Perioperative Care; Fluid and Electrolyte

INTRODUCTION

Excess fluid in the bloodstream can be caused by water retention, drinking excessive amounts of water, decreased ability of the kidneys to produce urine, or an elevated blood pressure and bounding pulses are often seen with fluid volume excess.

Fluid volume deficit also known as dehydration can be a common occurrence and nursing diagnosis for many patients. Dehydration is when there is a loss of too much fluid from the body. This leads to a lack of water in the body's cells and blood vessels Decreased blood pressure with an elevated heart rate and a weak or thready pulse are hallmark signs of fluid volume deficit.

LEARNING OUTCOME

At the end of the lecture, the students will be able to:

• Explain fluid excess/deficit causes, symptoms, treatment
• Explain sodium, potassium, calcium, phosphate, magnesium imbalances

What causes excessive fluid in the body?

Fluid overload is also called hypervolemia. It's when you have too much fluid in your body. It can be caused by several different conditions including heart failure, kidney failure, cirrhosis, or pregnant

 

Water retention, called “edema”, refers to excess fluid that is improperly stored in the muscles and other organs of the body. The main causes of water retention are a sodium-heavy diet and lifestyles in which sitting and standing for many hours. The main symptom of water retention is the swelling of extremities and puffiness in the abdomen and face.   Treatment for water retention is lifestyle changes, like increasing movement and altering diet.

Edema is caused by nutrient deficiencies and imbalances, with vitamin A, vitamin C, vitamin B-6, magnesium, and zinc being common vitamins and minerals that have an effect on symptoms. , edema is affected by behavioural habits; the way a person physically moves and exercises and how they massage their muscles has a significant impact on the presence or severity of the disease

The causes of water retention include numerous diseases plus some lifestyle issues.

·         Too much salt in my diet. Excess salt in the body disrupts the body’s water balance and can result in fluid storage in the muscles.

·         Certain medications. Hormonal medications, diabetic medications, and many other types of prescription medications may affect fluid retention and cause edema.

·         Kidney disease. Improper functioning of the liver can cause fluid build-up, including from diseases like glomerulonephritis and nephrotic syndrome.

·         Lack of movement. Sitting too long can make it harder for the blood to circulate from the legs back up to the heart.

·    Cancer. Malignant tumours on the muscles and lymph nodes can cause edema.

·    Heart failure. If the heart is not able to pump blood as normal it will try to make up for the poor circulation by increasing the amount of blood it is circulating through the body. This causes the liver, body cavities, and legs among other locations to swell.

Chronic lung disease. When fluid builds up in the lungs·   , it is called pulmonary edema. There is a circular effect from emphysema (damaged air sacs in the lungs) causing shortness of breath that causes the heart to pump harder, which then creates pressure from blood vessels that pushes fluid into the lungs and makes breathing even more difficult.

   Liver disease. Liver disease such as cirrhosis makes it more difficult for the organ to function, slowing blood flow. This causes increased pressure in the veins which can lead to fluid build-up in the legs.   Malignant lymphoedema. If cancer cells cause blockages in the lymphatic system, lymph fluid can back up in the body.

   Hormonal changes. Hormones are responsible for maintaining balance in the body, and so if there are disruptions to one’s hormones or a condition in the thyroid (the gland that produces many hormones), hydration levels may be affected and water retention is more likely to occur.

   Thyroid disease. Severe cases of hypothyroidism are called myxedema and can have numerous serious symptoms including major fluid retention and swelling, particularly in the legs and face.   Premenstrual syndrome (PMS). Hormonal changes surrounding PMS impact how fluid is stored in the body and can cause swelling.

·    Arthritis. The affected joints from arthritis will often swell with water, which often makes moving the affected joints even more difficult and painful.

  Allergic reaction. An allergic reaction is an underlying reason behind some people’s edema. A major allergic reaction often causes immediate inflammation and bloating, but smaller allergies may cause milder but still noticeable swelling and edema.

   Autoimmune diseases such as lupus. Lupus prevents the kidneys from functioning properly, leading to fluid build-up that can cause water retention and swelling.

·  Substantial changes in air pressure. Air pressure affects how the body stores water, so plane rides may be one reason for water retention. Symptoms of Water Retention

Generalized edema -Swelling. Particularly in the fingers, , ankles, feet, toes and lower legs that is due to fluid retention.

· Bloating. Particularly in the stomach and abdomen.

· Puffiness. The cheeks, eyes, or entire face may be puffy in appearance and to the touch because of water retention.

· Stiffness and muscle pain. Water retention often makes the affected body parts feel stiffer, and it may become painful to move the affected areas.

· Fatigue and lethargy. The excess water from edema may cause significant fatigue and lethargy, as the muscles become heavier and more sensitive.

  Crackles in the lungs upon auscultation Dyspnea• Orthopnea Cough

·   Weight gain, , Headache

    Treatments for Water Retention

1.    Controlling salt consumption

2.    Adding magnesium to the daily diet

3.   Adding potassium to the daily diet

4   Consuming b-6 supplements

5.   Consuming more protein

6   Use compression socks

7.   Consume dandelion

8.  Don't consume refined carbs

9. Implement self-treatment for fluid retention

10.   Seek medical care from doctor

Three of the most efficient methods for treating water retention are reducing salt intake, increasing magnesium in your diet, and using compression socks.

Controlling salt comsumption

Controlling salt consumption is one of the best treatments for water retention, as fluid retention is typically due to high salt concentrations in the body. symptom. Try to avoid foods with high sodium and salt content. This includes salted meats, processed cheeses, salty snacks, or dishes that heavily use soy sauce. Cutting back on these foods helps to reduce salt levels and restore the proper ratio of water to salt in the body.

2. Consuming Vitamin B-6 Supplements

Consuming vitamin B-6 supplements helps to treat water retention by providing the body with the proper tools to help build red blood cells.

3 Don't Consume Refined Carbs

If possible, do not consume refined carbs (foods like pasta, bread, and other grains) in abundance if you want to treat water retention.  Many nutritionists have identified these foods as common culprits for stomach and abdominal bloating. Additionally, these foods may have high sodium or salt contents, making them not ideal in the treatment of water retention.

4. Adding Magnesium to the Daily Diet

Adding magnesium to your daily diet can effectively treat water retention, particularly in those whose fluid retention symptoms are caused by premenstrual syndrome or other estrogen-specific hormonal change. The Journal of Women’s Health found that when women were given 200 mg of magnesium supplement pills, most of their fluid retention symptoms – bloating in the abdomen, swelling of the breasts and extremities, and weight gain – were significantly decreased within two months. People should receive daily in their diet is between 310-400 mg. Magnesium-rich foods, such as those illustrated below, include cereals, yogurt, rice, black beans, and peanut butter. Chia seed

5,Adding potassium to daily diet

Adding potassium to your daily diet is another easy way to treat water retention at home, as potassium helps process sodium (salt) out of the body. Eating foods high in potassium – such as bananas, sweet potato, spinach, avocados, and mushrooms (illustrated below) – reduces the bloating from fluid retention and “helps relax blood vessel walls, which helps lower blood pressure,” .

The American Heart Association notes that “most women should get 2,600 milligrams of potassium a day and men 3,400 milligrams a day, but… on average, men eat about 3,000 mg/day, and women eat about 2,300 mg/day” (2018).

6 Comsuming  more protein

Consuming more proteins – such as meat, beans, leafy green vegetables, etc. – helps with treating water retention. In patients with liver disease, protein deficiency is common and may contribute to symptoms of edema, particularly in the lower extremities. According to the Gastroenterological Society of Australia, patients with chronic liver disease can manage their symptoms (including fluid retention symptoms) by incorporating low-salt, high-protein foods into their daily diet, such as the examples below.

 7Use compression socks

Compression socks are a helpful tool in treating water retention, as they relieve the symptom of swelling in the legs and feet by preventing blood from pooling there so it returns more quickly to the heart for circulation. Compression socks are one of the most common treatments for edema in the feet and ankles .. They are normally worn all day but taken off to sleep at night. They can have a rapid positive effect to reduce discomfort as soon as worn, though they are not a long-term cure.

8 Consuming dandelion extract (known as “lion’s tooth”) may be helpful in treating fluid retention, as it is thought to be a natural diuretic with high levels of potassium. Those two aspects make it ideal for reducing salt levels in the body and flushing excess fluid through urination.

9 Implement self-treatment for fluid retention

 Some additional at-home remedies include cardio exercises, massages, and soaking in an Epsom salt bath for 15-20 minutes. These additional remedies relieve some of the discomfort associated with water retention by improving circulation and easing muscle pain.

Parsley aids in increased urine production, which is helpful with fluid retention. It is made     into tea and consumed daily. Calyces (from hibiscus plants). is said to reduce hypertension and treat mild edema. Green or black tea. Because of the caffeine content, both green and black tea may serve as diuretics.

Drugs for Water Retention Treatment?

The drugs for water treatment are usually diuretics, a type of medicine that increases urination. Diuretics are classified into three categories.

1.   Thiazide. Including chlorthalidone and hydrochlorothiazide. These lower blood pressure as they work as a diuretic.

2.   Loop. Including torsemide and furosemide. These are used for patients with chronic heart failure.

3.   Potassium sparing. Including amiloride and triamterene. These diuretics deplete less of the body’s natural potassium than other diuretics do.

1.   Congestive heart failure. Water retention can occur when a weakened heart is not pumping blood efficiently through the body.   Excess blood may back up in the legs, ankles, and feet, leading to edema.

2.    Pregnancy. The additional weight in the abdomen puts pressure on the bladder and the legs, which may result in some fluid retention in the lower limbs, ankles, and feet.

3.    Allergic reactions. The swelling of the face and limbs is a common side effect of allergic reactions. difficulty breathing, tightness in the chest, itchiness, hives, and red eyes are some other typical symptoms that occur.

4.    Recovery from surgery. The stress of surgery and its recovery, and the more limited movement that can often occur post-surgery, may temporarily cause edema.

5.   New medications. Sometimes a medication’s side effects include edema. If a new medicine is causing edema, consult with a doctor to see if the dosage is adjusted, or if an alternative medication is provided instead.

6.   Poor diet. A diet that is inconsistent and/or unhealthy puts an individual at risk of experiencing fluid retention.

7.    Venous insufficiency. A disease that “makes it hard for the veins to push blood back up to the heart,” and is often caused by chronic sitting/standing for long periods of time,

Deficient Fluid Volume (also known as Fluid Volume Deficit (FVD), hypovolemia) is a state or condition where the fluid output exceeds the fluid intake. It occurs when the body loses both water and electrolytes from the ECF in similar proportions. Common sources of fluid loss are the gastrointestinal tract, polyuria, and increased perspiration. Risk factors for deficient fluid volume are as follows: vomiting, diarrhea, GI suctioning, sweating, decreased intake, nausea, inability to gain access to fluids, adrenal insufficiency, osmotic diuresis, haemorrhage, coma, third-space fluid shifts, burns, ascites, and liver dysfunction. Fluid volume deficit may be an acute or chronic condition managed in the hospital, outpatient center, or home setting.

Appropriate management is vital to prevent potentially life-threatening hypovolemic shock. Older patients are more likely to develop fluid imbalances. The management goals are to treat the underlying disorder and return the extracellular fluid compartment to normal, restore fluid volume, and correct any electrolyte imbalances.

Aetiology for fluid volume deficit:

• Abnormal losses through the skin, GI tract, or kidneys.
• Decrease in intake of fluid (e.g., inability to intake fluid due to oral trauma)
• Bleeding
• Movement of fluid into third space.
• Diarrhea
• Diuresis
• Abnormal drainage
• Inadequate fluid intake
• Increased metabolic rate (e.g., fever, infection)

Signs and symptoms

The following are the common signs and symptoms presented for dehydrated patients presenting fluid volume deficit that can help guide your nursing assessment:

• Alterations in mental state
• Patient complaints of weakness and thirst that may or may not be accompanied by tachycardia or weak pulse
• Weight loss (depending on the severity of fluid volume deficit)
• Concentrated urine, decreased urine output
• Dry mucous membranes, sunken eyeballs
• Weak pulse, tachycardia

·      Decreased skin turgor, Decreased weight

• Decreased blood pressure, haemoconcentration
• Postural hypotension, Dizziness, syncope

Goals and outcomes for fluid volume deficit:

• Patient is normovolemic as evidenced by systolic BP greater than or equal to 90 mm HG (or patient’s baseline), absence of orthostasis, HR 60 to 100 beats/min, urine output greater than 30 mL/hr and normal skin turgor.
• Patient demonstrates lifestyle changes to avoid progression of dehydration.
• Patient verbalizes awareness of causative factors and behaviors essential to correct fluid deficit.
• Patient explains measures that can be taken to treat or prevent fluid volume loss.
• Patient describes symptoms that indicate the need to consult with health care provider.

Nursing assessment and rationales for fluid volume deficit

1. Monitor and document vital signs, especially BP and HR.
A decrease in circulating blood volume can cause hypotension and tachycardia. Alteration in HR is a compensatory mechanism to maintain cardiac output. Usually, the pulse is weak and irregular if electrolyte imbalance also occurs. Hypotension is evident in hypovolemia.

2. Assess skin turgor and oral mucous membranes for signs of dehydration.
Signs of dehydration are also detected through the skin. The skin of elderly patients losses elasticity.

3. Monitor BP for orthostatic changes (changes seen when changing from supine to standing position). Monitor HR for orthostatic changes.
A common manifestation of fluid loss is postural hypotension. It is manifested by a 20-mm Hg drop in systolic BP and a 10 mm Hg drop in diastolic BP. The incidence increases with age.

4. Assess alteration in mentation/sensorium (confusion, agitation, slowed responses).
Alteration in mentation/sensorium may be caused by abnormally high or low glucose, electrolyte abnormalities, acidosis, decreased cerebral perfusion, or developing hypoxia. Impaired consciousness can predispose a patient to aspiration regardless of the cause.

5. Assess color and amount of urine. Report urine output less than 30 ml/hr for two (2) consecutive hours.
Normal urine output is considered normal, not less than 30ml/hour. Concentrated urine denotes fluid deficit.

6. Monitor and document temperature.
Febrile states decrease body fluids by perspiration and increased respiration. This is known as insensible water loss.

7. Monitor fluid status in relation to dietary intake.
Most fluid comes into the body through drinking, water in food, and water formed by the oxidation of foods. Verifying if the patient is on a fluid restraint is necessary.

8. Note the presence of nausea, vomiting, and fever.
These factors influence intake, fluid needs, and route of replacement.

9. Auscultate and document heart sounds; note rate, rhythm, or other abnormal findings.
Cardiac alterations like dysrhythmias may reflect hypovolemia or electrolyte imbalance, commonly hypocalcemia. MI, pericarditis, and pericardial effusion with/ without tamponade are common cardiovascular complications.

10. Monitor serum electrolytes and urine osmolality, and report abnormal values.
Elevated blood urea nitrogen suggests fluid deficit. Urine-specific gravity is likewise increased.

11. Ascertain whether the patient has any related heart problem before initiating parenteral therapy.
Cardiac and older patients are often susceptible to fluid volume deficit and dehydration due to minor changes in fluid volume. They also are susceptible to the development of pulmonary edema.

12. Weigh daily with the same scale, and preferably at the same time of day.
Weight is the best assessment data for possible fluid volume imbalance. An increase in 2 lbs a week is considered normal.

13. Identify the possible cause of the fluid disturbance or imbalance.
Establishing a database of history aids accurate and individualized care for each patient.

14. Monitor active fluid loss from wound drainage, tubes, diarrhea, bleeding, and vomiting; maintain accurate input and output record.
Fluid loss from wound drainage, diarrhea, bleeding, and vomiting cause decreased fluid volume and can lead to dehydration.

15. During treatment, monitor closely for signs of circulatory overload (headache, flushed skin, tachycardia, venous distention, elevated central venous pressure [CVP], shortness of breath, increased BP, tachypnea, cough).
Close monitoring for responses during therapy reduces complications associated with fluid replacement.

16. Monitor and document hemodynamic status, including CVP, pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP) if available in the hospital setting.
These direct measurements serve as an optimal guide for therapy.

17. Monitor for the existence of factors causing deficient fluid volume (e.g., gastrointestinal losses, difficulty maintaining oral intake, fever, uncontrolled type II diabetes mellitus, diuretic therapy).
Early detection of risk factors and early intervention can decrease the occurrence and severity of complications from deficient fluid volume. The gastrointestinal system is a common site of abnormal fluid loss.

Nursing interventions for fluid volume deficit

The following are the therapeutic nursing interventions for fluid volume deficit:

1. Urge the patient to drink the prescribed amount of fluid.
Oral fluid replacement is indicated for mild fluid deficit and is a cost-effective method for replacement treatment. Older patients have a decreased sense of thirst and may need ongoing reminders to drink. Being creative in selecting fluid sources (e.g., flavoured gelatine, frozen juice bars, sports drink) can facilitate fluid replacement. Oral hydrating solutions (e.g., Rehydrate) can be considered as needed.

2. Aid the patient if they cannot eat without assistance, and encourage the family or SO to assist with feedings as necessary.
Dehydrated patients may be weak and unable to meet prescribed intake independently.

3. If the patient can tolerate oral fluids, give what oral fluids the patient prefers. Provide fluid and straw at bedside within easy reach. Provide fresh water and a straw.
Most elderly patients may have a reduced sense of thirst and may require continuing reminders to drink.

4. Emphasize the importance of oral hygiene.
A fluid deficit can cause a dry, sticky mouth. Attention to mouth care promotes interest in drinking and reduces the discomfort of dry mucous membranes.

5. Provide a comfortable environment by covering the patient with light sheets.
Drop situations where patients can experience overheating to prevent further fluid loss.

6. Plan daily activities.
Planning conserves the patient’s energy.

Interventions for severe hypovolemia:

7. Insert an IV catheter to have IV access.
Parenteral fluid replacement is indicated to prevent or treat hypovolemic complications.

8. Administer parenteral fluids as prescribed. Consider the need for an IV fluid challenge with an immediate infusion of fluids for patients with abnormal vital signs.
Fluids are necessary to maintain hydration status. Determination of the type and amount of fluid to be replaced and infusion rates will vary depending on clinical status.

9. Administer blood products as prescribed.
Blood transfusions may be required to correct fluid loss from active gastrointestinal bleeding.

10. Maintain IV flow rate. Stop or delay the infusion if signs of fluid overload transpire, refer to physician respectively.
Most susceptible to fluid overload are elderly patients and require immediate attention.

11. Assist the physician with inserting the central venous line and arterial line, as indicated.
A central venous line allows fluids to be infused centrally and for monitoring of CVP and fluid status. An arterial line allows for the continuous monitoring of BP.

12. Provide measures to prevent excessive electrolyte loss (e.g., resting the GI tract, administering antipyretics as ordered by the physician).
Fluid losses from diarrhea should be concomitantly treated with antidiarrheal medications, as prescribed. Antipyretics can decrease fever and fluid losses from diaphoresis.

13. Begin to advance the diet in volume and composition once ongoing fluid losses have stopped.
The addition of fluid-rich foods can enhance continued interest in eating.

14. Encourage to drink bountiful amounts of fluid as tolerated or based on individual needs.
A patient may have restricted oral intake in an attempt to control urinary symptoms, reducing homeostatic reserves and increasing the risk of dehydration or hypovolemia.

15. Enumerate interventions to prevent or minimize future episodes of dehydration.
A patient needs to understand the value of drinking extra fluid during bouts of diarrhea, fever, and other conditions causing fluid deficits.

16. Educate patient about possible causes and effects of fluid loss or decreased fluid intake.
Enough knowledge aids the patient in taking part in their plan of care.

17. Emphasize the relevance of maintaining proper nutrition and hydration.
Increasing the patient’s knowledge level will assist in preventing and managing the problem.

18. Teach family members how to monitor output in the home. Instruct them to monitor both intake and output.
An accurate measure of fluid intake and output is an important indicator of a patient’s fluid status.

19. Refer patient to home health nurse or private nurse to assist patient, as appropriate.
Continuity of care is facilitated through the use of community resources.

20. Identify an emergency plan, including when to ask for help.
Some complications of deficient fluid volume cannot be reversed in the home and are life-threatening. Patients progressing toward hypovolemic shock will need emergency care.

Basic physiology of electrolytes and their abnormalities, and the consequences of electrolyte imbalance.  

Electrolytes are essential for basic life functioning, such as maintaining electrical neutrality in cells, generating and conducting action potentials in the nerves and muscles. Sodium, potassium, and chloride are the significant electrolytes along with magnesium, calcium, phosphate, and bicarbonates. Electrolytes come from our food and fluids. 

These electrolytes can have an imbalance, leading to either high or low levels. High or low levels of electrolytes disrupt normal bodily functions and can lead to even life-threatening complications. 

Sodium

Sodium, which is an osmotically active cation, is one of the most important electrolytes in the extracellular fluid. It is responsible for maintaining the extracellular fluid volume, and also for regulation of the membrane potential of cells. Sodium is exchanged along with potassium across cell membranes as part of active transport. 

Sodium regulation occurs in the kidneys. The proximal tubule is where the majority of sodium reabsorption takes place. In the distal convoluted tubule, sodium undergoes reabsorption.  Sodium transport takes place via sodium-chloride symporters, which are by the action of the hormone aldosterone.

Among the electrolyte disorders, hyponatremia is the most frequent. Diagnosis is when the serum sodium level is less than 135 mmol/L. Hyponatremia has neurological Correction of body water osmolality restoration of cell volume by:

 provide high – sodium foods, below 125 mEq/L sodium and give 0.9 NaCl, or LR

manifestations. Patients may present with headaches, confusion, nausea, delirium. 

Hypernatremia presents when the serum sodium levels are greater than145 mmol/L. Symptoms of hypernatremia include tachypnea, sleeping difficulty, and feeling restless. Rapid sodium corrections can have serious consequences like cerebral edema and osmotic demyelination syndrome. 

Hyponatremia Hypernatremia

Potassium

Potassium is mainly an intracellular ion. The sodium-potassium adenosine triphosphatase pump has the primary responsibility for regulating the homeostasis between sodium and potassium, which pumps out sodium in exchange for potassium, which moves into the cells. In the kidneys, the filtration of potassium takes place at the glomerulus. The reabsorption of potassium takes place at the proximal convoluted tubule and thick ascending loop of Henle. Potassium secretion occurs at the distal convoluted tubule. Aldosterone increases potassium secretion. Potassium channels and potassium-chloride cotransporters at the apical membrane also secrete potassium

Potassium disorders are related to cardiac arrhythmias.

 Hypokalaemia occurs when serum potassium levels under 3.6 mmol/L—weakness, fatigue, and muscle twitching present in hypokalaemia

Common causes: - Inadequate K+ intake, K+ loss exceeds intake Shift of K+ into cells

 Hyperkalaemia occurs when the serum potassium levels are above 5.5 mmol/L, which can result in arrhythmias. Muscle cramps, muscle weakness, rhabdomyolysis, myoglobinuria are presenting signs and symptoms in hyperkaliemia.

•   Increase in the difference in the amount of potassium between ICF & ECF

•   Increased difference reduces the excitability of cells

•   Cell membranes especially nerves & muscles are less responsive to normal stimuli

•    Fatigue, anorexia, nausea and vomiting, muscle weakness, polyuria

•    decreased bowel motility

•       Paresthésies, leg camps, ↓ BP, iléus

•       abdominal distention, hypoactive reflexes,

•       ECG: flattened T waves, prominent U waves, - ST depression, prolonged PR interval

* most serious: lethal ventricular. arrhythmias; cardiac arrest

•       Fatigue, anorexia, nausea and vomiting, muscle weakness, polyuria

•       decreased bowel motility

•       paresthésies, leg camps, ↓ BP, ileus

•       abdominal distention, hypoactive reflexes,

•       ECG: flattened T waves, prominent U waves,

                                - ST depression, prolonged PR interval

         * most serious: lethal ventricular

              arrhythmias; cardiac arrest

Calcium

Calcium has a significant physiological role in the body. It is involved in skeletal mineralization, contraction of muscles, the transmission of nerve impulses, blood clotting, and secretion of hormones. The diet is the predominant source of calcium. It is mostly present in the extracellular fluid. Absorption of calcium in the intestine is primarily under the control of the hormonally active form of vitamin D, which is 1,25-dihydroxy vitamin D3. Parathyroid hormone also regulates calcium secretion in the distal tubule of kidneys. Calcitonin acts on bone cells to increase the calcium levels in the blood.

•       Hypocalcaemia diagnosis requires checking the serum albumin level to correct for total calcium, and the diagnosis is when the corrected serum total calcium levels are less than 8.8 mg/dl, as in vitamin D deficiency or hypoparathyroidism. Checking serum calcium levels is a recommended test in post-thyroidectomy patients.

•        Hypercalcemia is when corrected serum total calcium levels exceed 10.7 mg/dl, as seen with primary hyperparathyroidism. Humoral hypercalcemia presents in malignancy, primarily due to PTHrP secretion. Oral calcium with Vitamin D , be given 30 minutes before meals (improve GI absorption)

•       Avoid giving calcium & bicarbonate in the same solution (precipitate will form)

•       IV calcium diluted in D5W

Bicarbonate

The acid-base status of the blood drives bicarbonate levels. The kidneys predominantly regulate bicarbonate concentration and are responsible for maintaining the acid-base balance. Kidneys reabsorb the filtered bicarbonate and also generate new bicarbonate by net acid excretion, which occurs by excretion of both titrable acid and ammonia. Diarrhea usually results in loss of bicarbonate, thus causing an imbalance in acid-base regulation. 

Magnesium

Magnesium is an intracellular cation. Magnesium is mainly involved in ATP metabolism, contraction and relaxation of muscles, proper neurological functioning, and neurotransmitter release. When muscle contracts, calcium re-uptake by the calcium-activated ATPase of the sarcoplasmic reticulum is brought about by magnesium.] Hypomagnesemia occurs when the serum magnesium levels are less under 1.46 mg/dl. It can present with alcohol use disorder and gastrointestinal and renal losses—ventricular arrhythmias, which include torsade’s de pointes seen in hypomagnesemia. 

Chloride

Chloride is an anion found predominantly in the extracellular fluid. The kidneys predominantly regulate serum chloride levels. Most of the chloride, which is filtered by the glomerulus, is reabsorbed by both proximal and distal tubules (majorly by proximal tubule) by both active and passive transport

Hyperchloremia can occur due to gastrointestinal bicarbonate loss. Hypochloremia presents in gastrointestinal losses like vomiting or excess water gain like congestive heart failure. 

Phosphorus

Phosphorus is an extracellular fluid cation. Eighty-five percent of the total body phosphorus is in the bones and teeth in the form of hydroxyapatite; the soft tissues contain the remaining 15%. Phosphate plays a crucial role in metabolic pathways. It is a component of many metabolic intermediates and, most importantly of adenosine triphosphate (ATPs) and nucleotides. Phosphate is regulated simultaneously with calcium by Vitamin D3, PTH, and calcitonin. The kidneys are the primary avenue of phosphorus excretion. 

Phosphorus imbalance may result due to three processes: dietary intake, gastrointestinal disorders, and excretion by the kidneys

Both hyponatremia and hypernatremia, as well as hypomagnesemia, can lead to neurological consequences such as seizure disorders. 

Hypokalemia and hyperkalemia, as well as hypocalcemia, are more responsible for arrhythmias.

Bicarbonate imbalance can lead to metabolic acidosis or alkalosis.

Some of the common causes of electrolyte disorders seen in clinical practices are:

·         Hyponatremia: low dietary sodium intake, primary polydipsia, SIADH, congestive heart failure, hepatic cirrhosis, failure of adrenal glands, hyperglycemia, dyslipidemia

·         Hypernatremia: unreplaced fluid loss through the skin and gastrointestinal tract, osmotic diuresis, hypertonic saline administration

·         Hypokalemia: hyperaldosteronism, loop diuretics 

·         Hyperkalemia: increase release from cells as in metabolic acidosis, insulin deficiency, beta-blocker or decreased potassium excretion as in acute or chronic kidney disease, aldosterone deficiency or resistance

·         Hypercalcemia: malignancy, hyperparathyroidism, chronic granulomatous disease

·         Hypocalcaemia: acute pancreatitis, parathyroid hormone deficiency after thyroidectomy, neck dissection, resistance to parathormone, hypomagnesemia, sepsis 

·         Hypermagnesemia: increase oral magnesium intake

·         Hypomagnesemia: renal losses as in diuretics, alcohol use disorder, or GI losses as in diarrhea

·         Bicarbonate level: increases in primary metabolic alkalosis or compensation to primary respiratory acidosis - decreases in primary metabolic acidosis or compensation to primary respiratory alkalosis.

·         Hyperchloremia: normal saline infusion

·         Hypochloremia: GI loss as in diarrhea, renal losses with diuretics

·         Hypophosphatemia: refeeding syndrome, vitamin D deficiency, hyperparathyroidism

·         Hyperphosphatemia: hypoparathyroidism, chronic kidney disease