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CHAPTER 17
(3) Fluid balance (oedema)
As a result of the paralytic vasodilatation following the interruption of the vasoconstrictor
fibres in the spinal cord, the fluid balance is disturbed, the more so as in the early days
following transection of the cervical cord the renal function is slowed down resulting in
oliguria and sometimes even anuria. This results in changes in the hydrostatic and colloid
osmotic pressure leading to increased transudation of fluid from the intravascular into
the intrastitional spaces and formation of oedema. Therefore, fluid intake has to be
considered most carefully. In patients who arrived following routine administration of
large intravenous isotonic saline or glucose solutions, the over-infusion resulted in
pulmonary oedema, which in turn increased the hypoventilation caused by the paralysis of
the intercostals and abdominal muscles in these high lesions. In those cases who died,
the post mortem showed large amounts of fluid in the chest cavity indicating that these
patients were drowned in their own body fluids. One man, aged 51, with a complete
lesion below C4/5 received 3 litres of dextran together with adrenaline before being
transferred to Stoke Mandeville. He was dead on arrival and the necropsy revealed a
massive pulmonary oedema. Therefore, promoting diuresis in overhydrated tetraplegics
is imperative. Intravenous urea has been used as an osmotic diuretic but in recent years
mannitol solution (half a litre of 20 per cent solution) has proved the most effective
measure (see also chapter on Renal Deficiency).
(4) Nutritional deficiency
Meteorism with loss or impairment of the digestive intestinal function as well as disturb
ances of the fluid balance may lead to nutritional deficiency, especially if the paralysis of
the peristalsis in the initial stage of tetraplegia also involves the stomach resulting in
acute dilatation which, in turn, increases the respiratory distress. This is indeed a very
serious complication, the more so as vomiting occurs which not only may lead to depletion
of electrolytes, but the danger of inhalation of vomit resulting in acute blockage of the
airways leading to pulmonary collapse is great. Gastric aspiration through a nasal tube
should be instituted as soon as possible and the removed gastro-intestinal secretion
replaced with nutrient fluids at a rate of 40-50 ml per hour, gradually increasing the
amount of fluid commensurate with the improvement of the function of the stomach.
Loss of gastric hydrochloric acid may result in alkalosis and has to be treated accord
ingly. Failure of absorption from the small intestine as a result of the paralysis of peristalsis
and associated with acidosis makes intravenous transfusion necessary, which should be
continued as long as the paralysis or impairment of intestinal function persists. Amongst
the administered nutrient fluids, fruit juice expressed from grapefruit and oranges rich
in vitamins and mixed with glucose, have been found invaluable. Parentrovite, a concen
trated B and C complex with glucose in injectable form, is recommended in these cases.
Attention must be paid to the caloric requirement of these patients, and the provision
of at least 1,800 to 2,000 K calories should be established. To counteract depletion of
body protein, intravenous infusion of amino-acid solutions may be necessary as long as
oral intake of food is not possible. Cheshire & Coats (1966), in their comprehensive
