage,
respiratory arrest, brain-stem herniation, and death

Effects of Hyponatremia on the Brain

and Adaptive Responses

N Engl J Med 2000; 342:1581-1589 May 25, 2000

Work up for Hyponatremia

Work up for Hyponatremia

Plasma Osmolality
Volume Status ( if Hypotonic Hyponatremia)
Urinary Osmolality
Glucocorticoids and Thyroid levels

Treatment of Hyponatremia

1. Treatment of underlying cause

2. Correction of Hyponatremia

Asymptomatic : slow correction

Symptomatic

: rapid but controlled correction

(Maximum Rate of Correction: < 10 meq / L / day)

Formulas for Use in Managing Hyponatremia and

Characteristics of Infusates

N Engl J Med 2000; 342:1581-1589 May 25, 2000

Practical Exercise

A 58-year-old man with small-cell lung carcinoma presents with

severe confusion and lethargy. Clinically, he is euvolemic, and he
weighs 60 kg. The serum sodium concentration is 108 mmol per liter,
the serum potassium concentration is 3.9 mmol per liter, serum
osmolality is 220 mOsm per kilogram of water, the serum urea
nitrogen concentration is 5 mg per deciliter , the serum creatinine
concentration is 0.5 mg per deciliter and urine osmolality is 600
mOsm per kilogram of water

Answer

Formula:

The estimated volume of total body water is 36 liters (0.60 60)

The retention of 1 liter of 3 percent sodium chloride is estimated to increase
the serum sodium concentration by 10.9 mmol per liter ([513 108] [36 +
1]=10.9).
The initial goal is to increase the serum sodium concentration by 5mmol per
liter over the next 12 hours.
Therefore, 0.46 liter of 3 percent sodium chloride (5 10.9), or 38 ml per hour,
is required.

Summary : Correction of Hyponatremia

Hypovolemic
Hypotonic
Hyponatremia

Euvolemic
Hypotonic
Hyponatremia

Hypervolemic
Hypotonic
Hyponatremia

1. Volume Replacement

1. Symptomatic:
3% Saline +
furosemide

1. Water Restriction

2. Isotonic Saline
3. Half normal saline
(after isotonic saline)

2. Diuretics and V2
antagonists
2. Asymptomatic
Water restriction
Isotonic saline
Demeclocycline
Fludrocortisone
Selective V2
antagonist

3. Hypertonic saline
rarely
4. Dialysis

Osmotic Demyelination Syndrome

The neurologic complications of chronic hyponatremia present in a

stereotypical biphasic pattern that has been called the osmotic
demyelination syndrome

Patients initially improve neurologically with correction of

hyponatremia, but then, 1 to several days later, new, progressive,
and sometimes permanent neurologic decits emerge e.g.
quadriplegia, dysphagia, dysarthria etc.

Most patients with the osmotic demyelination syndrome survive, and

those with persistent decits can be diagnosed with magnetic
resonance imaging

SIADH: Euvolemic Hypotonic Hyponatremia

Main causes:
1.
2.
3.
4.
5.

CNS disorders: Trauma, Tumor, Hemorrhage, Stroke, Infections

Pulmonary Disorders: Infections, cancers, mechanical ventilation
Cancers: Lung, Pancreas, Prostate, Renal, Leukemia
Drugs: Antidepressants, Antipsychotics, Carbamazepine
Others: Pain, Stress, Postoperative, Pregnancy, Hypokalemia

Diagnosis of SIADH
1.
2.
3.
4.
5.
6.

Hyponatremia
[Na] < 136 mEq / L
Decreased Serum Osmolality < 280 mOsm / kg
Increased Urine Osmolality
> 150 mOsm / kg
Absence of cardiac, liver, renal disease
Normal Thyroid and Adrenal function
Urinary sodium
> 20 mEq / L

Treatment of SIADH
1.
2.
3.
4.
5.

Treatment of underlying cause

Free water restriction
Hypertonic saline +/- furosemide
Demeclocycline or Lithium
V2 Vasopressin Receptor Antagonist:
Conivaptan

Hypernatremia

Hypernatremia

Extracellular-Fluid and Intracellular-Fluid Compartments under

Normal Conditions and during States of Hypernatremia.

Normal Condition

Pure water loss reduces the size of

each compartment proportionately
e.g. Diabetes Insipidus
Hypotonic sodium loss causes a relatively
larger loss of volume in the extracellularfluid compartment than in the intracellularfluid compartment e.g. vomiting

Potassium loss in addition to hypotonic

sodium loss further reduces the
intracellular-fluid compartment e.g.
osmotic diuresis
Hypertonic sodium gain results in
an increase in extracellular fluid but
a decrease in intracellular fluid e.g.
hypertonic bicarbonate infusion

Effects of Hypernatremia on the Brain and

Adaptive Responses

N Engl J Med 2000; 342:1493-1499 May 18, 2000

Clinical Features of Hypernatremia

Common symptoms in infants include hyperpnea, muscle weakness,

restlessness, a characteristic high-pitched cry, insomnia, lethargy, and even
coma.
Convulsions are typically absent

Intense thirst may be present initially, but it dissipates as the disorder

progresses

The level of consciousness is correlated with the severity of the

hypernatremia

Muscle weakness, confusion, and coma are sometimes manifestations of

coexisting disorders rather than of the hypernatremia itself.

Formulas for Use in Managing Hypernatremia

and Characteristics of Infusates

N Engl J Med 2000; 342:1493-1499 May 18, 2000

Causes of Hypernatremia

Causes of Hypernatremia
Hypovolemic
Hypernatremia

Euvolemic
Hypernatremia

Hypervolemic
Hypernatremia

1. Extra Renal Losses

1. Cental Diabetes
Insipidus

1. Hypertonic saline
infusion

2. Renal Losses

2. Nephrogenic Diabetes
Insipidus

2. Mineralocorticoid
excess

Work up of Hypernatremia
Urinary Osmolality
Urinary Sodium
Volume status

Work up of Hypernatremia

Treatment of Hypernatremia

Treatment of Hypernatremia
Hypovolemic
Hypernatremia

Euvolemic
Hypernatremia

Hypervolemic
Hypernatremia

1. Extra Renal Losses

1. Cental Diabetes
Insipidus

1. Hypertonic saline
infusion

2. Renal Losses

2. Nephrogenic Diabetes
Insipidus

2. Mineralocorticoid
excess

1. Restore access to water

2. Replace Volume
3. Calculate and give Free

Desmopressin
Na restriction +
Thiazide

Dextrose water +
furosemide*

Water Deficit
*furosemide-induced diuresis is equivalent to one-half isotonic saline solution

Treatment of Hypernatremia
Managing the underlying cause may mean:
Stopping gastrointestinal fluid losses;
Controlling pyrexia, hyperglycemia, and
glucosuria;
Withholding lactulose and diuretics;
Treating hypercalcemia and hypokalemia;
Moderating lithium-induced polyuria; or
Correcting the feeding preparation

Practical Exercise: Pure Water Loss

A 76-year-old man presents with a severe obtundation,
dry mucous membranes, decreased skin turgor, fever,
tachypnea, and a blood pressure of 142/82 mm Hg
without orthostatic changes. The serum sodium
concentration is 168 mmol per liter, and the body weight
is 68 kg.

Answer
The estimated volume of total body water is 34 liters (0.5 68).
According to formula 1,
the retention of 1 liter of 5 percent dextrose will reduce the serum sodium
concentration by 4.8 mmol per liter ([0168] [34+1]= 4.8).
The goal of treatment is to reduce the serum sodium concentration by
approximately 10 mmol per liter over a period of 24 hours. Therefore, 2.1 liters of
the solution (10 4.8) is required.
With 1.5 liters added to compensate for average obligatory water losses over the
24-hour period, a total of 3.6 liters will be administered for the next 24 hours, or 150
ml per hour.

Natures Water and

Electrolyte Balance