Electrolyte Electrolyte disturbancesdisturbances
Moderator Dr Sumesh RaoModerator Dr Sumesh Rao
Presenter Dr Nikhil MPPresenter Dr Nikhil MP
Disorders of sodium Disorders of sodium balancebalance
Normal plasma sodium is 135 to 145 Normal plasma sodium is 135 to 145 meq/lmeq/l
HyponatremiaHyponatremia
Plasma sodium <135 Plasma sodium <135 meq/lmeq/l
TypesTypes Hypoosmolal hyponatremiaHypoosmolal hyponatremia
Hyponatremia with normal plasma Hyponatremia with normal plasma osmolalityosmolality
Hyponatremia with elevated Hyponatremia with elevated plasma osmolality plasma osmolality
Hypoosmolal Hypoosmolal hyponatremiahyponatremia
TypesTypes
HypovolemicHypovolemic
EuvolemicEuvolemic
HypervolemicHypervolemic
HyopovolemicHyopovolemic RenalRenal diuretics diuretics mineralocorticoid deficiency mineralocorticoid deficiency salt wasting nephropathiessalt wasting nephropathies osmotic diuresisosmotic diuresis renal tubular acidosisrenal tubular acidosis GastrointestinalGastrointestinal vomitingvomiting diarrheadiarrhea fistulafistula integumentaryintegumentary sweatingsweating burnsburns
Euvolemic Euvolemic Primary polydipsiaPrimary polydipsia SIADHSIADH Arginine vasopressin release due Arginine vasopressin release due
to pain,nauseato pain,nausea Glucocorticoid deficiencyGlucocorticoid deficiency HypothyroidismHypothyroidism Chronic renal insufficiencyChronic renal insufficiency
Hypervolemic Hypervolemic Congestive cardiac failureCongestive cardiac failure
Cirrhosis Cirrhosis
Nephrotic syndromeNephrotic syndrome
PseudohyponatremiaPseudohyponatremia
Hyponatremia with normal plasma Hyponatremia with normal plasma
osmolality osmolality marked hyperlipidemiamarked hyperlipidemia marked hyperproteinemia.marked hyperproteinemia. TURP syndromeTURP syndrome Hyponatremia with elevated plasma Hyponatremia with elevated plasma
osmolality osmolality hyperglycemiahyperglycemia mannitol.mannitol.
Clinical featuresClinical features
mainlymainly
Clinical featuresClinical features Primarily neurologicalPrimarily neurological Increased ICF volumeIncreased ICF volume severity:depends on rapidity of severity:depends on rapidity of
onset and absolute increase in onset and absolute increase in plasma sodium concentrationplasma sodium concentration
Asymtomatic or nausea,vomitingAsymtomatic or nausea,vomiting Depressed level of Depressed level of
consciousness,confusion,agitatioconsciousness,confusion,agitationn
Stupor,seizures and coma.Stupor,seizures and coma.
Cerebral edema Cerebral edema < 120 < 120 meq/lmeq/l
Cardiac symptoms Cardiac symptoms < 100 < 100 meq/lmeq/l
diagnosisdiagnosis
history & physical examinationhistory & physical examination 3 tests3 tests
plasma osmolalityplasma osmolality
urinary osmolalityurinary osmolality
urinary sodium excretionurinary sodium excretion
Plasma osmolality = 2 Na + Plasma osmolality = 2 Na + glucoseglucose + + BUNBUN
18 2.818 2.8
cont…….cont……. Plasma osmolality lowPlasma osmolality low impaired function impaired function assess renal statusassess renal status primary renal disease primary renal disease normalnormalAssess volume statusAssess volume status volume depletion volume depletion
volume overloadvolume overload normovolemicnormovolemic
CCF CCF urinary sodium(meq/lurinary sodium(meq/l) )
nephrotic nephrotic Adrenal &Adrenal &
cirrhosis cirrhosisthyroidthyroid insufficiency <10 >20 insufficiency <10 >20 normal diarrhea salt wasting normal diarrhea salt wasting
nephropathy nephropathy vomiting diuretics vomiting diuretics Able to dilute urineAble to dilute urineIn response to water loadIn response to water load dilute urine dilute urine
psyhogenic polydipsiapsyhogenic polydipsia no yes no yes SIADHSIADH
treatmenttreatment
Goals of therapyGoals of therapy To raise plasma sodium To raise plasma sodium
concentration by restricting concentration by restricting water intake and promoting water intake and promoting water losswater loss
To correct underlying disorderTo correct underlying disorder
principlesprinciples 0.9%0.9% & & 3% saline3% saline: Hypovolemic: Hypovolemic
Water restrictionWater restriction :Euvolemic :Euvolemic
&&
HypervolemicHypervolemic
When to treat....?When to treat....?
SymptomaticSymptomatic
Plasma sodium < 120 meq/lPlasma sodium < 120 meq/l
Cont….Cont…. Rate of correction depends on Rate of correction depends on
absence or presence of neurologic absence or presence of neurologic dysfunction.dysfunction.
In asymptomatic patients :In asymptomatic patients : 0.5 to 1 meq/l/hr or 10 to 12 meq/l 0.5 to 1 meq/l/hr or 10 to 12 meq/l
over first 24 hoursover first 24 hours
Severe symptomatic hyponatremia Severe symptomatic hyponatremia (<110 meq/l) (<110 meq/l)
hypertonic salinehypertonic saline 1 to 2 meq/l/hr for the first 3 to 4 1 to 2 meq/l/hr for the first 3 to 4
hrs,total not exceeding more than hrs,total not exceeding more than 12meq/l/ 24hrs.12meq/l/ 24hrs.
To calculate Na deficitTo calculate Na deficit
SodiumSodium deficitdeficit=total body water X=total body water X
(desired Na - present Na)(desired Na - present Na)
TBWTBW = body wt x 0.6 males = body wt x 0.6 males
0.5 females0.5 females
Change in plasma sodiumChange in plasma sodium
Infusate sodium/l Infusate sodium/l - - Serum sodiumSerum sodium
TBW + 1TBW + 1
Case historyCase history
A 45 yr male ,50 kg by wt A 45 yr male ,50 kg by wt presented with presented with
altered sensorium and agitation.a altered sensorium and agitation.a diagnosis of diagnosis of
hypoosmolar hyponatremia is hypoosmolar hyponatremia is made.plasma made.plasma
sodium is 110 meq/l .sodium is 110 meq/l .
sodium requirement= desired Na – sodium requirement= desired Na – serum Na X serum Na X
TBWTBW
= 130 - 110 X 0.6 = 130 - 110 X 0.6 X 50X 50
= 600 meq= 600 meq
change in Na = infusate Na - serum Nachange in Na = infusate Na - serum Na
TBW + 1TBW + 1
= 513 - 110 = 403 = 13 = 513 - 110 = 403 = 13 meq/lmeq/l
30 + 1 3130 + 1 31
100 ml 1.3 meq/l100 ml 1.3 meq/l
800 ml over 24 hrs app 34 800 ml over 24 hrs app 34 ml/hrml/hr
Rapid correction can lead to…Rapid correction can lead to…
osmotic demyelination osmotic demyelination syndrome(central syndrome(central
Pontine myelinolysis)Pontine myelinolysis)
chronic hyponatremiachronic hyponatremia
flaccid paralysis,dysarthria,dysphagia.flaccid paralysis,dysarthria,dysphagia.
no specific treatment.no specific treatment.
Anaesthetic implicationsAnaesthetic implications
Plasma Na > 130meq/l for Plasma Na > 130meq/l for patients undergoing elective patients undergoing elective surgery & is considered safesurgery & is considered safe
Lower levels can result in Lower levels can result in signifcant cerebral edema signifcant cerebral edema
Decrease in MAC: Decrease in MAC: intraoperativelyintraoperatively
Agitation & Agitation & confusion :confusion :postoperatively postoperatively
HypernatremiaHypernatremia
Plasma Plasma sodium>145meq/lsodium>145meq/l
causescauses
Impaired thirstImpaired thirst
comacoma
essential hypernatremiaessential hypernatremia Solute diuresisSolute diuresis
diabetic ketoacidosisdiabetic ketoacidosis
non-ketotic hyperosmolar non-ketotic hyperosmolar comacoma
excessive water lossexcessive water loss
diabetes insipidusdiabetes insipidus
sweatingsweating
TypesTypes
Hypernatremia with low body Hypernatremia with low body sodium contentsodium content
Hypernatremia with normal body Hypernatremia with normal body sodium contentsodium content
Hypernatremia and increased Hypernatremia and increased body sodium contentbody sodium content
Hypernatremia with low Hypernatremia with low body sodium contentbody sodium content
Water loss in excess of sodium Water loss in excess of sodium loss.loss.
eg:osmotic diuresiseg:osmotic diuresis
diarrheadiarrhea
sweatingsweating
Hypernatremia with normal Hypernatremia with normal total body sodium contenttotal body sodium content
Due to water lossDue to water loss
Diabetes insipidusDiabetes insipidus
central diabetes insipiduscentral diabetes insipidus
nephrogenic diabetes nephrogenic diabetes insipidusinsipidus
Hypernatremia and increased Hypernatremia and increased total body sodium contenttotal body sodium content
Following administration of large Following administration of large quantitiesquantities
of hypertonic saline solutionsof hypertonic saline solutions
Clinical featuresClinical features
mainlymainly
Mainly due to Mainly due to contracted ICF volumecontracted ICF volume
Mainly neurologicalMainly neurological alered mental statusalered mental status irritabilityirritability weaknessweakness focal neurological deficitsfocal neurological deficits coma &deathcoma &death
Prone for intracerebral or subarachnoid Prone for intracerebral or subarachnoid haemorrhagehaemorrhage
diagnosisdiagnosis
ECF volumeECF volume not increased increased hypertonic not increased increased hypertonic
Nacl orNacl or sodium sodium
bicarbonatebicarbonate min volume of max min volume of max concentrated urine noconcentrated urine no yesyesInsensible water loss urine osmole Insensible water loss urine osmole Gastrointestinal excretion rateGastrointestinal excretion rate >750 mosmol/d>750 mosmol/d no yes no yes
renal response diureticrenal response diuretic to desmopressin osmotic diuresisto desmopressin osmotic diuresis urine osmolalityurine osmolality
increased unchangedincreased unchanged
central DI nephrogenic DIcentral DI nephrogenic DI
treatmenttreatment
Goals of therapyGoals of therapy
To correct water deficitTo correct water deficit
To stop ongoing water lossTo stop ongoing water loss
principlesprinciples Correction should be done over Correction should be done over 48 48
toto 72 hours72 hours..
Hypotonic solution like 5% Hypotonic solution like 5% dextrose.dextrose.
Plasma Na should be lowered by Plasma Na should be lowered by 0.50.5 meq/l/hrmeq/l/hr or not more than or not more than 12meq/l/12meq/l/ 24 hrs.24 hrs.
To calculate water deficitTo calculate water deficit
WaterWater deficitdeficit==plasma Na - 140plasma Na - 140 X TBW X TBW
140140
Rapid correction can lead to…Rapid correction can lead to…
Seizures or permanent neurologic Seizures or permanent neurologic damagedamage
Anaesthetic implicationsAnaesthetic implications
Increases MACIncreases MAC Enhance uptake of inhalation Enhance uptake of inhalation
anaesthtics by decreasing anaesthtics by decreasing cardiac output. cardiac output.
Predisposes to hypotension & Predisposes to hypotension & hypoperfusion of tissueshypoperfusion of tissues
Decreases volume of distribution Decreases volume of distribution and reduction in dose of and reduction in dose of intravenous agentsintravenous agents
Disorders of potassium Disorders of potassium balancebalance
Normal plasma potassium is 3.5 to 5 Normal plasma potassium is 3.5 to 5 meq/lmeq/l
HypokalemiaHypokalemia
Plasma potassium < 3.5 Plasma potassium < 3.5 meq/lmeq/l
causescauses
Redistribution into cellsRedistribution into cells
Increased lossIncreased loss
Decreased intakeDecreased intake
Redistribution into cellsRedistribution into cells Metabolic alkalosisMetabolic alkalosis HormonalHormonal insulininsulin beta 2 agonistbeta 2 agonist alpha antagonistalpha antagonist Anabolic stateAnabolic state vit B12 /folic acidvit B12 /folic acid total parentral nutritiontotal parentral nutrition othersothers Hypokalemic periodic paralysisHypokalemic periodic paralysis hypothermia hypothermia barium toxicity.barium toxicity.
Increased lossIncreased loss Renal Renal primary hyperaldosteronismprimary hyperaldosteronism secondary hyperaldosteronismsecondary hyperaldosteronism congenital adrenal hyperplasiacongenital adrenal hyperplasia cushings syndromecushings syndrome bartters syndromebartters syndrome liddles syndrome liddles syndrome renal tubular acidosisrenal tubular acidosis diabetic ketoacidosisdiabetic ketoacidosis diuretics,aminoglycosides,penicillindiuretics,aminoglycosides,penicillin amphotericin-Bamphotericin-B Gastrointestinal Gastrointestinal
integumentaryintegumentary
Decreased intakeDecreased intake
StarvationStarvation
Clay ingestionClay ingestion
Clinical featuresClinical features
Manifestations vary between Manifestations vary between patientpatient
AsymptomaticAsymptomatic
<3 mq/l<3 mq/l
Fatigue,myalgia&lower extremity Fatigue,myalgia&lower extremity weaknessweakness
NeuromuscularNeuromuscular
NeuromuscularNeuromuscular
Fatigue,myalgia,muscular weaknessFatigue,myalgia,muscular weakness
Progressive weakness and Progressive weakness and hypoventilationhypoventilation
as severity increasesas severity increases
RhabdomyolysisRhabdomyolysis
Paralytic ileusParalytic ileus
cardiovascularcardiovascular
Abormal electrocardiogramAbormal electrocardiogram ArrhythmiasArrhythmias Orthostatic hypotensionOrthostatic hypotension Decreased cardiac contractilityDecreased cardiac contractility Potentiates arrhythmogenic Potentiates arrhythmogenic
potential of digoxinpotential of digoxin Myocardial fibrosisMyocardial fibrosis
ECG ChangesECG Changes Appearance of Appearance of U waveU wave Flattening or inversion of T waveFlattening or inversion of T wave ST segment depressionST segment depression Prolonged QT intervalProlonged QT interval Prominent U wave Prominent U wave Prolonged PR intervalProlonged PR interval Widening of QRS complexWidening of QRS complex Ventricular arrhythmiasVentricular arrhythmias
diagnosisdiagnosis
history history urinary potassium excretion urinary potassium excretion
<15mmol/d >15mmol/d.<15mmol/d >15mmol/d.
assess acid- base statusassess acid- base status metabolic acidosis metabolic metabolic acidosis metabolic
alkalosisalkalosis lower gastrointestinal loss diureticlower gastrointestinal loss diuretic vomiting vomiting k+loss via sweatk+loss via sweat
>15 meq/day>15 meq/day assess k+ excretionassess k+ excretion
TTKG>4 TTKG<2 salt TTKG>4 TTKG<2 salt wasting nephropathywasting nephropathy
osmotic osmotic diuresisdiuresis
Assess acid-base status diureticAssess acid-base status diuretic
metabolic metabolicmetabolic metabolic acidosis alkalosisacidosis alkalosis yesyesDKA hypertension DKA hypertension
mineralocorticoid mineralocorticoid Proximal RTA Proximal RTA no no
excessexcessDistal RTA vomiting liddles Distal RTA vomiting liddles
syndromesyndrome bartters bartters diuretic abusediuretic abuse hypomagnesemiahypomagnesemia
treatmenttreatment
Therapeutic goalsTherapeutic goals
To correct potassium deficitTo correct potassium deficit
To minimize ongoing lossesTo minimize ongoing losses
To prevent life threatening To prevent life threatening complicationscomplications
principlesprinciples
Safer to correct potassium via oral Safer to correct potassium via oral routeroute
A decrement of 1mmol/l in plasma A decrement of 1mmol/l in plasma potassium may represent a total potassium may represent a total body k+ deficit of 200 to 400meqbody k+ deficit of 200 to 400meq
Dextrose containing solutions Dextrose containing solutions avoidedavoided
treatmenttreatment
When to treat…..?When to treat…..?
3.5 to 4 mq/l3.5 to 4 mq/l
Increased intake of Increased intake of potassium containing food.potassium containing food.
3 to 3.5 mq/l3 to 3.5 mq/l
Only in high risk patients.Only in high risk patients.
< 3 mq/l needs definitive < 3 mq/l needs definitive treatment.treatment.
Oral potassiumOral potassium Safer Safer Potassium chloridePotassium chloride preparation of preparation of
choicechoice Potassium bicarbonate and citratePotassium bicarbonate and citrate Mild to moderate hyperkalemia kcl 60 Mild to moderate hyperkalemia kcl 60
to 80 meq/day in 3 to 4 divided dosesto 80 meq/day in 3 to 4 divided doses Severe or symptomatic – kcl 40 mq 6Severe or symptomatic – kcl 40 mq 6thth
hourly under ECG monitoringhourly under ECG monitoring 15 ml solution=20 meq15 ml solution=20 meq 8 meq/tab8 meq/tab
Iv potassiumIv potassium
Severe symptomatic hypokalemiaSevere symptomatic hypokalemia Continous ECG monitoring & Continous ECG monitoring &
frequent k+ estimationfrequent k+ estimation Never give KCl directly IV.Never give KCl directly IV. Rapid IV correction can cause Rapid IV correction can cause
dangerous hyperkalemia.dangerous hyperkalemia. Use isotonic salineUse isotonic saline Do not mix with dextrose Do not mix with dextrose
containing solutionscontaining solutions..
Cont…..Cont….. 15% KCl solution in 10 ml 15% KCl solution in 10 ml
ampoule.ampoule.
10 ml = 20 meq of potassium = 10 ml = 20 meq of potassium = 1.5 g KCl.1.5 g KCl.
How long to give?How long to give?
As cardiac rhythm returns As cardiac rhythm returns to normal KCl drip is tapered and to normal KCl drip is tapered and oral k+ initiated. oral k+ initiated.
Cont….Cont….
should not exceed 8meq/hr via should not exceed 8meq/hr via peripheral veinperipheral vein
central venous catheter in case central venous catheter in case of faster replacements&should of faster replacements&should not exceed more than 20 not exceed more than 20 meq/hourmeq/hour
Anaesthetic implicationsAnaesthetic implications Chronic hypokalemia more succeptible Chronic hypokalemia more succeptible
for arrhythmiasfor arrhythmias ECG monitoringECG monitoring Glucose free solutionsGlucose free solutions Potentiates neuromuscular blockersPotentiates neuromuscular blockers Avoid alkalosisAvoid alkalosis Hyperventilation avoidedHyperventilation avoided
HyperkalemiaHyperkalemia
Plasma potassium >5 Plasma potassium >5 meq/lmeq/l
causescauses Decreased renal excreation of potassiumDecreased renal excreation of potassium
renal failurerenal failure
primary hypoaldosteronismprimary hypoaldosteronism
secondary hypoaldosteronismsecondary hypoaldosteronism
drugsdrugs
spironolactonespironolactone
nsaidsnsaids
ace inhibitorsace inhibitors
trimethoprimtrimethoprim
heparinheparin
Cont…Cont… Due to extracellularDue to extracellular movement of k+movement of k+ acidosisacidosis hyperkalemic periodic paralysishyperkalemic periodic paralysis succinylcholinesuccinylcholine rhabdomyolysisrhabdomyolysis cell lysis following chemotherapycell lysis following chemotherapy digitalis overdosedigitalis overdose Enhanced chloride reabsorptionEnhanced chloride reabsorption cyclosporinecyclosporine Gordons syndromeGordons syndrome Increased potassium intakeIncreased potassium intake pseudohyperkalemiapseudohyperkalemia
Clinical featuresClinical features
skeletalskeletal
skeletalskeletal
Weakness,flaccid paralysisWeakness,flaccid paralysis
HypoventilationHypoventilation
CVSCVS
cardiaccardiac Increased T-wave amplitude 6 to 7 Increased T-wave amplitude 6 to 7
meq/lmeq/l Prolonged PR intervalProlonged PR interval
QRS widening 7 to 8 QRS widening 7 to 8 meq/lmeq/l
Loss of P waveLoss of P wave
sine wave patternsine wave pattern 8 to 9 8 to 9 meq/l meq/l
Ventricullar fibrillation or asystole > Ventricullar fibrillation or asystole > 9meq/l9meq/l
diagnosisdiagnosisExclude Exclude
pseudohyperkalemia&transcellular k+ pseudohyperkalemia&transcellular k+ shiftsshifts
Exclude oliguric renal failureExclude oliguric renal failure
stop NSAIDs and ACE inhibitorsstop NSAIDs and ACE inhibitors
assess k+ secretionassess k+ secretion
Cont……Cont…… TTKG < 5TTKG < 5 TTKG > 10TTKG > 10 decreased circulating vol decreased circulating vol
Response to low protien dietResponse to low protien diet 9a-fludrocortisone9a-fludrocortisone
TTKG >10 TTK<10TTKG >10 TTK<10 primary/secondary hypotension HTN primary/secondary hypotension HTN hypoaldosteronism high renin & low renin&hypoaldosteronism high renin & low renin& aldosterone aldosterone
aldosteronealdosterone
pseudohypoaldosteronism Gordons pseudohypoaldosteronism Gordons syndromesyndrome
k+diuretics cyclosporinek+diuretics cyclosporine distal RTAdistal RTA
treatmenttreatment
principlesprinciples >6meq/l should be treated>6meq/l should be treated
To minimize membrane excitabilityTo minimize membrane excitability
To shift potassium into cellsTo shift potassium into cells
Promote potassium lossPromote potassium loss
Calcium gluconateCalcium gluconate 10% solution in 10 ml ampoules10% solution in 10 ml ampoules 10ml of 10% calcium gluconate IV 10ml of 10% calcium gluconate IV
over 5 to 10 minover 5 to 10 min Repeated if no change in ECG is Repeated if no change in ECG is
seen after 5 to 10 minseen after 5 to 10 min How it helps……?How it helps……? protects the myocardium protects the myocardium
from toxicity to potassiumfrom toxicity to potassium
Insulin & glucoseInsulin & glucose
10 to 20 units of regular insulin in 10 to 20 units of regular insulin in 50 ml of 25 to 50 % dextrose50 ml of 25 to 50 % dextrose
Initial bolus should be followed by Initial bolus should be followed by continous infusion of 5% dextrose continous infusion of 5% dextrose
effect begins in 15 min & peak in effect begins in 15 min & peak in 60 min60 min
cont…..cont….. Sodium bicarbonateSodium bicarbonate
7.5 % of 50 to 100 ml is given 7.5 % of 50 to 100 ml is given as IV slowly over 10 to 20 min.as IV slowly over 10 to 20 min.
Beta agonistBeta agonist
salbutamol 20 mg in 4 ml saline salbutamol 20 mg in 4 ml saline by nebulisation by nebulisation
Loop & thiazide diureticsLoop & thiazide diuretics
Cont…Cont… Cation exchange resinsCation exchange resins sodium polystyren sulphonatesodium polystyren sulphonate promote exchange of Na for K promote exchange of Na for K
in in GIT GIT
25 to 50g with 100ml of 20% 25 to 50g with 100ml of 20%
sorbitol 3 to 4 times a daysorbitol 3 to 4 times a day
Haemodialysis Haemodialysis
Anaesthetic implicationsAnaesthetic implications ECG monitoringECG monitoring Succinylcholine avoidedSuccinylcholine avoided Potssium free solutionsPotssium free solutions Avoid acidosisAvoid acidosis Potentiates neuromuscular Potentiates neuromuscular
blockersblockers Mild hyperventilationMild hyperventilation
Disorders of calcium Disorders of calcium balancebalance
Normal plasma calcium 8.5 to Normal plasma calcium 8.5 to 10.5 mg/dl.10.5 mg/dl.
50% in ionized form ,40% 50% in ionized form ,40% protein bound,10% complexed protein bound,10% complexed with anionswith anions
hypocalcemiahypocalcemia
Plasma calcium <8.5 mg Plasma calcium <8.5 mg dldl
causescauses HypoparathyroidismHypoparathyroidism Vitamin D deficiencyVitamin D deficiency nutritionalnutritional malabsorptionmalabsorption HyperphosphatemiaHyperphosphatemia Precipitation of calciumPrecipitation of calcium pancreatitispancreatitis rhabdomyolysisrhabdomyolysis Chelation of calciumChelation of calcium rapid blood transfusionrapid blood transfusion rapid infusion of large amount of rapid infusion of large amount of
albumins albumins
Hallmark of hypocalcemia is Hallmark of hypocalcemia is TETANYTETANY
Parasthesia in circumoral region & Parasthesia in circumoral region & extremitiesextremities
Laryngospasm,bronchospasmLaryngospasm,bronchospasm Abdominal cramps,urinary Abdominal cramps,urinary
frequencyfrequency Hypotension & arrhythmiasHypotension & arrhythmias Latent hypocalcemiaLatent hypocalcemia
Chvosteks signChvosteks sign
Trousseaus signTrousseaus sign
ECGECG
Prolongation of QT intervalProlongation of QT interval
treatmenttreatment Symptomatic hypocalcemia – emergencySymptomatic hypocalcemia – emergency 10 ml of 10% 10 ml of 10% calcium calcium
gluconategluconate IV over 10 minutes. IV over 10 minutes.
Iv calcium should not be given with Iv calcium should not be given with bicarbonate or phosphate containing bicarbonate or phosphate containing solutionsolution
Serial calcium measurementsSerial calcium measurements
Correction of co-existing alkalosisCorrection of co-existing alkalosis
Calcium supplimentation in long Calcium supplimentation in long term term
Anaesthetic implicatonsAnaesthetic implicatons
Corrected preoperativelyCorrected preoperatively Serial ionized calcium level Serial ionized calcium level
monitoredmonitored Potentiates negative inotropic Potentiates negative inotropic
effect of barbiturates and volatile effect of barbiturates and volatile anaestheticsanaesthetics
LaryngospasmLaryngospasm Alkalosis should be avoidedAlkalosis should be avoided
hypercalcemiahypercalcemia
plasma calcium > 10.5 plasma calcium > 10.5 mg/dl mg/dl
causescauses HyperparathyroidismHyperparathyroidism MalignancyMalignancy Pagets disease of bonePagets disease of bone Excessive vitamin D intakeExcessive vitamin D intake Granulomatous disordersGranulomatous disorders Milk- alkali syndromeMilk- alkali syndrome DrugsDrugs thiazides thiazides lithiumlithium
Clinical featuresClinical features AnorexiaAnorexia Nausea,vomitingNausea,vomiting WeaknessWeakness PolyuriaPolyuria AtaxiaAtaxia IrritabilityIrritability LethargyLethargy confusionconfusion
ECG changesECG changes
Pronged PR intervalPronged PR interval
Widened QRS complexWidened QRS complex
Shortened QTShortened QT
treatmenttreatment HydrationHydration with normal saline with normal saline Loop diuretics like frusemideLoop diuretics like frusemide haemodialysishaemodialysis Urine output > 3 litres /dayUrine output > 3 litres /day k+ and Mg+k+ and Mg+ Severe cases bisphosphonatesSevere cases bisphosphonates pamindronate 60 to 80 mg iv pamindronate 60 to 80 mg iv
over 4 hrsover 4 hrs calcitonin 2 to 8 U subcutcalcitonin 2 to 8 U subcut 90% due to malignancy & 90% due to malignancy &
hyperparathyroidismhyperparathyroidism
Anaesthetic implicationsAnaesthetic implications
Saline diuresisSaline diuresis
K+ & Mg+K+ & Mg+
decreased dose of neuromuscular decreased dose of neuromuscular blockersblockers
Cvp & pulmonary pressure monitoringCvp & pulmonary pressure monitoring
Hyperventilation avoidedHyperventilation avoided
Disorders of magnesium Disorders of magnesium balancebalance
hypomangnesemiahypomangnesemia
Plasma mg+ <1.7 Plasma mg+ <1.7 meq/lmeq/l
causescauses Inadequate intakeInadequate intake Reduced gasroinestinal absorptionReduced gasroinestinal absorption malabsorptionmalabsorption small bowel /biliary fistulasmall bowel /biliary fistula severe diarrheasevere diarrhea prolonged nasogastric suctionigprolonged nasogastric suctionig Renal lossesRenal losses diuresisdiuresis hyperparathyroidismhyperparathyroidism DrugsDrugs theophyllinetheophylline diuretics,ethyl alcoholdiuretics,ethyl alcohol aminoglycoside,amphotericin B aminoglycoside,amphotericin B
clinical featuresclinical features AsymptomaticAsymptomatic Associated with hypocalcemia & Associated with hypocalcemia &
hypokalemiahypokalemia Anorexia,weakness,parasthesiaAnorexia,weakness,parasthesia Confusion,seizures&comaConfusion,seizures&coma Atrial fibrillationAtrial fibrillation Potentiates digitalis toxicityPotentiates digitalis toxicity Prolongation of PR &QT intervalProlongation of PR &QT interval
treatmenttreatment
AsymptomaticAsymptomatic
2g 2g oral magnesium sulfateoral magnesium sulfate
SymptomaticSymptomatic
magnesium sulfate 1 TO 2 g magnesium sulfate 1 TO 2 g IV over 10 minIV over 10 min
1 ml of 50% solution 1 ml of 50% solution contains 4 meqcontains 4 meq
Things to be monitoredThings to be monitored
Tendon reflexesTendon reflexes
Respiratory rateRespiratory rate
Urine outputUrine output
Anaesthetic implicationsAnaesthetic implications
No specific anaesthetic No specific anaesthetic interactionsinteractions
Coexistent electrolyte Coexistent electrolyte imbalances should be correctedimbalances should be corrected
HypermagnesemiaHypermagnesemia
Plasma mg > 2.5 meq/lPlasma mg > 2.5 meq/l
causescauses Antacids or laxativesAntacids or laxatives
IatrogenicIatrogenic
HypothyroidismHypothyroidism
Adrenal insufficiencyAdrenal insufficiency
Lithium administrationLithium administration
Clinical featuresClinical features
Hyporeflexia ,drowsiness & skeletal Hyporeflexia ,drowsiness & skeletal muscle weaknessmuscle weakness
HypotensionHypotension
Prolonged PR interval & widening of Prolonged PR interval & widening of QRS complexQRS complex
Respiratory arrestRespiratory arrest
treatmenttreatment
10 ml of 10% 10 ml of 10% calcium gluconate calcium gluconate IVIV over 10 min over 10 min
Loop diuretic with ½ normal Loop diuretic with ½ normal saline in 5% dextrose saline in 5% dextrose
Peritoneal / haemodialysisPeritoneal / haemodialysis
Anaesthetic considerationsAnaesthetic considerations
tendon reflexes, respiratory rate & urine tendon reflexes, respiratory rate & urine outputoutput
Potentiates negative inotropic effects of Potentiates negative inotropic effects of anaestheticsanaesthetics
Neuromuscular blockers decreased by 25 to Neuromuscular blockers decreased by 25 to 50%50%
ReferancesReferances Harrisons ,16Harrisons ,16thth edition edition
Millers anesthesia,6Millers anesthesia,6thth edition edition
Clinical anesthesiologyMorgan,4Clinical anesthesiologyMorgan,4THTH editionedition
Practical guidelines on fluid therapy , Practical guidelines on fluid therapy , sanjay pandyasanjay pandya