Ch 28 management of patient with fluid electrolyte disturbances
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Ch 28 Management of patient with fluid & electrolyte disturbances. R1 최 정 현. Fluid compartment. Intracellular fluid. (ATP)-dependent pump Na+ : K+ = 3:2 K+  concentrated intracellularly Na+  extracelluarly

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Ch 28 Management of patient with fluid & electrolyte disturbances

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Ch 28 management of patient with fluid electrolyte disturbances

Ch 28 Management of patient with fluid & electrolyte disturbances

R1 최 정 현


Fluid compartment

Fluid compartment


Intracellular fluid

Intracellular fluid

  • (ATP)-dependent pump

    • Na+ : K+ = 3:2

    • K+  concentrated intracellularly

    • Na+  extracelluarly

    • 이러한 unequal exchange는 Nondiffusible protein으로 인한 intracellular hyperosmolality를 방지

    • Ischemia, hypoxia시 pump기능 감소  swelling of cells


Extracellular fluid

Extracellular fluid

  • Provide

    • a medium for

      • cell nutrients and electrolyte

      • Cellular waste products

  • 1.interstitial fluid

    • 대부분 free fluid보다는 proteoglycan과 chemical association을 통해 gel형태로 존재

    • Negative pr.를 가짐(-5mmHg)

      • Vol.이 증가하여 free fluid증가하여 positive pr.되면 edema가 됨.

  • 2.intravascular fluid

    • Commonly referred to as plasma

    • Plasma protein(주로 albumin)은 ISF로 나갈 수 없기 때문에 유일한 osmotically active solute이 됨.


Edema

edema

  • ECF가 계속 증가하게 되면 blood volume은 증가하지 않고 결국 ISF만 증가하게 되어 tissue edema가 생기게 됨.


Exchange between fluid compartments

Exchange between fluid compartments

  • Diffusion:random movement of molecule due to their kinetic energy

  • Rate of diffusion

    • Membrane permeability

    • Substance concentration difference

    • Pressure difference

    • Electrical potential에 의해 결정됨.


1 diffusion through cell membrane

1. Diffusion through cell membrane

  • ISF와 ICF사이의 diffusion

    • Lipid bylayer를 직접 통과

      • Oxygen, CO2, water, lipid soluble molecule

    • Protein channel을 통해

      • Na+, K+, Ca+과 같은 cation

    • Carrier protein을 통해(facilitated diffusion)

      • Glucose, amino acid

  • Fluid exchange는 nondiffusible solute concentration의 차이에 의한 osmotic force에 의하게 됨.


2 diffusion through capillary endothelium

2. Diffusion through capillary endothelium

  • Oxygen, CO2, water, lipid soluble substance memb.직접 통과

  • Low-molecular-weight water-soluble substances(Na+, Cl-, K+, glc.)  intercellular cleft를 잘 통과.

  • High molecular-weight substances cleft잘 통과 못함.(liver, lung제외)

  • Fluid exchage는 osmotic force와 hydrostatic force에 의함.


Ch 28 management of patient with fluid electrolyte disturbances

  • Venous end에서 재흡수 되지 않은 fluid는 lymphatic flow를 통해 돌아감.


Disorders of water balance

Disorders of water balance

  • Normal adult daily water intake

    • 2500mL (energy substrate의 대사산물 300mL포함)

  • Daily water loss

    • 1500mL : urine

    • 400mL : respi. Tract evaporation

    • 400mL : skin evaporation

    • 100mL : sweat

    • 100mL : feces

  • Water content및 cell volume의 변화는 특히 뇌와 같은 곳의 심각한 기능 이상을 초래할 수 있다.


Plasma sodium conc ecf icf osmolality relationship

Plasma sodium conc.과 ECF,ICF osmolality와의 relationship

  • Plasma osmolality(mOsm/kg)

    = [Na+]*2 + BUN/2.8 + glc./18

  • Effective Plasma osmolality(mOsm/kg)

    = [Na+]*2 + glc./18

  • Normally varies 280 ~ 290 mOsm/L

  • Osmolal gap : 측정치와 계산치의 차이

    • Ethanol, mannitol, methanol, ethylen glycol, isopryl alchohol

    • CRF, ketoacidosis, 다량의 glycine

    • Marked hyperlipidemia, hyper proteinemia


Control of plasma osmolality

Control of plasma osmolality

1. Secretion of ADH

hypothalamus의 supraoptic and paraventricular nuclei에서 감지.

ECF osm. ↑  cell shrink  ADH분비(from post. Pituitary)  renal collecting tubule에서 재흡수 증가

ECF osm. ↓  반대

2. Nonosmotic release ADH

carotid baroreceptor, atrial stretch receptor

 blood vol.이 5~10%감소시 stimulate ADH

pain, emotional stress, hypoxia시도 자극가능.

3. Thirst

hypothalamus의 lat. Preoptic area에서 ECF osm.증가시 thirst 생기게 함.


Hyperosmolality hypernatremia

Hyperosmolality & Hypernatremia

  • Hyperosmolaity가 항상 hypernatremia([Na+]>145 mEq/L)와 연관이 있는 것은 아님.

    • Ex.) Marked hyperglycemia

      • Glc. 100 mg/dL 증가시 plasma Na+ 1.6 mEq감소

  • Hypernatremia(loss of water)는 보통 thirst에 의한 수분섭취로 예방이 되기 때문에 주로 unable to drink, very aged, very young, altered consciousness pt.에서 나타나게 됨.


Hypernatremia

Hypernatremia

  • & low total body sodium content

    • Water and Na+ loss

    • Osmotic diuresis, diarrhea, sweat

    • Sign of hypovolemia

  • & normal total body sodium content

    • Pure water loss

    • M/c cause : dibetes insipidus

      • Central : ADH 분비 감소

      • Nephrogenic : ADH 반응성 감소

  • & increased total body sodium content

    • Hypertonic saline solution주입시

    • Hyperaldosterinism, cushing synd.에서 나타날 수도 있음.


Clinical manifestation of hypernatremia

Clinical manifestation of hypernatremia

  • Neurological (cellular dehydration으로)

    • Restlesness, lethargy, hyperreflexia

    • Seizure, coma, death로 발전 가능

    • Brain volume의 급격한 감소시 cerebral vein rupture로 ICH, SAH도 발생 가능.


Tx of hypernatremia

Tx. Of hypernatremia

  • Rapid correction주의 : Sz.,brain edema, permanent neurological damage, death가능

  • 시간당 0.5 mEq이상속도로 교정 되지 않게 주의


Anesthetic consideration

Anesthetic consideration

  • Hypernatremia

    • 동물실험에서 MAC 증가

    • 주로 fluid deficit과 관련

    • Elective surgery에서 150 mEq이상시 원인교정이 될때까지 수술 연기되어야 함.


Hypoosmlality hyponatremia

Hypoosmlality & hyponatremia

  • Hypoosmolality와 hyponatremia([Na+]<135 mEq/L)는 거의 항상 연관되어 있다.

  • 예외 : pseudohyponatremia


Hypoosmolal hyponatremia

Primary polydipsia

SIADH

Glucocorticoid deficiency

Hypothyrodism

Drug-induced

Hypoosmolal hyponatremia 분류 및 치료

CHF

Cirrhosis

Nphrotic syndrome

Vomiting

Diarrhea

Sweat, burn

Third spacing

Diuretics

Mineralocorticoid deficiency

Salt-losing nephropathy

Osmotic diuresis

Renal tubular acidosis

  • 예외 : Vomiting시 Una가 20 mEq이상일 수 있다.:metabolic alkalosis 교정을 위해 HCO3배출될때 Na+함께 배출되기 때문.

    • 단, Urine Cl-가 10 mEq이하


Clinical manifestation of hyponatremia

Clinical manifestation of hyponatremia

  • Sx.(주로 neurological, intracellular water증가 때문)

    • 125 mEq/L이상의 mild to moderate에서는 종종 asymptomatic

    • Early Sx.

      • Anorexia, nausea, weakness

    • Progressive cerebral edema lethargy, confusion, seizure, coma, death

    • Serious manifestation은 보통 120 mEq/L이하에서 나타남.

    • Risk : premenopausal women


Hyponatremia

Hyponatremia 교정

  • 보통 125 mEq/L 이상으로 교정시 Sx.이 완화됨.

  • Na+ defic = TBW*(desired[Na+]-present[Na+])

  • 교정속도

    • Mild Sx.시 : 0.5 mEq/L/h or less

    • Moderate : 1 mEq/L/h or less

    • Sevre : 1.5 mEq/L/h or less

  • 급속교정시 central pontine myelinolysis로 permanent neurological sequelae생길 수


Anesthetic consideration1

Anesthetic consideration

  • General anesthesia시 130 mEq/L이상이면 safe

  • Elective op.시 Sx.없더라도 130 mEq/L이상으로 교정해 주어야 함.

  • MAC감소

  • Postop. Agitation, confusion, somnolence

  • TUR-P 를 받는 환자는 irrigation fluid로 부터 다량의 water흡수하여 acute water intoxication의 high risk가 됨.


Disorders of sodium balance

Disorders of sodium balance

  • ECF volume 은 totoal body sodium content와 직접적으로 비례관계

  • Positive sodium balance  ECF vol. ↑

  • Negative sodium balance  ECF vol. ↓

  • ECF volume과 total body sodium content는 renal Na+ excretion의 조정에 의해 조절됨.


Control mechanism sodium balance

Control mechanism(sodium balance)

  • Sensors of volume

    • Baroreceptor

      • At carotid sinus : SNS activity, nonosmotic ADH

      • Afferent renal arteriols : RAA system

      • Stretch receptor in both atria : atrial natriuretic h., ADH를 modulation


Control mechanism sodium balance1

Control mechanism(sodium balance)

  • Effectors of volume change

    • Renin-angitensin-aldosterone

      • Renin  angiotensin II ↑  aldosterone ↑  enhancing Na+ reabsorption(prox. Renal tubule)

      • Angiotensin II : direct vasoconstrictor, norepi. Potentiate

    • ANP

      • Atrial distention시 분비

      • 2 major action

        • Arterial vasodilation

        • Increased urinalry sodium and water excretion


Control mechanism sodium balance2

Control mechanism(sodium balance)

  • Effectors of volume change

    • Brain natriuretic peptide

      • Ventricle overdistention시 ventricle에서 분비

      • 보통 ANP의 20% level이지만 acute CHF시 ANP level exceed

    • Pressure natriuresis

      • BP가 조금만 증가해도 urinary Na+ excretion 상대적으로 크게 증가

    • SNS activity

      • 활성화시

        • Na+ reabsorption증가(prox. Renal tubule)

        • Renal vasoconstruction  renal blood flow 감소


Control mechanism sodium balance3

Control mechanism(sodium balance)

  • Effectors of volume change

    • GFR and plasma sodium concentration

      • Filtered Na+양과 비례

    • Tubuloglomerular balance

      • Rate of renal tubular flow

      • Changes in peritubular capillary hydrostatic and oncotic pressure

    • Antidiuretic hormone


Volume regulation vs osmoregulation

Volume regulation VS Osmoregulation


Anesthetic consideration2

Anesthetic consideration

  • Hypovolemic patient

    • Sensitive to vasodilating, negative inotropic effect

      • Volatile anesthetics, barbiturate, histamine release agent(morphine, meperidine, curare, atracurium)

      •  dosage 줄여야 함.

    • 또한 spinal or dpidural anesthesia시 sympathetic blockade에도 sensitive

    • 만약 마취전 hypovolemia를 교정할수 없다면

      •  ketamine이 induction agent of choice

      • Etomidate가 suitable alternative


Anesthetic consideration3

Anesthetic consideration

  • Hypervolemia

    • 술전 diuretics로 교정

    • 가능하다면 Cardiac, renal, hepatic function의 이상을 교정해줌.

    • Major hazard

      • Pulmonary interstitial edema

      • Alveolar edema

      • Large collection of pleural or ascitic fluid


Disorders of potassium balance

Disorders of potassium balance

  • Potassium

    • Cell membrane의 electrophysiology

    • Carbohydrate, protein synthesis에 주요역할

  • Intracellular concentration : 140 mEq/L

  • Extracellular conc. : 4 mEq/L


Normal potassium balance

Normal potassium balance

  • Dietary potassium intake :

    • 평균 80 mEq/d (40~140)

  • Excreted

    • Urine : 70 mEq (distal tubule)

    • GI tract : 10 mEq


Intercompartment shift of potassium

Intercompartment shift of potassium

  • Occur following

    • Changes in extracellular pH

    • Circulating insulin level

    • Circulating catecholamine activity

    • Plasma osmolality

    • hypothermia


Intercompartment shift of potassium1

Intercompartment shift of potassium

  • Insulin & catecholamine : Na+-K+ ATPase 에 직접작용하여  plasma [K+] 낮춤.

  • Exercise시 muscle에서 K+ release  plasma [K+] 증가(synd. of periodic paralysis)

  • Acidosis시 H+ 이 cell안으로 들어가며 K+ 나옴 plasma [K+] 증가

  • Alkalosis  plasma [K+] 감소

  • B2-adrenergic agonist투여시 m.과 liver의 uptake로  plasma [K+] 감소

  • Acute increase in plasma osmolality시 solvent drag현상으로  plasma [K+] 증가

  • Hypothermia시 cellular uptake로  plasma [K+] 감소

    • Rewarming시 reverse되므로 hypothermia상태에서 K+투여는 rewarming시 transient hyperkalemia야기할 수 있다.


Hypokalemia

Hypokalemia

Gastmintestinal losses

  • Vomiting

    • dirrhea, particularly secretory diarrhea

      ECF  ICF shift

  • Acute a|ka|osis

  • Hypoka|emic periodic para|ysis

  • Barium ingestion

  • |nsulin therapy

  • Vitamin B12 therapy

  • Thyrotoxicosis (rare|y)

    lnadequate intake

    Cf.) frozen red cell수혈시 발생가능.

     이 cell들은 potassium loss상태로 수혈 수 K+을 흡수하게 됨.

  • [K+] < 3.5 mEq/L

  • 원인

    Excess renal loss

    • MineraloCorticoid excess

      • Primary hypera|dosteronism (Conn’s syndrome)

      • G|ucoconicoid--remediable hyperaldosteronism

    • Renin excess

      • Renovascular hypertension

    • Bartterl’s syndrome

    • Lidd|e’s syndrome

    • Diuresis

    • Chronic metabo|ic a|kalosis

    • Antibiotics

      • Carbenicil|in

      • Gentamicin

      • Amphotericin B

    • Rena| tubu|ar acidosis

      • Dista|, gradient-limited

      • Proxima|

      • Ureterosigmoidostomy


Hypokalemia1

Hypokalemia

  • Clinical manifestation

    • 보통 3mEq/L 이하로 떨어지기 전까지는 asymtomatic

      <Effects of hypokalemia>

  • Cardiovascular

    • Electrocardiographic changes/arrhythmia5

    • Myocardia| dysfunction

  • Neuromuscular

    • Skeletal murk weakness

    • Tetany

    • Rhabdomyo|ysis

    • Ileus

  • Renal

    • Polyuria (nephrogenic diabetes insipidus)

    • Increased ammonia production

    • Increased bicarbonate reabsorption

  • Hormonal

    • Decreased insulin secretion

    • Decreased aldosterone secretion

  • Metabolic

    • Negative nitrogen balance

    • Encephalopathy in patients with liver disease


Ch 28 management of patient with fluid electrolyte disturbances

  • Due to Delayed ventricular repolarization

    • T wave flattening and inversion

    • Prominent U wave

    • ST segment depression

    • Increased P wave amplitude

    • Prolongation of the PR interval


Treatment of hypokalemia

Treatment of hypokalemia

  • Associated organ dysfunction의 severity에 따라 결정됨.

  • Significant ECG change시(ST segment change, arrhythmia)  continuous ECG monitoring (특히 IV K+ replacement중)

  • Weakness가 있는 환자는 주기적인 muscle strength 평가가 필요


Treatment of hypokalemia1

Treatment of hypokalemia

  • Oral replacement

    • potassium chloride solution

    • Safest

    • 60 ~ 80 mEq/d

    • Require several days

  • IV replacement

    • Serious cardiac manifestation또는 muscle weakness시

    • 8 mEq/h속도를 넘지 않게 , 240mEq/d넘지 않게

    • Dextorse-containing solution은 피함  insulin분비로 plasma K+낮춤.

    • 빠른 주입시(10-20mEq/h)  central line필요(femoral catheter가 좋음. ), close ECG monitoring 필요

  • Metabolic alkalosis시  potassium chloride사용. : 부족한 chloride도 같이 교정 가능

  • Metabolic acidosis시  potassium bicarbonate or equivalent(K+ acetate, K+ citrate)

  • Diabetic ketoacidosis시  potassium phosphate사용 : concomitant hypophosphatemia도 교정


Anesthetic consideration4

Anesthetic consideration

  • Common preoperative finding

  • Elective surgery시 lower limit를 가짐

    • 3~3.5 mEq/L

  • ECG change가 없는 chronic mild hypokalemia시 anesthetic risk는 증가하지 않음.

  • But, digoxin 투여 환자에서는 risk증가하므로 4mEq/l이상으로 유지하는 것이 좋음.

  • Intraop.에서

    • Atrial or ventricular arrhythmia시 IV potassium보충해야함.

    • Hyperventilation을 피하여 K+감소를 방지


Hyperkalemia

Hyperkalemia

  • 5.5 mEq/L 이상

  • Kidney의 tremendous excretion capacity로 정상인에서는 거의 생기지 않음.

  • 하루 500mEq 배출 가능.

  • SNS & insulin분비가 plasma [K+]의 급격한 증가를 막는데 중요한 역할.


Hyperkalemia1

Hyperkalemia의 원인

  • Due to extracellular movement

    • Succinylcholine  평균 0.5 mEq/L증가

    • Acidosis

    • Cell lysis following chemotherapy

    • Hemolysis

    • Rhabdomyolysis

    • Massive tissue trauma

    • Hyperosmolality

    • Digitalis overdose

    • Arginine hydrocloride and b2-adrenergic blockade

    • Hyperkalemic periodic paralysis


Hyperkalemia2

Hyperkalemia의 원인

  • Decreased renal excretion

    • Renal failure

    • AIDS

    • Spironolactone

    • ACEi

    • NSAID

    • Pentamidine

    • Trimethoprim

  • Increased potassium intake

    • Salt substitutes

    • Stored whole blood transfusion시 : 21일이 지난 후에는 1unit가 30 mEq/L까지 증가시킬 수 있음.  plasma의 양을 최소화 함으로써 예방.


Clinical manifestation

clinical manifestation

  • Most important effect

    • Skeletal muscle weakness

    • Cardiac manifestation


Clinical manifestation1

clinical manifestation

  • Most important effect

    • Skeletal muscle weakness

      • 보통 8 mEq/L 이상이 될때까지는 생기지 않음.

      • Sustained spontaneous depolarization 과 inactivation of Na+ channel에 의함(succinylchoiline과 비슷)

         결국 ascending paralysis초래

    • Cardiac manifestation


Clinical manifestation2

clinical manifestation

  • Most important effect

    • Skeletal muscle weakness

    • Cardiac manifestation

      • Delayed depolarization에 의함

      • 7mEq/L이상에서 생김

      • ECG change

        • Peaked T-wave(종종 shortened QT동반)

        • Widening of QRS complex

        • PR prolongation

        • Loss of P wave

        • Loss of R wave amplitude

        • ST depression(occationally elevation)

        • Sine wave

        • Ventricular fibrillation and asystole


Treatment of hyperkalemia

Treatment of hyperkalemia

  • Hyperkalemia associated with hypoaldostronism  mineralocorticoid replacement

  • Calcium

    • partially antagonize cardiac effect

    • Rapid but short

    • Digoxin toxicity를 potentiation하므로 주의

  • Metabolic acidosis  sodium bicarbonate

  • B-agonist  massive transfusion으로 인한 hyperkalemia시 유용.

  • Epinephrine  rapidly decrease

  • Glucose and insulin : peak effect 도달에 1h 걸림.

  • Furosemide  renal excretion 증가

  • Kayexalate

  • Dialysis


Anesthetic consideration5

Anesthetic consideration

  • ECG : carefully monitored

  • Contraindicated

    • succinylcholine

    • H/S : K+ containing

  • Metabolic or respiratory acidosis피함.

  • Mild hyperventilation이 desirable

  • NMBAs effect를 accentuation할 수 있으므로 neuromuscular function을 주의깊게 minitoring.


Disorders of calcium balance

Disorders of calcium balance

  • Total body calcium의 98%는 bone이지만 normal extracellular calcium conc.의 유지는 homeostasis에 중요

  • Biological function

    • Muscle contraction

    • Release of neurotransmitter and hormone

    • Blood coagulation

    • Bone metabolism


Normal calcium balance

Normal calcium balance

  • Intake : 600 ~ 800 mg/d

    • 주로 porx. Small bowel에서 흡수

    • 80%는 feces로 배출됨.

  • Renal calcium excretion

    • 100 mg/d (50~ 300)


Ch 28 management of patient with fluid electrolyte disturbances

  • Plasma calcium conc.

    • 8.5 ~ 10.5 mg/dL (2.1~2.6 mmol/L)

    • 50% : free ionized form

    • 40% : protein bound (albumin)

    • 10% : complex with anion(citrate, aminoacid)

  • Plsma [Ca2+]

    • 4.75 ~ 5.3 mg/dL

    • 2.38 ~ 2.66 mEq/L

    • 1.19 ~ 1.33 mmol/L

  • Plasma albumin conc.변화시  total calcium conc.에는 영향을 주지만 ionized form에는 영향없음.

  • Plasma pH 변화시  degree of protein binding에 영향  ionized form에 영향을 줌.


Regulation of extracellular ionized calcium conc

Regulation of extracellular ionized calcium conc.

<Vit. D>

Cholecalciferol

↓ (Liver)

25 cholecalciferol

↓ (Kidney)

1,25 dihydroxy calciferol

PTH

Vit. D

calcitonin

Plasma Ca2+ ↓

PTH ↑

bone

Distal renal tubule

Small intestine

-----  calcitonin  -----

Reabsorption증가

Calcium재흡수 증가

Calcium흡수 증가

Plsma [Ca2+]


Hypercalcemia

Hypercalcemia


Hypercalcemia1

Hypercalcemia

  • Clinical manifestation

    • Anorexia, N/V, weakness, polyuria

    • Ataxia, irritability, lethargy, confusion시 급격하게 coma로 진행할 수

    • ECG

      • Shortend ST seg.

      • Shortened QT interval

    • Digitalis의 cardiac sensitivity증가

    • Pancreatitis, peptic ulcer, renal failure 시 발생가능


Tx of hypercalcemia

Tx. Of hypercalcemia

  • Most effective initial treatment

    • Rehydration후 IV saline + loop diuretics

  • Severe시 (>15 mg/dl)

    • Bisphosphonate : pamidronate 60~90 mg IV

    • Calcitonin : 2~8 U/kg SC

  • Dialysis : renal or cardiac failure시

  • Granulomatous dis.와 같은 vit. D induced hypercalcemia시 glucocorticoid투여


Anesthetic consideration6

Anesthetic consideration

  • Hypercalcemia는 medical emergency로서 가능하다면 마취약제 투여전에 반드시 교정되어야함.

  • Intraop. 에서 saline diuresis시행

    • Hypovolemia 주의

  • Cardiac reserve감소 환자에서는 CVP, Pul. A. pr. Monitring고려

  • Acidosis는 calcium level높일 수 있으므로 피해야 함.


Hypocalcemia

Hypocalcemia


Clinical manifestation of hypocalcemia

Clinical manifestation of hypocalcemia

  • Paresthesia

  • confusion

  • laryngeal stridor(laryngospasm)

  • carpopedal spasm(Trousseau’s sign)

  • masseter spasm(Chvostek’s sign)

  • seizure

  • Biliary colic, bronchospasm

  • Arrhythmia

  • Digoxin, b-agonist반응성 감소

  • ECG

    • QT interval prolongation

    • Hypocalcemia의 정도와 severity가 비례하지는 않음.


Tx of hypocalcemia

Tx. of hypocalcemia

  • 즉시 IV calcium chloride : 3~5 ml of 10% sloution

  • 또는 calcium gluconate : 10~20ml of 10% sloution

  • Precipitation이 생기지 않도록 bicarbonate나 phosphate가 함유된 solution과 같이 투여하면 안됨.

  • Chronic 시

    • Oral calcium(CaCO3)

    • Vitamine D replacement

  • 마취전에 반드시 교정되어야 하며 마취 중 alkalosis를 피해야 함.


Disorders of phosphorus balance

Disorders of phosphorus balance

  • Intake

    • 800 ~ 1500 mg/d

    • 80%는 prox. Small bowel에서 흡수됨.

  • Vitamine D  phosphorus 흡수 증가시킴.

  • Kidney

    • Excretion의 주요 경로

    • Total body phosphorus 조절역할

  • PTH  phophorus의 excretion을 증가시킴

    • 하지만 bone에서의 phophorus release를 induce


Ch 28 management of patient with fluid electrolyte disturbances

  • Plasma phosphorus concentration

    • Organic and inorganic forms

    • Organic : 주로 phopholipid

    • Inorganic

      • 80%는 kidney에서 filterable, 20% protein bound

      • 주로 H2PO4-나 HPO4 2-상태로 존재(1:4)

    • Normal conc.

      • 2.5 ~4.5 mg/dL in adult

      • Up to 6mg/dL in children

    • Fasting시 측정하여야 함

      • Carbohydrate가 phophors를 일시적으로 감소시키기 때문


Hyperphophatemia

Hyperphophatemia

  • 어떤 functional disturbance에 직접적인 역할을 하지는 않음.

  • 하지만 plasma [Ca2+]에 이차적인 영향을 주게 됨.

  • Marked Hyperphophatemia 시 bone과 soft tissue의 deposition과 precipitation으로 plasma [Ca2+] level감소시킴.

  • Tx.

    • Aluminum hydroxide

    • Aluminum carbonate


Hypophosphatemia

Hypophosphatemia

  • Mild to moderate (1.5~2.5 mg/dL)  asymptomatic

  • Severe (<1.0 mg/dL)  widespread organ dysfunction

    • Cardiomyopathy

    • Impaired oxygen delivery(2,3-diphosphoglycerate감소로)

    • Hemolysis

    • Impaired leukocyte function

    • Platelet dysfunction

    • Encephalopathy

    • Skeletal myopathy

    • Respiratory failure

    • Rhabdomyolysis

    • Skeletal dimineralization

    • Metabolic acidosis

    • Hepatic dysfunction


Hypophosphatemia1

Hypophosphatemia

  • Tx.

    • Oral phosphorus replacement가 선호

    • Sever 시 IV로 potassium or sodium phosphate가 사용됨.

  • Anesthetic consideration

    • Hyperglycemia나 respiratory alkalosis피함


Disorders of magnesium balance

Disorders of magnesium balance

  • Intake

    • 평균 20-30mEq/d

    • 주로 distal small bowel 통해 흡수

  • Excretion

    • 주로 kidney통해 elimination

    • 평균 6-12mEq/d

  • Plasma [Mg2+] conc. : 1.7 ~ 2.1 mEq/L사이에서 조절됨.


Hypermagnesemia

Hypermagnesemia

  • 원인

    • Excessive intake

    • Renal imoairment

    • Or both

    • Iatrogenic Hypermagnesemia

      • Gestational HTN시 Mg sulfate therapy시 생길수

    • 그 외

      • Adrenal insufficiency

      • Hypothyroidism

      • Rhabdomyloysis

      • Lithium administration


Hypermagnesemia1

Hypermagnesemia

  • Clinical manifestation

    • Hyporeflexia

    • Sedation

    • Skeletal m. weakness

    • Ach. 의 release와 sensitivity를 감소시킴.

    • Vasodilation, bradycardia, myocardial depression hypotension

    • Respiratory arrest도 생길 수 있음.


Hypermagnesemia2

Hypermagnesemia

  • Treatment

    • IV calcium(1g calcium gluconate)

    • Loop diuretics c ½ N/S in 5% DW

    • Dialysis

  • Anesthetic consideration

    • Vasodilating and negative inotropic agent주의

    • NMBAs 는 20~50%까지 사용량 줄임.


Hypomagnesemia

Hypomagnesemia


Hypomagnesemia1

Hypomagnesemia

  • Clinical manifestation

    • 대부분 asymptomatic

    • Anorexia, weakness, fasciculation, paresthesia, confusion, ataxia, seizure생길 수

    • 종종 hypocalcemia, hypokalemia와 연관됨

    • Atrial fibrilation incidence증가와 관련있음.


Hypomagnesemia2

Hypomagnesemia

  • Treatment

    • Oral Mg sulfate heptahydrate, Mg oxide

    • IM Mg sulfate

    • Serious시  IV Mg sulfate 1-2g (15-60분동안 서서히 주입)

  • Anesthetic consideration

    • 동반된 electrolyte disturbance교정이 중요.

    • Isolated Hypomagnesemia는 술전 교정이 중요

      • Cardiac arrhythmia의 위험 때문

      • 더욱이 Mg  antiarrhythmic effect와 cerebral protective effect가 있음.


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