Electrolyte disturbances

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Electrolyte disturbances

  1. 1. Electrolyte disturbances Moderator Dr Sumesh Rao Presenter Dr Nikhil MP
  2. 2. Disorders of sodium balance
  3. 3. Normal plasma sodium is 135 to 145 meq/l
  4. 4. Hyponatremia
  5. 5. Plasma sodium <135 meq/l
  6. 6. Types <ul><li>Hypoosmolal hyponatremia </li></ul><ul><li>Hyponatremia with normal plasma osmolality </li></ul><ul><li>Hyponatremia with elevated plasma osmolality </li></ul>
  7. 7. Hypoosmolal hyponatremia
  8. 8. Types <ul><li>Hypovolemic </li></ul><ul><li>Euvolemic </li></ul><ul><li>Hypervolemic </li></ul>
  9. 9. Hyopovolemic <ul><li>Renal </li></ul><ul><li>diuretics </li></ul><ul><li>mineralocorticoid deficiency </li></ul><ul><li>salt wasting nephropathies </li></ul><ul><li>osmotic diuresis </li></ul><ul><li>renal tubular acidosis </li></ul><ul><li>Gastrointestinal </li></ul><ul><li>vomiting </li></ul><ul><li>diarrhea </li></ul><ul><li>fistula </li></ul><ul><li>integumentary </li></ul><ul><li>sweating </li></ul><ul><li>burns </li></ul>
  10. 10. Euvolemic <ul><li>Primary polydipsia </li></ul><ul><li>SIADH </li></ul><ul><li>Arginine vasopressin release due to pain,nausea </li></ul><ul><li>Glucocorticoid deficiency </li></ul><ul><li>Hypothyroidism </li></ul><ul><li>Chronic renal insufficiency </li></ul>
  11. 11. Hypervolemic <ul><li>Congestive cardiac failure </li></ul><ul><li>Cirrhosis </li></ul><ul><li>Nephrotic syndrome </li></ul>
  12. 12. Pseudohyponatremia <ul><ul><li>Hyponatremia with normal plasma </li></ul></ul><ul><ul><li>osmolality </li></ul></ul><ul><li>marked hyperlipidemia </li></ul><ul><li>marked hyperproteinemia. </li></ul><ul><li>TURP syndrome </li></ul><ul><li>Hyponatremia with elevated plasma osmolality </li></ul><ul><li>hyperglycemia </li></ul><ul><li>mannitol. </li></ul>
  13. 13. Clinical features
  14. 14. <ul><li>mainly </li></ul>
  15. 15. Clinical features <ul><li>Primarily neurological </li></ul><ul><li>Increased ICF volume </li></ul><ul><li>severity:depends on rapidity of onset and absolute increase in plasma sodium concentration </li></ul><ul><li>Asymtomatic or nausea,vomiting </li></ul><ul><li>Depressed level of consciousness,confusion,agitation </li></ul><ul><li>Stupor,seizures and coma. </li></ul>
  16. 16. <ul><li>Cerebral edema < 120 meq/l </li></ul><ul><li>Cardiac symptoms < 100 meq/l </li></ul>
  17. 17. diagnosis
  18. 18. <ul><li>history & physical examination </li></ul><ul><li>3 tests </li></ul><ul><li>plasma osmolality </li></ul><ul><li>urinary osmolality </li></ul><ul><li>urinary sodium excretion </li></ul><ul><li>Plasma osmolality = 2 Na + glucose + BUN </li></ul><ul><li>18 2.8 </li></ul>
  19. 19. cont……. <ul><li>Plasma osmolality low </li></ul><ul><li>impaired function </li></ul><ul><li>assess renal status primary renal disease </li></ul><ul><li>normal </li></ul><ul><li>Assess volume status volume depletion volume overload </li></ul><ul><li>normovolemic CCF </li></ul><ul><li>urinary sodium(meq/l ) nephrotic </li></ul><ul><li>Adrenal & cirrhosis </li></ul><ul><li>thyroid insufficiency <10 >20 </li></ul><ul><li>normal diarrhea salt wasting nephropathy </li></ul><ul><li>vomiting diuretics </li></ul><ul><li>Able to dilute urine </li></ul><ul><li>In response to water load dilute urine psyhogenic polydipsia </li></ul><ul><li>no yes </li></ul><ul><li>SIADH </li></ul>
  20. 20. treatment
  21. 21. Goals of therapy <ul><li>To raise plasma sodium concentration by restricting water intake and promoting water loss </li></ul><ul><li>To correct underlying disorder </li></ul>
  22. 22. principles <ul><li>0.9% & 3% saline : Hypovolemic </li></ul><ul><li>Water restriction :Euvolemic </li></ul><ul><li>& </li></ul><ul><li>Hypervolemic </li></ul>
  23. 23. When to treat....? <ul><li>Symptomatic </li></ul><ul><li>Plasma sodium < 120 meq/l </li></ul>
  24. 24. Cont…. <ul><li>Rate of correction depends on absence or presence of neurologic dysfunction. </li></ul><ul><li>In asymptomatic patients : </li></ul><ul><li>0.5 to 1 meq/l/hr or 10 to 12 meq/l over first 24 hours </li></ul><ul><li>Severe symptomatic hyponatremia (<110 meq/l) </li></ul><ul><li>hypertonic saline </li></ul><ul><li>1 to 2 meq/l/hr for the first 3 to 4 hrs,total not exceeding more than 12meq/l/ 24hrs. </li></ul>
  25. 25. To calculate Na deficit <ul><li>Sodium deficit =total body water X </li></ul><ul><li>(desired Na - present Na) </li></ul><ul><li>TBW = body wt x 0.6 males </li></ul><ul><li>0.5 females </li></ul>
  26. 26. Change in plasma sodium <ul><li>Infusate sodium/l - Serum sodium </li></ul><ul><li>TBW + 1 </li></ul>
  27. 27. Case history <ul><li>A 45 yr male ,50 kg by wt presented with </li></ul><ul><li>altered sensorium and agitation.a diagnosis of </li></ul><ul><li>hypoosmolar hyponatremia is made.plasma </li></ul><ul><li>sodium is 110 meq/l . </li></ul>
  28. 28. <ul><li>sodium requirement= desired Na – serum Na X </li></ul><ul><li>TBW </li></ul><ul><li>= 130 - 110 X 0.6 X 50 </li></ul><ul><li>= 600 meq </li></ul>
  29. 29. <ul><li>change in Na = infusate Na - serum Na </li></ul><ul><li>TBW + 1 </li></ul><ul><li>= 513 - 110 = 403 = 13 meq/l </li></ul><ul><li>30 + 1 31 </li></ul><ul><li>100 ml 1.3 meq/l </li></ul><ul><li>800 ml over 24 hrs app 34 ml/hr </li></ul>
  30. 30. Rapid correction can lead to… <ul><li>osmotic demyelination syndrome(central </li></ul><ul><li>Pontine myelinolysis) </li></ul><ul><li>chronic hyponatremia </li></ul><ul><li>flaccid paralysis,dysarthria,dysphagia. </li></ul><ul><li>no specific treatment. </li></ul>
  31. 31. Anaesthetic implications <ul><li>Plasma Na > 130meq/l for patients undergoing elective surgery & is considered safe </li></ul><ul><li>Lower levels can result in signifcant cerebral edema </li></ul><ul><li>Decrease in MAC: intraoperatively </li></ul><ul><li>Agitation & confusion : postoperatively </li></ul>
  32. 32. Hypernatremia
  33. 33. Plasma sodium>145meq/l
  34. 34. causes
  35. 35. <ul><li>Impaired thirst </li></ul><ul><li>coma </li></ul><ul><li>essential hypernatremia </li></ul><ul><li>Solute diuresis </li></ul><ul><li>diabetic ketoacidosis </li></ul><ul><li>non-ketotic hyperosmolar coma </li></ul><ul><li>excessive water loss </li></ul><ul><li>diabetes insipidus </li></ul><ul><li>sweating </li></ul>
  36. 36. Types <ul><li>Hypernatremia with low body sodium content </li></ul><ul><li>Hypernatremia with normal body sodium content </li></ul><ul><li>Hypernatremia and increased body sodium content </li></ul>
  37. 37. Hypernatremia with low body sodium content <ul><li>Water loss in excess of sodium loss. </li></ul><ul><li>eg:osmotic diuresis </li></ul><ul><li>diarrhea </li></ul><ul><li>sweating </li></ul>
  38. 38. Hypernatremia with normal total body sodium content <ul><li>Due to water loss </li></ul><ul><li>Diabetes insipidus </li></ul><ul><li>central diabetes insipidus </li></ul><ul><li>nephrogenic diabetes insipidus </li></ul>
  39. 39. Hypernatremia and increased total body sodium content <ul><li>Following administration of large quantities </li></ul><ul><li>of hypertonic saline solutions </li></ul>
  40. 40. Clinical features
  41. 41. <ul><li>mainly </li></ul>
  42. 42. <ul><li>Mainly due to contracted ICF volume </li></ul><ul><li>Mainly neurological </li></ul><ul><li>alered mental status </li></ul><ul><li>irritability </li></ul><ul><li>weakness </li></ul><ul><li>focal neurological deficits </li></ul><ul><li>coma &death </li></ul><ul><li>Prone for intracerebral or subarachnoid haemorrhage </li></ul>
  43. 43. diagnosis
  44. 44. <ul><li>ECF volume </li></ul><ul><li>not increased increased hypertonic Nacl or </li></ul><ul><li>sodium bicarbonate </li></ul><ul><li>min volume of max </li></ul><ul><li>concentrated urine no </li></ul><ul><li>yes </li></ul><ul><li>Insensible water loss urine osmole </li></ul><ul><li>Gastrointestinal excretion rate </li></ul><ul><li>>750 mosmol/d </li></ul><ul><li>no yes </li></ul><ul><li>renal response diuretic </li></ul><ul><li>to desmopressin osmotic diuresis </li></ul><ul><li>urine osmolality </li></ul><ul><li>increased unchanged </li></ul><ul><li>central DI nephrogenic DI </li></ul>
  45. 45. treatment
  46. 46. Goals of therapy <ul><li>To correct water deficit </li></ul><ul><li>To stop ongoing water loss </li></ul>
  47. 47. principles <ul><li>Correction should be done over 48 to 72 hours . </li></ul><ul><li>Hypotonic solution like 5% dextrose. </li></ul><ul><li>Plasma Na should be lowered by 0.5 meq/l/hr or not more than 12meq/l/ 24 hrs. </li></ul>
  48. 48. To calculate water deficit <ul><li>Water deficit = plasma Na - 140 X TBW </li></ul><ul><li>140 </li></ul>
  49. 49. Rapid correction can lead to… <ul><li>Seizures or permanent neurologic damage </li></ul>
  50. 50. Anaesthetic implications <ul><li>Increases MAC </li></ul><ul><li>Enhance uptake of inhalation anaesthtics by decreasing cardiac output. </li></ul><ul><li>Predisposes to hypotension & hypoperfusion of tissues </li></ul><ul><li>Decreases volume of distribution and reduction in dose of intravenous agents </li></ul>
  51. 51. Disorders of potassium balance
  52. 52. Normal plasma potassium is 3.5 to 5 meq/l
  53. 53. Hypokalemia
  54. 54. Plasma potassium < 3.5 meq/l
  55. 55. causes
  56. 56. <ul><li>Redistribution into cells </li></ul><ul><li>Increased loss </li></ul><ul><li>Decreased intake </li></ul>
  57. 57. Redistribution into cells <ul><li>Metabolic alkalosis </li></ul><ul><li>Hormonal </li></ul><ul><li>insulin </li></ul><ul><li>beta 2 agonist </li></ul><ul><li>alpha antagonist </li></ul><ul><li>Anabolic state </li></ul><ul><li>vit B12 /folic acid </li></ul><ul><li>total parentral nutrition </li></ul><ul><li>others </li></ul><ul><li>Hypokalemic periodic paralysis </li></ul><ul><li>hypothermia </li></ul><ul><li>barium toxicity. </li></ul>
  58. 58. Increased loss <ul><li>Renal </li></ul><ul><li>primary hyperaldosteronism </li></ul><ul><li>secondary hyperaldosteronism </li></ul><ul><li>congenital adrenal hyperplasia </li></ul><ul><li>cushings syndrome </li></ul><ul><li>bartters syndrome </li></ul><ul><li>liddles syndrome </li></ul><ul><li>renal tubular acidosis </li></ul><ul><li>diabetic ketoacidosis </li></ul><ul><li>diuretics,aminoglycosides,penicillin </li></ul><ul><li>amphotericin-B </li></ul><ul><li>Gastrointestinal </li></ul><ul><li>integumentary </li></ul>
  59. 59. Decreased intake <ul><li>Starvation </li></ul><ul><li>Clay ingestion </li></ul>
  60. 60. Clinical features
  61. 61. <ul><li>Manifestations vary between patient </li></ul><ul><li>Asymptomatic </li></ul><ul><li><3 mq/l </li></ul><ul><li>Fatigue,myalgia&lower extremity weakness </li></ul>
  62. 62. Neuromuscular
  63. 63. Neuromuscular <ul><li>Fatigue,myalgia,muscular weakness </li></ul><ul><li>Progressive weakness and hypoventilation </li></ul><ul><li>as severity increases </li></ul><ul><li>Rhabdomyolysis </li></ul><ul><li>Paralytic ileus </li></ul>
  64. 64. cardiovascular <ul><li>Abormal electrocardiogram </li></ul><ul><li>Arrhythmias </li></ul><ul><li>Orthostatic hypotension </li></ul><ul><li>Decreased cardiac contractility </li></ul><ul><li>Potentiates arrhythmogenic potential of digoxin </li></ul><ul><li>Myocardial fibrosis </li></ul>
  65. 65. ECG Changes <ul><li>Appearance of U wave </li></ul><ul><li>Flattening or inversion of T wave </li></ul><ul><li>ST segment depression </li></ul><ul><li>Prolonged QT interval </li></ul><ul><li>Prominent U wave </li></ul><ul><li>Prolonged PR interval </li></ul><ul><li>Widening of QRS complex </li></ul><ul><li>Ventricular arrhythmias </li></ul>
  66. 67. diagnosis
  67. 68. <ul><li>history </li></ul><ul><li>urinary potassium excretion <15mmol/d >15mmol/d. </li></ul><ul><li>assess acid- base status </li></ul><ul><li>metabolic acidosis metabolic alkalosis </li></ul><ul><li>lower gastrointestinal loss diuretic </li></ul><ul><li>vomiting </li></ul><ul><li>k+loss via sweat </li></ul>
  68. 69. <ul><li>>15 meq/day </li></ul><ul><li>assess k+ excretion </li></ul><ul><li>TTKG>4 TTKG<2 salt wasting nephropathy </li></ul><ul><li>osmotic diuresis </li></ul><ul><li>Assess acid-base status diuretic </li></ul><ul><li>metabolic metabolic </li></ul><ul><li>acidosis alkalosis </li></ul><ul><li>yes </li></ul><ul><li>DKA hypertension mineralocorticoid </li></ul><ul><li>Proximal RTA no excess </li></ul><ul><li>Distal RTA vomiting liddles syndrome </li></ul><ul><li>bartters </li></ul><ul><li>diuretic abuse </li></ul><ul><li>hypomagnesemia </li></ul>
  69. 70. treatment
  70. 71. Therapeutic goals <ul><li>To correct potassium deficit </li></ul><ul><li>To minimize ongoing losses </li></ul><ul><li>To prevent life threatening complications </li></ul>
  71. 72. principles <ul><li>Safer to correct potassium via oral route </li></ul><ul><li>A decrement of 1mmol/l in plasma potassium may represent a total body k+ deficit of 200 to 400meq </li></ul><ul><li>Dextrose containing solutions avoided </li></ul>
  72. 73. treatment
  73. 74. When to treat…..? <ul><li>3.5 to 4 mq/l </li></ul><ul><li>Increased intake of potassium containing food. </li></ul><ul><li>3 to 3.5 mq/l </li></ul><ul><li>Only in high risk patients. </li></ul><ul><li>< 3 mq/l needs definitive treatment. </li></ul>
  74. 75. Oral potassium <ul><li>Safer </li></ul><ul><li>Potassium chloride preparation of choice </li></ul><ul><li>Potassium bicarbonate and citrate </li></ul><ul><li>Mild to moderate hyperkalemia kcl 60 to 80 meq/day in 3 to 4 divided doses </li></ul><ul><li>Severe or symptomatic – kcl 40 mq 6 th hourly under ECG monitoring </li></ul><ul><li>15 ml solution=20 meq </li></ul><ul><li>8 meq/tab </li></ul>
  75. 76. Iv potassium <ul><li>Severe symptomatic hypokalemia </li></ul><ul><li>Continous ECG monitoring & frequent k+ estimation </li></ul><ul><li>Never give KCl directly IV. </li></ul><ul><li>Rapid IV correction can cause dangerous hyperkalemia. </li></ul><ul><li>Use isotonic saline </li></ul><ul><li>Do not mix with dextrose containing solutions . </li></ul>
  76. 77. Cont….. <ul><li>15% KCl solution in 10 ml ampoule. </li></ul><ul><li>10 ml = 20 meq of potassium = 1.5 g KCl. </li></ul><ul><li>How long to give? </li></ul><ul><li>As cardiac rhythm returns to normal KCl drip is tapered and oral k+ initiated. </li></ul>
  77. 78. Cont…. <ul><li>should not exceed 8meq/hr via peripheral vein </li></ul><ul><li>central venous catheter in case of faster replacements&should not exceed more than 20 meq/hour </li></ul>
  78. 79. Anaesthetic implications <ul><li>Chronic hypokalemia more succeptible for arrhythmias </li></ul><ul><li>ECG monitoring </li></ul><ul><li>Glucose free solutions </li></ul><ul><li>Potentiates neuromuscular blockers </li></ul><ul><li>Avoid alkalosis </li></ul><ul><li>Hyperventilation avoided </li></ul>
  79. 80. Hyperkalemia
  80. 81. Plasma potassium >5 meq/l
  81. 82. causes <ul><li>Decreased renal excreation of potassium </li></ul><ul><li>renal failure </li></ul><ul><li>primary hypoaldosteronism </li></ul><ul><li>secondary hypoaldosteronism </li></ul><ul><li>drugs </li></ul><ul><li>spironolactone </li></ul><ul><li>nsaids </li></ul><ul><li>ace inhibitors </li></ul><ul><li>trimethoprim </li></ul><ul><li>heparin </li></ul>
  82. 83. Cont… <ul><li>Due to extracellular movement of k+ </li></ul><ul><li>acidosis </li></ul><ul><li>hyperkalemic periodic paralysis </li></ul><ul><li>succinylcholine </li></ul><ul><li>rhabdomyolysis </li></ul><ul><li>cell lysis following chemotherapy </li></ul><ul><li>digitalis overdose </li></ul><ul><li>Enhanced chloride reabsorption </li></ul><ul><li>cyclosporine </li></ul><ul><li>Gordons syndrome </li></ul><ul><li>Increased potassium intake </li></ul><ul><li>pseudohyperkalemia </li></ul>
  83. 84. Clinical features
  84. 85. skeletal
  85. 86. skeletal <ul><li>Weakness,flaccid paralysis </li></ul><ul><li>Hypoventilation </li></ul>
  86. 87. <ul><li>CVS </li></ul>
  87. 88. cardiac <ul><li>Increased T-wave amplitude 6 to 7 meq/l </li></ul><ul><li>Prolonged PR interval </li></ul><ul><li>QRS widening 7 to 8 meq/l </li></ul><ul><li>Loss of P wave </li></ul><ul><li>sine wave pattern 8 to 9 meq/l </li></ul><ul><li>Ventricullar fibrillation or asystole > 9meq/l </li></ul>
  88. 91. diagnosis <ul><li>Exclude pseudohyperkalemia&transcellular k+ shifts </li></ul><ul><li>Exclude oliguric renal failure </li></ul><ul><li>stop NSAIDs and ACE inhibitors </li></ul><ul><li>assess k+ secretion </li></ul>
  89. 92. Cont…… <ul><li>TTKG < 5 TTKG > 10 </li></ul><ul><li>decreased circulating vol </li></ul><ul><li>Response to low protien diet </li></ul><ul><li>9a-fludrocortisone </li></ul><ul><li>TTKG >10 TTK<10 </li></ul><ul><li>primary/secondary hypotension HTN </li></ul><ul><li>hypoaldosteronism high renin & low renin& </li></ul><ul><li>aldosterone aldosterone </li></ul><ul><li>pseudohypoaldosteronism Gordons syndrome </li></ul><ul><li>k+diuretics cyclosporine </li></ul><ul><li>distal RTA </li></ul>
  90. 93. treatment
  91. 94. principles <ul><li>>6meq/l should be treated </li></ul><ul><li>To minimize membrane excitability </li></ul><ul><li>To shift potassium into cells </li></ul><ul><li>Promote potassium loss </li></ul>
  92. 95. Calcium gluconate <ul><li>10% solution in 10 ml ampoules </li></ul><ul><li>10ml of 10% calcium gluconate IV over 5 to 10 min </li></ul><ul><li>Repeated if no change in ECG is seen after 5 to 10 min </li></ul><ul><li>How it helps……? </li></ul><ul><li>protects the myocardium from toxicity to potassium </li></ul>
  93. 96. Insulin & glucose <ul><li>10 to 20 units of regular insulin in 50 ml of 25 to 50 % dextrose </li></ul><ul><li>Initial bolus should be followed by continous infusion of 5% dextrose </li></ul><ul><li>effect begins in 15 min & peak in 60 min </li></ul>
  94. 97. cont….. <ul><li>Sodium bicarbonate </li></ul><ul><li>7.5 % of 50 to 100 ml is given as IV slowly over 10 to 20 min. </li></ul><ul><li>Beta agonist </li></ul><ul><li>salbutamol 20 mg in 4 ml saline by nebulisation </li></ul><ul><li>Loop & thiazide diuretics </li></ul>
  95. 98. Cont… <ul><li>Cation exchange resins </li></ul><ul><li>sodium polystyren sulphonate </li></ul><ul><li>promote exchange of Na for K in </li></ul><ul><li>GIT </li></ul><ul><li>25 to 50g with 100ml of 20% sorbitol 3 to 4 times a day </li></ul><ul><li>Haemodialysis </li></ul>
  96. 100. Anaesthetic implications <ul><li>ECG monitoring </li></ul><ul><li>Succinylcholine avoided </li></ul><ul><li>Potssium free solutions </li></ul><ul><li>Avoid acidosis </li></ul><ul><li>Potentiates neuromuscular blockers </li></ul><ul><li>Mild hyperventilation </li></ul>
  97. 101. Disorders of calcium balance
  98. 102. <ul><li>Normal plasma calcium 8.5 to 10.5 mg/dl. </li></ul><ul><li>50% in ionized form ,40% protein bound,10% complexed with anions </li></ul>
  99. 103. hypocalcemia
  100. 104. Plasma calcium <8.5 mg dl
  101. 105. causes <ul><li>Hypoparathyroidism </li></ul><ul><li>Vitamin D deficiency </li></ul><ul><li>nutritional </li></ul><ul><li>malabsorption </li></ul><ul><li>Hyperphosphatemia </li></ul><ul><li>Precipitation of calcium </li></ul><ul><li>pancreatitis </li></ul><ul><li>rhabdomyolysis </li></ul><ul><li>Chelation of calcium </li></ul><ul><li>rapid blood transfusion </li></ul><ul><li>rapid infusion of large amount of albumins </li></ul>
  102. 107. <ul><li>Hallmark of hypocalcemia is TETANY </li></ul><ul><li>Parasthesia in circumoral region & extremities </li></ul><ul><li>Laryngospasm,bronchospasm </li></ul><ul><li>Abdominal cramps,urinary frequency </li></ul><ul><li>Hypotension & arrhythmias </li></ul><ul><li>Latent hypocalcemia </li></ul><ul><li>Chvosteks sign </li></ul><ul><li>Trousseaus sign </li></ul>
  103. 110. ECG <ul><li>Prolongation of QT interval </li></ul>
  104. 111. treatment <ul><li>Symptomatic hypocalcemia – emergency </li></ul><ul><li>10 ml of 10% calcium gluconate IV over 10 minutes. </li></ul><ul><li>Iv calcium should not be given with bicarbonate or phosphate containing solution </li></ul><ul><li>Serial calcium measurements </li></ul><ul><li>Correction of co-existing alkalosis </li></ul><ul><li>Calcium supplimentation in long term </li></ul>
  105. 112. Anaesthetic implicatons <ul><li>Corrected preoperatively </li></ul><ul><li>Serial ionized calcium level monitored </li></ul><ul><li>Potentiates negative inotropic effect of barbiturates and volatile anaesthetics </li></ul><ul><li>Laryngospasm </li></ul><ul><li>Alkalosis should be avoided </li></ul>
  106. 113. hypercalcemia
  107. 114. <ul><li>plasma calcium > 10.5 mg/dl </li></ul>
  108. 115. causes <ul><li>Hyperparathyroidism </li></ul><ul><li>Malignancy </li></ul><ul><li>Pagets disease of bone </li></ul><ul><li>Excessive vitamin D intake </li></ul><ul><li>Granulomatous disorders </li></ul><ul><li>Milk- alkali syndrome </li></ul><ul><li>Drugs </li></ul><ul><li>thiazides </li></ul><ul><li>lithium </li></ul>
  109. 116. Clinical features <ul><li>Anorexia </li></ul><ul><li>Nausea,vomiting </li></ul><ul><li>Weakness </li></ul><ul><li>Polyuria </li></ul><ul><li>Ataxia </li></ul><ul><li>Irritability </li></ul><ul><li>Lethargy </li></ul><ul><li>confusion </li></ul>
  110. 117. ECG changes <ul><li>Pronged PR interval </li></ul><ul><li>Widened QRS complex </li></ul><ul><li>Shortened QT </li></ul>
  111. 119. treatment <ul><li>Hydration with normal saline </li></ul><ul><li>Loop diuretics like frusemide </li></ul><ul><li>haemodialysis </li></ul><ul><li>Urine output > 3 litres /day </li></ul><ul><li>k+ and Mg+ </li></ul><ul><li>Severe cases bisphosphonates </li></ul><ul><li>pamindronate 60 to 80 mg iv over 4 hrs </li></ul><ul><li>calcitonin 2 to 8 U subcut </li></ul><ul><li>90% due to malignancy & hyperparathyroidism </li></ul>
  112. 120. Anaesthetic implications <ul><li>Saline diuresis </li></ul><ul><li>K+ & Mg+ </li></ul><ul><li>decreased dose of neuromuscular blockers </li></ul><ul><li>Cvp & pulmonary pressure monitoring </li></ul><ul><li>Hyperventilation avoided </li></ul>
  113. 121. Disorders of magnesium balance
  114. 122. hypomangnesemia
  115. 123. Plasma mg+ <1.7 meq/l
  116. 124. causes <ul><li>Inadequate intake </li></ul><ul><li>Reduced gasroinestinal absorption </li></ul><ul><li>malabsorption </li></ul><ul><li>small bowel /biliary fistula </li></ul><ul><li>severe diarrhea </li></ul><ul><li>prolonged nasogastric suctionig </li></ul><ul><li>Renal losses </li></ul><ul><li>diuresis </li></ul><ul><li>hyperparathyroidism </li></ul><ul><li>Drugs </li></ul><ul><li>theophylline </li></ul><ul><li>diuretics,ethyl alcohol </li></ul><ul><li>aminoglycoside,amphotericin B </li></ul>
  117. 125. clinical features <ul><li>Asymptomatic </li></ul><ul><li>Associated with hypocalcemia & hypokalemia </li></ul><ul><li>Anorexia,weakness,parasthesia </li></ul><ul><li>Confusion,seizures&coma </li></ul><ul><li>Atrial fibrillation </li></ul><ul><li>Potentiates digitalis toxicity </li></ul><ul><li>Prolongation of PR &QT interval </li></ul>
  118. 126. treatment <ul><li>Asymptomatic </li></ul><ul><li>2g oral magnesium sulfate </li></ul><ul><li>Symptomatic </li></ul><ul><li>magnesium sulfate 1 TO 2 g IV over 10 min </li></ul><ul><li>1 ml of 50% solution contains 4 meq </li></ul>
  119. 127. Things to be monitored <ul><li>Tendon reflexes </li></ul><ul><li>Respiratory rate </li></ul><ul><li>Urine output </li></ul>
  120. 129. Anaesthetic implications <ul><li>No specific anaesthetic interactions </li></ul><ul><li>Coexistent electrolyte imbalances should be corrected </li></ul>
  121. 130. Hypermagnesemia
  122. 131. Plasma mg > 2.5 meq/l
  123. 132. causes <ul><li>Antacids or laxatives </li></ul><ul><li>Iatrogenic </li></ul><ul><li>Hypothyroidism </li></ul><ul><li>Adrenal insufficiency </li></ul><ul><li>Lithium administration </li></ul>
  124. 133. Clinical features <ul><li>Hyporeflexia ,drowsiness & skeletal muscle weakness </li></ul><ul><li>Hypotension </li></ul><ul><li>Prolonged PR interval & widening of QRS complex </li></ul><ul><li>Respiratory arrest </li></ul>
  125. 134. treatment <ul><li>10 ml of 10% calcium gluconate IV over 10 min </li></ul><ul><li>Loop diuretic with ½ normal saline in 5% dextrose </li></ul><ul><li>Peritoneal / haemodialysis </li></ul>
  126. 135. Anaesthetic considerations <ul><li>tendon reflexes, respiratory rate & urine output </li></ul><ul><li>Potentiates negative inotropic effects of anaesthetics </li></ul><ul><li>Neuromuscular blockers decreased by 25 to 50% </li></ul>
  127. 136. Referances <ul><li>Harrisons ,16 th edition </li></ul><ul><li>Millers anesthesia,6 th edition </li></ul><ul><li>Clinical anesthesiologyMorgan,4 TH edition </li></ul><ul><li>Practical guidelines on fluid therapy , sanjay pandya </li></ul>
  128. 137. thank you

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