Understanding Normal Electrolyte Values

Normal Electrolyte Values

• Cation electrolytes include sodium (Na), potassium (K), calcium (Ca), magnesium (Mg), and hydrogen (H).
• Anion electrolytes include chloride (Cl), bicarbonate (HCO3), phosphate (HPO4), sulfate (SO4), and proteinase.
• In normal labs, most anions are not individually measured.
• Electrolytes are measured in milliequivalents (mEq), indicating chemical activity rather than weight.
• Electrolyte concentrations differ between intracellular and extracellular fluids.
• Electrolyte measurements are typically taken from extracellular fluid, predominantly plasma.
• Normal sodium levels are 135-145.
• Normal potassium levels are 3.5-5.
• Normal chloride levels are 95-105.
• Normal bicarbonate levels are 24-31.
• Normal calcium levels are 8.5-10.
• Normal phosphorus levels are 2.5-4.5.
• Normal magnesium levels are 1.8-3.

Potassium

• A major intracellular electrolyte, with 98% found inside the cells.
• Normal potassium levels are 3.5-5.
• Common food sources include bananas, oranges, melon, cooked spinach, broccoli, potatoes, tomatoes, milk, and meat.

Hypokalemia

• Hypokalemia can be caused by diarrhea, vomiting, gastric suction, bulimia, and starvation.
• Other causes include corticosteroid administration, hyperaldosteronism, carbenicillin, amphotericin B, diuretics, and digoxin toxicity.
• Osmotic diuresis and alkalosis may also contribute to hypokalemia.

Hypokalemia Signs and Symptoms

• Neurological symptoms include fatigue, muscle weakness, paresthesia, and leg cramps.
• Other neurological signs are hypoactive reflexes.
• Gastrointestinal symptoms include anorexia, nausea, vomiting, decreased bowel motility, ileus, and abdominal distension.
• Genitourinary symptoms include polyuria.
• Cardiac symptoms include ventricular asystole or fibrillation and decreased blood pressure.
• ECG findings include flattened T waves, prominent U waves, ST depression, and prolonged PR interval.

Hypokalemia Treatment

• Treatment involves increased dietary intake of potassium.
• Potassium supplements may also be necessary.

Hyperkalemia

• Pseudo hyperkalemia and oliguric kidney injury can lead to hyperkalemia.
• Use of potassium-conserving diuretics in patients with renal insufficiency can cause hyperkalemia.
• Other causes include metabolic acidosis, Addison's disease, crush injury, and burns.
• Stored bank blood transfusions, rapid IV administration of potassium, ACE inhibitors, NSAIDs, and cyclosporine can also lead to hyperkalemia.

Hyperkalemia Signs and Symptoms

• Neurological symptoms include muscle weakness, flaccid paralysis, paresthesias, irritability, and anxiety.
• Gastrointestinal symptoms include intestinal colic, cramps, and abdominal distension.
• Cardiac symptoms include progression from tachycardia to bradycardia and dysrhythmias.
• ECG findings include tall, tented T waves, prolonged PR interval and QRS duration, and absent P waves with ST depression.

Hyperkalemia Treatment

• Treatment involves dietary restriction.
• Administration of cation exchange resins.
• Emergency pharmacologic therapy includes IV calcium gluconate.
• IV sodium bicarbonate is used in acidotic states.
• Insulin and glucose may also be administered.
• Dialysis is an option if hyperkalemia is not resolved.

Magnesium

• An abundant intracellular cation.
• Normal magnesium levels are 1.8-3 mg/dL.
• Common food sources include green vegetables, nuts, legumes, bananas, and oranges.

Hypomagnesemia

• Chronic alcoholism, hyperparathyroidism, and hyperaldosteronism can cause hypomagnesemia.
• The diuretic phase of acute kidney injury may also lead to hypomagnesemia.
• Other causes include malabsorptive disorders, refeeding after starvation, parenteral nutrition, chronic laxative use, diarrhea, acute MI, heart failure, decreased serum K+ and Ca+, and certain pharmacologic agents.

Hypomagnesemia Signs and Symptoms

• Neurological symptoms include irritability, positive Trousseau's sign, positive Chvostek's sign, insomnia, mood changes, and increased tendon reflex.
• Gastrointestinal symptoms include anorexia and vomiting.
• Cardiac symptoms include increased blood pressure.
• ECG findings include PVCs, flat or inverted T waves, depressed ST segment, prolonged PR interval, and widened QRS.

Hypomagnesemia Treatment

• Treatment includes dietary changes.
• Oral magnesium salt administration.
• IV magnesium replacement may be necessary.

Hypermagnesemia

• The oliguric phase of acute kidney injury can cause hypermagnesemia.
• Other causes include adrenal insufficiency, excessive IV magnesium administration, diabetic ketoacidosis, and hypothyroidism.

Hypermagnesemia Signs and Symptoms

• Neurological symptoms include muscle weakness, drowsiness, hypoactive reflexes, and coma.
• Integumentary signs include flushing and diaphoresis.
• Respiratory symptoms include depressed respirations.
• Cardiac symptoms include hypotension and cardiac arrest.
• ECG findings include tachycardia progressing to bradycardia, prolonged PR interval and QRS, and peaked T waves.

Hypermagnesemia Treatment

• Treatment includes dietary restriction.
• Hemodialysis with magnesium-free dialysate.
• Loop diuretics, sodium chloride, or LR IV solutions can be used.
• These increase magnesium excretion in patients with adequate renal function.

Sodium

• Plays a major role in controlling water distribution.
• Establishes the electrochemical state necessary for muscle contraction and nerve impulses.
• Food sources include bacon, butter, processed food, table salt, and cheese.

Hyponatremia

• Loss of sodium, gain of the water, hyperglycemia, and heart failure can cause a loss of sodium.

Hyponatremia Signs and Symptoms

• Gastrointestinal symptoms include anorexia, nausea, and vomiting.
• Neurological symptoms include headache, lethargy, dizziness, confusion, muscle cramps, muscular twitching, and seizures.
• Integumentary signs include papilledema and dry skin.
• Cardiac symptoms include increased pulse and decreased blood pressure.
• Other symptoms include weight gain and edema.
• Labs include: low serum & urine sodium, low urine specific gravity, and osmolality

Hyponatremia Treatment

• Sodium replacement.
• Water restriction.
• Pharmacologic therapy may be involved.

Hypernatremia

• Fluid deprivation.
• Excess corticosteroid administration.
• Excess sodium bicarbonate administration.
• Excess sodium chloride administration.
• Salt-water near-drowning.

Hypernatremia Signs and Symptoms

• Neurological symptoms include thirst and elevated body temperature.
• Other symptoms include hallucinations, lethargy, restlessness, and irritability.
• Simple partial or tonic-clonic seizures, hyperreflexia, and twitching.
• Respiratory symptoms include pulmonary edema.
• Gastrointestinal symptoms include nausea, vomiting, and anorexia.
• Other symptoms include swollen dry tongue and sticky mucosa membrane.
• Cardiac symptoms include increased pulse and blood pressure.
• Labs include: Increased serum sodium, decreased urine sodium, increased urine specific gravity and osmolality, decreased CVP.

Hypernatremia Treatment

• Gradual lowering of sodium levels.
• Administration of hypotonic electrolyte solution.
• Encourage fluid intake orally when possible.
• Administer sufficient free water with tube feedings.

Chloride

• Binds with hydrogen in the stomach to form hydrochloric acid.
• Used by the choroid plexus to form cerebrospinal fluid.
• Acts as a buffer in exchanges of oxygen and carbon dioxide and red blood cells.
• Assists in acid-base balance.
• Food source: table salt.

Hypochloremia

• Addison's disease.
• Reduced intake or absorption.
• Untreated diabetic ketoacidosis.
• Chronic respiratory acidosis.
• Excessive sweating, vomiting, gastric suction, diarrhea.
• Metabolic alkalosis.
• Loop, osmotic, or thiazide diuretic use.
• Overuse of bicarbonate.
• Rapid removal of ascitic fluid with high sodium content.
• IV fluids that lack chloride.
• Draining fistulas and ileostomies.
• Heart failure and cystic fibrosis.

Hypochloremia Signs and Symptoms

• Neuromuscular symptoms include agitation, irritability, tremors, muscle cramps, hyperactive deep tendon reflexes, hypertonicity, tetany, seizures, and coma.
• Respiratory symptoms include slow, shallow respirations.
• Cardiac symptoms include dysrhythmias.
• Labs indicate: ↓ serum chloride, ↓ serum sodium, ↑ pH, ↑ serum bicarbonate, ↑ total carbon dioxide content, ↓ urine chloride level,↓ serum potassium

Hypochloremia Treatment

• Treat underlying problem.
• Dietary supplementation.
• IV fluids (normal or half-normal saline).
• Discontinue or change diuretics as necessary.

Hyperchloremia

• Excessive sodium chloride infusion.
• Head injury (sodium retention).
• Hypernatremia.
• Kidney injury.
• Corticosteroid use.
• Dehydration.
• Severe diarrhea.
• Respiratory alkalosis.
• Administration of certain diuretics, overdose of salicylates, kayexalate, acetazolamide, phenylbutazone, and ammonium chloride use.
• Hyperparathyroidism.
• Metabolic acidosis.

Hyperchloremia Signs and Symptoms

• Neuromuscular symptoms: lethargy, weakness, decline in cognitive status, coma.
• Respiratory symptoms: tachypnea, deep rapid respirations, dyspnea.
• Cardiac symptoms: ↓ cardiac output, tachycardia, pitting edema, dysrhythmias.
• Labs indicate: ↑ serum chloride, ↑ serum potassium and sodium, ↓ serum pH, ↓ serum bicarbonate, normal anion gap, ↑ urinary chloride level.

Hyperchloremia Treatment

• Correct underlying cause.
• Hypotonic IV solutions may be given.
• IV lactated ringers solution.
• IV sodium bicarbonate.
• Restriction of sodium, chloride, and fluids.

Calcium and Phosphorus

• Calcium is a major component of bones and teeth
• Nerve impulse transmission.
• Muscle contraction regulation.
• Activating enzymes.
• Blood coagulation.
• FOOD: Milk and dairy products, green leafy veggies, canned salmon, canned sardines, fresh oysters.

Hypocalcemia

• Hypoparathyroidism (may follow thyroid surgery or radical neck dissection).
• Malabsorption.
• Pancreatitis.
• Alkalosis.
• Vitamin D deficiency.
• Massive subcutaneous infection, generalized peritonitis.
• Massive transfusion of citrated blood.
• Chronic diarrhea.
• Diuretic phase of kidney injury.
• ↑ PO4 (Phosphates).
• Fistulas and burns.
• Alcoholism.

Hypocalcemia Signs and Symptoms

• Neuromuscular include Numbness, tingling of fingers, toes, and circumoral (surrounding the mouth) region.
• Positive Trousseau sign
• Positive Chvostek sign
• Seizures
• Carpopedal spasms (hands and feet)
• Hyperactive deep tendon reflexes
• Irritability
• anxiety
• Respiratory: bronchospasm
• Hematologic: impaired clotting time, ↓ prothrombin
• Gastrointestinal: diarrhea
• Cardiac: ↓BP
• ECG: Prolonged QT interval and lengthened ST interval

Hypocalcemia Treatment

• Nutritional therapy
• Vitamin D supplements
• Calcium supplements
• Encourage oral intake

Hypercalcemia

• Hyperparathyroidism.
• Malignant neoplastic disease.
• Prolonged immobilization.
• Overuse of calcium supplements or Vitamin D excess.
• Oliguric phase of renal failure.
• Acidosis.
• Corticosteroid therapy, thiazide diuretic use, digoxin toxicity.

Hypercalcemia Signs and Symptoms

• Neuro: muscular weakness, hypoactive deep tendon reflexes Lethargy.
• GI: Constipation, Anorexia, nausea and vomiting.
• GU: polyuria and polydipsia, Dehydration, calcium stones.
• Skeletal: deep bone pain, pathologic fractures.
• General: flank pain.
• Cardiac: hypertension.
• Labs: ECG: shortened ST segment and QT interval, bradycardia, heart blocks

Hypercalcemia Treatment

• Administer fluids.
• IV phosphate.
• Lasix.
• Calcitonin.
• Chemo, surgery, or radiation in cancer-associated hypercalcemia.
• Dietary restriction of calcium intake.
• Encourage fluid intake.

Phosphorus

• Essential to the function of muscle and red blood cells.
• Key role in oxygen release from hemoglobin.
• Maintains acid-base balance.
• Supports the nervous system.
• Metabolism of carbohydrates, proteins, and fats.
• Provides structural support for bones and teeth.
• Found in milk, dairy products, organ meats, nuts, fish, poultry, and whole grains.
• calcium and phosphorus will always be opposite high calcium, low phosphorus

Hypophosphatemia

• Refeeding after starvation.
• Alcohol withdrawal.
• Diabetic ketoacidosis.
• Respiratory and metabolic alkalosis.
• Low magnesium, low potassium.
• Vomiting and diarrhea.
• Hyperparathyroidism.
• Hyperventilation.
• Vitamin D deficiency associated with malabsorptive disorders.
• Burns.
• Parenteral nutrition.
• Diuretic and antacid use.

Hypophosphatemia Signs and Symptoms

• Neuro: parathesias, muscle weakness, confusion, and seizures.
• Nystagmus.
• Skeletal: bone pain and tenderness.
• Respiratory: respiratory failure.
• Cardiac: chest pain, cardiomyopathy, and tissue hypoxia.
• General: increased susceptibility to infection.

Hypophosphatemia Treament

• Phosphorus added to IV liquids.
• Dietary supplementation.
• Aggressive replacement is avoided except in extreme circumstances

Hyperphosphatemia

• Acute kidney injury and chronic kidney disease.
• Excessive intake of phosphorus.
• Vitamin D excess.
• Respiratory and metabolic acidosis.
• Hypoparathyroidism.
• Volume depletion.
• Leukemia/lymphoma treated with cytotoxic agents.
• Increased tissue breakdown, rhabdomyolysis.

Hyperphosphatemia Signs and Symptoms

• Neuro: tetany, muscle weakness, hyperactive reflexes.
• GI: anorexia, N/V.
• Cardiac: tachycardia.
• General: Signs and symptoms of hypocalcemia, soft tissue calcifications in lungs, heart, kidneys, and cornea.

Hyperphosphatemia Treatment

• Treat underlying disorder.
• Dietary restriction.
• Phosphate binders.