Electrolyte cases Amir H - PowerPoint Presentation

1. Electrolyte casesAmir H SamClinical Lecturer

2. Learning objectivesTo interpret the clinical data in patients with serum electrolyte abnormalities.To plan the investigations and management of patients with serum electrolyte abnormalities.

3. Case 1A 67-year-old man was started on bendroflumethiazide for hypertension 2 weeks ago. On examination he has dry mucous membranes and decreased skin turgor. His past medical history is otherwise unremarkable.Urea & electrolytes:Na+: 129 mmol/LK+: 3.5 mmol/LUr: 8.0 mmol/LCr: 100 μmol/L

4. Hyponatraemic patient

5. Hyponatraemic patient

6. Hyponatraemic patient

7. Case 1: ManagementVolume replacement with 0.9% saline

8. Case 2A 57-year-old woman is admitted with increasing breathlessness worse on lying flat. Her past medical history includes a Non-STEMI and hyperlipidaemia. She is on ramipril, bisoprolol, aspirin and simvastatin. On examination she has elevated JVP, bibasal crackles and bilateral leg oedema.Urea & electrolytes:Na+: 128 mmol/LK+: 4.5 mmol/LUr: 8.0 mmol/LCr: 100 μmol/L

9. Hyponatraemic patient

10. Hyponatraemic patient

11. Hyponatraemic patient

12. Case 2: ManagementFluid restrictionTreat the underlying cause

13. Case 3A 55-year-old man presents with jaundice. He has a past history of excessive alcohol intake. On examination he has multiple spider naevi, shifting dullness and splenomegaly. Urea & electrolytes:Na+: 122 mmol/LK+: 3.5 mmol/LUr: 2.0 mmol/LCr: 80 μmol/L

14. Hyponatraemic patient

15. Hyponatraemic patient

16. Hyponatraemic patient

17. Case 3: ManagementFluid restrictionTreat the underlying cause

18. Case 4A 40-year-old woman presents with fatigue, weight gain, dry skin and cold intolerance. On examination she looks pale.Urea & electrolytes:Na+: 130 mmol/LK+: 4.2 mmol/LUr: 5.0 mmol/LCr: 65 μmol/L

19. Hyponatraemic patient

20. Hyponatraemic patient

21. Hyponatraemic patient

22. Hyponatraemic patient TFTsShort Synacthen testPlasma & urine osmolality? Clinically hypovolaemic? Fluid overloaded

23. Case 4: ManagementTreat the underlying cause: Thyroxine replacement

24. Case 5A 45-yeard-old woman presents with dizziness and nausea. On examination she looks tanned and has postural hypotension.Urea & electrolytes:Na+: 128 mmol/LK+: 5.5 mmol/LUr: 9.0 mmol/LCr: 110 μmol/L

25. Hyponatraemic patient

26. Hyponatraemic patient

27. Hyponatraemic patient TFTsShort Synacthen testPlasma & urine osmolality? Clinically hypovolaemic? Fluid overloaded

28. Case 5: ManagementTreat the underlying cause: Hydrocortisone & Fludrocortisone

29. Case 6A 62-year-old man presents with chest pain, cough and weight loss. On examination he looks cachectic. He has a 30 pack year smoking history.Urea & electrolytes:Na+: 125 mmol/LK+: 3.5 mmol/LUr: 7.0 mmol/LCr: 85 μmol/L

30. Hyponatraemic patient

31. Hyponatraemic patient

32. Hyponatraemic patient TFTsShort Synacthen testPlasma & urine osmolality? Clinically hypovolaemic? Fluid overloaded

33. Diagnosis of SIADHNo HypovolaemiaNo HypothyroidismNo Adrenal insufficiencyReduced plasma osmolality ANDIncreased urine osmolality (>100)

34. Causes of SIADHCNS pathologyLung pathologyDrugs (SSRI, TCA, opiates, PPIs, carbamazepine)Tumours

35. Case 7A 20-year-old man presents with polyuria and polydipsia. On examination he has bitemporal hemianopia.Urea & electrolytes:Na+: 150 mmol/LK+: 4.0 mmol/LUr: 5.0 mmol/LCr: 70 μmol/L

36. Causes of hypernatraemiaUreplaced water lossGastrointestinal losses, sweat lossesRenal losses: osmotic diuresis, reduced ADH release/action (Diabetes insipidus)Patient cannot control water intake e.g. children, elderly

37. Control of water balanceADH (vasopressin)water retentionthrough water channels (aquaporin-2)

38. Investigations in suspected diabetes insipidusSerum glucose (exclude diabetes mellitus)Serum potassium (exclude hypokalaemia)Serum calcium (exclude hypercalcaemia)Plasma & urine osmolalityWater deprivation test

39. Case 8A 65-year-old man with type 2 diabetes mellitus and hypertension presents with malaise and drowsiness. He is on a basal bolus insulin regimen, ramipril, amlodipine, simvastatin and aspirin.Urea & electrolytes:Na+: 125 mmol/LK+: 6.5 mmol/LUr: 18.0 mmol/LCr: 250 μmol/L 

40. AdrenalLung Angiotensin IAngiotensin IIAldosterone Angiotensinogen(from liver)Renin (from JGA)Convertingenzyme(lung)Na+K+Angiotensin II GFR

41. AdrenalLung Angiotensin IAngiotensin IIAldosterone Angiotensinogen(from liver)Renin (from JGA)Convertingenzyme(lung)Na+K+Angiotensin IIACE inhibitor

42. AdrenalLung Angiotensin IAngiotensin IIAldosterone Angiotensinogen(from liver)Renin (from JGA)Convertingenzyme(lung)Na+K+Angiotensin IIAddison’s disease

43. Potassium release from cellsRhabdomyolysisAcidosisK+K+H+Need to maintain electroneutrality

44. Causes of hyperkalaemiaRenal impairment: reduced renal excretionDrugs: ACE inhibitors, ARBs, spironolactoneLow Aldosterone Addison’s diseaseType 4 renal tubular acidosis (low renin, low aldosterone)Release from cells: rhabdomyloysis, acidosis

45. ECG in hyperkalaemia Peaked T waves

46. Management of hyperkalaemia10 ml 10% calcium gluconate50 ml 50% dextrose + 10 units of insulinNebulized salbutamolTreat the underlying cause

47. Case 9A 50-year-old man is referred with hypertension that has been difficult to control despite maximum doses of amlodipine, ramipril and bisoprolol.Urea & electrolytes:Na+: 140.0 mmol/LK+: 3.0 mmol/LUr: 4.0 mmol/LCr: 70 μmol/L

48. Aldosterone & potassium secretion Aldosterone Lumen + Na+ K+ Na+ K+Principal cells(cortical collecting tubule)

49. Case 9: initial investigationAldosterone: Renin ratio