Emergency electrolyte approach and

management
 เนือ้ หาเยอะ, จำยาก
แต่ แก้ ง่าย
Na เพราะ…
- เกินก็ขับออก ขาดก็ให้ เสริม

สอนง่ าย, จำง่ าย

แต่ แก้ ยาก
เพราะ…
- ประเมิน Volume status แต่ ละขาแก้ ไม่ เหมือนกัน
K
- ต้ องคำนวณ กลัวแก้ เร็วเกิน + Re-lowering
 Outline
Outline
1. Hyponatremia
2. Hypernatremia
3. Hyperkalemia
Hyponatremia
 Hyponatremia
• Definition: Serum Na <135 mEq/L
• Excess total body water relative to total body Na
• Classification
• Based on acuity: Acute <48 hr, Chronic >/ 48 hr
• Based on severity: asymptomatic, mod-severe, severe
• Based on volume status: Hypovolemic, Euvolemic, Hypervolemic
 Steps in approach
1. Exclude Pseudohyponatremia:
• Hyperglycemia: ↓ Na 1.6 (if BS<400), 2.4 mEq/L (if BS>400) for ↑100 mg/dL in
glucose conc.

• Severe hypertriglyceride (thousands of mg/dL) ↑ TG 500 mg/dL ↓ PNa 1 mEq/L

• Severe hyperproteinemia (paraprotein > 10 g/dL)
 Steps in approach
2. Symptoms: Severity
3. Volume status assessment
• Hypovolumic
• Euvolumic
• Hypervolumic
 Hyponatremia: symptoms

Severity Symptoms

Nausea without vomiting

Fatiqued
Moderately severe
Confusion
Headache

Vomiting
Cardiorespiratory distress
Severe Abnormal and deep solemnence
Seizures
Coma (GCS \< 8)
 Hyponatremia
Isotonic hyponatremia (280-295) Sosm > 295 -> Hyperglycemia, Contrast, Mannitol,
- Hypertriglyceride, IVIg(Sucrose)
Hyperproteinemia True Hyponatremia, Corrected Na = Na + (Glu-100)/100 x 2
- Not correct if Direct ion selective Sosm<280
(ABG) Uosm < 100 -> Polydipsia, Tea and toast syndrome,
- TG q 100 mg/dl -> Na 0.2 Beer potomania
- (TP – 8) q 1 g/dl -> Na 0.25 Access “ECF Volume ADH dependent Hyponatremia

Hypovolemic Euvolemic Hypervolemic

↓ TBW ↑ TBW ↑↑ TBW
↓ ↓ TBNa ↔ TBNa ↑ TBNa

UNa > 20 UNa < 20 UNa > 20 UNa > 20 UNa < 20
Renal loss Extrarenal
- Diuretic - Vomitting
AI AKI Cirrhosis
- Renal salt wasting Cardiac failure
-
- Diarrhea Hypothyroid CKD
Cerebral salt wasting - 3rd space loss : Burn,
- Osmotic diuresis SIAD Nephrotic
Pancreatitis
- 1o AI
 Low solute intake + Free water excess
Posm < 280 - 1o Polydipsia คนแก่ –> กินได้ น้อย, If 400 mOsm
Uosm < 100 - Beer potomania และ Minimum Uosm ↑, If 200 mOsm/Kgน้ำ
- Tea and toast syndrome กินน้ำเกิน 2 L -> Free water เกิน

Solute intake
10 mosm/kg Solute 500 mosm
กินน้ำได้ มากสุด = 10 L
Minimum Uosm ถ้ ากินมากกว่านัน้ จะเกิด Free water เกินในร่างกาย
50 mosm/Kg น้ำ Hyponatremia

BW 50 Kg
 Extrarenal loss
Posm < 280
- Diarrhea
Uosm > 100 - Vomitting
Hypovolemia - 3rd space loss : Pancreatitis, Burn
UNa < 20

Loss Water > Na Hypernatremia

 EABV -> 
ดื่มเฉพาะน้ำเปล่าทดแทน
ADH

Hyponatremia
 Renal loss
Posm < 280 - Diuretic (Thiazide > Furosemide)
Uosm > 100 - Renal salt wasting
Hypovolemia - Cerebral salt wasting
UNa > 20 - Osmotic diuresis (Glucose, Urea, Mannitol, Ketone)
- 1o AI -> Aldo def. -> Na loosing at collecting duct (HyperK + Met. acido)
- Ectopic ANP (Rare, Small cell lung cancer) :  ANP ->  Aldo

Why Furosemide -> Hypernatremia ?

*** Cortisol def. -> Euvolemic hyponatremia ***

 Renal loss

Renal Salt Wasting Cerebral Salt Wasting

 Fanconi syndrome
 Subarachnoid hemorrhage
 Recovery of ATN
 Traumatic brain
Mx :  Tubulointerstitial disease (Analgesic
 CNS infection Mx :
- NSS nephropathy, Chronic pyelonephritis, - NSS
 CNS tumor
- Salt 2-4 g Nephrocalcinosis, Cystic kidney) - Salt 2-4 g
 Stroke
 Drugs (Ampho, Cisplatin, Bactrim) - Fludro 0.1
 AVM
 Post renal
mg po

1-2 Week after Event, Persist 2-4 Week

 Sympathetic  BNP ->  RAAS

Renal Na loss > Water Renal Na loss > Water

 Euvolemic Hyponatremia
Posm < 280
AI
Uosm > 100
Severe Hypothyroid
Euvolemia
SIAD
UNa - Variable

AI  Cortisol, BP ->  ADH

 Cardiac output ->  BP -> 
Hypothyroid  GFR
ADH
SIAD  ADH
SIAD : Diagnosis

 Uric < 4
 Posm < 275
 FeNa > 1%
 Uosm > 100  FeUrea > 55%
 Euvolemia  FeUric > 12%
 UNa > 40  Fail to NSS
  Correct c fluid
Normal Thyroid,
restriction
cortisol  Water loading
 No recent diuretic test
 SIAD : Causes

Harrison Nephrology and Acid-Base Disorder 2 nd ed.

Brenner & Rector’s the kidney 10th edition
 SIADH CSW/RSW
Volume status Euvolemia Hypovolemia
Respond to NSS
Urine volume Normal to Low Normal to High
Fluid balance + -
Na Low
Uosm >100
Una >40
Hct, Urea  
FeP  > 20
ADH 
BNP  
Uric, FeUric after FeUric  FeUric > 12%
correction After correct
 Hypervolemia
Posm < 280
Uosm > 100 Nephrotic
Cirrhosis
Hypervolemia Cardiac failure
UNa < 20
Underfill Overfill

 CO ->  Effective circulatory volume  ENaC

Hypoalbumin
 Oncotic P a ANP response
 EABV “Primary renal
 RAAS  Sym  ADH  RAAS, Sym Na retention”

Salt retention Water retention Salt and water retention

 Treatment : Hyponatremia
• Severe Symptomatic hyponatremia
• Mild to no symptoms
1. Hypovolumic hyponatermia
2. Euvolumic hyponatremia
3. Hypervolumic hyponatremia
 Treatment : Hyponatremia
c i t a mo t pmy s e r e v e S

Symptoms Treatment Goal Check Serum Na

Repeat doses (max 3) until symptoms imporve or

3%NaCL 150 ml IV in 20 min Immediately
reach target ↑PNa 5mmol/L in 1st hour

Or 3%NaCl 100 ml Iv bolus
Severe
Or 3% NaCl IV drip 2-4 ml/kg/hr
Repeat doses (max X3) until symptoms improve
Target ↑PNa 4-6 mmol/L in 6 Hr
Every 2-3 hr
Target ↑PNa 2-4mmol/hr until symptoms
improve

Moderately severe 3%NaCL 150 ml IV in 20 min Target ↑PNa 4-6 mmol/L in 24 hr Frequent
 Treatment : Hyponatremia
Goal
Duration Limit

Several hrs Excessive correction not known to be harmful

Acute

1-2 days Avoid increasing PNa >10 mmol/L per day

Avoid increasing PNa >8 mmol/L per day

Chronic >/ 2 days or unknown
Consider Re-lowering in high risk for ODS
 Treatment : Hyponatremia

True Hyponatremia, Sosm<280 -  Free water

-  Solute
Uosm < 100 -> Polydipsia, Tea and toast syndrome,
Beer potomania
Access “ECF Volume ADH dependent Hyponatremia

Hypovolemic Euvolemic Hypervolemic

↓ TBW ↑ TBW ↑↑ TBW
↓ ↓ TBNa ↔ TBNa ↑ TBNa

SIAD
Fluid restriction
NSS to Euvolemic  Solute (Urea, Salt) Salt and Water restriction
Salt tab & Fludrocortisone Tolvaptan, Lasix
(Salt wasting) Lasix, Tolvaptan
AI -> Pred
Hypothyroid -> thyroxine
 Treatment : Hyponatremia
Hypovolemic hyponatremia
• Restore extracellular volume with IV 0.9% NaCl or balanced crystalloid solution 0.5-1
ml/kg/hr
• In case of hemodynamic instability, the need for rapid fluid resuscitation overrides the
risk of an overly rapid increase in serum sodium concentration
 Treatment : Hyponatremia
No to mild symptoms Mx Causes
Hypovolemic hyponatremia
ชาย 50 ปี , 50 Kg, อุจจาระร่วง –> Hypovolemic hyponatremia
PNa = 125 mEq/L
Plan แก้ ด้วย 0.9% NaCl -> 10 mEq/L in 24 hr -> Rate ?
Na deficit = TBW x Na
= 0.6 x 50 x (135-125)
= 300 mEq
0.9% NaCl 154 mEq/L -> 300/154 -> 1.9 L
0.9 NaCl rate 1900/24 = 80 ml/hr
F/U Na q 6-8 hr. (Shut down ADH effect ->  Na)
 Treatment : Hyponatremia
Euvolemic hyponatremia
• Restricting fluid intake as first-line treatment
• Second line treatments
• Increasing solute intake with 0.25–0.50 g/kg per day of urea or a combination of
low-dose loop diuretics and oral sodium chloride
 Treatment : Hyponatremia
No to mild symptoms Mx Causes
SIAD
ชาย 50 ปี , 50 Kg, SIAD due to lung cancer
PNa = 120 mEq/L, UNa = 100 mEq/L, UK = 50 mEq/L, ปั สสาวะออก 1000 ml

Free water clearance = V x [1 – (UNa + UK)/PNa]

(UNa + UK)/Pna
< 1  Restrict < 500
~1  Restrict 500-700
> 1  Restrict < 1000
= 1000 x [1 – (100+50)/120]
= - 250
Insensible 500 ml
กินน้ำได้ 250 ml/day (ทำไม่ได้ )
แนะนำให้ Restrict oral fluid < 500
+ Mx อื่นๆ :  Na, Urea, Lasix, Tolvaptan
 Treatment : Hyponatremia
Hypervolemic hyponatremia
• Restricting fluid intake to prevent further volume overload
 Overcorrection
> 10 in 24 hr. or > 18 in 48 hr. - Chronic hyponatremia
- Pna < 105
- Hypokalemia
> 8 in 24 hr. or > 16 in 48 hr. High Risk - Malnutrition
- Alcoholism, Cirrhosis

ถ้ ายังไม่เกิน แต่แนวโน้ มจะเกิน

Osmotic demyelination syndrome (ODS)
5% DW rate Urine output

- Central Pontine Myelinosis (CPM), Extrapontine

- Lucid interval 5% DW 3 ml/kg/hr x 2 hr.
- 2-6 Days after Rapid correction
- Locked-in syndrome, Paresis ,Dysphagia , Ataxia,
Coma, Dysarthria, Seizure
DDAVP 1 mcg IV Stat
- MRI : Hypersignal T2 at Pons and Basal GG (F/U 2-4
Wk.)
F/U Na q 2-4 hr. (Goal < 12 mEq/day)
Hypernatremia
 Hypernatremia
• Definition: Plasma Na> 145 mEq/L
Access “ECF Volume” P
Polyuria

Euvolemic Hypovolemic Hypervolemic

“Pure water loss” “Hypotonic water
“Sodium gain”
↓ TBW loss”
↓ TBW
↔ TBNa ↓ ↓ TBW
↑↑ TBNa
↓ TBNa

Renal loss Una < 20 mmol/l

- DI -
P - Hypodipsia
GI (Diarrhea, NG)
Una > 20 (>100)
- Osm R. Dysfn - Sodium bicarb infusion
Extra-renal loss Una > 20 mmol/l - NSS/ Salt tab P
- Sweat - Burn - 1o Aldosteronism
- Osmotic (Manitol, Glu,
- Respiratory - Cushing
Urea)
- Water loss to cell (Heavy P - Loop diuretic
exercise, Seizure)
 U/P osm < 0.9
Uosm < 150
24 hr-Uosm < 800
P olyuria U/P osm > 0.9
U0sm > 250
24 hr-Uosm > 1000
FEosm < 3% Feosm > 3%

Water diuresis Solute diuresis

2 (Una + Uk) / Uosm
- DI
> 0.6 < 0.4
- 1o Polydipsia (HypoNa)
Electrolyte Non-Electrolyte

Water deprivation test UAG = Na + K - Cl

< 70 > 70 - Glucose (3+)
- Urea
- มักเกิด Trimester 3 – Cl Non-Cl
- Central DI - Contrast
Week หลังคลอด - Nephrogenic DI - NaCl
- Mannitol
- HCO3 (UpaH
- Placental Vasopressiness - Gestational DI > 7.4)
- DDAVP - Polydipsia - Ketone (4+)
- Anion
 Treatment Hypernatremia
Hypovolemic hypernatremia
• Correction of volume deficit
• IV isotonic saline
• Treatment for etiology of losses (eg. Insulin, remove osmotic diuresis)
• Correction of water deficit + ongoing loss
• Calculate water deficit + ongoing loss
• Administer 0.45% saline, 5%dextrose, or oral fluid
 Correct Hypernatremia

Free water def. = (Naตอนนี ้ – Naที่ต้องการ )/ Naที่ต้องการ x TBW

Free water deficit TBW = (0.6, 0.5, 0.45) x BW
0.6 = ชาย, 0.5 = หญิง, ชายแก่, 0.45 = หญิงแก่

Ongoing water loss Urine Water loss = V x (1 – (UNa + UK)/PNa)

10 ml/kg/day
Insensible water loss
↑Temp 1 C -> 2.5 ml/kg/day
 Treatment Hypernatremia
Euvolemic hypernatremia
• Correction of water deficit
• Calculate water deficit + ongoing loss
• Administer 0.45% saline, 5%dextrose, or oral fluid
• Long-term therapy
• Central DI: DDAVP
• Nephrogenic DI
• Correction of serum K, Ca
• Removal of offending drugs
• Low sodium diet
• HCTZ
หญิง 50 ปี , 50 Kg, Central DI, ปั สสาวะออก 250 ml/hr
PNa = 155 mEq/L, UNa = 37 mEq/L, UK = 13 mEq/L

DDAVP 1-2 mcg IV q12 hr

Free water deficit = (155-145)/145 x 50 x 0.5 = 1.7 L.

Ongoing loss = 250 x {1 – (37+13)/155} = 170 ml/hr

Insensible loss = 50 x 10 = 500/24 hr

Free water = 1.7 L + 0.5 L = 2.3 L in 24 hr (Rate 100 ml/hr)

F/U Na q 4-6 hr.

ชาย 50 ปี , 50 Kg, อุจจาระร่วง –> Hypovolemic hypernatremia
PNa = 155 mEq/L
Plan แก้ ด้วย 0.45% NaCl 10 mEq/L in 24 hr -> Rate ?

Adrogue-Madias Formula

∆Na =

∆Na =

∆Na =

↓10 mEq/L/day => 4 L of 0.45 Nacl => Rate 160 ml/hr

 Treatment Hypernatremia
Hypervolemic hypernatremia
• Removal of sodium
• Discontinuing offending agents
• Furosemide
• Hemodialysis as required in renal insufficiency
Hyperkalemia
 Etiologies of Hyperkalemia
Exogenous K administration Endogenous K production

Excessive oral K intake in CKD Rhabdomyolysis

Transfusion-related hyperkalemia Hemolysis
(Old-blood, high rate and volume, irradiated blood) Acute tumor lysis syndrome

Redistribution Reduced urinary K distribution

Hypertonic mannitol
Digitalis overdose
Contrast media
Severe AKI,
Succinylcholine
advanced stage CKD (GFR <20 mL/min) Hypoaldosteronism
Β-blocker
Aldosterone resistance
Metabolic acidosis
Heavy exercise
Hyperkalemic periodic paralysis (HYPP)
 Hyperkalemia
24 hr. Urine K < 40

Shift Load  K Excretion

 B-Blocker
 Succinylcholine Endogenous TTKG <5
 Rhabdomyo.
 Met.acidosis Renal fail (GFR
 TLS HyperK
(Normal gap,
<20) RTA 4 NG Met. acido
Uremic)  Reperfusion
 Rewarming acute limb
(Therapeutic hypothermia)

Aldo-resistance Aldo-deficiency

Drugs  Renin BB, NSAIDs, DN

SLE
- Block ENaC (Amiloride, Post-KT
Pseudohyperkalemia Bactrim, CNI) Tubulointerstitial disease  AI,II ACEI, ARB
- Block MR (Aldactone) Post obstruction
Hemolysis (ตอนเจาะเลือด)  Aldosterone 1o AI, UFH/LMWH,
Ketoconazole
 Hyperkalemia : Management

Emergency management
• EKG changes
• Muscle weakness
 Hyperkalemia : Management

1. Stabilize excitable tissue

• 10% Calcium gluconate 1 amp IV slowly push in 2-3 min
• Repeat every 5 mins if EKG not improved
2. Shifts potassium into cells
• RI 10 u + 50%glucose 50 ml IV bolus ( if DTX>250 no need to use glucose)
• Ventolin 10-20 ml NB over 10 min, beware tachycardia
• 7.5% NaHCO3 when metabolic acidosis
 Hyperkalemia : Management

3. Remove potassium from the body

• Kalimate 30 g + water 60 ml po, 60 g + water 200 ml RS
• Kayexelate 30 g + water po, 60g + water 200 ml RS
• Furosemide 20-40 mg IV bolus
4. Hemodialysis : Failed medication
 Hyperkalemia : Management

5. Prevention of recurrence
• DM: control plasma glucose
• Adrenal insufficiency: hormone replacement
• CKD : renal replacement therapy
• Medications : avoid use
Hyperkalemia : Management

EKG Change

Shift
- เร็ว แต่ไม่ได้ ขบั K
ออกจากร่าง
- RI
- Salbutamol
- HCO3

ช้ ากว่า

ต้ องมีปัสสาวะ
ต้ อCurtesy
งมี Nephro
Aj. Praopilad
 Hyperkalemia

Mx :
- 10% Calcium gluconate 10 ml IV slowly push (Drip in 30 min, If Digoxin
intox)
- Salbutamol 10-20 mg NB
- 50% Glucose 50 ml + RI 10 U IV, F/U DTX next 2 hr.
- 7.5% NaHCO3 100 ml IV drip in 1 hr. (If acidosis)
- Lasix 40 mg IV
ิ ธิภาพน ้อย
- Kalimate 30 mg po q 4 hr. (Rectal suppo. เร็วกว่า แต่ประสท
กว่า)
- Restrict K intake (Low K diet < 2 g/day)