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文檔簡介
ElectrolyteandMetabolic
DisturbancesMET1
?ObjectivesReviewcausesandclinicalmanifestationsofsevereelectrolytedisturbancesOutlineemergentmanagementofelectrolytedisturbancesRecognizeacuteadrenalinsufficiencyandappropriatetreatmentDescribemanagementofseverehyperglycemicsyndromesPrinciplesofElectrolyteDisturbancesImpliesanunderlyingdiseaseprocessTreattheelectrolytechange,butseekthecauseClinicalmanifestationsusuallynotspecifictoaparticularelectrolytechange,e.g.,seizures,arrhythmiasPrinciplesofElectrolyteDisturbancesClinicalmanifestationsdetermineurgencyoftreatment,notlaboratoryvaluesSpeedandmagnitudeofcorrectiondependent
onclinicalcircumstancesFrequentreassessmentofelectrolytesrequiredHypokalemiaEtiology–renalloss,extrarenalloss,transcellularshift,decreasedintakeManifestations–cardiac,neuromuscular,gastrointestinalDeficitpoorlyestimatedbyserumlevelsHypokalemiaTitrateadministrationofK+againstserumlevelandmanifestationsCorrecthypomagnesemiaECGmonitoringwithemergentadministrationAllowablemaximumivdoseperhourcontroversialTreathypokalemiaurgentlyinacidosisHyperkalemiaEtiology–renalfailure,transcellularshifts,celldeath,drugs,pseudohyperkalemiaManifestations–
cardiac,neuromuscularHyperkalemia–TreatmentStopintakeGivecalciumforcardiactoxicityShiftK+intocell–glucose+insulin,NaHCO3,inhaled-agonistRemovefrombody–diuretics,sodiumpolystyrenesulfonate,
dialysisPediatricConsiderations–
PotassiumReplaceatmaximumivrate<1.0mmol/kg/hr;monitorECGHyperkalemiaECGabnormality:calciumgluconateorchlorideShift:NaHCO3,glucose+insulin,inhaled-agonistsRemoval:diuretic,sodiumpolystyrenesulfonate,dialysisMET9
–?HyponatremiaHypo-osmolarhyponatremiaEuvolemicHypovolemicHypervolemicNormo-orhyperosmolarhyponatremiaPseudohyponatremiaManifestations–neurologic,muscular,gastrointestinalHyponatremia–TreatmentHypovolemicNa–givenormalsaline,ruleoutadrenalinsufficiencyHypervolemicNa–increasefreeH2OlossEuvolemichyponatremiaRestrictfreewaterintakeIncreasefreewaterlossNormalorhypertonicsalineCorrectslowlyduetopossibilityofdemyelinatingsyndromesHypernatremiaEtiology–H2Oloss,H2Ointake,NaintakeManifestations–neurologic,muscularH2Odeficit(L)=[0.6wt(kg)][obsNa-1]
140
Hypernatremia–TreatmentProvideintravascularvolumereplacementConsidergivingone-halfoffreeH2OdeficitinitiallyReduceNacautiously:0.5-1.0mmol/L/hrSecondaryneurologicsyndromeswithrapidcorrection
PediatricConsiderations–SodiumHyponatremia–seizures:titrate3%NaCl;usualdose1.5-2.5mmol/kgHypernatremia–calculateH2Odeficitas4mL/kgforeach1mmol/LserumNa>145mmol/LDecreaseserumNanofasterthan0.5mmol/L/hrMET14
?OtherElectrolyteDeficits
Ca,PO4,MgMayproduceseriousbutnonspecificcardiac,neuromuscular,respiratory,andothereffectsAllareprimarilyintracellularions,sodeficitsdifficulttoestimateTitratereplacementagainstclinicalfindings
OtherElectrolyteDisorders
HypocalcemiaCalciumchlorideorgluconateBolus+continuousinfusionHypercalcemiaRehydrationwithnormalsalineLoopdiureticsOtherElectrolyteDisordersHypophosphatemiaReplacementivforlevel<1mg/dL(0.32mmol/L)HypomagnesemiaEmergentadministrationover5–10minsLessurgentadministrationover
10–60minsAcuteAdrenalInsufficiencyNonspecificmanifestationsAbdominalpain,nausea,emesisOrthostatic/refractoryhypotensionLaboratoryfindingsHyponatremia,hyperkalemiaHypoglycemiaAcuteAdrenalInsufficiencyBaselinebloodsamplesVolumeandglucoseinfusionDexamethasoneorhydrocortisoneACTHstimulationtestifneededTreatprecipitatingconditionsHyperglycemicSyndromesDiabeticketoacidosis(DKA)Hyperglycemichyperosmolarstate(HHS)Manifestations–dehydration,polyuria/
polydipsia,alteredmentalstatus,BP,nausea,emesis,abdominalpainHyperglycemicSyndromes–LaboratoryHyperglycemia/hyperosmolalityKetonemia/ketonuria(DKA)Increasedaniongapmetabolicacidosis(DKA)Electrolytechanges(K,PO4,Na)HyperglycemicSyndromes–TreatmentIdentifyandtreatprecipitatingfactorsRestorefluid/electrolytebalanceInsulin–ivbolusandinfusionAddglucosetoinfusionwhenglucose<250-300mg/dL(13.9-16.7mmol/L)Treatelectrolytechanges(K,PO4)NaHCO3rarelyneededPediatricConsiderations–DKAInsulin–bolusnotused,titrateivinfusionTitratefluidasserumNaincreases;excessivehypotonicfluidmaycausecerebraledemaMET23
?ThyroidStormExaggeratedmanifestationsof
hyperthyroidismSupportivemeasuresSpecificmeasuresPropylthiouracilormethimazolePropranololPotassiumorsodiumiodideDexamethasone,sodiumipodateMyxedemaComaManifes
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