UG Module 8 - Lesson 7

Electrolytes play a vital role in maintaining homeostasis within the body. They help to regulate myocardial and neurological functions, fluid balance, oxygen delivery, acid-base balance and much more. Electrolyte imbalances can develop by the following mechanisms: excessive ingestion; diminished elimination of an electrolyte; less drinking or excessive elimination of an electrolyte. 

Total body water is distributed in two major compartments: 55.755 is intracellular fluid (ICF), and 25-45% is extracellular fluid (ECF). The ECF is further subdivided into intravascular (plasma water) and extravascular (interstitial) spaces in a ratio of 1:3 extracellular fluid volume deficit is a common fluid disorder in surgical patients. The fluid deficit is not water only, but water and electrolytes in approximately the same percentage as they exist in normal extracellular fluid. 

Management 

(A) Water deficit 

• Intake of water 
• IV 5% Dextrose or Dextrose saline or Normal saline 

• Intake output chart should always be maintained to properly adjust the fluid administration and to prevent water intoxication. 

(B) Water excess 

• Fluid intake should be stopped, particularly IV fluid 
• IV 200ml hypotonic (5.85%) saline solution should be given. This may be added with a diuretic (patient remain in stupor with renal insufficiency) 

(C) Electrolyte Imbalance 

1. a) Sodium

Hyper natraemia 

Clinical features include: –  

• Puffiness of the face,  
• Pitting oedema in the sacral region & ankle region,  

• Increased weight & polyuria,  
• In infants increased tension in anterior fontanelle 

Management 

• Stoppage of infusion  
• Diuretics if oedema present 

• Treatment of apparent hypernatremia should be according to the merit of the individual cases 

Hyponatraemia 

Clinical features include: – 

• Sunken eyes,  
• Anxious,  

• Dry tongue, hard & reddish brown,  
• Dry skin, wrinkled & subcutaneous tissue feel laxed, 
• BP reduced,  
• Pulse will be fast,  
• Urine becomes dark & scanty with high specific gravity 

Management 

• IV normal saline (0.9%) 
• Ringer’s solution may be administered in case normal saline is not available. 
• Renal function should be monitored 
• When there is severe loss of plasma volume, infusion of plasma or plasma substitutes should be considered. 

1. b) Potassium

Hyperkalaemia 

Clinical features include: – 

• Nausea,  
• Vomiting,  

• Intermittent intestinal colic & diarrhoea,  
• Low bp,  
• Low heart rate,  
• Poor peripheral circulation and Cyanosed skin. 

Management 

• Exogenous administration of potassium should be stopped 
• Temporary lowering of serum potassium & suppression of myocardial effect of hyperkalaemia can be accomplished by IV administration of 10% solution of calcium gluconate. 

Hypokalaemia 

Clinical features include: – 

• Gradual onset of drowsiness,  

• Speech becomes slow & slurred,  
• Muscular hypotonia & weakness,  
• Incontinence of urine, peripheral bp is lowered & pulse rate becomes slow,  
• Skin remains warm & dry,  
• Reddish flush of face,  

• Severe thirst. 

Management 

• Oral administration of potassium is always chosen first 
• Potassium salt should be administered orally or potassium chlorides in the form of effervescent tablets 2gm 6 hourly. 
• When patient is comatose or nauseous & has difficulty in swallowing, iv administration is unavoidable. 

• If potassium deficit is due to excessive vomiting – potassium chloride is administered 
• If urine volume is adequate – 2gm of potassium chloride may be administered IV over a period of 4 hours. 
• If potassium deficit is due to diarrhoea – orally potassium citrate 2gm is administered every 6 hourly. The IV solution should contain sodium acetate in addition to potassium chloride. 

1. c) Magnesium

Deficiency of Magnesium 

Clinical features include: – 

• Hyperactive tendon reflexes  
• Muscle tremors 
• Tetany 
• Irritable, aggressive & restlessness. 

Management 

Magnesium deficiency is best treated by parenteral administration of magnesium chloride or sulphate solution about 2mEq of magnesium per kg body weight administered daily when the renal function is good 

Excess of Magnesium 

Clinical features include:  

• Excess of mg leads to lethargy,  

• Weakness, and  
• Progressive loss of deep reflexes 

Management 

• Acute symptoms may be controlled by slow iv administration of 5 to 10meq of calcium chloride or gluconate, 
• Persistence of symptoms, peritoneal dialysis or haemodialysis should be done. 

1. d) Calcium

Hypercalcaemia 

Clinical features include: – 

Early-stage symptoms:  

• Anorexia,  

• Nausea, 
• Vomiting,  
• Fatigue,  
• Lassitude &  
• Weakness. 

Later stage symptoms: 

• Headache,  
• Pain in the back & extremities, 
• Thirst,  
• Polyuria,  

• Polydipsia,  
• Stupor, and  
• Coma 

Management 

• Intravenous phosphate should be given slowly over a period of 12 hours once daily for more than 2 to 3 days. 

• Corticosteroids 

Hypocalcaemia 

Hypocalcaemia presents with clinical features like:  

• Numbness, 
• Tingling sensation in the circumoral region & the tip of fingers &toes,  

• Hyper tendon jerk,  
• Muscle cramp with carpopedal spasms & tetany 
• The Chvostek’s sign will be positive. 

Management 

• IV administration of calcium gluconate or chloride 

• Calcium lactate may be given orally with supplement of vitamin D. 

Hypovolemic shock is an emergency condition in which severe blood and fluid loss make the heart unable to pump enough blood to the body due to decreased preload. It leads to multiple organ failure. 

Causes includes: Haemorrhage, Severe diarrhoea and vomiting, Excessive diuresis, Burns etc 

Classification 

• Class 1: Blood loss up to 750ml  

Symptoms 

• BP : Normal 
• Pulse rate : <100 

• Pulse pressure : Normal/ Increased 
• Urine output : >30ml/hr 
• Respiratory rate : 14-20/min 
• Mental status/ CNS : Slightly anxious 

• Class 2: BL of 750-1500ml 

Symptoms 

• BP : Normal 
• Pulse rate : 100-120 
• Pulse pressure : Decreased 

• Urine output : 20-30ml/hr 
• Respiratory rate : 20-30/min 
• Mental status/ CNS : Mildly anxious 

• Class 3: BL of 1500-2000ml 

Symptoms 

• BP : Decreased 
• Pulse rate : 120-140 
• Pulse pressure : Decreased 
• Urine output : 5-15ml/hr 

• Respiratory rate : 30-40/min 
• Mental status/ CNS : Anxious/ Confused 

• Class 4: BL above 2000ml 

Symptoms  

• BP : Decreased 
• Pulse rate : >140 
• Pulse pressure : Decreased 
• Urine output : Negligible 
• Respiratory rate : >35/min 

• Mental status/ CNS : Confused/Lethargic 

Management 

Initial treatment for shock states includes: 

1. Causative treatment or arrest blood losses 

Can be surgical measures as well as bandaging and cauterisation, based on cause of ongoing haemorrhage. 

1. Volume repletion 

Solution for volume replacement includes: – 

• Isotonic crystalloid solutions 

E.g.: Normal saline, Ringer solution, Lactated ringer solutions 

• Hypertonic crystalloid solutions 

E.g.: Hypertonic saline 

• Colloid solutions 

E.g.: Dextrans, Gelatines, Hetastarch, Human albumin  

1. Inotropic therapy 

Only after volume replacement 

Used to improve Cardiac Output 

E.g.: Dobutamine 

1. Vasomotor therapy 

• Only used as temporary method 
• Used in case of haemorrhages which outruns the Volume replacement 
• Used only until surgical procedure stops the haemorrhage 

E.g.: Noradrenaline, Dopamine, Adrenaline 

BLEEDING PER RECTAL

It is the condition in which the blood is lost through Rectum. Blood in the stool can be bright red or maroon in colour. There are chances that patient may complain of pain per rectum and anus and abdominal pain or cramping. The bleeding may arise from any part of the GI-Tract including rectum. 

Management 

• Diagnostic procedures, such as endoscopy, colonoscopy or angiography, may be done to pin point the source of bleeding. 

• Blood transfusions to combat blood loss in severe rectal bleeding,  

• Drainage of stomach contents. 

• Intravenous fluid replacement. 

• Surgery may be required in severe cases. 

HAEMATEMESIS 

Hematemesis is the vomiting of blood. The vomited blood volume in excess of 5.5 litres could be life threatening. 

Management 

Minimal blood loss 

• Kept NPO (nil per os) 
• Proton pump inhibitor (e.g omeprazole) 
• Blood Transfusion (if Hb% <8.0gdl) 

Significant blood loss  

• Resuscitation 
• Fluid/Blood is administered preferably by central venous catheter 
• Patient has to be prepared of immediate endoscopy 

The bleeding or haemorrhage from the nose, referred to as epistaxis, is caused by the rupture of tiny, distended vessels in the mucous membrane of any area of the nose. It is common in all age groups. 

Common site of epistaxis is the anterior septum, where three major blood vessels enter the nasal cavity:  

• the anterior ethmoidal artery on the forward part of the roof (Kessel Bach’s plexus)  

• the sphenopalatine artery in the posterosuperior region, and  

• the internal maxillary branches (the plexus of veins located at the back of the lateral wall under the inferior turbinate). 

Types of Epistaxis  

1. Anterior Epistaxis (Most common, less severe and easy to control)  

1. Posterior Epistaxis (Less common, more severe and difficult to control) 

Management of Epistaxis  

Management of Epistaxis depends on the location of the bleeding site. A nasal speculum or headlight may be used to determine the site of bleeding in the nasal cavity. Most nosebleeds originate from the anterior portion of the nose. Initial treatment may include applying direct pressure. 

• Little’s area – pinching the nose with thumb and index finger for about 5 minutes- compression of vessels.  
• Trotter’s method – patient is made to sit, leaning a little forward over a basin to spit any blood, and breathe quietly from mouth- cold compresses should be applied to nose to cause reflex vasoconstriction. 
• Anterior nasal pressure with joined tongue depressors. 

If these measures are unsuccessful, additional treatment is indicated.  

• In anterior nosebleeds, the area may be treated with a silver nitrate applicator and Gel foam, or by electrocautery. Topical vasoconstrictors, such as adrenaline or cocaine (0.5%), and phenylephrine may be prescribed.  

• If bleeding is occurring from the posterior regions, cotton pledgets soaked in a vasoconstricting solution may be inserted into the nose to reduce the blood flow and improve the examiner’s view of the bleeding site. 

• Alternatively, a cotton tampon may be used to try to stop the bleeding. Suction may be used to remove excess blood and clots from the field of inspection. 

• Nasal packing with bayonet forceps and ribbon gauze. 

• When the origin of the bleeding cannot be identified, the nose may be packed with gauze impregnated with petrolatum jelly or antibiotic ointment; a topical anaesthetic spray and decongestant agent may be used prior to inserting the gauze packing, or a balloon-inflated catheter may be used. 

• The packing may remain in place for 48 hours or up to 5 or 6 days if necessary to control bleeding.  

• Antibiotics may be prescribed because of the risk of iatrogenic sinusitis and toxic shock syndrome.