ELECTROLYTE IMBALANCES

IN SURGERY
PART 2
CALCIUM DISORDERS
Calcium Disorders
• Most abundant electrolyte in the human body
• 99% in bone, 1% circulating
• About 50% is bound to proteins, hence only remaining 50% is biologically active
• Important for
• Nerve and muscle excitability
• Essential component of blood clotting cascade
• Regulated by
• PTH – increases serum calcium level
• Calcitonin – decreases serum calcium
• Vitamin D – increases calcium level
HYPOCALCEMIA
Hypocalcemia - Introduction
• Normal level 2.2 – 2.6mmol/L
• Hypocalcemia < 2.2mmol/L
• Calculate for corrected Calcium
• 0.02(40 – Albumin level) + Serum calcium
• Causes?
Hypocalcemia – Causes
• Hypoparathyroidism
• Post-parathyroidectomy
• Inadvertent surgical removal during thyroidectomy
• Neck irradiation/radioiodine therap
• Infiltrative disease – malignancy
• Vitamin D deficiency/resistance
• Chronic kidney disease
• Hyperphosphatemia – formation of calcium phosphate crystals
• Tumor lysis syndrome
• Acute pancreatitis – saponification
• Blood transfusion – citrate (anticoagulant) can bind with calcium
• Sepsis or severe illness
Hypocalcemia – Clinical Features
• Symptoms are due to neuromuscular irritability leading to tetany
• Symptoms of tetany can be
• Mild – perioral numbness, paraesthesias of hand and feet, muscle cramps
• Severe – carpopedal spasm, laryngospasm, focal/generalized seizures
• Less specific symptoms – fatigue, anxiety, irritability
• Classical clinical findings
• Trousseau’s sign
• Chvostek’s sign
• ECG – prolonged QT interval, sinus bradycardia
Hypocalcemia – Clinical Features
Hypocalcemia - Management
• When to treat?
• Symptoms – numbness, paraesthesia, carpopedal spasm, tetany, seizures
• ECG changes – prolonged QT interval
• Corrected calcium <1.9 mmol/L
• Intravenous calcium correction
• About 90-180mg of elemental calcium is required
• 10cc IV calcium gluconate 10% will give 90mg of elemental calcium
• Dilute in 40cc of normal saline or dextrose, infuse the 50cc preparation over 10-20
minutes
• Do not use solutions that contain bicarbonate and phosphate
• Can form insoluble salts
Hypocalcemia - Management
• Monitoring
• Continuous cardiac monitor for cardiac arrhythmias
• Repeat serum calcium 4-6 hours post correction

• Start oral calcium and vitamin D

• Oral calcium supplement (elemental calcium 1-2 grams/day)
• Calcium lactate (300mg contains 39mg of elemental Ca) – about 13%
• Calcium carbonate (500mg contains 200mg elemental Ca) – about 40%
• Vitamin D
• Calcitriol – a type of vitamin D3
HYPERCALCEMIA
Hypercalcemia – Introduction
• Relatively common clinical problem
• Mild 2.6 – 3.0mmol/L
• Moderate 3 – 3.5mmol/L
• Severe > 3.5mmol/L
Hypercalcemia – Causes focusing on causes related to surgery
• Hyperparathyroidism – primary and tertiary
• Malignancy
• Thyrotoxicosis
• Drugs – tamoxifen, thiazides, lithium
• Rhabdomyolysis
• Acute renal failure
Hypercalcemia – Clinical features
• Asymptomatic or non-specific symptoms
• Fatigue, constipation, depression
• Classically described as stones, bones, abdominal groans and
psychiatric moans
• GI – nausea, vomiting, abdominal pain
• Nephrolithiasis – colic pain
• Bone pain – may be due to malignancy or primary hyperparathyroidism
• Less common but severe
• Weakness, confusion, stupor and coma
• ECG shortened QT interval
Hypercalcemia - Management
• Mild to moderate hypercalcemia – no immediate treatment required
• Assess cause and treat
• Oral or intravenous hydration
• Avoidance of aggravating factors – thiazides, dehydration, prolonged
inactivity, high calcium diet
• Consider bisphosphonates in moderate hypercalcemia
• Taken once a week – T Alendronate 70mg weekly (FOSAMAX)
• Swallow with full glass of water on plain stomach then sit upright for 30mins before eat
• Effective by 2nd to 4th day
• Severe hypercalcemia - > 3.5mmol/L OR change in sensorium (coma,
stupor)
Hypercalcemia - Management
• Volume expansion with isotonic saline at rate of 200-300ml/hour
• Order IVD NS 1 pint over 2 hour, then adjust to maintain urine output at 100-
150ml/hour
• If renal/heart failure, trial of loop diuretics to induce diuresis
• Zoledronic acid (IV Zometa 4mg)
• 5ml in one vial containing 4mg of Zolendronic acid
• Dilute in 100cc of NS
• Infuse over 15 minutes
• Vitals monitoring prior and during and after
• Monitor for allergic reaction
• Superior to pamidronate acid in reversing hypercalcemia
due to malignancy
Hypercalcemia - Management
• This should result in reduction of serum calcium in 12-24 hours
• Repeat serum Ca and Alb in 12 hours

• IV Calcitonin 5IU/kg
• If Zometa unavailable
• Dilute 5 IU/kg in 500cc normal saline – infused over 6 hours
• Repeat serum Ca after 2 hours of infusion

• Treat the cause!

PHOSPHATE DISORDERS
Hypophosphatemia
• Normal value
• 0.95 – 1.45 mmol/L
• Defined as <0.8 mmol/L
• Causes include
• Hyperparathyroidism
• Vitamin D deficiency
• Refeeding syndrome
• Clinical features – mainly asymptomatic and non specific
• Weakness, altered mental status, bone pain (uncommon)
Hypophosphatemia - Treatment
• When to immediately treat?
• Severe hypophosphatemia (< 0.3 mmol/L) and critically ill, intubated patients
• Moderate hypophosphatemia (0.3–0.8 mmol/L) on a ventilator
• This is bcos hypophosphatemia is a potential cause of prolonged ventilation

• When to treat orally?

• Moderate hypophosphatemia (0.3–0.8 mmol/L) in nonventilated patients
• Mild hypophosphatemia
Hypophosphatemia - Treatment
• Potassium dihydrogen phosphate
• Previously used – discontinued now due to stock inavailability and expensive
• 1 amp contains 10mmol of phosphate
• Dilute 1 ampoule in 250cc of NS and infuse over 5 hours
• Sodium glycerophosphate
• Currently used in HRPB – cheaper about RM 17, more easily available
• 1 amp contains 20ml or 20mmol of phosphate
• Dilute 1 ampoule in 1 pint NS and infuse over 5 hours

• Repeat phosphate 6 hours after correction

HYPERPHOSPHATEMIA
Hyperphosphatemia
• Normal value 0.95 – 1.45 mmol/L
• Defined as >1.45mmol/L
• Usually asymptomatic and no treatment required
• Causes
• Tumor lysis syndrome, Rhabdomyolysis, Exogenous intake
• AKI/CKD
• Hypoparathyroidism
• Non-specific symptoms – fatigue, nausea, vomiting
• May present with hypocalcemia symptoms
• Treatment – hydration and diuresis
• Repeat serum phosphate in 12-24 hours
• If severe, may need hemodialysis
MAGNESIUM DISORDERS
Hypomagnesemia - Introduction
• Common in hospital, especially in the ICU setting
• Normal value 0.65 – 1.05mmol/L
• Defined as < 0.5mmol/L
• Causes include
• Starvation, alcoholism
• TPN use, refeeding syndrome
• Acute pancreatitis
• Diarrhea and vomiting
• GI fistulas
• Drugs – mainly diuretics (loop, osmotic and thiazides)
Hypomagnesemia – Clinical Features
• Symptoms similar to hypocalcemia due to neuromuscular irritability
• Muscle weakness, tremor, paresthesias, tetany, convulsions
• Positive Chvostek/Trousseau sign

• ECG changes
• Widened QRS, prolonged QT, U waves
Hypomagnesemia - Management
• When to treat immediately?
• No recommended cut off point
• Patient with severe symptoms – tetany, arrhythmias, seizures
• Patient in the ICU setting with hypomagnesemia
• IV MgSO4
• If hemodynamically unstable
• 1-2g MgSO4 given over 15 mins
• If stable, then 4 – 8g to replete the deficit
• Each ampoule contains 2.47g of MgSO4
• Dilute 2 ampoules of MgSO4 in 50cc D5% infuse over 1 hour
• Order as IV MgSO4 5g in 50cc D5% over 1 hour
• Repeat Mg 6 hours post correction
Hypomagnesemia
• Monitoring
• Magnesium toxicity
• Reduced tendon reflexes
• Reduced urine output < 30cc/hour
• Reduced RR <12/min
• Antidote – IV Calcium gluconate 10% 10cc
HYPERMAGNESEMIA
Hypermagnesemia
• Rare but can be seen in patients with severe renal insufficiency
• Causes include
• Overcorrection of magnesium
• Excess intake in TPN
• Clinical features
• 2 – 3 mmol/L – Nausea, flushing, headache, lethargy, drowsiness, and
diminished deep tendon reflexes
• 3 – 5 mmol/L – Somnolence, hypocalcemia, absent deep tendon reflexes,
hypotension, bradycardia, and ECG changes (prolonged PR, widened QRS)
• > 5 mmol/L - Muscle paralysis, apnea and respiratory failure, complete heart
block, and cardiac arrest
Hypermagnesemia – Management
• Goals of therapy – hydrate and diuresis
• IV Calcium to stabilize the heart
• IV Calcium gluconate 10% 10cc over 10mins
• Hydration
• IVD Isotonic saline titrated to induce urine output of 100-150cc/hour
• Diuresis
• In the absence of kidney disease, loop diuretic can be used
• Moderate kidney impairment – may require higher dose of loop diuretic
• ESRF – hemodialysis
• Stopping magnesium intake
• Repeat serum magnesium 12-24 hours
THANK YOU
REFERENCES
• Sabiston Textbook of Surgery, the Biological Basis of Modern Surgical Practice, 20th edition
• Schwartz’s Principles of Surgery, 11th Edition
• Bailey and Love, Short Practice of Surgery
• Spasovski et.al., Clinical practice guideline on diagnosis and treatment of hyponatraemia, European Journal
of Endocrinology, 2014
• Basic Sciences for the MRCS, 3rd Edition
• Sarawak Handbook of Medical Emergencies
• Uptodate
• Emedicine
• BMJ Best Practice
• HRPB Hyponatremia Pathway
• Life in the Fast Lane
• Blue Book application
• Expert opinion by Ms Pooi Yee, HRPB Pharmacist