1. Copyright 2008 Society of Critical Care Medicine Management of Life- Threatening Electrolyte and Metabolic Disturbances

2. 1 Copyright 2008 Society of Critical Care Medicine Objectives Review the emergent management of severe electrolyte disturbances Recognize manifestations of acute adrenal insufficiency and initiate appropriate treatment Describe the management of severe hyperglycemic syndromes

3. 2 Copyright 2008 Society of Critical Care Medicine Case Study 80-year-old woman with hypertension and heart failure Confusion, lethargy, poor oral intake and weakness for 3 days BP 108/70 mm Hg, HR 110/min, R 18/min Nonsustained ventricular tachy- cardia on monitor What risk factors does this patient have for electrolyte disturbances? What electrolyte disorders might contribute to her presentation?

4. 3 Copyright 2008 Society of Critical Care Medicine Treat the electrolyte change, but search for the cause Clinical manifestations are usually not specific to a particular electrolyte change Clinical circumstances determine urgency of treatment rather than electrolyte concentration Frequent reassessment of electrolyte abnormalities required Principles of Electrolyte Disturbances

5. 4 Copyright 2008 Society of Critical Care Medicine Case Study 80-year-old woman with hypertension and heart failure Confusion, lethargy, poor oral intake and weakness for 3 days Nonsustained ventricular tachy- cardia on monitor Laboratory value: K 2.5 mmol/L How would you initiate evaluation and treatment of this patient?

6. 5 Copyright 2008 Society of Critical Care Medicine Hypokalemia (K<3.5 mmol/L) K 2.5 mmol/L and No Symptoms Enteral replacement KCl 20-40 mmol every 4-6 h K  2.5 mmol/L (<3 mmol/L if on Digoxin) Life-ThreateningSymptoms Non-Life Threatening or No Symptoms IV KCl 20-30 mmol/h via Central Catheter Enteral replacement KCl 20-40 mmol every 2-4 h and/or IV KCl 10 mmol/h Treatment of Hypokalemia

7. 6 Copyright 2008 Society of Critical Care Medicine Case Study 80-year-old woman with hypertension and heart failure ECG How would you initiate treatment of this patient? Laboratory value: K 7.8 mmol/L

8. 7 Copyright 2008 Society of Critical Care Medicine Treatment of Hyperkalemia Calcium for cardiac toxicity (ECG abnormalities) Redistribute potassium  Insulin and glucose  Sodium bicarbonate  Inhaled  2 -agonists Remove potassium  Loop diuretic  Sodium polystyrene sulfonate  Dialysis

9. 8 Copyright 2008 Society of Critical Care Medicine Case Study 80-year-old woman with hypertension and heart failure Confusion, lethargy, poor oral intake and weakness for 3 days Nonsustained ventricular tachy- cardia on monitor Laboratory value: Na 118 mmol/L How would you initiate evaluation of this patient to determine the etiology?

10. 9 Copyright 2008 Society of Critical Care Medicine Etiology of Hyponatremia Presence of ↑ Glucose ↑ Proteins or Lipids Mannitol Assess Volume Status Urine Osmolarity (U osm ) Urine Sodium (U Na ) FE Na Hyponatremia (Na<135 mmol/L) Hypo-osmolar Hyponatremia Consider Hyperosmolar Hyponatremia Pseudohyponatremia Yes No

11. 10 Copyright 2008 Society of Critical Care Medicine Etiology of Hyponatremia Hypovolemia Hypervolemia U osm >300 mOsm/L U Na <20 mmol/L FE Na <1% U osm >300 mOsm/L U Na >20 mmol/L FE Na >1% U osm >300 mOsm/L U Na <10-20 mmol/L FE Na <1% VomitingDiarrheaThird-Space Fluid Loss Fluid Loss DiureticsAldosteroneDeficiency Renal Tubular Dysfunction Congestive Heart Failure Cirrhosis Renal Failure With/Without Nephrosis With/Without Nephrosis

12. 11 Copyright 2008 Society of Critical Care Medicine Etiology of Hyponatremia Euvolemia U osm <100 mOsm/L U Na >30 mmol/L U osm >100 mOsm/L (usually >300) U Na >30 mmol/L Polydipsia Inappropriate Water Administration to Children Administration to Children SIADHHypothyroidism Adrenal Insufficiency

13. 12 Copyright 2008 Society of Critical Care Medicine Hypovolemic Hypervolemic Euvolemic  Restrict free-water intake  Increase free-water loss  Replace intravascular volume with normal saline or hypertonic saline When would you use hypertonic saline? How fast would you correct the sodium concentration? Management of Hyponatremia

14. 13 Copyright 2008 Society of Critical Care Medicine Case Study 80-year-old woman with hypertension and heart failure Confusion, lethargy, poor oral intake and weakness for 3 days Nonsustained ventricular tachy- cardia on monitor Laboratory value: Na 168 mmol/L How would you treat this patient?

15. 14 Copyright 2008 Society of Critical Care Medicine Normal saline if hemodynamically unstable Hypotonic fluid when stable  Intravenous fluids  Enteral free water Quantity  H 2 O deficit (L) = [0.6  wt (kg) ]  [Measured Na - 1] 140 Rate of correction Treatment of Hypernatremia

16. 15 Copyright 2008 Society of Critical Care Medicine Case Study 34-year-old man with flu-like syndrome Febrile, tachycardic and hypotensive Antibiotics and volume initiated Admitted to floor 2 hours later, systolic BP 60 mm Hg Hypotensive in ICU after 40 mL/kg fluids and norepinephrine 10  g/min What metabolic disorders may contribute to the hypotension? What testing is needed?

17. 16 Copyright 2008 Society of Critical Care Medicine Support blood pressure with fluids and vasopressors Treat precipitating conditions Perform a short ACTH stimulation test if indicated Administer IV hydrocortisone 200- 300 mg/24 hours Consider fludrocortisone Treat until critical illness resolves Treatment for Acute Adrenal Insufficiency

18. 17 Copyright 2008 Society of Critical Care Medicine Hyperglycemic Syndromes 25 year-old type I diabetic; venous pH 7.26, glucose 290 mg/dL, HCO 3 16 mmol/L, anion gap 16 mmol/L, urine ketones (+) 51 year-old with no chronic illness; Na 141 mmol/L, Cl 98 mmol/L, HCO 3 13 mmol/L, glucose 1640 mg/dL, BUN 70 mg/dL, urine ketones (+) Is this diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS)?

19. 18 Copyright 2008 Society of Critical Care Medicine Hyperglycemic Syndromes 73 year-old type II diabetic; Na 163 mmol/L, Cl 134 mmol/L, HCO 3 21 mmol/L, glucose 1282 mg/dL, BUN 62 mg/dL, urine ketones (-) Is this diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS)?

20. 19 Copyright 2008 Society of Critical Care Medicine Hyperglycemic Syndromes Characteristics of Hyperglycemic Syndromes DKAHHS Glucose> 250 mg/dL> 600 mg/dL Arterial/venous pH≤ 7.3> 7.3 Anion gapIncreasedVariable Serum/urine ketonesPositiveNegative or small Serum osmolarityNormalIncreased

21. 20 Copyright 2008 Society of Critical Care Medicine Initial Evaluation Mental status Degree of dehydration Presence of infection or other precipitating condition Laboratory studies  Glucose  Venous or arterial pH  Electrolytes, renal function  Urine or serum ketones  Complete blood count  ECG

22. 21 Copyright 2008 Society of Critical Care Medicine Fluids Insulin Electrolytes Crystalloids Add glucose to fluids when glucose 250-300 mg/dL Regular insulin loading dose (0.1-0.15 U/kg) Regular insulin infusion (0.1 U/kg/h) If K <3.3 mmol/L hold insulin and replace K Add K to fluids if K >3.3 but <5 mmol/L Management of Hyperglycemic Syndromes

23. 22 Copyright 2008 Society of Critical Care Medicine Continuous insulin infusion Goal  80-110 mg/dL (4.4-6.1 mmol/L)  140-180 mg/dL (7.8-10 mmol/L)  <150 mg/dL (8.3 mmol/L) Patient selection Protocol important to optimal outcomes Hyperglycemia of Critical Illness

24. 23 Copyright 2008 Society of Critical Care Medicine Questions

25. 24 Copyright 2008 Society of Critical Care Medicine Key Points Give KCl through a central venous catheter for life-threatening hypokalemia Consider calcium administration for hyperkalemia with ECG changes followed by interventions to shift K intracellularly Limit the increase in serum Na to 8-12 mmol/L in the first 24 h in symptomatic euvolemic hyponatremia Patients with hypernatremia and hemodynamic instability should have normal saline administered

26. 25 Copyright 2008 Society of Critical Care Medicine Key Points Patients with possible adrenal insufficiency should have emergent treatment with a glucocorticoid Treatment goals for hyperglycemic syndromes are to restore fluid and electrolyte balance, provide insulin and identify precipitants In DKA, insulin infusion should be continued until acidosis and ketosis have resolved

27. 26 Copyright 2008 Society of Critical Care Medicine Key Points Maintain glucose 250-300 mg/dL in HHS until plasma osmolality  315 mOsm/kg Potassium should be added to fluids in hyperglycemic syndromes as soon as K <5 mmol/L and urine output is adequate A protocol for glycemic control should be chosen to avoid hyperglycemia and minimize hypoglycemia in critically ill patients