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ALL YOU NEED TO KNOW ABOUT MET ABOLIC CONDITIONS (Na+, K+, Ca2+) Anirudh Manivannan & Sumayyah Imran Kindly reviewed by Dr Rajiv Ark Here’s what we do: ■ Weekly tutorials open to all! 18:00 every Thursday ■ Fteaching diagnostic technique from a If you’re new here… clinical perspective Welcome to ■ Reviewed by doctors to ensure accuracy T eaching ■ We’ll keep you updated about our Things! upcoming events via email and groupchats!Sodium balance Sumayyah ImranHyponatraemiaAn 88-year-old woman presents to A and E with a 6-hour history of vomiting, muscle cramps, lethargy, and confusion. She has a past medical history of heart failure, and is on ramipril, bisoprolol, spironolactone, and furosemide. She lives in a care home.1) A to E assessmentOn examination, the patient has dry mucous membranes and cold peripheries, and her CRT is 3s. The patient’s BP is 98/60 mmHg and her HR is 120 bpm. Her U&E results are shown on the next slide.Sodium = 110 mmol/L Potassium = 4 mmol/L Chloride = 100 mmol/L Bicarbonate = 25 mmol/L Urea = 3.4 mmol/L Creatinine = 90 mmol/LSodium = 110 mmol/L Potassium = 4 mmol/L Chloride = 100 mmol/L Bicarbonate = 25 mmol/L Urea = 3.4 mmol/L Creatinine = 90 mmol/LHyponatraemia ■ Normal serum sodium: 135-145 mmol/L ■ Hyponatraemia = Serum sodium < 135 mmol/L ❖ Mild hyponatraemia: 130-134 mmol/L ❖ Moderate hyponatraemia: 120-129 mmol/L ❖ Profound hyponatraemia: <120 mmol/LSigns and symptoms ■ Often asymptomatic Early ■ Headache ■ Nausea ■ Lethargy ■ Dizziness ■ Confusion ■ Muscle cramps ■ Vomiting Late ■ Seizures ■ Coma ■ Respiratory arrest (cerebral oedema and raised ICP)Assessing and managing hyponatraemia Hypertonic saline used if SEVERE hyponatraemia - symptomsed byAssessing chronic mild/moderate hyponatraemia 1) Plasma osmolarity 2) Fluid balance 3) Urine sodium PsychDBAssessing chronic mild/moderate hyponatraemia 1) Plasma osmolarity ■ Osmolarity = number of solute molecules per litre of solvent ■ Osmolality = number of solute molecules per kg of solvent ■ Osmolarity = 2Na + glucose + urea ❖ Isotonic hyponatraemia (normal osmolarity): 275-295 mOsm/kg ❖ Hypotonic hyponatraemia (low osmolarity): <275 mOsm/kg ❖ Hypertonic hyponatraemia (high osmolarity): >295 mOsm/kg 2) Fluid balance 3) Urine sodium Glucose Sodium Water Lipid/protein Hypotonic hyponatraemia Isotonic hyponatraemia Hypertonic hyponatraemia ● True hyponatraemia ● Pseudohyponatraemia ● Translocational ● Reduced serum 1) Hyperlipidaemia/ hyponatraemia sodium/increased total hyperproteinaemia 1) Hyperglycaemia body water (TBW) 2) Apparent plasma volume 2) Increase in plasma increase osmolarity (2Na + 3) Apparent TBW increase ↑glucose + urea) with no change in sodium 3) Water moves out of ICF 4) Apparent dilution of into ECF sodium 4) Dilution of sodiumAssessing chronic mild/moderate hyponatraemia 1) Plasma osmolarity Hypotonic hyponatraemia 2) Fluid balance ■ Hypovolaemic ■ Euvolaemic ■ Hypervolaemic 3) Urine sodiumHow do we assess a patient’s fluid balance?Fluid balance assessmentAssessing chronic mild/moderate hyponatraemia 1) Plasma osmolarity 2) Fluid balance 3) Urine sodium ■ High (>20 mmol/L) = Renal issue ❖ When sodium should be reabsorbed, it is being excreted renally (salt-wasting) ● Low (<10 mmol/L)= Non-renal issue ❖ Sodium is being reabsorbed to compensate for losses elsewhere (non-salt wasting)Hypotonic hypovolaemic hyponatraemia High urine sodium Low urine sodium Renal sodium loss, e.g. due to: Non-renal water and sodium loss, e.g. due to: ■ Diuretics (loop, thiazide, and ■ Vomiting potassium-sparing) ■ Diarrhoea Failure of renal sodium reabsorption, e.g. due ■ Burns to: ■ Adrenal insufficiency ■ Dehydration ■ Salt-wasting nephropathiesDiuretics and hyponatraemia 1) Inhibition of sodium and water reabsorption 2) Increased urinary and reduced serum sodium 3) Hypovolaemic hyponatraemiaAdrenal insufficiency and hyponatraemia 1) Reduced mineralocorticoid (aldosterone) 2) Reduced sodium reabsorption and potassium secretion by collecting duct cells 3) Reduced water reabsorption in tubule 4) Increased urinary and reduced serum sodium (and increased serum potassium) 5) Hypovolaemic hyponatraemiaHypotonic euvolaemic hyponatraemia High urine sodium Low urine sodium Water but not sodium reabsorbed by kidney, ■ Water intoxication (primary polydipsia) e.g. due to: ■ SIADH ■ Hypothyroidism Causes of SIADH: Major operations ADH secretion from ectopic sites Drugs CNS disorders Hormone insufficiency Other Pulmonary disease A 45-year-old woman on the surgical ward develops thirst, exhaustion, and lethargy 12 hours post-colectomy. On examination, she has no peripheral oedema, normal skin turgor, and clear lung bases. Her U&E results are shown below: Sodium = 120 mmol/L Potassium = 4.9 mmol/L Chloride = 98 mmol/L Bicarbonate = 23 mmol/L Urea = 2.5 mmol/L Creatinine = 80 mmol/L What is the single most likely cause of her presentation? A. Malabsorption B. SIADH C. Adrenal insufficiency D. Dehydration E. Diarrhoea A 45-year-old woman on the surgical ward develops thirst, exhaustion, and lethargy 12 hours post-colectomy. On examination, she has no peripheral oedema, normal skin turgor, and clear lung bases. Her U&E results are shown below: Sodium = 120 mmol/L Potassium = 4.9 mmol/L Chloride = 98 mmol/L Bicarbonate = 23 mmol/L Urea = 2.5 mmol/L Creatinine = 80 mmol/L What is the single most likely cause of her presentation? A. Malabsorption B. SIADH C. Adrenal insufficiency D. Dehydration E. Diarrhoea SIADH 1) Inappropriate/continuous ADH secretion (MADCHOP) 2) Increased water reabsorption by collecting duct cells without sodium reabsorption 3) Water redistributed equally into all fluid compartments, diluting sodium 4) Euvolaemic hyponatraemia Causes of SIADH: SIADH Major operations ADH secretion from ectopic sites ● Small cell lung cancer Features ● Pancreatic cancer ● Hypotonic euvolaemic ● Prostate cancer hyponatraemia Drugs ● Urine sodium > 20 ● See right → mmol/L CNS disorders ● Urine osmolality > ● Stroke plasma osmolality ● Trauma ● Tumour ● Subarachnoid/subdural Treatment ● Fluid restriction haemorrhage MyEndoConsult (500-1000ml/day) Hormone insufficiency ● ADH receptor ● Hypothyroidism antagonists (-vaptans), ● Adrenal insufficiency demeclocycline Other Pulmonary disease ● TB ● Pneumonia A 58-year-old man presents to A&E with lethargy and nausea. He has a past medical history of hypertension, trigeminal neuralgia, and GORD. He has a serum sodium of 119 mmol/L. On examination, he has normal skin turgor, no evidence of mucosal dryness, and no peripheral oedema or ascites. His BP is 130/80 mmHg and his HR is 90 bpm. Which of the following medications is most likely to have caused his presentation? A. Ramipril B. Spironolactone C. Amlodipine D. Omeprazole E. Carbamazepine A 58-year-old man presents to A&E with lethargy and nausea. He has a past medical history of hypertension, trigeminal neuralgia, and GORD. He has a serum sodium of 119 mmol/L. On examination, he has normal skin turgor, no evidence of mucosal dryness, and no peripheral oedema or ascites. His BP is 130/80 mmHg and his HR is 90 bpm. Which of the following medications is most likely to have caused his presentation? A. Ramipril B. Spironolactone C. Amlodipine D. Omeprazole E. CarbamazepineHypotonic hypervolaemic hyponatraemia Low urine sodium “Failures”, resulting in reduced cardiac output, increased ADH secretion, and water retention in the kidneys out of proportion with sodium retention, e.g: ■ Congestive cardiac failure (CCF) ■ Liver failure ■ Kidney failure ■ Nephrotic syndromeHypotonic hypervolaemic hyponatraemiaTreating chronic mild/moderate true hyponatraemia An 85-year-old woman presents to A&E following a seizure. On examination, she has dry mucous membranes, her JVP is not visible, and she has a BP of 80/60mmHg. Her U&E results are shown below: Sodium = 121 mmol/L Potassium = 4.5 mmol/L Chloride = 109 mmol/L Bicarbonate = 27 mmol/L Urea = 3.6 mmol/L Creatinine = 100 mmol/L What is the single most appropriate management option for this patient? A. Fluid restriction to 500ml/day B. 3% saline C. 0.9% saline D. Tolvaptan E. Furosemide An 85-year-old woman presents to A&E following a seizure. On examination, she has dry mucous membranes, her JVP is not visible, and she has a BP of 80/60mmHg. Her U&E results are shown below: Sodium = 121 mmol/L Potassium = 4.5 mmol/L Chloride = 109 mmol/L Bicarbonate = 27 mmol/L Urea = 3.6 mmol/L Creatinine = 100 mmol/L What is the single most appropriate management option for this patient? A. Fluid restriction to 500ml/day B. 3% saline C. 0.9% saline D. Tolvaptan E. FurosemideTreating severe/acute hyponatraemia ■ Acute/severe hyponatraemia is treated using hypertonic (3% NaCl) saline ■ Patient should be monitored on ICU/HDUCorrecting hyponatraemia ■ Severe/acute hyponatraemia should be corrected at <10 mmol/L/day (usually 4-6 mmol/L) ■ If hyponatraemia is corrected too fast, there is a risk of central pontine myelinolysis:SummaryHypernatremiaDefinition, signs, and symptoms ● Hypernatremia = Serum sodium >145 mmol/L ❏ Lethargy ❏ Weakness ❏ Confusion ❏ Agitation ❏ Seizures ❏ ComaCauses Loss of pure water Excessive sodium intake ■ Osmotic diuresis in DKA/HHS ■ IV saline ■ Diarrhoea ■ Parenteral nutrition ■ Vomiting ■ Enteral feeding ■ Burns ■ Diuretics ■ Diabetes insipidus Insufficient pure water intake ■ Old age ■ Acute illnessTreatment ■ Treat underlying cause ■ Dehydration/pure water loss: Encourage oral rehydration + Normal saline (issue is not sodium but lack of pure water) ■ Excess sodium intake: Hypotonic fluids, e.g. dextrose ■ Sodium should not be corrected at a rate greater than 0.5 mmol/hour due to risk of cerebral oedemaTOPIC TWO Anirudh ManivannanSBA A 67 year old woman is started on a new medication. She develops nausea, muscle weakness and palpitations. Her ECG is below: What single medication could have caused it? A. Furosemide B. Alendronic Acid C. Spironolactone D. Salbutamol E. BendroflumethiazideSBA A 6palpitations. Her ECG is below:a new medication. She develops nausea, muscle weakness and What single medication could have caused it? A. Furosemide B. Alendronic Acid C. Spironolactone D. Salbutamol E. BendroflumethiazideHyperkalaemia - Causes Hyperkalemia MACHINE! Medications - ACEi, NSAIDs Acidosis - metabolic and respiratory Cellular Destruction- burns, traumatic injury Hypoaldosteronism/Haemolysis Intake - excessive Nephrons - renal failure Excretion - impaired Drugs causing hyperkalemia - K+ BANK! K+ supplements Beta blockers ACEi and ARBs NSAIDs K+ sparing diuretics - spironolactone!PA TIENT CASE! A 47-year-old female presents to the accident and emergency department with persistent nausea and vomiting. She reports feeling very tired and has noticed some recent unintentional weight loss. On examination, she appears drowsy. Hyperpigmentation is noted in the palms of both hands. Her observations are as follows: temperature 37.3 rate 18. oxygen saturations 96% on air, blood pressure 90/54, heart rate 95, respiratory What is the very thing you should do? What electrolyte disturbance(s) do you expect to find? What other clinical features could you expect?PA TIENT CASE! A 47-year-old female presents to the accident and emergency department with persistent nausea and vomiting. She reports feeling very tired and has noticed some recent unintentional weight loss. On examination, she appears drowsy. Hyperpigmentation is noted in the palms of both hands. Her observations are as follows: temperature 37.3 rate 18. oxygen saturations 96% on air, blood pressure 90/54, heart rate 95, respiratory What is the very thing you should do? A-E assessment What electrolyte disturbance(s) do you expect to find? What other clinical features could you expect?PA TIENT CASE! A nausea and vomiting. She reports feeling very tired and has noticed some recentstent unintentional weight loss. On examination, she appears drowsy. Hyperpigmentation is noted in the palms of both hands. Her observations are as follows: temperature 37.3 degrees, oxygen saturations 96% on air, blood pressure 90/54, heart rate 95, respiratory rate 18. A-E assessmentry thing you should do? What electrolyte disturbance(s) do you expect to find? Hyperkalaemia, Hyponatraemia, Metabolic Acidosis - Addison’s disease What other clinical features could you expect?Hyperkalemia - Clinical Features - Can be life threatening! MURDER! - Muscle weakness - Urine Output Low/None - Respiratory Failure (due to muscle weakness) - Decreased cardiac contractility - Early - muscle twitches and cramps - Reflexes ECG Changes! (order of severity) 1. Tall tented T waves 2. Flattened P waves 3. Prolonged PR interval 4. Widened QRS complexesHyperkalemia - Investigations 1. U&Es 2. 12-lead ECG + Blood Gases (Arterial or Venous) Classification of Hyperkalemia Hyperkalemia Management - All patients with severe hyperkalemia AND/OR ECG changes must be treated urgently! Principles of Treatment Modalities 1. Stabilisation of the cardiac membrane - 10ml of 10% IV calcium gluconate over 10 mins 2. Short term shift of K+ from ECF to ICF - IV insulin (10U soluble insulin) in 50ml of 50% dextrose (prepared bags),nebulised salbutamol 3. Removal of potassium from body: - Calcium resonium PO/PR - Lokelma (Sodium zirconium cyclosilicate) - Loop diuretics - Dialysis SBA A 48 year old man with a background of severe Crohn's disease is admitted with a flare of his condition. He is currently unable to tolerate oral intake. He is otherwise fit and well. Examination is unremarkable but bloods show: Sodium 144 mmol/L 135 - 145 Potassium 2.7 mmol/L 3.5 - 5.3 Urea 3.2 mmol/L 2.5 - 7.8 Creatinine 94 µmol/L 60 - 120 An ECG is unremarkable. What is the most appropriate management of this patient? A. 1L IV normal saline with 40mmol potassium over 6 hours B. 40mmol potassium chloride bolus C. 1L IV Hartmann's solution over 6 hours D. 1L IV normal saline with 40mmol potassium over 1 hours E. 1L IV Hartmann's solution over 1 hours SBA A 48 year old man with a background of severe Crohn's disease is admitted with a flare of his condition. He is currently unable to tolerate oral intake. He is otherwise fit and well. Examination is unremarkable but bloods show: Sodium 144 mmol/L 135 - 145 Potassium 2.7 mmol/L 3.5 - 5.3 Urea 3.2 mmol/L 2.5 - 7.8 Creatinine 94 µmol/L 60 - 120 An ECG is unremarkable. What is the most appropriate management of this patient? A. 1L IV normal saline with 40mmol potassium over 6 hours B. 40mmol potassium chloride bolus C. 1L IV Hartmann's solution over 6 hours D. 1L IV normal saline with 40mmol potassium over 1 hours E. 1L IV Hartmann's solution over 1 hoursHypokalemia HIGH YIELD Summary K+ less than 3.5 mmol/L Clinical Features: Muscle weakness, palpitations - Causes: RENAL (diuretics, RTA) and EXTRA-RENAL (reduced oral intake, gut losses, shift into ICF) - Ix: U&Es, ECG, Blood Gases ECG Changes: - U waves, small/absent T waves, prolonged PR, ST depression, long QT - Magnesium - for concurrent hypomagnesemia Management: In severe hypokalemia (K+ < 3.0): 1. Cardiac monitoring 2. Correct magnesium levels 3. IV replacement of potassium (remember max rate is 10mmol/hour!) - Potassium can be given quicker via central line in ITU with cardiac monitoringSBA A 65-year-old male presents with altered mental status, constipation, and abdominal pain. What is the most likely cause of these findings? A. Osteomalacia B. Primary hyperparathyroidism C. Hypoparathyroidism D. Renal failure E. Addison's diseaseSBA A 65-year-old male presents with altered mental status, constipation, and abdominal pain. What is the most likely cause of these findings? A. Osteomalacia B. Primary hyperparathyroidism C. Hypoparathyroidism D. Renal failure E. Addison's diseaseHypercalcemia Causes MOST IMPORTANT CAUSES: 1. Excess PTH release (Primary Hyperparathyroidism) 2. Malignancy - Multiple Myeloma, Bone Metastases, Paraneoplastic Syndromes 3. Vitamin D toxicity Hypercalcemia Features, Investigations and Management Symptoms: Ix: Bone profile (inc. PTH levels, Vitamin D levels) ECG (shortened QT), Malignancy screen (serum protein electrophoresis - MM), Sarcoidosis screen, 24h urinary calcium, bone scan, TFTs, general imaging, parathyroid imaging Management: 1. Rehydration with IV crystalloid fluid 2. Treatment of underlying cause Additional considerations: Bisphosphonates Surgery, Cinacalcet, DialysisSBA A 60 year old strict vegan visits his GP with tingling in his fingers and painful spasms of the hands and feet. A bloods test is sent of which shows a correct calcium 1.34 mmol/L (2.2-2.6). He is referred directly to hospital. Which of the following is the most important test to perform urgently? A. Nerve conduction studies B. Arterial blood gas C. Tissue transglutaminase antibody D. ECG E. PTH LevelSBA A 60 year old strict vegan visits his GP with tingling in his fingers and painful spasms of the hands and feet. A bloods test is sent of which shows a correct calcium 1.34 mmol/L (2.2-2.6). He is referred directly to hospital. Which of the following is the most important test to perform urgently? A. Nerve conduction studies B. Arterial blood gas C. Tissue transglutaminase antibody D. ECG E. PTH LevelHypocalcemia Causes MOST IMPORTANT CAUSES: 1. Hypocalcemia with low PTH - hypoparathyroidism 2. Hypocalcemia with high PTH - vitamin D deficiency, pseudohypoparathyroidism, CKD 3. Hypocalcemia due to compartmental shifts - acute pancreatitis, Hypocalcemia Features, Investigations and Management Symptoms: CATS go NUMB Ix: Bone profile, U&Es, Vitamin D, PTH, Magnesium, ECG Management: 1. Treat underlying cause 2. If severe hypocalcemia - administer 10ml of 10% calcium gluconate over 10 mins 3. Monitor for ECG changesTHANKS FOR WATCHING! Tutor 1: Sumayyah Imran Tutor 2: Anirudh Manivannan Please fill out the feedback form on Medall and see you next week!