ELECTROLYTES

Electrolytes
- Ions capable of carrying an electric charge
INTRODUCTION

A. Cations : positive charged ions  cathode

B. Anions : negative charged ions  anode
• Introduction
• Water
FUNCTION EXAMPLE
• Osmolality 1. Volume & osmotic regulation Na, Cl, K
• Sodium
• Potassium 2. Myocardial rhythm & contractility K, Mg, Ca
• Chloride 3. Cofactors in enzyme activation Mg, Ca, Zn
• Bicarbonate
• Magnesium 4. Regulation of ATPase pumps Mg
• Calcium
• Phosphate 5. Acid-base balance Bicarbonate, K, Cl
• Lactate 6. Blood coagulation Ca, Mg
• Anion Gap
7. Neuromuscular excitability K, Ca, Mg
8. Production and use of ATP from glucose Mg, Phosphate
* Because of many of these functions require electrolyte
concentrations to be held within narrow ranges, the body has
complex systems for monitoring and maintaining electrolytes
concentrations.
 • 40% to 75% of total body weight
• Declines with age and state of obesity
WATER • Women has lower water content than men (fat content)

COMPARTMENTS:
1. Intracellular fluid (2/3 of the total body water)
• Introduction 2. Extracellular fluid (1/3 of the total body water
• Water a. Intravascular ECF : plasma (93% is water)
• Osmolality
• Sodium
b. Interstitial cell fluid : surrounds cells in the tissue
• Potassium
• Chloride TRANSPORT MECHANISMS
• Bicarbonate 1. Active transport
• Magnesium • Requires energy to move ions across cellular membranes (e.g., use of
• Calcium
ATP from ATPase-dependent ion pumps
• Phosphate
• Lactate
• Anion Gap 2. Diffusion
• Passive movement of ions across the membranes
• Basically depends on size and charge of the ion and on the nature of
the membrane through which it is passing

* Distribution of water in the various body fluid compartments is

controlled by maintaining the concentration of electrolytes and proteins
in the individual compartments
 WATER

• Introduction
• Water
• Osmolality
• Sodium
• Potassium
• Chloride
• Bicarbonate
• Magnesium
• Calcium
• Phosphate
• Lactate
• Anion Gap
 OSMOLALITY
OSMOLALITY • Physical property of a solution that is based on the
concentration of solutes (expressed as milimoles) per
kilogram solvent (w/w).
• Introduction • Freezing point depression and vapor pressure decrease are
• Water the basis for routine measurements of osmolality
• Osmolality
• Sodium
• Potassium BODY’S RESPONSE TO INCRESASED BLOOD OSMOLALITY
• Chloride
• Bicarbonate
• Magnesium 1. Sensation of thirst
• Calcium water content of the ECF diluting elevated solute
• Phosphate
• Lactate
osmolality of the plasma
• Anion Gap 2. Secretion of arginine vasopressin hormone (AVP)
aka Antidiuretic hormone (ADH)
secreted by the posterior pituitary gland, acts on the
collecting tubules causing increase in water
reabsorption
 MAINTAINING NORMAL PLASMA OSMOLALITY
OSMOLALITY

• 275 to 295 mOsm/kg

• Osmoreceptors in the hypothalamus respond quickly to the
• Introduction small changes in osmolality.
• Water
• Osmolality
• Sodium a. 1% to 2% osmolality four-fold rise in the AVP
• Potassium b. 1% to 2% osmolality  shuts off AVP production
• Chloride
• Bicarbonate
• Magnesium
• Calcium
• Phosphate
• Lactate
• Anion Gap
 REGULATION OF BLOOD VOLUME
OSMOLALITY
Renin-Angiotensin-Aldosterone-System (RAAS)
- regulates flow of blood to and within the kidney
• Introduction
• Water
JUXTAGLOMERULAR APPARATUS
• Osmolality
• Sodium
 Macula densa of the DCT & JG cells in the afferent arteriole,
• Potassium ↓Na, ↓BP, ↓Circulating blood volume
• Chloride
 Renin (JG cells)→ Angiotensinogen → Angiotensin I (inert
• Bicarbonate
• Magnesium hormone)
• Calcium  ↓ ACE (lungs)
• Phosphate
• Lactate  Angiotensin II (active)
• Anion Gap  Dilation of afferent arteriole
 Constriction of efferent arteriole
 Aldosterone release
 ↑Na reabsorption in DCT & CD
 Antidiuretic hormone (ADH) release
 ↑H20 reabsorption in CD
 REGULATION OF BLOOD VOLUME
RAAS Renin-Angiotensin-Aldosterone-System (RAAS)

• Introduction
• Water
• Osmolality
• Sodium (blood borne substrate)
• Potassium
• Chloride
• Bicarbonate
• Magnesium
• Calcium
• Phosphate
• Lactate
• Anion Gap
 DETERMINATION OF OSMOLALITY
OSMOLALITY
Specimen: serum and urine

Major electrolytes affecting serum osmolality:

• Introduction 1. Sodium
• Water 2. Chloride
• Osmolality 3. Bicarbonate
• Sodium
• Potassium
• Chloride Determination:
• Bicarbonate 1. Measurements of the freezing point depression and vapor
• Magnesium pressure
• Calcium
• Phosphate
2. Use of osmometers (mOsm/kg)
• Lactate - standardized using NaCl reference solution
• Anion Gap

Osmolality Freezing point depression & Vapor pressure

 OSMOLAL GAP
- Reflects the difference between the measured osmolality and
OSMOLALITY
calculated osmolality
- Indirectly indicates the presence of osmotically active substances
other than sodium, urea or glucose (e.g., ethanol, methanol,
• Introduction ethylene glycol, lactate or beta-hydroxybutyrate)
• Water
• Osmolality mg mg
glucose ( ) BUN ( )
•
•
Sodium
2 Na + dl
+ dL
Potassium 20 3
• Chloride
• Bicarbonate
glucose BUN
• Magnesium 1.86 Na + + +9
• Calcium 18 2.8
• Phosphate
• Lactate Reference ranges for Osmolality
• Anion Gap
Serum 275-295 mOsm/kg
Urine (24h) 300-900 mOsm/kg
Urine/serum ratio 1.0-3.0
Random urine 50-1200 mOsm/kg
Osmolal gap 5-10 mOsm/kg
 • Also known as NATRIUM
Na+ • Most abundant cation in the ECF
SODIUM • 90% of all extracellular cations and largely determines the
osmolality of the plasma

• Introduction Normal plasma osmolality = 295 mOsm/kg

• Water 270 mOsm/kgNa and other anions
• Osmolality
• Sodium
• Potassium Na, K – ATPase ion pump
• Chloride - Used to prevent ECF and cell Na to reach equilibrium
• Bicarbonate - Moves three Na ions out of the cell in exchange for two K
• Magnesium
• Calcium
ions moving into the cell as ATP is converted to ADP
• Phosphate
• Lactate
• Anion Gap
 Regulating sodium concentration
Na+
SODIUM 1. Intake of water in response to thirst
- stimulated or suppressed by plasma osmolality
- THIRST: major defense against hyperosmolality and
• Introduction hypernatremia
• Water
• Osmolality
2. Excretion of water
• Sodium
• Potassium - largely affected by AVP release in response to changes in
• Chloride blood volume and osmolality
• Bicarbonate
• Magnesium
3. Blood volume status
• Calcium
• Phosphate
• Lactate HORMONES AFFECTING SODIUM LEVELS
• Anion Gap
1. Aldosterone- promotes absorption of sodium
- promotes sodium retention and K increase

2. Atrial Natriuretic Factor (ANF)

- blocks aldosterone and renin secretion
- inhibits the action of angiotensin 1 and vasopressin
 HYPONATREMIA
Na+ • Serum or plasma level less than 135 mmol/L
• Levels below 130 mmol/L is clinically significant
SODIUM
• One of the most common electrolyte disorders among
hospitalized and non hospitalized patients
• Introduction CAUSES OF HYPONATREMIA
• Water INCREASED SODIUM INCREASED WATER WATER IMBALANCE
• Osmolality LOSS RETENTION
• Sodium (decreased plasma
proteinsedema)
• Potassium
• Chloride Hypoadrenalism Renal failure Excess water intake
• Bicarbonate (decreased aldosterone
production)
• Magnesium
• Calcium Potassium deficiency Nephrotic syndrome SIADH (associated with CNS
• Phosphate (inverse relationship in the disorders, malignancies &
renal tubules) pulmonary disease like P.
• Lactate carini pneumonia)
• Anion Gap
Diuretic use (thiazides) Hepatic cirrhosis Pseudohyponatremia
(hyperproteinemic and
hyperlipidemic samples)
Ketonuria Congestive heart failure
Salt-losing nephropathy
Prolonged vomiting or
diarrhea
Severe burns
 Na+ CLASSIFICATION OF HYPONATREMIA BY OSMOLALITY
SODIUM
WITH LOW OSMOLALITY
Increased sodium loss, increased water restriction
• Introduction WITH NORMAL OSMOLALITY
• Water Increased non-sodium cations, Lithium excess, Increased
• Osmolality gamma-globulins, Severe hyperkalemia, severe
• Sodium hypermagnesemia, severe hypercalcemia, pseudohyponatremia,
• Potassium hyperlipidemia, hyperproteinemia, pseudohypokalemia due to in-
• Chloride vitro hemolysis
• Bicarbonate
• Magnesium WITH HIGH OSMOLALITY
• Calcium Hyperglycemia, mannitol infusion
• Phosphate
• Lactate
• Anion Gap
 HYPONATREMIA WITH NORMAL RENAL FUNCTION
Na+ CAUSE SERUM URINE 24-HOUR URINE
OSMOLALITY
SERUM K
SODIUM Na Na URINE Na
1. Overhydration Low Low Low Low Normal or
Low
• Introduction 2. Diuretics Low Low High Low Low
• Water 3. SIADH Low High High High Normal or
• Osmolality Low
• Sodium
• Potassium 4. Adrenal failure Mildly Normal High High
• Chloride elevated
• Bicarbonate 5. Bartter’s Low Low High Low Low
• Magnesium Syndrome
• Calcium
6. Diabetc Low Normal Normal Normal HIgh
• Phosphate
Hyperosmolality
• Lactate
• Anion Gap
FRACTIONAL EXCRETION
- Quantity of a substance excreted in the urine expressed as
the fraction of the filtered load of the same substance

a. Pre-renal azotemia: FE of Na of <0.01

b. Acute tubular necrosis: FE of Na >0.01
 SYMPTOMS OF HYPONATREMIA
Na+ Na: 125-130 mmol/L
SODIUM Primarily gastrointestinal
Na: < 125 mmol/L
Neuropsychiatric (nausea, vomiting, muscular weakness,
• Introduction headache, lethargy, and ataxia)
• Water
• Osmolality More severe symptoms include seizures, coma, and respiratory
• Sodium depression
• Potassium Na: <120 mmol/L for 48 hours or less (acute hyponatremia)
• Chloride
• Bicarbonate Considered to be a medical emergency
• Magnesium
• Calcium TREATMENT OF HYPONATREMIA
• Phosphate 1. Fluid restriction and providing hypertonic saline
• Lactate a. Cerebral myelinolysis correction too rapid
• Anion Gap
b. Cerebral edema  correction too slow
* In Bartter’s syndrome, hyponatremia is not corrected by
fluid restriction
2. Use pharmacologic agents
* Conivaptan: US FDA approved AVP receptor antagonist
- Blocks action of AVP in the collecting ducts of the receptor,
thus decreased water reabsorption
 HYPERNATREMIA
Na+ • Results from excess loss of water relative to sodium loss,
SODIUM decreased water intake, or increased sodium intake and
retention
• Na levels of >145 mmol/L
• Introduction
• Water CAUSES OF HYPERNATREMIA
• Osmolality
• Sodium EXCESS WATER DECREASED WATER INCREASED INTAKE
• Potassium LOSS INTAKE OR RETENTION
• Chloride Diabetes insipidus Older persons Hyperaldosteronism
• Bicarbonate Renal tubular disorder Infants Sodium bicarbonate
• Magnesium excess
• Calcium
• Phosphate Prolonged diarrhea Mental impairment Dialysis fluid excess
• Lactate Profuse sweating
• Anion Gap
Severe burns
 Na+ HYPERNATREMIA (150 mmol/L) RELATED TO URINE
OSMOLALITY
SODIUM
URINE OSMOLALITY <300 mOsm/kg
Diabetes insipidus (impaired secretion of AVP or kidneys cannot
respond to AVP)
• Introduction
• Water URINE OSMOLALITY 300-700 mOsm/kg
• Osmolality Partial defect in AVP release or response to AVP
• Sodium
• Potassium Osmotic diuresis
• Chloride URINE OSMOLALITY >700 mOsm/kg
• Bicarbonate Loss of thirst
• Magnesium
• Calcium Insensible loss of water (breathing, skin)
• Phosphate Gastrointestinal loss of hypotonic fluid
• Lactate
Excess intake of sodium
• Anion Gap
 Na+ SYMPTOMS OF HYPERNATREMIA
• Altered mental status, lethargy, irritability, restlessness,
SODIUM seizures, muscle twitching, hyper-reflexes, fever, nausea or
vomiting, difficult respiration and increased thirst
• >160 mmol/L is associated to 60% to 75% mortality
• Introduction
• Water
• Osmolality
• Sodium TREATMENT OF HYPERNATREMIA
• Potassium • Correction of underlying condition that caused water
• Chloride
depletion or sodium retention
• Bicarbonate
• Magnesium • Must be corrected gradually because too rapid correction of
• Calcium serious hypernatremia (≥160 mmol/L) can induce cerebral
• Phosphate edema and death
• Lactate
• Maximal rate should be 0.5mmol/L
• Anion Gap
 Determination of Sodium
Na+ • Specimen: Serum
SODIUM
Plasma (lithium heparin, ammonium heparin,
lithium oxalate)
• Introduction
Urine (24 h)
• Water Sweat
• Osmolality
• Sodium • Not affected by hemolysis
• Potassium
• Chloride
• Ion-selective electrode (ISE): most routinely used method
• Bicarbonate • Other methods include
• Magnesium 1. Flame emission spectrophotometry
• Calcium 2. Atomic absorption spectrophotometry (AAS)
• Phosphate
• Lactate
3. Colorimetry (Albanese Lein)
• Anion Gap
Reference ranges for Sodium
Serum, plasma 136-145 mmol/L
Urine (24hr) 40-220 mmol/d (varies
with diet)
CSF 136-150 mmol/L
 • Also known as “KALIUM”
K+ • Major intracellular cation in the body (20X)
POTASSIUM • Single most important analyte in terms of abnormality being
immediately life-threatening
• Has major effect on contraction of skeletal and cardiac
• Introduction muscles
• Water
• Osmolality
• Sodium
• Insert RMP
• Potassium • Also affects the H concentration in the blood (e.g., in
• Chloride hypokalemia, as K is lost from the body, Na and H move into
• Bicarbonate the cell thereby causing alkalosis
• Magnesium
• Calcium Regulating potassium concentration
• Phosphate 1. Renal function related to tubular reabsorption and secretion
• Lactate 2. Potassium uptake from the ECF into the cells
• Anion Gap

FACTORS INFLUENCING DISTRIBUTION OF K BETWEEN

CELLS AND THE ECF
1. K loss (hypoxia, hypomagnesemia, or digoxin overdose
2. Insulin promotes acute entry of K into skeletal muscle and
liver
3. Catecholamines (epinephrine) promote cellular entry of K
 K+ EFFECT OF EXERCISE
• Exercise tend to increase plasma K by 0.3 to 1.2 mmol/L
POTASSIUM
(mild to moderate exercise) and 2 t0 3 mmol/L (exhaustive
exercise)
• Introduction • Forearm exercise during venipuncture can cause erroneous
• Water increase in serum K
• Osmolality
• Sodium
EFFECT OF HYPEROSMOLALITY
• Potassium
• Chloride • May lead to gradual depletion of K
• Bicarbonate
• Magnesium EFFECT OF CELLULAR BREAKDOWN
• Calcium
• Releases K into the ECF (e.g., tumor lysis syndrome and
• Phosphate
• Lactate massive transfusion)
• Anion Gap
 HYPOKALEMIA ( 2.5 mmol/L)
K+ GASTROINTESTINAL LOSS
POTASSIUM Vomiting, diarrhea, gastric suction, intestinal tumor,
malabsorption, cancer therapy, large doses of laxatives
RENAL LOSS
• Introduction Diuretics, nephritis, RTA, hyperaldosteronism, Cushing’s
• Water syndrome, hypomagnesemia, acute leukemia
• Osmolality CELLULAR SHIFT
• Sodium
Alkalosis, insulin overdose
• Potassium
• Chloride DECREASED INTAKE
• Bicarbonate
• Magnesium SYMPTOMS OF HYPOKALEMIA
• Calcium 1. Weakness
• Phosphate 2. Fatigue
• Lactate
• Anion Gap 3. Constipation
4. Paralysis  difficulty in breathing
5. Increased arrythmia may lead to sudden death

TREATMENT OF HYPOKALEMIA
1. IV replacement
2. Diet with high K content (dried fruits, nuts, bran cereals,
bananas and orange juice)
 HYPERKALEMIA (6.5 mmol/L)
K+ DECREASED RENAL EXCRETION
POTASSIUM Renal failure, hyperaldosteronism, Addison’s disease, diuretics
CELLULAR SHIFT
Acidosis, muscle injury, chemotherapy, leukemia, hemolysis
• Introduction INCREASED INTAKE
• Water
• Osmolality Oral or IV potassium replacement therapy
• Sodium ARTIFACTUAL
• Potassium Sample hemolysis, thrombocytosis, prolonged tourniquet use or
• Chloride excessive clenching
• Bicarbonate
• Magnesium SYMPTOMS OF HYPERKALEMIA
• Calcium 1. Muscle tingling, numbness, or mental confusion
• Phosphate 2. Cardiac arrhythmia cardiac arrest
• Lactate
• Anion Gap
TREATMENT OF HYPOKALEMIA
1. IV replacement
2. Diet with high K content (dried fruits, nuts, bran cereals,
bananas and orange juice)
 DETERMINATION OF POTASSIUM

K+ 1. Collection of sample
• “Artifactual hyperkalemia”- due to the release of K by platelets
POTASSIUM (resulting to 0.1-0.7 mmol/L increase in the serum over plasma),
thrombocytosis
• Tourniquet application, excessively clenching of fists, exercise of
• Introduction arm
• Water • Storing blood on ice
• Osmolality • HEMOLYSIS (0.5% RBC can increase level by 0.5mmol/L to 30%
• Sodium increase in gross hemolysis)
• Potassium 2. Specimen: Serum
• Chloride Plasma (Heparin-anticoagulant of choice)
• Bicarbonate
Urine (24 hprevent diurnal variation)
• Magnesium
• Calcium 3. Methods: a. ISE using valinomycin membrane to selectively bind K
• Phosphate b. Emission Flame Photometry
• Lactate c. AAS
• Anion Gap d. Colorimetry (Lockhead and Purcell)

Reference ranges for Potassium

Serum 3.5-5.1 mmol/L
Plasma Males: 3.5-4.5 mmol/L
Females: 3.4-4.4 mmol/L
Urine (24 h) 25-125 mmol/d
 • Major extracellular anion
Cl- • Maintains osmolality, blood volume, and electric neutrality
CHLORIDE • Shifts secondarily to a movement of Na or HCO3 (chief
counter ion of Na)
• Excreted in the urine and sweat. Excessive sweating
• Introduction stimulates aldosterone secretion, which acts on the sweat
• Water glands to conserve Na and Cl
• Osmolality
• Sodium
• Potassium Electroneutrality as maintained by “Chloride shift”
• Chloride Aka Hamburger shift or Hamburger phenomenon, named after
• Bicarbonate Hartog Jakob Hamburger
• Magnesium
• Calcium
• Phosphate
• Lactate
• Anion Gap
 CLINICAL APPLICATIONS
Cl- • Disorders are often a result of the same causes that disturb Na
levels because Cl passively follows Na
CHLORIDE
• HYPERCHLOREMIA- may result when there is an excess loss of
HCO3 as a result of GI losses, RTA, or metabolic acidosis
• Introduction • HYPOCHLOREMIA- may result when there is excess loss of Cl
• Water from prolonged vomiting, diabetic ketoacidosis, aldosterone
• Osmolality deficiency, pyelonephritis)
• Sodium
• Potassium DETERMINATION OF CHLORIDE
• Chloride
• Bicarbonate 1. Collection of sample
• Magnesium Marked hemolysis may result to DECREASE of Cl due to dilutional
• Calcium
effect
• Phosphate
• Lactate
2. Specimen: Serum
• Anion Gap Plasma (Lithium heparin-anticoagulant of choice)
Urine (24 h)
Sweat
3. Methods:
a. ISE using ion-exchange membrane to selectively bind Cl
b. Amperometric-coulometric titration(Cotlove Chloridometer)

Ag2+ + 2Cl-  AgCl2

 DETERMINATION OF CHLORIDE
Cl- 3. Methods: c. Mercurimetric Titration (Schales and Schales)
CHLORIDE
Diphenylcarbazone: indicator
HgCl2 (blue violet) : end product
d. Spectrophotometric Methods
• Introduction 1. Mercuric thiocyanate (Whitehorn Titration Method)
• Water
• Osmolality
2. Ferric Perchlorate
• Sodium
• Potassium Reference ranges for Chloride
• Chloride
• Bicarbonate Plasma, serum 98-107 mmol/L
• Magnesium Urine (24 h) 110-250 mmol/d, varies
• Calcium
• Phosphate with diet
• Lactate
• Anion Gap
 • Second most abundant anion in the ECF
HCO3- • Total CO2 comprises of bicarbonate ion, H2CO3, and dissolved
CO2
BICARBONATE
• 90% of Total CO2 is HCO3 its measurement is indicative of
HCO3 measurement
• Major component of buffering system in the blood
• Introduction
• Water
• Osmolality CA CA
• Sodium CO2 + H20  H2CO3  H + HCO3
• Potassium
• Chloride
• Bicarbonate
• Magnesium
• Calcium
• Phosphate
REGULATION:
• Lactate
• Anion Gap
85% of HCO3 is
reabsorbed in the
kidneys
 CLINICAL APPLICATION
HCO3- • Acid-base imbalances cause changes in the HCO3 and
BICARBONATE CO2 levels
CONDITION Compensated by Effect
Metabolic acidosis Hyperventilation Lowers pCO2
• Introduction (decreased HCO3)
• Water
• Osmolality Metabolic alkalosis Hypoventilation Increases pCO2
• Sodium (HCO3 retained)
• Potassium
• Chloride DETERMINATION OF CO2
• Bicarbonate 1. Specimen: serum or plasma (lithium heparin)
• Magnesium
ideally collected in an anaerobic condition
• Calcium
• Phosphate Sample remains capped until determination
• Lactate (decrease of 6mmol/L/hr)
• Anion Gap 2. TOTAL CO2 determination Reference ranges for venous CO2
a. ISE: pCO2 electrode
Plasma, serum 23-29 mmol/L
b. Enzymatic method:
PEF Carboxylate
Phosphoenolpyruvate + HCO3  Oxaloacetate + H2PO4
MDH
Oxaloacetate + NADH + H  Malate + NAD
 • Fourth most abundant cation in the body
Mg2+ •
•
Second most abundant intracellular cation
Essential cofactor of more than 300 enzymes
MAGNESIUM
• Significant findings are associated with cardiovascular, metabolic
and neuromuscular disorders
• Sources: raw nuts, dry cereals, and “hard” drinking water,
• Introduction vegetables, meats, fish, and fruits
• Water
• Osmolality FORMS
• Sodium
1. Free Mg/ Ionized form : 55% (physiologically active)
• Potassium
• Chloride
2. Protein-bound Mg : 30%
• Bicarbonate 3. Complexed with ions : 15%
• Magnesium
• Calcium REGULATION
• Phosphate • Kidneys: can readily reabsorb Mg in deficiency status or excrete
• Lactate excess Mg in overload states
• Anion Gap • Mg regulation appears to be related to Ca and Na

HORMONES AFFECTING Mg LEVELS

• PTH increases renal reabsorption of Mg and enhances
reabsorption of Mg in the intestine (however ionized Ca has
greater effect of PTH)
• Aldosterone and thyroxine apparently have opposite effect on
PTH, increasing renal excretion of Mg
 Mg2+ CAUSES OF HYPOMAGNESEMIA
MAGNESIUM REDUCED INATKE INCREASED EXCRETION-RENAL
Poor diet; starvation Tubular disorder
Prolonged magnesium therapy (IV) Glomerulonephritis
Chronic alcoholsim Pyelonephritis
• Introduction
• Water DECREASED ABSORPTION INCREASED EXCRETION-
• Osmolality ENDOCRINE
• Sodium Malabsorption syndrome Hyperthyroidism
• Potassium Surgical resection of small intestine Hyperaldosteronism
• Chloride Nasogastric suction Hyperparathyroidism
• Bicarbonate Pancreatitis
• Magnesium Vomiting
• Calcium Diarrhea
• Phosphate Laxative abuse
• Lactate Neonatal
• Anion Gap Primary
Congenital
INCREASED EXCRETION-DRUG MISCELLANEOUS
INDUCED
Diuretics Excess lactation
Antibiotics Pregnancy
Digitalis
 SYMPTOMS OF HYPOMAGNESEMIA
Mg2+ CARDIOVASCULAR PSYCHIATRIC
MAGNESIUM
Arrhythmia Depression
Hypertension Agitation
Digitalis toxicity Psychosis
• Introduction NEUROMUSCULAR METABOLIC
• Water Weakness Hypokalemia
• Osmolality Cramps Hypocalcemia
• Sodium Ataxia Hypophosphatemia
• Potassium Tremor Hyponatremia
• Chloride Seizure
• Bicarbonate Tetany
• Magnesium Paralysis
• Calcium Coma
• Phosphate
• Lactate
• Anion Gap
TREATMENT FOR HYPOMAGNESEMIA
1. Oral intake of magnesium lactate, magnesium oxide, or
magnesium chloride or an antacid that contains magnesium
2. Magnesium sulfate IV
 Mg2+ CAUSES OF HYPERMAGNESEMIA
MAGNESIUM DECREASED EXCRETION
Acute or chronic renal failure
Hypothyroidism
Hypoaldosteronism
• Introduction
Hypopituitarism (dec. growth hormone)
• Water
• Osmolality INCREASED INTAKE
• Sodium Antacids
• Potassium Enemas
• Chloride Cathartics
• Bicarbonate Therapeutic (eclampsia, cardiac arrhythmia)
• Magnesium
• Calcium MISCELLANEOUS
• Phosphate Dehydration
• Lactate Bone carcinoma
• Anion Gap Bone metastasis
 SYMPTOMS OF HYPERMAGNESEMIA
Mg2+ CARDIOVASCULAR NEUROMUSCULAR
MAGNESIUM Hypotension Decreased reflexes
Bradycardia Dysaarthria
Heart Block Respiratory depression
Paralysis
• Introduction
• Water DERMATOLOGIC METABOLIC
• Osmolality Flushing Hypocalcemia
• Sodium Warm skin
• Potassium GASTROINTESTINAL HEMOSTATIC
• Chloride
• Bicarbonate Nausea Decreased thrombin generation
• Magnesium Vomiting Decreased platelet adhesion
• Calcium NEUROLOGIC
• Phosphate
Lethargy
• Lactate
Coma
• Anion Gap

TREATMENT FOR HYPERMAGNESEMIA

1. Discontinue Mg intake
2. Immediate supportive therapy for cardiac, neuromucular,
respiratory or neurologic abnormalities
 DETERMINATION OF MAGNESIUM
Mg2+ 1. Specimen: Serum or Lithium heparin plasma
MAGNESIUM Urine (24 h)
• Mg concentration in the RBC is 10x greater than that in the ECF
• Oxalate, citrate, and EDTA are unacceptable because they will bind
• Introduction Mg
• Water
• Osmolality 2. 2.1. Colorimetric
• Sodium a. calmagite  (+) reddish-violet complex
• Potassium b. formazan dye * Uses Ca shelter to
• Chloride c. methylthymol blue prohibit interference
• Bicarbonate
• Magnesium
2.2 AAS: reference method
• Calcium
• Phosphate 2.3 Dye-Lake Method-Titan Yellow Dye
• Lactate (Clayton Yellow or Thiazole yellow)
• Anion Gap

Reference ranges for Magnesium

Serum, 0.63-1.0 mmol/L
colorimetric (1.26-2.10 mmol/L)