Overview of postoperative electrolyte abnormalities
- Nicole Siparsky, MD, FACS
Nicole Siparsky, MD, FACS
- Assistant Professor of Surgery
- Rush Medical College
- Section Editors
- Hilary Sanfey, MD
Hilary Sanfey, MD
- Section Editor — General Surgical Principles; Quality and Safety
- Professor of Surgery
- SIU School of Medicine
- Richard H Sterns, MD
Richard H Sterns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Fluid and Electrolytes
- Professor of Medicine
- University of Rochester School of Medicine and Dentistry
Postoperative surgery patients are prone to electrolyte derangements related to the loss of blood and bodily fluids, the stress response to surgery, intravenous fluid administration, blood transfusion, and the underlying surgical disease.
The etiology, evaluation, and management of common electrolyte abnormalities following surgery are reviewed here. The estimation of fluid losses and correction of fluid volume deficits following surgery are discussed separately. (See "Overview of postoperative fluid therapy in adults".)
ETIOLOGIES OF POSTOPERATIVE ELECTROLYTE ABNORMALITIES
Fluid therapy — Electrolyte abnormalities observed in the postoperative period often result from the administration of intravenous fluids, fluid shifts, transfusion, and parenteral nutritional support (when indicated). (See "Overview of postoperative fluid therapy in adults" and "Postoperative parenteral nutrition".)
Crystalloid fluids — A variety of crystalloids are used in fluid resuscitation after surgery, including 0.9% sodium chloride, Lactated Ringer’s (LR) solution, and balanced salt solutions such as Plasma-Lyte (table 1).
●Although the sodium concentration of 0.9% saline (154 mEq/L) is higher than the normal plasma sodium concentration, it equals the sodium concentration of the aqueous phase of plasma, which is the phase that is in osmotic equilibrium with the rest of body fluids. However, the chloride concentration of 0.9% saline is much higher than that of plasma because the solution contains no bicarbonate.
- Chowdhury AH, Cox EF, Francis ST, Lobo DN. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte® 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Ann Surg 2012; 256:18.
- Russell JA. Bench-to-bedside review: Vasopressin in the management of septic shock. Crit Care 2011; 15:226.
- Steele A, Gowrishankar M, Abrahamson S, et al. Postoperative hyponatremia despite near-isotonic saline infusion: a phenomenon of desalination. Ann Intern Med 1997; 126:20.
- Awad S, Allison SP, Lobo DN. The history of 0.9% saline. Clin Nutr 2008; 27:179.
- Cuesta M, Thompson C. The relevance of hyponatraemia to perioperative care of surgical patients. Surgeon 2015; 13:163.
- Chung HM, Kluge R, Schrier RW, Anderson RJ. Postoperative hyponatremia. A prospective study. Arch Intern Med 1986; 146:333.
- Sterns RH. Disorders of plasma sodium--causes, consequences, and correction. N Engl J Med 2015; 372:55.
- Palmer BF. Regulation of Potassium Homeostasis. Clin J Am Soc Nephrol 2015; 10:1050.
- Hess JR. Red cell changes during storage. Transfus Apher Sci 2010; 43:51.
- Morrison A, McMillan L, Campbell JD, Petrik J. Evaluation of a potassium removal filter on irradiated red cells stored in SAGM. Transfus Med 2015; 25:320.
- Raza S, Ali Baig M, Chang C, et al. A prospective study on red blood cell transfusion related hyperkalemia in critically ill patients. J Clin Med Res 2015; 7:417.
- Bennett-Guerrero E, Kirby BS, Zhu H, et al. Randomized study of washing 40- to 42-day-stored red blood cells. Transfusion 2014; 54:2544.
- Mann KG, Whelihan MF, Butenas S, Orfeo T. Citrate anticoagulation and the dynamics of thrombin generation. J Thromb Haemost 2007; 5:2055.
- Vandromme MJ, McGwin G Jr, Weinberg JA. Blood transfusion in the critically ill: does storage age matter? Scand J Trauma Resusc Emerg Med 2009; 17:35.
- Ho KM, Leonard A. Risk factors and outcome associated with hypomagnesemia in massive transfusion. Transfusion 2011; 51:270.
- Huber D, Witt L, Sümpelmann R, et al. Comparison of bicarbonate-buffered fluid and isotonic saline solution as Cell Saver washing fluids for packed red blood cells. Paediatr Anaesth 2013; 23:1021.
- Peng YG, Janelle GM, Perschau ER, et al. Dilutional hypokalemia-induced arrhythmias associated with intraoperative cell salvage and reinfusion. J Cardiothorac Vasc Anesth 2006; 20:568.
- Read MS, Coles P, Pomeroy M, et al. Conditioning out-of-date bank-stored red blood cells using a cell-saver auto-transfusion device: effects on numbers of red cells and quality of suspension fluid. Anaesthesia 2014; 69:1206.
- John CA, Day MW. Central neurogenic diabetes insipidus, syndrome of inappropriate secretion of antidiuretic hormone, and cerebral salt-wasting syndrome in traumatic brain injury. Crit Care Nurse 2012; 32:e1.
- Kirkman MA, Albert AF, Ibrahim A, Doberenz D. Hyponatremia and brain injury: historical and contemporary perspectives. Neurocrit Care 2013; 18:406.
- Mjaaland KE, Kivle K, Svenningsen S, et al. Comparison of markers for muscle damage, inflammation, and pain using minimally invasive direct anterior versus direct lateral approach in total hip arthroplasty: A prospective, randomized, controlled trial. J Orthop Res 2015; 33:1305.
- Zutt R, van der Kooi AJ, Linthorst GE, et al. Rhabdomyolysis: review of the literature. Neuromuscul Disord 2014; 24:651.
- Ayach T, Nappo RW, Paugh-Miller JL, Ross EA. Postoperative hyperkalemia. Eur J Intern Med 2015; 26:106.
- Sukhu T, Krupski TL. Patient positioning and prevention of injuries in patients undergoing laparoscopic and robot-assisted urologic procedures. Curr Urol Rep 2014; 15:398.
- Chakravartty S, Sarma DR, Patel AG. Rhabdomyolysis in bariatric surgery: a systematic review. Obes Surg 2013; 23:1333.
- Genthon A, Wilcox SR. Crush syndrome: a case report and review of the literature. J Emerg Med 2014; 46:313.
- Watson JD, Gifford SM, Clouse WD. Biochemical markers of acute limb ischemia, rhabdomyolysis, and impact on limb salvage. Semin Vasc Surg 2014; 27:176.
- Hsieh PM, Hung KC, Chen YS. Tumor lysis syndrome after transarterial chemoembolization of hepatocellular carcinoma: case reports and literature review. World J Gastroenterol 2009; 15:4726.
- Lee Hamm L, Hering-Smith KS, Nakhoul NL. Acid-base and potassium homeostasis. Semin Nephrol 2013; 33:257.
- Perez GO, Oster JR, Vaamonde CA. Serum potassium concentration in acidemic states. Nephron 1981; 27:233.
- Viera AJ, Wouk N. Potassium Disorders: Hypokalemia and Hyperkalemia. Am Fam Physician 2015; 92:487.
- Rueth NM, Murray SE, Huddleston SJ, et al. Severe electrolyte disturbances after hyperthermic intraperitoneal chemotherapy: oxaliplatin versus mitomycin C. Ann Surg Oncol 2011; 18:174.
- Newman DB, Siontis KC, Chandrasekaran K, et al. Intervention to reduce inappropriate ionized calcium ordering practices: a quality-improvement project. Perm J 2015; 19:49.
- Kraft MD, Btaiche IF, Sacks GS, Kudsk KA. Treatment of electrolyte disorders in adult patients in the intensive care unit. Am J Health Syst Pharm 2005; 62:1663.
- Capatina C, Paluzzi A, Mitchell R, Karavitaki N. Diabetes Insipidus after Traumatic Brain Injury. J Clin Med 2015; 4:1448.
- ETIOLOGIES OF POSTOPERATIVE ELECTROLYTE ABNORMALITIES
- Fluid therapy
- - Crystalloid fluids
- - Transfusion
- - Related to parenteral nutrition or prescription error
- Fluid loss
- - Third-spacing fluid loss
- - Gastrointestinal loss
- - Urinary loss
- Brain injury
- Related to tissue injury/ischemia and reperfusion
- Refeeding syndrome
- Acid-base imbalance
- Underlying surgical diseases and their treatment
- LABORATORY MONITORING
- Electrolyte replacement
- - Goal
- - Route
- - Amount
- - Rate
- Electrolyte excess
- SUMMARY AND RECOMMENDATIONS