Severe electrolyte disorders following cardiac surgery: a prospective controlled observational study.
BACKGROUND
Electrolyte disorders are an important cause of ventricular and supraventricular arrhythmias as well as various other complications in the intensive care unit. Patients undergoing cardiac surgery are at risk for development of tachyarrhythmias, especially in the period during and immediately after surgical intervention. Preventing electrolyte disorders is thus an important goal of therapy in such patients. However, although levels of potassium are usually measured regularly in these patients, other electrolytes such as magnesium, phosphate and calcium are measured far less frequently. We hypothesized that patients undergoing cardiac surgical procedures might be at risk for electrolyte depletion, and we therefore conducted the present study to assess electrolyte levels in such patients.


METHODS
Levels of magnesium, phosphate, potassium, calcium and sodium were measured in 500 consecutive patients undergoing various cardiac surgical procedures who required extracorporeal circulation (group 1). A total of 250 patients admitted to the intensive care unit following other major surgical procedures served as control individuals (group 2). Urine electrolyte excretion was measured in a subgroup of 50 patients in both groups.


RESULTS
All cardiac patients received 1 l cardioplegia solution containing 16 mmol potassium and 16 mmol magnesium. In addition, intravenous potassium supplementation was greater in cardiac surgery patients (mean +/- standard error: 10.2 +/- 4.8 mmol/hour in cardiac surgery patients versus 1.3 +/- 1.0 in control individuals; P < 0.01), and most (76% versus 2%; P < 0.01) received one or more doses of magnesium (on average 2.1 g) for clinical reasons, mostly intraoperative arrhythmia. Despite these differences in supplementation, electrolyte levels decreased significantly in cardiac surgery patients, most of whom (88% of cardiac surgery patients versus 20% of control individuals; P < 0.001) met criteria for clinical deficiency in one or more electrolytes. Electrolyte levels were as follows (mmol/l [mean +/- standard error]; cardiac patients versus control individuals): phosphate 0.43 +/- 0.22 versus 0.92 +/- 0.32 (P < 0.001); magnesium 0.62 +/- 0.24 versus 0.95 +/- 0.27 (P < 0.001); calcium 1.96 +/- 0.41 versus 2.12 +/- 0.33 (P < 0.001); and potassium 3.6 +/- 0.70 versus 3.9 +/- 0.63 (P < 0.01). Magnesium levels in patients who had not received supplementation were 0.47 +/- 0.16 mmol/l in group 1 and 0.95 +/- 0.26 mmol/l in group 2 (P < 0.001). Urinary excretion of potassium, magnesium and phosphate was high in group 1 (data not shown), but this alone could not completely account for the observed electrolyte depletion.


CONCLUSIONS
Patients undergoing cardiac surgery with extracorporeal circulation are at high risk for electrolyte depletion, despite supplementation of some electrolytes, such as potassium. The probable mechanism is a combination of increased urinary excretion and intracellular shift induced by a combination of extracorporeal circulation and decreased body temperature during surgery (hypothermia induced diuresis). Our findings may partly explain the high risk of tachyarrhythmia in patients who have undergone cardiac surgery. Prophylactic supplementation of potassium, magnesium and phosphate should be seriously considered in all patients undergoing cardiac surgical procedures, both during surgery and in the immediate postoperative period. Levels of these electrolytes should be monitored frequently in such patients.
Polderman
Kees H
KH
Intensive Care Medicine, Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands. k.polderman@tip.nl
Girbes
Armand R J
AR
D000328:Adult; D000368:Aged; D002118:Calcium / Q000097:blood; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000379:methods; D002314:Cardioplegic Solutions / Q000008:administration & dosage; D016022:Case-Control Studies; D005112:Extracorporeal Circulation / Q000009:adverse effects*; D006801:Humans; D007036:Hypothermia, Induced; D007362:Intensive Care Units; D008274:Magnesium / Q000097:blood; D008875:Middle Aged; D008991:Monitoring, Physiologic; D019370:Observation; D019990:Perioperative Care; D010758:Phosphorus / Q000097:blood; D011183:Postoperative Complications / Q000517:prevention & control; D011188:Potassium / Q000097:blood; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012964:Sodium / Q000097:blood; D014554:Urination; D014883:Water-Electrolyte Imbalance / Q000209:etiology* / Q000503:physiopathology
D002314:Cardioplegic Solutions; D010758:Phosphorus; D012964:Sodium; D008274:Magnesium; D011188:Potassium; D002118:Calcium