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May also have played a role. Residual urine volume was higher in group 1 than in

Group 2; however, the time period in which urine volumes were produced in group

1 is unknown, because we were unable to determine the last time that the

Patients had urinated before the occurrence of head injury. In addition,

Spontaneous urine loss could have occurred in group 1 patients at the scene of

Their accident; this would lead to an underestimation of residual urine levels.

Almost all patients in group 1 had diuresis in excess of 300 ml/hr in the

Period immediately preceding ICU admission and in the first 3 hrs of ICU stay,

And urine production was significantly higher in group 1 than in group 2.

Although this does not prove that polyuresis was the cause of electrolyte

Deficiencies in group 1, it seems likely that high urine production and renal

Excretion of electrolytes contributed to the occurrence of electrolyte

Disorders. Nine patients in group 1 had received a single dose of mannitol

Before electrolyte measurement; however, the average time interval between

Mannitol administration and electrolyte assessment was <60 mins. Moreover,

There was no significant difference in electrolyte levels between group 1

Patients who had received mannitol and those who had not. Thus, it seems highly

Unlikely that mannitol administration alone caused the differences between

Groups 1 and 2, although it may have been a contributing factor in some

Patients.

It is difficult to determine to what extent outcome in our patients was

Affected by the presence of electrolyte disorders. Survival was significantly

Lower in group 1; to some extent, this was to be expected in view of the

Difference in morbidity as indicated by higher APACHE II scores and the severity

Of disease in group 1. On the other hand, some of the factors leading to higher

APACHE II scores in group 1 could be associated with electrolyte disorders

Present in group 1. For example, tachycardia and tachycardic arrhythmias leading

To higher APACHE II scores in group 1 may have been, in part, induced by

Electrolyte depletion; episodes of low blood pressure were, in some cases,

Induced by tachycardia; and high Na levels and low K levels found in group 1 led

Directly to attribution of APACHE II score points. The use of antiarrhythmic

Medication in the course of ICU stay was higher in group 1, but it is unclear to

What extent electrolyte disorders played a role in this difference. Moreover,

Measures to correct electrolyte disorders were initiated promptly when low

Levels of electrolytes were found in our patients. Thus, it remains unclear as

To what extent these disorders contributed to the occurrence of arrhythmias in

Our patients.

In most icus, Na and K are measured routinely at admission in all patients,

Including those with cerebral injury. However, Mg and P are not measured on a

Routine basis; therefore, deficiencies in levels of these electrolytes are

Likely to remain undetected for a longer period of time. We feel that

Intensivists and others treating patients with severe head injuries should be

Aware of this potential problem and that levels of Mg and P should be measured.