美国重症医学FCCM的基础教程电解质代谢紊乱教材课程
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• Manifestations – cardiac, neuromuscular
MET 7 ®
Hyperkalemia – Treatment
• Stop intake • Give calcium for cardiac toxicity • Shift K+ into cell – glucose + insulin, NaHCO3,
• Implies an underlying disease process • Treat the electrolyte change, but seek the
cause • Clinical manifestations usually not specific to
a particular electrolyte change, e.g., seizures, arrhythmias
Myxedema Comaຫໍສະໝຸດ Baidu
• Manifestations of severe hypothyroidism
• Supportive measures – airway, fluids, glucose, warming
• Titrate fluid as serum Na increases; excessive hypotonic fluid may cause cerebral edema
MMEETT 2233 ®
Thyroid Storm
• Exaggerated manifestations of hyperthyroidism
inhaled -agonist • Remove from body – diuretics, sodium
polystyrene sulfonate, dialysis
MET 8 ®
Pediatric Considerations – Potassium
• Replace at maximum iv rate <–1.0 mmol/kg/hr; monitor ECG
Electrolyte and Metabolic Disturbances
MET 1 ®
Objectives
• Review causes and clinical manifestations of severe electrolyte disturbances
• Outline emergent management of electrolyte disturbances
rapid correction
MET 13 ®
Pediatric Considerations – Sodium
• Hyponatremia – seizures: titrate 3% NaCl; usual dose 1.5-2.5 mmol/kg
• Hypernatremia – calculate H2O deficit as 4 mL/kg for each 1 mmol/L serum Na >145 mmol/L
• Supportive measures • Specific measures
– Propylthiouracil or methimazole – Propranolol – Potassium or sodium iodide – Dexamethasone, sodium ipodate
MET 24 ®
Hypernatremia
• Etiology – H2O loss, H2O intake, Na intake
• Manifestations – neurologic, muscular • H2O deficit (L) =
[ 0.6 wt (kg) ] [ obs Na - 1 ] 140
MET 20 ®
Hyperglycemic Syndromes – Laboratory
• Hyperglycemia/hyperosmolality • Ketonemia/ketonuria (DKA) • Increased anion gap metabolic acidosis
(DKA) • Electrolyte changes (K, PO4, Na)
MET 10 ®
Hyponatremia – Treatment
• Hypovolemic Na – give normal saline, rule out adrenal insufficiency
• Hypervolemic Na – increase free H2O loss • Euvolemic hyponatremia
• Hypocalcemia – Calcium chloride or gluconate – Bolus + continuous infusion
• Hypercalcemia – Rehydration with normal saline – Loop diuretics
MET 16 ®
Other Electrolyte Disorders
• Recognize acute adrenal insufficiency and appropriate treatment
• Describe management of severe hyperglycemic syndromes
MET 2 ®
Principles of Electrolyte Disturbances
• Decrease serum Na no faster than 0.5 mmol/L/hr
MET 14 ®
Other Electrolyte Deficits Ca, PO4, Mg
• May produce serious but nonspecific cardiac, neuromuscular, respiratory, and other effects
MET 3 ®
MET 4 ®
Hypokalemia
• Etiology – renal loss, extrarenal loss, transcellular shift, decreased intake
• Manifestations – cardiac, neuromuscular, gastrointestinal
<250-300 mg/dL (13.9-16.7 mmol/L) • Treat electrolyte changes (K, PO4) • NaHCO3 rarely needed
MET 22 ®
Pediatric Considerations – DKA
• Insulin – bolus not used, titrate iv infusion
MET 19 ®
Hyperglycemic Syndromes
• Diabetic ketoacidosis (DKA) • Hyperglycemic hyperosmolar state
(HHS) • Manifestations – dehydration, polyuria/
polydipsia, altered mental status, BP, nausea, emesis, abdominal pain
MET 9 ®
Hyponatremia
• Hypo-osmolar hyponatremia – Euvolemic – Hypovolemic – Hypervolemic
• Normo- or hyperosmolar hyponatremia – Pseudohyponatremia
• Manifestations – neurologic, muscular, gastrointestinal
MET 17 ®
Acute Adrenal Insufficiency
• Nonspecific manifestations – Abdominal pain, nausea, emesis – Orthostatic/refractory hypotension
• Laboratory findings – Hyponatremia, hyperkalemia – Hypoglycemia
• All are primarily intracellular ions, so deficits difficult to estimate
• Titrate replacement against clinical findings
MET 15 ®
Other Electrolyte Disorders
• Hyperkalemia – ECG abnormality: calcium gluconate or chloride – Shift: NaHCO3, glucose + insulin, inhaled -agonists – Removal: diuretic, sodium polystyrene sulfonate, dialysis
• Deficit poorly estimated by serum levels
MET 5 ®
Hypokalemia
• Titrate administration of K+ against serum level and manifestations
• Correct hypomagnesemia • ECG monitoring with emergent administration • Allowable maximum iv dose per hour
controversial • Treat hypokalemia urgently in acidosis
MET 6 ®
Hyperkalemia
• Etiology – renal failure, transcellular shifts, cell death, drugs, pseudohyperkalemia
MET 21 ®
Hyperglycemic Syndromes – Treatment
• Identify and treat precipitating factors • Restore fluid/electrolyte balance • Insulin – iv bolus and infusion • Add glucose to infusion when glucose
MET 12 ®
Hypernatremia – Treatment
• Provide intravascular volume replacement • Consider giving one-half of free H2O deficit
initially • Reduce Na cautiously: 0.5-1.0 mmol/L/hr • Secondary neurologic syndromes with
MET 18 ®
Acute Adrenal Insufficiency
• Baseline blood samples • Volume and glucose infusion • Dexamethasone or hydrocortisone • ACTH stimulation test if needed • Treat precipitating conditions
• Hypophosphatemia – Replacement iv for level < 1 mg/dL (0.32 mmol/L)
• Hypomagnesemia – Emergent administration over 5–10 mins – Less urgent administration over 10–60 mins
– Restrict free water intake – Increase free water loss – Normal or hypertonic saline • Correct slowly due to possibility of demyelinating syndromes
MET 11 ®
MET 7 ®
Hyperkalemia – Treatment
• Stop intake • Give calcium for cardiac toxicity • Shift K+ into cell – glucose + insulin, NaHCO3,
• Implies an underlying disease process • Treat the electrolyte change, but seek the
cause • Clinical manifestations usually not specific to
a particular electrolyte change, e.g., seizures, arrhythmias
Myxedema Comaຫໍສະໝຸດ Baidu
• Manifestations of severe hypothyroidism
• Supportive measures – airway, fluids, glucose, warming
• Titrate fluid as serum Na increases; excessive hypotonic fluid may cause cerebral edema
MMEETT 2233 ®
Thyroid Storm
• Exaggerated manifestations of hyperthyroidism
inhaled -agonist • Remove from body – diuretics, sodium
polystyrene sulfonate, dialysis
MET 8 ®
Pediatric Considerations – Potassium
• Replace at maximum iv rate <–1.0 mmol/kg/hr; monitor ECG
Electrolyte and Metabolic Disturbances
MET 1 ®
Objectives
• Review causes and clinical manifestations of severe electrolyte disturbances
• Outline emergent management of electrolyte disturbances
rapid correction
MET 13 ®
Pediatric Considerations – Sodium
• Hyponatremia – seizures: titrate 3% NaCl; usual dose 1.5-2.5 mmol/kg
• Hypernatremia – calculate H2O deficit as 4 mL/kg for each 1 mmol/L serum Na >145 mmol/L
• Supportive measures • Specific measures
– Propylthiouracil or methimazole – Propranolol – Potassium or sodium iodide – Dexamethasone, sodium ipodate
MET 24 ®
Hypernatremia
• Etiology – H2O loss, H2O intake, Na intake
• Manifestations – neurologic, muscular • H2O deficit (L) =
[ 0.6 wt (kg) ] [ obs Na - 1 ] 140
MET 20 ®
Hyperglycemic Syndromes – Laboratory
• Hyperglycemia/hyperosmolality • Ketonemia/ketonuria (DKA) • Increased anion gap metabolic acidosis
(DKA) • Electrolyte changes (K, PO4, Na)
MET 10 ®
Hyponatremia – Treatment
• Hypovolemic Na – give normal saline, rule out adrenal insufficiency
• Hypervolemic Na – increase free H2O loss • Euvolemic hyponatremia
• Hypocalcemia – Calcium chloride or gluconate – Bolus + continuous infusion
• Hypercalcemia – Rehydration with normal saline – Loop diuretics
MET 16 ®
Other Electrolyte Disorders
• Recognize acute adrenal insufficiency and appropriate treatment
• Describe management of severe hyperglycemic syndromes
MET 2 ®
Principles of Electrolyte Disturbances
• Decrease serum Na no faster than 0.5 mmol/L/hr
MET 14 ®
Other Electrolyte Deficits Ca, PO4, Mg
• May produce serious but nonspecific cardiac, neuromuscular, respiratory, and other effects
MET 3 ®
MET 4 ®
Hypokalemia
• Etiology – renal loss, extrarenal loss, transcellular shift, decreased intake
• Manifestations – cardiac, neuromuscular, gastrointestinal
<250-300 mg/dL (13.9-16.7 mmol/L) • Treat electrolyte changes (K, PO4) • NaHCO3 rarely needed
MET 22 ®
Pediatric Considerations – DKA
• Insulin – bolus not used, titrate iv infusion
MET 19 ®
Hyperglycemic Syndromes
• Diabetic ketoacidosis (DKA) • Hyperglycemic hyperosmolar state
(HHS) • Manifestations – dehydration, polyuria/
polydipsia, altered mental status, BP, nausea, emesis, abdominal pain
MET 9 ®
Hyponatremia
• Hypo-osmolar hyponatremia – Euvolemic – Hypovolemic – Hypervolemic
• Normo- or hyperosmolar hyponatremia – Pseudohyponatremia
• Manifestations – neurologic, muscular, gastrointestinal
MET 17 ®
Acute Adrenal Insufficiency
• Nonspecific manifestations – Abdominal pain, nausea, emesis – Orthostatic/refractory hypotension
• Laboratory findings – Hyponatremia, hyperkalemia – Hypoglycemia
• All are primarily intracellular ions, so deficits difficult to estimate
• Titrate replacement against clinical findings
MET 15 ®
Other Electrolyte Disorders
• Hyperkalemia – ECG abnormality: calcium gluconate or chloride – Shift: NaHCO3, glucose + insulin, inhaled -agonists – Removal: diuretic, sodium polystyrene sulfonate, dialysis
• Deficit poorly estimated by serum levels
MET 5 ®
Hypokalemia
• Titrate administration of K+ against serum level and manifestations
• Correct hypomagnesemia • ECG monitoring with emergent administration • Allowable maximum iv dose per hour
controversial • Treat hypokalemia urgently in acidosis
MET 6 ®
Hyperkalemia
• Etiology – renal failure, transcellular shifts, cell death, drugs, pseudohyperkalemia
MET 21 ®
Hyperglycemic Syndromes – Treatment
• Identify and treat precipitating factors • Restore fluid/electrolyte balance • Insulin – iv bolus and infusion • Add glucose to infusion when glucose
MET 12 ®
Hypernatremia – Treatment
• Provide intravascular volume replacement • Consider giving one-half of free H2O deficit
initially • Reduce Na cautiously: 0.5-1.0 mmol/L/hr • Secondary neurologic syndromes with
MET 18 ®
Acute Adrenal Insufficiency
• Baseline blood samples • Volume and glucose infusion • Dexamethasone or hydrocortisone • ACTH stimulation test if needed • Treat precipitating conditions
• Hypophosphatemia – Replacement iv for level < 1 mg/dL (0.32 mmol/L)
• Hypomagnesemia – Emergent administration over 5–10 mins – Less urgent administration over 10–60 mins
– Restrict free water intake – Increase free water loss – Normal or hypertonic saline • Correct slowly due to possibility of demyelinating syndromes
MET 11 ®