How is electrolyte imbalance treated?

Treatment of Electrolyte Imbalance

Immediately assess for life-threatening disturbances requiring urgent intervention (hyperkalemia with ECG changes, severe hyponatremia with seizures), initiate targeted correction with IV calcium for cardioprotection in hyperkalemia or hypertonic saline for symptomatic hyponatremia, while simultaneously addressing the underlying cause. 1

Immediate Assessment and Stabilization

• Perform an ECG immediately to detect life-threatening cardiac manifestations, particularly peaked T waves, widened QRS complexes, or arrhythmias that indicate dangerous hyperkalemia requiring immediate intervention 1
• Assess hydration status through clinical examination (skin turgor, mucous membranes, hemodynamic parameters) and laboratory evaluation including serum electrolytes, osmolality, BUN/creatinine, and arterial blood gases 2, 3
• Determine the pattern of electrolyte abnormalities to identify the underlying cause: gastrointestinal losses typically cause hypokalemia, hyponatremia, and metabolic alkalosis; renal losses from diuretics cause similar patterns; endocrine disorders require specific hormonal evaluation 1

Life-Threatening Imbalances Requiring Immediate Intervention

Hyperkalemia with ECG Changes

• Administer IV calcium chloride (10 mL of 10% solution) or calcium gluconate (30 mL of 10% solution) immediately for cardiac membrane stabilization (Class I recommendation) 1
• Follow with measures to shift potassium intracellularly: insulin (10 units regular insulin with 25g dextrose), beta-2 agonists (nebulized albuterol), and sodium bicarbonate if concurrent metabolic acidosis exists 1
• Enhance potassium elimination through loop diuretics, potassium-binding resins, or dialysis depending on renal function and severity 2

Severe Symptomatic Hyponatremia

• For patients with altered mental status or seizures, administer 3% hypertonic saline at 100 mL bolus over 10 minutes, which can be repeated up to 2-3 times if symptoms persist 4
• Monitor sodium levels closely to avoid overly rapid correction (target increase of 4-6 mEq/L in first 24 hours) to prevent osmotic demyelination syndrome 4

Fluid Resuscitation Strategy

• Use balanced crystalloids (lactated Ringer's or Plasma-Lyte) rather than 0.9% normal saline for resuscitation and volume maintenance to avoid worsening hyperchloremic acidosis and electrolyte derangements 1
• In severe acute ulcerative colitis, provide IV fluid and electrolyte replacement with potassium supplementation of at least 60 mmol/day, as hypokalemia or hypomagnesemia can promote toxic dilatation 2
• For patients with multiple electrolyte imbalances and volume depletion, balanced crystalloid resuscitation addresses both volume depletion and hyponatremia simultaneously 1

Systematic Correction Approach Based on Specific Imbalances

Hypokalemia

• Use potassium chloride specifically (not potassium citrate or acetate) to avoid worsening metabolic alkalosis, which commonly accompanies hypokalemia from gastrointestinal or diuretic losses 1
• In patients receiving furosemide therapy, monitor for hypokalemia development, especially with brisk diuresis, inadequate oral electrolyte intake, cirrhosis, or concomitant corticosteroid use 5
• Serum potassium should be determined frequently during the first few months of diuretic therapy and periodically thereafter, with abnormalities corrected or the drug temporarily withdrawn 5

Hypocalcemia and Hypomagnesemia

• Correct hypomagnesemia before or concurrent with hypocalcemia, as magnesium deficiency impairs parathyroid hormone secretion and prevents effective calcium correction 1
• Furosemide may lower serum calcium (rarely causing tetany) and magnesium; accordingly, serum levels should be determined periodically 5

Hypophosphatemia

• In patients receiving kidney replacement therapy (KRT), hypophosphatemia occurs in 60-80% of ICU patients and is associated with worsening respiratory failure, cardiac arrhythmias, and prolonged hospitalization 2
• Monitor phosphate, potassium, and magnesium closely in patients receiving intensive KRT modalities (CKRT, PIKRT), as these treatments efficiently remove electrolytes 2
• Consider phosphate replacement (20-30 mEq/L potassium phosphate) in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 6

Hyponatremia

• Hypovolemic hyponatremia: Manage with isotonic saline rehydration 4
• Hypervolemic hyponatremia (heart failure, cirrhosis, renal failure): Address the underlying cause and restrict free water intake 4
• Euvolemic hyponatremia (SIADH): Restrict free water intake to 800-1000 mL/day and consider vasopressin receptor antagonists for persistent cases 4

Hypernatremia

• Correct with oral or IV hypotonic fluids depending on severity, with the induced change in serum osmolality not exceeding 3 mOsm/kg/h to prevent cerebral edema 6
• In hyperglycemic hyperosmolar syndrome, fluid replacement should correct estimated deficits (typically 9 liters or 100-200 mL/kg) within the first 24 hours 6

Identifying and Treating Underlying Causes

Common Etiologies

• Gastrointestinal losses (vomiting, diarrhea, nasogastric suction): Cause hypokalemia, hyponatremia, and metabolic alkalosis; loss of gastric contents results in excessive chloride loss, while diarrhea causes predominant base loss 1, 7
• Medications: Diuretics, ACE inhibitors, ARBs, NSAIDs commonly cause imbalances; avoid potassium-sparing diuretics, ACE inhibitors, or ARBs in salt-wasting disorders as they worsen hypovolemia 1
• Endocrine disorders (Addison's disease, SIADH, hyperaldosteronism): Require specific hormonal treatment in addition to electrolyte correction 1
• Renal dysfunction: In patients with kidney failure receiving KRT, electrolyte abnormalities are common (cumulative incidence up to 65%) and require close monitoring 2

Specific Clinical Contexts

• In severe ulcerative colitis, perform unprepared flexible sigmoidoscopy to exclude cytomegalovirus infection and stool assay for Clostridium difficile, which increases morbidity and mortality 2
• In diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome, obtain bacterial cultures and administer appropriate antibiotics if infection is suspected 6, 8

Monitoring During Treatment

• Draw blood every 2-4 hours for serum electrolytes, glucose, BUN, creatinine, and osmolality during active correction of severe imbalances 6, 8
• Monitor fluid input/output, hemodynamic parameters, and clinical examination to assess progress with fluid replacement 6
• Serum electrolytes (particularly potassium), CO2, creatinine, and BUN should be determined frequently during the first few months of diuretic therapy and periodically thereafter 5
• Serum and urine electrolyte determinations are particularly important when the patient is vomiting profusely or receiving parenteral fluids 5

Critical Pitfalls to Avoid

• Never assume electrolyte imbalances are the sole cause of cardiac arrest; survivors should receive definitive therapy unless transient reversible causes are definitively proven 1
• Avoid overly rapid correction of chronic hyponatremia (>8-10 mEq/L in 24 hours) or hypernatremia (>3 mOsm/kg/h), as this increases the risk of osmotic demyelination syndrome or cerebral edema 6, 4
• Never start insulin before excluding hypokalemia in diabetic emergencies, as insulin drives potassium intracellularly and can precipitate life-threatening hypokalemia 6
• In hepatic cirrhosis with ascites, sudden alterations of fluid and electrolyte balance may precipitate hepatic coma; therapy should not be instituted until the basic condition is improved, and strict observation is necessary during diuresis 5
• Observe all patients receiving diuretic therapy for signs of fluid or electrolyte imbalance: dryness of mouth, thirst, weakness, lethargy, drowsiness, restlessness, muscle pains or cramps, muscular fatigue, hypotension, oliguria, tachycardia, arrhythmia, or gastrointestinal disturbances 5
• Premature termination of treatment before complete resolution (e.g., stopping insulin in DKA before ketosis clears) can lead to recurrence of the metabolic emergency 8

Special Considerations in Specific Populations

Critically Ill Patients

• Electrolyte imbalances are significant predictors of mortality in ICU patients with respiratory failure, with sodium exhibiting a "U-shaped" relationship where both hyponatremia and hypernatremia increase mortality risk 9
• Low potassium and calcium levels are associated with significantly higher mortality rates in critically ill patients 9

Patients on Kidney Replacement Therapy

• Electrolyte abnormalities shall be closely monitored (Grade A recommendation) as KRT efficiently removes electrolytes, particularly causing hypophosphatemia, hypokalemia, and hypomagnesemia 2
• The parallel initiation of medical nutrition, especially carbohydrate-rich formulas, may precipitate refeeding syndrome with severe hypophosphatemia 2

Pediatric Patients

• In premature neonates receiving furosemide, doses exceeding 1 mg/kg/24 hours may develop toxic plasma levels including ototoxicity; hearing loss has been associated with furosemide use in neonates 5