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ELECTROLYTE DISTURBANCES

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by

Rachel Heap

on 21 April 2015

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Transcript of ELECTROLYTE DISTURBANCES

ELECTROLYTE DISTURBANCES
DIABETIC KETOACIDOSIS

DKA
Diagnosis
1. diabetic
blood sugar high (>14)
3. acidotic
pH <7.3
2. ketones
blood and urine
History and examination
thirst, polydipsia, polyuria, weight loss, intercurrent infection, dry+++, tachypnoeic, ketones on breath
Plan A:
Plan B:
Investigations
Monitoring - bloods
Sodium
Chloride
Bicarbonate
Lactate
Ketones
Urea
Potassium
Magnesium
Phosphate
where sodium goes, water follows
blood volume and flow haemostasis
acid-base balance
energy and electrical activity
Chloride, bicarbonate, lactate, ketones, urea
Potassium, magnesium, phophate
Pathophysiology and principles of management
Sodium
Dehydrated
Hyperglycaemic
Precipitating factors
Electrolyte imbalance
Acidotic
Glucose is an osmotic diuretic
Resuscitate - at least 20mls/kg iv fluid. May need 3 - 10 litres.
Start insulin.
Do not drop BSL >5mmol/hr.
Determine type. Manage accordingly.
Look for and manage.
Can kill. Be vigilant, manage expectantly, avoid complications.
Complications
Look for and manage.
Dehydrated
Hyperglycaemic
Acidotic
'Electrolyte
imbalance'
Glucose
diabetes control and osmolality
Glucose
diabetes control and osmolality
acid-base balance
electrical stability and energy
Psuedohyponatraemia
Correct sodium for hyperglycaema
actual Na = measured Na + (gluc/3)
low volume, pressure,
or renal blood flow
#1
renin-angiotensin-aldosterone;
iso-osmolar Na and water retention
#2
ADH;
usually maintains osmolality.
BUT, will sacrifice osmolality if flow inadequate
Free water retention
Excess free water
low renal blood flow
hypovolaemia
cardiac failure
SIADH
lung
CNS
malignancy
polydipsia
Hyponatraemia
Free water deficiency
dehydration
Hypernatraemia
Excess salt
hypertonic saline
sodium bicarbonate
oral salt
Do not change corrected Na by > 2 mmol/l/hr
X
X
Salt depletion
diuretics
adrenocortical failure
inappropriate fluid replacement
Which iv fluids to choose
too rapid a rise in Na = central pontine myelinolysis
too rapid a fall in Na = cerebral oedema
serum Na often 'normal' or low
use normal saline 2l or 20mls/kg for resus if haemodynamically unstable,
then choose fluid according to corrected sodium

do not decrease by more than 2mmol/l/hr, or 24 mmol/l/day
SODIUM and FLUID STATUS
Start insulin
Do not drop BSL >5mmol/hr
The aim is to turn off ketosis
Once BSL <16,
start dextrose
Do not turn off insulin until eating/drinking and starting sc regime
1. ABG
2. BXS
3. Anion Gap
-ve = metabolic acidosis
= (Na + K) - (Cl + HCO3)
RAISED AG (>30)
ketones
lactate
kidneys
exogenous
NORMAL AG
chloride
(too much saline)
ACID BASE STATUS
ketoacidosis - insulin and glucose
determine type, treat accordingly
lactate - hypoperfusion, fluid resus,
look for sepsis/ischaemia

chloride - iv fluids, NOT just saline!
carbohydrate
insulin
ATP
fats
ATP
ketones
acid
where sodium goes, water follows
blood volume and flow haemostasis
dehydrated and hyperglycaemic
actually hypernatraemic when
corrected Na calculated

?pH
DKA
carbohydrate
insulin
ATP
vein
cell
K
Mg
PO4
X
carbohydrate
insulin
ATP
vein
cell
K
Mg
PO4
low K, low Mg
electrical instability
low phosphate
no ATP
ELECTROLYTE IMBALANCE
Ensure safe levels before driving them lower
Can kill.
Be vigilant,
manage expectantly,
avoid complications.

RACHEL HEAP
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