Le Disionie

Ligia J DominguezDicembre 1 2016

Università degli Studi di Palermo. Facoltà di Medicina e ChirurgiaUnità Operativa Complessa di Geriatria e Lungodegenza

Scuola di Specilizzazione in Geriatria

• 22239 patients in the ER, Bern, Jan 2010 to Dec 2011

• 8.5% one diuretic, 2.5% two, 0.4% three or four

• Loop diuretics: independent RF for hyperNa and

hypoK

• TZD: independent RF for hypoNa and hypoK

• Cox regression: ALL FORMS OF DYSNATREMIA

AND DYSKALEMIA WERE INDEPENDENT RF FOR IN

HOSPITAL MORTALITY

HypoNa OR 1.55, p=0.004HyperNa OR 3.21, p=0.0001

Surv

ival

Na

HypoK OR 1.89, p=0.0001HyperK OR 2.35, p=0.0001

Surv

ival

K

• Possible causes of hospital admissions during extreme heat

• 23.7 million Medicare enrollees 1999-2010

•Heat exposure: 2 days with To > 99th percentile

• AMONG OLDER ADULTS, PERIODS OF EXTREME HEAT

WERE ASSOCIATED WITH INCREASED RISK OF

HOSPITALIZATION FOR:

o FLUID AND ELECTROLYTE DISORDERS

o RENAL FAILURE

o URINARY TRACT INFECTION

o SEPTICEMIAo HEAT SHOCK

Bobb et al., JAMA 2014

Bobb et al., JAMA 2014

Schirò, Dominguez, Barbagallo, G Geront 2015

Na

Na

NEJM 2015

Astrocytes and the

Neurovascular Unit

Total body water is commonly reduced

Impairments in thirst sensation

Impaired renal function

Less responsive to hormonal mediators

of water, electrolyte, and mineral balance

Changes in water and electrolyte

homeostasis with aging

MORE VULNERABLE TO IATROGENIC EVENTS

Miller, et al 2016

Miller, et al 2016

Hyponatremia

Iponatremia ipertonica (>295 mOsm/L)

Accumulo di soluti osmoticamente attivi

(i.e., iperglicemia)

Iponatremia isotonica o

pseudoiponatremia (280-295 mOsm/L)Iperlimidemia o iperproteinemia che

causano un Na falsamente ridotto

Iponatremia ipotonica o vera (<280

mOsm/L)

VALUTAZIONE DELLA VOLEMIA

Ipovolemia

U [Na]>20

PERDITE RENALI:

- eccesso diuretici

- carenza mineralcort.

- nefropatie

- acidosi tubulare

- alcalosi metabolica

- chetonuria

- diuresi osmotica

U [Na]<20

PERDITE EXRARENALI:

- vomito

- diarrea

- sudorazione profusa

- ustioni

- traumi

- occlusioni intestinali

Euvolemia

U [Na]>20

- SIADH

- ipocortisolismo

- ipotiroidismo

- farmaci

- stress

- chirurgia

Ipervolemia

U [Na]>20

IRA o IRC

U [Na]<20

- S. nefrosica

- cirrosi

- scompenso cardiaco

Algoritmo diagnostico della iponatremia

Schirò, Dominguez, Barbagallo, G Geront 2015

VALUTAZIONE DELLA VOLEMIA

Ipovolemia

U [Na]>20

PERDITE RENALI:

- eccesso diuretici

- carenza mineralcort.

- nefropatie

- acidosi tubulare

- alcalosi metabolica

- chetonuria

- diuresi osmotica

U [Na]<20

PERDITE EXRARENALI:

- vomito

- diarrea

- sudorazione profusa

- ustioni

- traumi

- occlusioni intestinali

Euvolemia

U [Na]>20

- SIADH

- ipocortisolismo

- ipotiroidismo

- farmaci

- stress

- chirurgia

Ipervolemia

U [Na]>20

IRA o IRC

U [Na]<20

- S. nefrosica

- cirrosi

- scompenso cardiaco

Algoritmo diagnostico della iponatremia

Schirò, Dominguez, Barbagallo, G Geront 2015

VALUTAZIONE DELLA VOLEMIA

Ipovolemia

U [Na]>20

PERDITE RENALI:

- eccesso diuretici

- carenza mineralcort.

- nefropatie

- acidosi tubulare

- alcalosi metabolica

- chetonuria

- diuresi osmotica

U [Na]<20

PERDITE EXRARENALI:

- vomito

- diarrea

- sudorazione profusa

- ustioni

- traumi

- occlusioni intestinali

Euvolemia

U [Na]>20

- SIADH

- ipocortisolismo

- ipotiroidismo

- farmaci

- stress

- chirurgia

Ipervolemia

U [Na]>20

IRA o IRC

U [Na]<20

- S. nefrosica

- cirrosi

- scompenso cardiaco

Algoritmo diagnostico della iponatremia

Schirò, Dominguez, Barbagallo, G Geront 2015

Hyponatremia

Clinical signs and symptoms

Nausea/vomiting

Lethargy

Headache

Confusion

Seizures

Non-cardiogenic pulmonary edema

Mostly due to CNS dysfun. and cerebral edema

Hyponatremia - Therapy

3% NS for severely symptomatic

patients with caution

Na increase: 8-12 mEq/L/day with NS

Central pontine myelinolysis

may be irreversible

dysarthria, dysphagia, spastic

paresis, coma

Check Na frequently

Hypernatremia

Hypernatremia

Clinical signs and symptoms

Nausea/vomiting

Restless, irritable, or letargic

Anorexia

Stupor/coma

Subarachnoid hemorrhage

NaIPERNATREMIA

IPOVOLEMIA

perdite renali

poliuria

PS basso

Nau >20 mEq/l

perdite extra-renali

oligo-anuria

PS alto

Nau <20 mEq/l

IPERVOLEMIA

eccessivo introito di

Na+

poliuria

Nau >20 mEq/l

EUVOLEMIA

ipodipsia

oligo-anuria

PS alto

Nau >20 mEq/l

diabete insipido

Poliuria

PS basso

Nau <20 mEq/l

Schirò, Dominguez, Barbagallo, G Geront 2015

Hypernatremia - Causes

Free water loss

Diuretics (loop)

Post obstructive diuresis

Acute and chronic renal disease

Sweating, fistula, burns, diarrhea, vomiting

Diabetes insipidus (central, nephrogenic)

Sodium gain

Hypertonic saline or sodium bicarbonate

Parenteral nutrition

Hyperaldosteronism

Cushing’s syndrome

Hypernatremia - Therapy

Underlying cause

Replace H20 po if possible

Correct hypovolemia with 0.45% NS and

Glucose 5

Frequent monitoring and fluid adjustment

with a goal of 0.5-1mEq/L decrease/hour

Vasopressin for central DI

Consequences of rapid changes in plasma Na

NEJM 2015

K Potassium Homeostasis – meal driven

NEJM 2015

K Potassium Homeostasis – between-meal fasting

NEJM 2015

K

NEJM 2015

Major cell types in the cortical collecting duct

NEJM 2015

Circadian Rhythm of Urinary K Excretion in

Humans during Two levels of K Intake

Hypokalemia

Hypokalemia

Clinical signs and symptoms

Generalized muscle weaknessParalytic ileusCardiac arrhythmias

Atrial tachycardiaAV dissociation

EKG changesFlat/inverted T wavesST segment depressionU waves

Ascending paralysis and impaired respiratory function (K<2 mEq/L)

Hypokalemia - Causes

GI lossVomiting, diarrhea (VIPoma, enteric fistula, malabsorption, jejunoileal bypass)

Renal loss Primary hyperaldosteronism, hypothermia, genetic syndromes (i.e. Liddle’s), type I and II RTA, drugs (I.e. amphotericin, foscarnet)

Transcellular shift Alkalosis, beta agonists, caffeine, insulin, thryrotoxicosis, hypokalemic periodic paralysis

Hypokalemia - Therapy

Determine the cause

KCl po or IV

0.5-1 mEq/kg IV over 1 hour if severe

(monitoring ECG and blood K)

Correct hypomagnesemia!

Hyperkalemia

Hyperkalemia

Clinical signs and symptoms

Muscle weakness/paresthesiasK>6 mEq/LEKG changespeaked T wavesprolonged PR intervalwidened QRS

Hyperkalemia - Causes

Impaired excretion Renal failure, hypocortisolism, drugs, type IV

RTA

Iatrogenic

Transcellular shift Acidosis, beta blockers, digitalis overdose,

somatostatin

Other Tumor lysis

rhabdomyolysis

Hyperkalemia - Therapy

Calcium gluconate IV

Insulin/glucose Insulin 0.1units/kg IV

Glucose D10

The most effective way to quickly lower K!!!

Sodium bicarbonate 1-2mEq/kg

Hemodialysis

Kayexalate

Inhaled Beta-2 agonists

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