傳染病學教案課件7流行性出血熱

HemorrhagicFeverwithRenalSyndromeZhangDazhi,M.DDepartmentofInfectiousDiseaseThesecondhospitalofCMUHemorrhagicFeverwithRenalS1OverviewPathogen:HantavirusesClinicalfeatures:fever；renalfailure；shock;hemorrhagicmanifestationsHemorrhagicfeverwithrenalsyndrome(HFRS)includesagroupofclinicallysimilarillnessesEpidemichemorrhagicfever(China)Koreanhemorrhagicfever(Korean)Nephropathisepidemica(PuumalaOverviewPathogen:Hantaviruses2VirologyofHantaviruseBelongtothefamilyBun-yaviridaeSphericalenvelopedvirusesabout80-120nmindiameterGenomeconsistsofthreesingle-stranded,negativesenseRNAsegments---S,M,LS(small):encodesneucleocapsidproteinM(medium):

encodesenvelopeglycoprotein

L(large):encodespolymeraseVirologyofHantaviruseBelong3Thevirusesthatcausehemorrhagicfeverwithrenalsyndromeinclude:HantaanDobrava-BelgradeSeoulPuumalaSinNombreviruscancause

hantaviruspulmonarysyndrome(America)VirologyofHantaviruseThevirusesthatcausehemorrh4Epidemiology

Sourcesoftransmission:rodentreservoirsVirusspeciesReservoirEpidemic&endemicareasHantaan

Stripedfieldmouse(Apodemus

agrarius)Korea,China,EasternRussiaSeoulNorwayrat(Rattus

norvegicus)WorldwidePuumalaBankvoles(Clethrionomys

glareolus)WesternEuropeDobrava-BelgradeYellow-neckedfieldmouse(Apodemus

flavicollis)BalkansStripedfieldmouse

Norwayrat

Bankvoles

Yellow-neckedfieldmouse

OccursmainlyinEuropeandAsiaEpidemiologySourcesoftransm5StripedfieldmouseApodemusagrarius

Stripedfieldmouse6NorwayratRattusnorvegicus,Norwayrat7BankvolesClethrionomysglareolusBankvoles8Yellow-neckedfieldmouseA.flavicollisYellow-neckedfieldmouse9Epidemiology

RouteoftransmissionExposuretoaerosolizedurine,droppings,orsalivaofinfectedrodentsDirectintroductionofinfectiousmaterialthroughbrokenskinorontomucousmembranesThroughrodentbitesfrominfectedanimalsFrommothertochildTransmissionfromhumantohumanisextremelyrare.EpidemiologyRouteoftransmis10EpizooticCycleRodentbreedingEpizooticCycleRodentbreeding11EpidemiologySusceptibilityofpopulationPeoplearegenerallysusceptibleCommonlyreportedinmaleadultSubclinicalinfectionrateis2.5~4.3%StableandpersistentimmunityEpidemiologySusceptibilityof12PathogenesisImmunemechanismsmayplayanmajorpathogenicroleViremiaisonlypresentinearlystageofinfection

NocytopathiceffectAtthetimethatseveresymptomsbegin

ViremiaisabsentSpecificantibodiesandTcellsaredetectedmarkedcytokineproduction,kallikrein-kininactivation,complementpathwayactivationPathogenesisImmunemechanisms13PathogenesisBasicpathologicalchanges

Systemicmicrovascularendothelialedema,degenerationandnecrosisThemostdramaticdamageisseeninthekidneysPathogenesisBasicpathological14Immunemediatedvascularendothelialinjury

IncreasedcapillarypermeabilityPlasmaextravasationInsufficientbloodvolumePrimaryshockoccursbeforeoliguricstageMassivehemorrhageorSecondaryinfectionorInsufficientwater-electrolytesupplyduringpolyuricstageInsufficientbloodvolumeSecondaryshock:occursafteroliguricstagePathogenesis:shockImmunemediatedMassivehemorr15Pathogenesis:hemorrhagetendencyDamageofthebloodvesselwallThrombocytopenia

UremicbleedingdefectsIncreaseofheparin–likesubstancesDICPathogenesis:hemorrhagetende16DecreasedbloodflowDirectinjurytothekidneyPathogenesis:acuterenalfailure

DecreasedbloodflowPathogene17

Histopathologicchangesinkidney(cortex)Smallarrow:interstitialedemawithmildinfiltrationofmononuclearcellsLargearrow:degenerationofrenaltubules

Arrowhead:proteinaceouscastsandexudateHistopatho18

Histopathologicchangesinkidney(medulla)

Mostprominentchangeinthemedullaiswell–definednecroticlesion(asterisk)*Histopathologicch19IntracranialhemorrhageinHFRSpatientIntracranialhemorrhageinHFR20ClinicalManifestations:overviewIncubationperiod:usually1to2weeksAtriadoffever,hemorrhage,andrenalinsufficiency5progressivestages:Febrilestage→Hypotensivestage→Oliguricstage→Polyuricstage→ConvalescentstageSkippingofphaseiscommoninatypicalandmildindividuals.Theindividualphasesmayoverlapinseverecases.ClinicalManifestations:overv21ClinicalManifestations:FebrilestageAbruptonsetoffeverlasting3-7daysGastrointestinaldiscomfort

Anorexia,nausea,vomitingandabdominalpainSystemictoxicsymptoms

Myalgia,triadofpains(Headache,lumbagoandretroorbitalpain)ClinicalManifestations:Febri22ClinicalManifestations:FebrilestageSignsofCapillaryinjury

CongestionHemorrhagictendencyExudationandedemaClinicalManifestations:Febri23ClinicalManifestations:FebrilestageCongestionDermathemia:triadofflushings

FlushingoverFace,theVareaoftheneck(drunkenface),andthebackMucosalhyperemia

Conjunctivalsuffusion,pharyngealinjectionClinicalManifestations:Febri24DrunkenfaceDrunkenface25ClinicalManifestations:FebrilestageHemorrhagictendencyDermatorrhagia①Petechiaeoftendevelopinareasofpressure,axilla②Ecchymosisinseverecase

Mucosalbleeding

Petechiaeintheconjunctivae,softpalateVisceralbleeding

Epistaxis,bloodystool,hemoptysis,cerebralbleedingClinicalManifestations:Febri26PetechiaeonaxillaPetechiaeonaxilla27EcchymosisinseverecaseEcchymosisinseverecase28SubconjunctivalhemorrhageSubconjunctivalhemorrhage29PetechiaeonthesoftpalatePetechiaeonthesoftpalate30ClinicalManifestations:FebrilestageExudationandedema→causepainPeriorbitaledema,chemosisRetroperitonealedemaAscitesAbdominalpain:Differentialdiagnosis?ClinicalManifestations:Febri31chemosischemosis32ClinicalManifestations:HypotensivestageLastsapproximatelyafewhoursto2daysExacerbationofthediseaseafterdefervescenceFallingbloodpressureandTachycardiaInseverecaseshock(primaryshock)

ClinicalManifestations:Hypot33ClinicalManifestations:OliguricstagePersistsfor2-5daysOliguria:urineoutput<400ml/dAnuria:urineoutput<50ml/dHemorrhagictendenciescontinueOnsetofrenalfailureSymptomsassociatedwithuremiaWater-sodiumretention

Hypentension;pulmonaryedema;ascitesAcidosis,electrolyteimbalance,BUN↑，Cr↑↑ClinicalManifestations:Oligu34ClinicalManifestations:DiureticstageLastforacoupleofdaysuptoweeksCharacterizedbydiuresisandhyposthenuriaMigratorystage:dailyurinevolumeincreasesfrom400mlto2000ml;exacerbationoftheazotemiaEarlypolyuricstage:Dailyurinevolume>2000ml;stabilizationoftheazotemiaLatepolyuricstage:Dailyurinevolume>3000ml;recoveroftheazotemiaFluidreplacementisinadequate→secondaryshockClinicalManifestations:Diure35ClinicalManifestations:Convalescentstagelastforaslongas1-3monthsDailyurinevolumereturnstonormalClinicalManifestations:Conva36ClinicalManifestationsWhatarefiveprogressivestagesofHFRS?Febrilestage;Hypotensivestage;Oliguricstage;Polyuricstage;ConvalescentstageClinicalManifestationsWhatar37LaboratoryfindingsBloodroutinetestLeukocytosiswithaleftshiftElevatedhematocritleverThrombocytopeniaAtypicallymphocytes

Q:ViralinfectionscausingleukocytosisHFRSInfectiousmononucleosisJapaneseencephalitisRabiesLaboratoryfindingsBloodrouti38LaboratoryfindingsUrineroutinetestHeavyproteinuriaHematuriaCastLaboratoryfindingsUrinerouti39MassiveproteinandsheddedepithelialcellsinurineformMembrane-likesubstanceMassiveproteinandsheddedep40LaboratoryfindingsBiochemicaltestsElevatedlevelsofliverenzymes,BUN,andserumcreatinineElectrolytedisturbancesAlteredcoagulationprofileLaboratoryfindingsBiochemical41LaboratoryfindingsEtiologicaldiagnosisEnzyme-linkedimmunosorbentassay(ELISA)

①Antihantaviral-specificIgM＞1:20(+)

Earlydiagnosticvalue②Antihantaviral-specificIgG＞1:40(+)

FourfoldorgreaterriseinIgGtitercanalsoconfirmsuspectedcasesIsolationofvirusRT-PCR:identifyviralRNALaboratoryfindingsEtiological42SummaryoftheclinicalfeaturesAtriadoffever,hemorrhage,andrenalinsufficiency5progressivestages:Febrilestage→Hypotensivestage→Oliguricstage→Polyuricstage→ConvalescentstageLaboratoryfinding:

LeukocytosisandthrombocytopeniaProteinuriaElevatedlevelsofBUN,andserumcreatinineSummaryoftheclinicalfeatur43ComplicationDigestivetractbleedingIntracranialhemorrhagesMyocardialdamagePulmonaryedema:ARDS,heartfailureSecondaryInfectionsSpontaneouskidneyruptureComplicationDigestivetractbl44Treatment:overviewEarlyrecognitionandhospitalization,bedrestTreatmentissupportivePreventforsecondaryinfectionPreventtheGIbleedingTreatment:overviewEarlyrecog45Treatment:FebrilestageAnti-viraltherapy:IVribavirinPreferablybegunwithinthefirst4daysofillnessReduceexudate:

RutosidsandvitaminCManagementofthefeverandtoxicsymptomsPhysicalcoolingShortcoursedexamethasone

PreventDICTreatment:FebrilestageAnti-v46Treatment:HypotensivestageSupplementofbloodvolumeModestcrystalloidinfusionHumanserumalbuminPlasmaVasoactiveagentsDopamine,norepinephrineCorrectionofacidosis5%SodiumBicarbonate

InjectionTreatment:HypotensivestageSu47Treatment:OliguricstageMaintenanceofinternalenvironmenthomeostasisRestrictthevolumeofinfusion

Dailyurinevolume+500-700mlControltheazotemiaSupplysufficientcarbohydratetoreducetheproteindegradationMaintainingelectrolytebalance

TreatmentofHyperkalemiaCorrectionofacidosis5%SodiumBicarbonate

InjectionTreatment:OliguricstageMaint48TreatmentofhyperkalemiaStopfurtherpotassiumaccumulation?Protectthecardiacmembrane

Calciumgluconate10%ShiftthepotassiumfromthebloodintothecellInsulinRemovalofpotassiumfromthebodyHaemodialysis,FurosemideTreatmentofhyperkalemiaStop49Treatment:OliguricstageDiuretics:furosemideCatharsis:rheumofficinaleConsiderDialysisinfollowingconditionsSevereazotemiaFluidoverloadthatcannotbemanagedwithdiureticsHyperkalemiarefractorytomedicaltherapySevereacid-basedisturbancesTreatment:OliguricstageDiure50TreatmentPolyuricstageMaintainfluidandelectrolytebalancePreventsecondaryinfection

AntibioticswithnephrotoxicpotentialshouldbeavoidedConvalescentstageMonitoredinresthomeTreatmentPolyuricstage51PrognosisFatalityraterangesfrom5to15%withHantaanvirustolessthan1%forPuumalavirusinfectionForsurvivors,convalescencecantakeseveralmonthsbutrecoveryisoftencompletePrognosisFatalityrateranges52PreventionRodentcontrolAvoidcontactwithrodenturine,droppings,saliva,andnestingmaterialsVaccinationPreventionRodentcontrol53Homework1.HantaanvirusismainlytransmittedbyPatientsCarriersSwineMosquitoesRodents（E）Homework1.Hantaanvirusism54Homework2.ThemostcardinalreasonofbleedinginfebrileperiodofEHFisA.DICB.Heparin-likesubstanceincreasingC.ThrombocytopeniaandvascularinjuryD.AzotemiaE.Coagulationfactordecreasing（C）Homework2.Themostcardinal55Homework3.ThemainreasonforearlyshockinEHFisInfection.Bloodplasma-losingHypervolemiaHemorrhageVomiting.(B)Homework3.Themainreasonfor56Homework4.Thepatienthadfever,lumbago,headacheforthreedays.Physicalexamination:drunkenface,petechiaeinaxillaryfolds,chemosis.Bloodroutinetest:WBC19×109，N83%,PLT20×109.Urineprotein(+++),RBC3-5/HP.ThediagnosismaybeTyphoidfeverTyphusAcuteglumerulonephritisEpidemichemorrhagicfeverLeptospirosis(D)Homework4.Thepatienthadfev57Homework5.WhichisnotproperinmanagementofhemorrhagicfeverwithrenalsyndromewhenhyperkalemiaoccursA.InsulinanddextrosesolutionsB.10%calciumgluconateC.5%sodiumbicarbonateD.HemodialysisE.Wholebloodtransfusion(E)Homework5.Whichisnotprope58Homework6.CanonicalhemorrhagicfeverwithrenalsyndromecausedbyHantaanvirusevolveinfiveidentifiablestages:______,______,______,______and______.7.GiveaintroductionaboutthemanagementprincipleoftheoliguricphaseofthehemorrhagicfeverwithrenalsyndromeHomework6.Canonicalhemorrhag59THEENDTHANKYOU!THEEND60HemorrhagicFeverwithRenalSyndromeZhangDazhi,M.DDepartmentofInfectiousDiseaseThesecondhospitalofCMUHemorrhagicFeverwithRenalS61OverviewPathogen:HantavirusesClinicalfeatures:fever；renalfailure；shock;hemorrhagicmanifestationsHemorrhagicfeverwithrenalsyndrome(HFRS)includesagroupofclinicallysimilarillnessesEpidemichemorrhagicfever(China)Koreanhemorrhagicfever(Korean)Nephropathisepidemica(PuumalaOverviewPathogen:Hantaviruses62VirologyofHantaviruseBelongtothefamilyBun-yaviridaeSphericalenvelopedvirusesabout80-120nmindiameterGenomeconsistsofthreesingle-stranded,negativesenseRNAsegments---S,M,LS(small):encodesneucleocapsidproteinM(medium):

encodesenvelopeglycoprotein

L(large):encodespolymeraseVirologyofHantaviruseBelong63Thevirusesthatcausehemorrhagicfeverwithrenalsyndromeinclude:HantaanDobrava-BelgradeSeoulPuumalaSinNombreviruscancause

hantaviruspulmonarysyndrome(America)VirologyofHantaviruseThevirusesthatcausehemorrh64Epidemiology

Sourcesoftransmission:rodentreservoirsVirusspeciesReservoirEpidemic&endemicareasHantaan

Stripedfieldmouse(Apodemus

agrarius)Korea,China,EasternRussiaSeoulNorwayrat(Rattus

norvegicus)WorldwidePuumalaBankvoles(Clethrionomys

glareolus)WesternEuropeDobrava-BelgradeYellow-neckedfieldmouse(Apodemus

flavicollis)BalkansStripedfieldmouse

Norwayrat

Bankvoles

Yellow-neckedfieldmouse

OccursmainlyinEuropeandAsiaEpidemiologySourcesoftransm65StripedfieldmouseApodemusagrarius

Stripedfieldmouse66NorwayratRattusnorvegicus,Norwayrat67BankvolesClethrionomysglareolusBankvoles68Yellow-neckedfieldmouseA.flavicollisYellow-neckedfieldmouse69Epidemiology

RouteoftransmissionExposuretoaerosolizedurine,droppings,orsalivaofinfectedrodentsDirectintroductionofinfectiousmaterialthroughbrokenskinorontomucousmembranesThroughrodentbitesfrominfectedanimalsFrommothertochildTransmissionfromhumantohumanisextremelyrare.EpidemiologyRouteoftransmis70EpizooticCycleRodentbreedingEpizooticCycleRodentbreeding71EpidemiologySusceptibilityofpopulationPeoplearegenerallysusceptibleCommonlyreportedinmaleadultSubclinicalinfectionrateis2.5~4.3%StableandpersistentimmunityEpidemiologySusceptibilityof72PathogenesisImmunemechanismsmayplayanmajorpathogenicroleViremiaisonlypresentinearlystageofinfection

NocytopathiceffectAtthetimethatseveresymptomsbegin

ViremiaisabsentSpecificantibodiesandTcellsaredetectedmarkedcytokineproduction,kallikrein-kininactivation,complementpathwayactivationPathogenesisImmunemechanisms73PathogenesisBasicpathologicalchanges

Systemicmicrovascularendothelialedema,degenerationandnecrosisThemostdramaticdamageisseeninthekidneysPathogenesisBasicpathological74Immunemediatedvascularendothelialinjury

IncreasedcapillarypermeabilityPlasmaextravasationInsufficientbloodvolumePrimaryshockoccursbeforeoliguricstageMassivehemorrhageorSecondaryinfectionorInsufficientwater-electrolytesupplyduringpolyuricstageInsufficientbloodvolumeSecondaryshock:occursafteroliguricstagePathogenesis:shockImmunemediatedMassivehemorr75Pathogenesis:hemorrhagetendencyDamageofthebloodvesselwallThrombocytopenia

UremicbleedingdefectsIncreaseofheparin–likesubstancesDICPathogenesis:hemorrhagetende76DecreasedbloodflowDirectinjurytothekidneyPathogenesis:acuterenalfailure

DecreasedbloodflowPathogene77

Histopathologicchangesinkidney(cortex)Smallarrow:interstitialedemawithmildinfiltrationofmononuclearcellsLargearrow:degenerationofrenaltubules

Arrowhead:proteinaceouscastsandexudateHistopatho78

Histopathologicchangesinkidney(medulla)

Mostprominentchangeinthemedullaiswell–definednecroticlesion(asterisk)*Histopathologicch79IntracranialhemorrhageinHFRSpatientIntracranialhemorrhageinHFR80ClinicalManifestations:overviewIncubationperiod:usually1to2weeksAtriadoffever,hemorrhage,andrenalinsufficiency5progressivestages:Febrilestage→Hypotensivestage→Oliguricstage→Polyuricstage→ConvalescentstageSkippingofphaseiscommoninatypicalandmildindividuals.Theindividualphasesmayoverlapinseverecases.ClinicalManifestations:overv81ClinicalManifestations:FebrilestageAbruptonsetoffeverlasting3-7daysGastrointestinaldiscomfort

Anorexia,nausea,vomitingandabdominalpainSystemictoxicsymptoms

Myalgia,triadofpains(Headache,lumbagoandretroorbitalpain)ClinicalManifestations:Febri82ClinicalManifestations:FebrilestageSignsofCapillaryinjury

CongestionHemorrhagictendencyExudationandedemaClinicalManifestations:Febri83ClinicalManifestations:FebrilestageCongestionDermathemia:triadofflushings

FlushingoverFace,theVareaoftheneck(drunkenface),andthebackMucosalhyperemia

Conjunctivalsuffusion,pharyngealinjectionClinicalManifestations:Febri84DrunkenfaceDrunkenface85ClinicalManifestations:FebrilestageHemorrhagictendencyDermatorrhagia①Petechiaeoftendevelopinareasofpressure,axilla②Ecchymosisinseverecase

Mucosalbleeding

Petechiaeintheconjunctivae,softpalateVisceralbleeding

Epistaxis,bloodystool,hemoptysis,cerebralbleedingClinicalManifestations:Febri86PetechiaeonaxillaPetechiaeonaxilla87EcchymosisinseverecaseEcchymosisinseverecase88SubconjunctivalhemorrhageSubconjunctivalhemorrhage89PetechiaeonthesoftpalatePetechiaeonthesoftpalate90ClinicalManifestations:FebrilestageExudationandedema→causepainPeriorbitaledema,chemosisRetroperitonealedemaAscitesAbdominalpain:Differentialdiagnosis?ClinicalManifestations:Febri91chemosischemosis92ClinicalManifestations:HypotensivestageLastsapproximatelyafewhoursto2daysExacerbationofthediseaseafterdefervescenceFallingbloodpressureandTachycardiaInseverecaseshock(primaryshock)

ClinicalManifestations:Hypot93ClinicalManifestations:OliguricstagePersistsfor2-5daysOliguria:urineoutput<400ml/dAnuria:urineoutput<50ml/dHemorrhagictendenciescontinueOnsetofrenalfailureSymptomsassociatedwithuremiaWater-sodiumretention

Hypentension;pulmonaryedema;ascitesAcidosis,electrolyteimbalance,BUN↑，Cr↑↑ClinicalManifestations:Oligu94ClinicalManifestations:DiureticstageLastforacoupleofdaysuptoweeksCharacterizedbydiuresisandhyposthenuriaMigratorystage:dailyurinevolumeincreasesfrom400mlto2000ml;exacerbationoftheazotemiaEarlypolyuricstage:Dailyurinevolume>2000ml;stabilizationoftheazotemiaLatepolyuricstage:Dailyurinevolume>3000ml;recoveroftheazotemiaFluidreplacementisinadequate→secondaryshockClinicalManifestations:Diure95ClinicalManifestations:Convalescentstagelastforaslongas1-3monthsDailyurinevolumereturnstonormalClinicalManifestations:Conva96ClinicalManifestationsWhatarefiveprogressivestagesofHFRS?Febrilestage;Hypotensivestage;Oliguricstage;Polyuricstage;ConvalescentstageClinicalManifestationsWhatar97LaboratoryfindingsBloodroutinetestLeukocytosiswithaleftshiftElevatedhematocritleverThrombocytopeniaAtypicallymphocytes

Q:ViralinfectionscausingleukocytosisHFRSInfectiousmononucleosisJapaneseencephalitisRabiesLaboratoryfindingsBloodrouti98LaboratoryfindingsUrineroutinetestHeavyproteinuriaHematuriaCastLaboratoryfindingsUrinerouti99MassiveproteinandsheddedepithelialcellsinurineformMembrane-likesubstanceMassiveproteinandsheddedep100LaboratoryfindingsBiochemicaltestsElevatedlevelsofliverenzymes,BUN,andserumcreatinineElectrolytedisturbancesAlteredcoagulationprofileLaboratoryfindingsBiochemical101LaboratoryfindingsEtiologicaldiagnosisEnzyme-linkedimmunosorbentassay(ELISA)

①Antihantaviral-specificIgM＞1:20(+)

Earlydiagnosticvalue②Antihantaviral-specificIgG＞1:40(+)

FourfoldorgreaterriseinIgGtitercanalsoconfirmsuspectedcasesIsolationofvirusRT-PCR:identifyviralRNALaboratoryfindingsEtiological102SummaryoftheclinicalfeaturesAtriadoffever,hemorrhage,andrenalinsufficiency5progressivestages:Febrilestage→Hypotensivestage→Oliguricstage→Polyuricstage→ConvalescentstageLaboratoryfinding:

LeukocytosisandthrombocytopeniaProteinuriaElevatedlevelsofBUN,andserumcreatinineSummaryoftheclinicalfeatur103ComplicationDigestivetractbleedingIntracranialhemorrhagesMyocardialdamagePulmonaryedema:ARDS,heartfailureSecondaryInfectionsSpontaneouskidneyruptureComplicationDigestivetractbl104Treatment:overviewEarlyrecognitionandhospitalization,bedrestTreatmentissupportivePreventforsecondaryinfectionPreventtheGIbleedingTreatment:overviewEarlyrecog105Treatment:FebrilestageAnti-viraltherapy:IVribavirinPreferablybegunwithinthefirst4daysofillnessReduceexudate:

RutosidsandvitaminCManagementofthefeverandtoxicsymptomsPhysicalcoolingShortcoursedexamethasone

PreventDICTreatment:FebrilestageAnti-v106Treatment:HypotensivestageSupplementofbloodvolumeModestcrystalloidinfusionHumanserumalbuminPlasmaVasoactiveagentsDopamine,norepinephrineCorrectionofacidosis5%SodiumBicarbonate

InjectionTreatment:HypotensivestageSu107Treatment:OliguricstageMaintenanceofinternalenvironmenthomeostasisRestrictthevolumeofinfusion

Dailyurinevolume+500-700mlControltheazotemiaSupplysufficientcarbohydratetoreducetheproteindegradationMaintainingelectrolytebalance

TreatmentofHyperkalemiaCorrectionofacidosis5%SodiumBicarbonate

InjectionTreatment:OliguricstageMaint108TreatmentofhyperkalemiaStopfurtherpotassiumaccumulation?Protectthecardiacmembrane

Calciumgluconate10%ShiftthepotassiumfromthebloodintothecellIn