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SPECIFIC WATER AND ELECTROLYTE ABNORMALITIES

WATER DEPLETION
in TBW of 1-2% or 350-700ml in blood osmolarity Stimulation of brain osmoreceptors Sensation of thirst Obvious dehydration {loss of skin tugor, thirst, dry tongue} 4-5% in TBW (1.5-2L) Combined with sodium loss

Causes of water depletion


Inadequate intake Excessive loss of gastrointestinal secretions.

WATER EXCESS
Common in post-op patients: large volumes of IV 5% dextrose during period of ADH secretion. Patient is hyponatraemic Patient remains well but may develop dependant oedema. Can result in pulmonary oedema (renal failure or cardiac failure patients)

HYPERNATRAEMIA (Na+ > 145mEq/L)


CAUSES Reduced intake
-Fasting -Nausea and Vomiting -Ileus -Reduced conscious level

Inappropriate urinary water loss


Diabetes Insipidus Diabetes Mellitus Excessive Sodium load (hypertonic fluids, parenteral nutrition

Increased loss
- Sweating - Respiratory tract loss -Burns

HYPERNATRAEMIA
Clinical manifestations
Thirst, dry tongue Restlessness Flushed skin Dry mucus membranes

Treatment patients water intake { oral intake/ adding H2O to NG feeds/ IV water as 5% dextrose solution.

HYPONATRAEMIA (Na+<135mEq/L)
Causes Low ECF Volume
Volume depletion (vomiting, diarrhoea, burns, fluid intake) Salt-losing renal disease Hypoadrenalism Diuretic use

Increased ECF Volume


Excessive water administration Excessive mannitol use Cardiac Failure Cirrhosis Nephrotic syndrome Renal failure

Normal ECF Volume


Hypothyroidisn Syndromes of inappropriate ADH secretion

Comorbidity such as cirrhosis, CF & renal impairment can become potential contributing factors.

HYPONATRAEMIA
Manifestations
Rapid weight gain Neurological symptoms
irritability, seizures

Muscle cramps Anorexia/Nausea/Vomiting

Treatment of Hyponatraemia
Identify cause correctly Determine whether plasma and/or ECF Volume is , or Normal. If ECF Volume is N or and no comorbidity excessive IV water administration..will correct spontaneously if water intake. If ECF Volume is => H2O & Na+ deficiency.will correct with administration of Normal Saline.

Treatment of hyponatraemia
Na+ < 120mmol/l usually as a result of comorbidity or if not SIADH. This requires careful management with water restriction, cautious 0.9% NaCl and occasional diuretic use. Plasma sodium slow correction (1mmol/hr) with regular monitoring.

HYPERKALAEMIA (K+> 5.5 mEq/L)


Causes Efflux of potassium from cells -Hemolysis - Rhabdomyolysis - Massive tissue damage (ischaemic bowel/ liver) Acidosis Impaired Excretion -Acute renal failure -Chronic renal failure -Drugs (ACE Inhibitors, spironolactone) Abnormalities of RAAS.

HYPERKALAEMIA
Manifestations
Weak skeletal muscles/paralyses > 8mEq/L Parasthesias Irritability Abdominal cramping with diarrhoea Irregular pulse ECG changes

Peaked T waves & shortened QT interval Depressed ST segment & widened QRS interval

HYPERKALAEMIA