Metabolic derangements may be multitudinous and severe. Electrolytes may be abnormal for many reasons, such as fluid overload, and cardiac and renal dysfunction. Hyponatremia is quite common, and rapid correction of significant hyponatremia should be avoided as it can lead to central pontine myelinolysis (CPM). Potassium concentrations may be either elevated or depressed depending on renal dysfunction and types of diuretics used. Mild hypocalcemia is common and usually of little clinical concern. However, if there is significant blood transfusion, calcium therapy may be required to maintain hemodynamic stability, since the diseased liver may not be capable of clearing the preservative citrate, which binds calcium, from the banked blood. Blood glucose concentrations are usually normal to elevated, depending on the presence of diabetes, and the patient's diet and hepatic function. Hypoglycemia may be seen in cases of fulminant hepatitis. Many patients arrive in the operating room with a slight metabolic acidemia, due to the accumulation of acidic metabolites not removed by the liver, or renal and circulatory dysfunction. ESLD patients may also hyperventilate, which causes respiratory alkalosis.
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