ch 28 management of patient with fluid electrolyte disturbances
Download
Skip this Video
Download Presentation
Ch 28 Management of patient with fluid & electrolyte disturbances

Loading in 2 Seconds...

play fullscreen
1 / 72

Ch 28 Management of patient with fluid & electrolyte disturbances - PowerPoint PPT Presentation


  • 257 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Ch 28 Management of patient with fluid & electrolyte disturbances' - sagittarius


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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.
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
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

  • 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
slide38
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)
slide52
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.

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+]

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.
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
slide62
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.
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.
ad