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