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Sodium and Potassium Imbalance

Sodium and Potassium Imbalance. An approach for primary care Dr Lori Wik October 5, 2019. Disclosures. I have nothing to disclose. Learning objectives. Sodium and Potassium. Sodium Imbalance: key ideas.

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Sodium and Potassium Imbalance

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  1. Sodium and Potassium Imbalance An approach for primary care Dr Lori Wik October 5, 2019

  2. Disclosures I have nothing to disclose

  3. Learning objectives

  4. Sodium and Potassium

  5. Sodium Imbalance: key ideas • Further laboratory investigations may be appropriate if the clinical assessment and patient history do not reveal the cause of the sodium imbalance • Serum sodium imbalances are more prevalent in older people and hyponatremia is more commonly seen in general practice than hypernatremia • The cause of the sodium imbalance is usually apparent (fluid depletion, medications or volume overload) • Urgent referral to ER is recommended for patients with serum sodium < 120 mmol/L or > 150 mmol/L or if labs are rapidly decreasing or increasing; if neurological symptoms are present or if the patient is systemically unwell

  6. Normal Sodium Hemostasis (surprise! Its all about the water!)

  7. The elderly are at increased risk

  8. Hyponatremia definition • One of the most common electrolyte imbalances encountered in the office setting • serum sodium < 135 • severe hyponatremia is when serum sodium <120 • The rate of change of sodium is important (rapidly changing sodium is worse than gradual changes) • due to too much water relative to sodium!

  9. An approach to hyponatremia in the office

  10. Determine the cause: volume status holds the key! • Hypovolemic: dehydration, diarrhea, diuretics, vomiting • Hypervolemic: CHF, cirrhosis, nephrotic syndrome, renal failure • Euvolemic: medications, SIADH, thyroid, adrenal insufficiency

  11. Determine the cause and treatment

  12. Hypernatremia definition:

  13. An approach in the office

  14. Look for the cause of water loss: normal people do not tend to have high sodium!!

  15. If the cause is not apparent from history • Limited testing can help to sort out the cause: • Urine osmols: high urine osmols (>600) means volume loss/dehydration, low urine osmols (<300) suggests diabetes insipidus • If the patient is stable with a mild or reversible cause of dehydration, it may be safe to treat in the primary care setting with oral rehydration, and close observation.

  16. Potassium imbalance: key concepts • Serum potassium imbalance is more prevalent in older people and people with co-morbidities (renal impairment or congestive heart failure) • Both hypokalemia and hyperkalemia can cause cardiac arrhythmias which may be life threatening • Urgent referral to secondary care is recommended for: • patients with serum potassium ≤ 2.5 mmol/L or ≥ 7 mmol/L • rapidly decreasing or increasing labs • neuromuscular symptoms or ECG changes • if the patient is systemically unwell • The cause of the potassium imbalance is usually clinically apparent, (vomiting, diarrhea, medications or renal impairment) • Further laboratory investigations may be indicated if the clinical assessment and history do not reveal the cause of the potassium imbalance

  17. Hyperkalemia

  18. Lewis J. Disorders of potassium concentration. Merck Manual, 2009. Available from: www.merckmanuals.com https://bpac.org.nz/BT/2011/September/imbalance.aspx

  19. Mechanism of hyperkalemia • Impaired Renal excretion • Renal failure • Hypoaldosteronism (eg: Addison’s) • MRA’s (spironolactone) • Medications that inhibit the RAS (ACEI, ARB, heparin, NSAIDs) • Shift of potassium out of cells (into the bloodstream): • Acidosis (eg: DKA or sepsis) • Digoxin, beta blockers, Septra • Increased circulating potassium: • Cell breakdown (tumor lysis, rhabdomyolysis) • Excessive potassium supplementation, salt substitutes, herbals (milkweed or nettle) • Pseudohyperkalemia

  20. The office approach

  21. Approach for Dr Wik’s darn CHF medications Extracted from the 2015 ccs heart failure guidelines

  22. Urgent treatment of severe hyperkalemia in hospital/monitored setting

  23. Hypokalemia

  24. Causes of hypokalemia

  25. The office approach to hypokalemia

  26. Treatment of hypokalemia

  27. sources • https://bpac.org.nz/BT/2011/September/imbalance.aspx • https://www.onlinecjc.ca/article/S0828-282X(15)00475-4/abstract • Lewis J. Disorders of potassium concentration. Merck Manual, 2009. Available from: www.merckmanuals.com • https://bpac.org.nz/BT/2011/September/imbalance.aspx

  28. Thank you! Any questions???

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