Koreksi Ele

ktro lit
Ca, Mg
Hipokalsemia
 Hipokalsemia
0 Kadar Kalsium ion <0.7 mmol/L atau <2.8mg/dL atau
kalsium total <7mg/dL
0 Penyebab :
0 Vitamin D yang tidak adekuat atau resisten terhadap
vitamin D
0 Hipoparatiroidism
0 Penyakit ginjal atau liver yang menyebabkan vitamin D
tidak adekuat
 HOW to
DIAGNOSE
 Kalsium dengan
hipoalbuminemia

Kadar Ca total (mg/dL) + (4 – serum alb (g/dL) x 0.8)

 Perubahan EKG pada
hipokalsemia

• QT interval memanjang
 Tatalaksana Hipokalsemia
Akut
0 100 – 300 mg elemental calcium dalam 50-100 mL
D5% atau NS 0.9% bolus selama 5-10 menit
0 Dilanjutkan drip 0.3 - 1mg elemental Ca2+/kgBB/jam
hingga perbaikan, dan bisa di ganti ke PO
0 Ditambah dengan kalsium oral dan calcitriol 0.25 – 1
mikrogram/hari
0 Koreksi cepat kalsium bisa menyebabkan aritmia
jantung sehingga pemberian ca glukonas harus di
monitor, terlebih pada pasien dengan terapi digoxin
0 Pantau kadar Ca2+ setiap 4-6jam

Reddi Alluru, Fluid, Electrolyte and Acid Base Disorders, 2nd ed

 Sediaan (mg) Elemental Ca (mg)
Ca Gluconas 10% 1 amp (1000mg) 93
Ca Chloride 10% 1000mg 273
Ca Gluceprate 22% 5ml 90
 Tatalaksana Hipokalsemia
Kronik
0 Tujuan  mengetahui dan memperbaiki penyebab
0 Kalsium dan vitamin D oral
0 True hipokalsemia  Kalsium karbonat dan kalsium
citrate oral dengan elemental calcium 1-2gram / hari
0 Hipoparatiroidism/gangguan PTH, CKD, dan
osteomalacia  Calcitriol 0.5-1 mikrogram/hari.
0 Defisiensi vit D  ergocalciferol 50.000 IU/minggu
atau 300.000 IU intramuscular/ 3 bulan dilanjutkan
per 6 bulan atau cholcalciferol 400-1000 Unit/hari

Reddi Alluru, Fluid, Electrolyte and Acid Base Disorders, 2nd ed

Hiperkalsemia
 Hiperkalsemia
0 Hiperkalsemia  kalsium >10.5 mEq/L atau 4.8
mg/dL
0 Etiologi :
0 Sekunder akibat peningkatan mobilisasi dari tulang
0 Peningkatan absorbsi Ca2+ di saluran gastrointestinal
0 Penurunan ekskresi Ca2+ pada urin
0 Akibat pengobatan
 Perubahan EKG pada
hiperkalsemia

• QT interval memendek
• Osborn Waves pada severe hypercalcaemia
 HIPERKALSEMIA
0 Tatalaksana akut
0 Meningkatkan ekskresi kalsium melalui ginjal :
pemberian NS 0.9% 300-500ml/jam hingga terjadi
diuresis (200-300ml/jam). Jika rehidrasi adekuat telah
tercapai, bisa ditappering down mjd 100-200 ml/jam
0 Menghambat resorbsi tulang
0 Hemodialisis / Dialisis Peritoneal
0 Tatalaksana kronis
0 Obati penyebab utama
0 Mempertahankan euvolemia
0 Mengurangi produksi 1,25(OH)2D3
0 Mengurangi absorbsi Ca2+ di saluran cerna, menghindari
preparat vitamin D
0 Mengurangi resorpsi tulang, steroid, menurunkan kadar
PTH, menghindari vitamin D
Hipomagnesemia
 HipoMagnesia
0 Bila kadar Mg <1.7 mg/dL
0 Etiologi:
0 Berkurangnya intake Mg2+
0 Reabsorbsi intestinal berkurang
0 Peningkatan ekskresi melalui urine
0 Obat – obatan
FEMg = [(UMg x PCr) / (PMg x UCr x 0.7)] x 100
 Magnesium dengan
hipoalbuminemia

Kadar magnesium + 0.005 (40 – Albumin)

 Manifestasi Klinis
0 Sebagian besar asimtomatik
0 Berdebar-debar, kelemahan otot, kram-kram
0 Aritmia
0 Neuromuskular
0 Kelemahan otot
0 Tremor
0 Parestesia
0 Kejang otot umum dan multifokal
 ECG of Hypomagnesia
0 Prolong QT
0 Atrial and Ventricular Ectopy
0 Torsades de pointes
0 Ventrikel Fibrilasi
ECG : Prolong QT (510ms)
 Tatalaksana
0 Emergency—IV route
0 8–16 mmol statim  MgSO4 2ml dalam 100 ml MS dalam 10
menit pada pasien hemodinamik tidak stabil dengan aritmia,
kejang atau gangguan neuromuskular yg berat (pada pasien
gangguan ginjal dosis dikurangi 50%)
0 40 mmol over next 5 h
0 Severely ill
0 48 mmol on day 1  17–25 mmol on days 2–5 (IM)
0 Stable with symptom : MgSO4 4-8ml dlm NS (IV) selama 12 – 24
jam
0 Asymptomatic—oral route
Sediaan 1amp MgSO4:
0 15 mmol/day 5 g ampoule (0,5 g/ml, 10 ml) for IM injection or IV
infusion
– 1 g magnesium sulfate contains approximately 4 mmol (8
mEq) of magnesium
Hypermagnesemia
 Hipermagnesia
0 Hipermagnesia  konsentrasi ion Mg plasma >2.2
mEq /L atau > 2.7 mg/dL
 Etiology
0 Patients With Renal Insufficiency
0 Magnesium-containing antacids (e.g., magnesium aluminum
hydroxide)
0 Magnesium-containing laxatives or enemas (e.g., magnesium citrate)
0 Patients With Normal Renal Function
0 Treatment of preeclampsia or eclampsia
0 Treatment of hypomagnesemia
0 Miscellaneous
0 Hypothyroidism
0 Hyperparathyroidism
0 Addison disease
0 Lithium treatment
Gejala
 Tatalaksana Hipermagnesia
Patients with adequate renal function and mild asymptomatic
hypermagnesemia require no treatment except to remove all sources of
exogenous magnesium. The half-time of elimination of magnesium is about
28 hours.

Magnesium excretion may be enhanced by saline solution infusion and the

use of loop diuretics.

Patients with symptomatic hypermagnesemia, especially those with

cardiovascular manifestations, require urgent treatment. The
recommended therapy is calcium gluconate 1 g IV over 5 minutes. Also
calcium gluconate (15 mg/kg) should be given over a 4-h period.

Patients with acute or chronic renal failure and symptomatic

hypermagnesemia require dialysis to remove excess magnesium.
CASE STUDY
1. A 22-year-old pregnant woman in her third
trimester was admitted for severe hypertension
(180/110 mmHg) and proteinuria. She was started
on magnesium sulfate (MgSO4) and labetalol. Her
blood pressure was controlled at 140/90 mmHg.
Four days later, she developed nausea and vomiting
and progressively became lethargic. Her blood
pressure dropped to 100/70 mmHg. Deep tendon
were decreased. Her serum creatinine was 2.0
mg/dL and Mg2+ was 6.2 mEq/dL.
 How to treat?
0 First, MgSO4 administration should be discontinued.
0 Second, calcium gluconate (20 mL of 10% solution)
should be given intravenously over a 10-min period to
counteract the manifestations of hypermagnesemia.
0 Third, if the symptoms persist, hemodialysis with a
dialysate containing low-Mg2+ concentration should
be done to remove Mg2+.
2. A 62-year-old man is admitted for chemotherapy of small cell (oat cell)
cancer of the lung with cisplatin. The patient is hydrated with 3 L of
normal saline prior to the initiation of chemotherapy. He subsequently
develops shortness of breath for which he receives furosemide 80 mg
intravenously. He excreted 4 L of urine in 24 h. 7 days later, the patient
started feeling weak. Physical examination reveals tetany, and Chvostek’s
and Trouasseau’s signs could be elicited. The labs:

Na+ = 135 mEq/L

K+ = 2.9 mEq/L
Cl− = 100 mEq/L
HCO3− = 26 mEq/L
BUN = 30 mg/dL
Creatinine = 1.6 mg/dL
Ca2+ = 7.0 mg/dL
Phosphate = 3.0 mg/dL
Albumin = 3.5 mg/dL
Mg2+ = 0.7 mEq/dL
 How to treat?
0 1 gram of MgSO4 50% 2 mL in 100 mL NS given in 30–60
min.
0 This treatment can be continued until plasma [Mg2+]
returns to normal.
0 Normalization of plasma [Mg2+] corrects Ca2+ and K+
3. A 62-year-old man was brought to the emergency
department with altered mental status. Physical examination
showed a confused well-developed male with labored
breathing. He was intubated to protect the airways. His blood
pressure was 132/78 mmHg with a pulse rate of 100 beats
per minute. Except for lower extremity ulcer, which was
rapped with a bandage containing white powder, the rest of
the examination was otherwise normal. His laboratory results
were as follows:
 How to treat?
0 Meningkatkan ekskresi kalsium melalui ginjal :
pemberian NS 0.9% 300-500ml/jam hingga terjadi
diuresis (200-300ml/jam).
0 Koreksi kalium
4. A 46-year-old hemodialysis-dependent woman is admitted for
parathyroidectomy. She has been on maintenance hemodialysis
for 6 years. She is noncompliant to diet and medications. She is
normotensive. Her only complaint is bone pain. Pertinent
laboratory results: serum [Ca2+] 12.4 mg/dL, phosphate 8.2
mg/dL, and PTH 3,940 pg/mL. She could not tolerate cinacalcet
because of gastrointestinal problems. A scan of parathyroid
glands shows bilateral adenoma. She had a total
parathyroidectomy. Postoperative serum [Ca2+] was 4.2 mg/dL
with ionized Ca2+ 1.9 mg/dL. She complained of tingling and
paresthesia of lower extremities. She had positive Trousseau’s
and Chvostek’s signs.
 How to treat?
0 Acute  calcium gluconate (10%) dissolved in 5%
dextrose over a period of 10–15 min, followed by 1
mg/kg/h of elemental Ca2+ orally until symptoms
improve.
0 Calcitriol 1 μg infusion in 20–30 min, followed by oral
calcitriol of 1 μg in a period of 24 h.
0 Chronic  two to three tablets of calcium carbonate
(elemental Ca2+ 1,000–1,500 mg) per day with 2 μg
of IV Zemplar on dialysis days (three times/week).
TERIMA KASIH