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Have the ‘Lytes Gone Out? Electrolyte and Metabolic Abnormality Management In Palliative Care – A case based discussion Dr. Jana Pilkey MD, FRCPC Internal.

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Presentation on theme: "Have the ‘Lytes Gone Out? Electrolyte and Metabolic Abnormality Management In Palliative Care – A case based discussion Dr. Jana Pilkey MD, FRCPC Internal."— Presentation transcript:

1 Have the ‘Lytes Gone Out? Electrolyte and Metabolic Abnormality Management In Palliative Care – A case based discussion Dr. Jana Pilkey MD, FRCPC Internal Medicine, Palliative Medicine Assistant Professor University of Manitoba

2 Objectives To list symptoms & treatments for hypercalcemia To list symptoms & treatments for hypercalcemia To gain approach to treatment of hyponatremia and hypernatremia To gain approach to treatment of hyponatremia and hypernatremia To list symptoms & prevention of refeeding syndrome To list symptoms & prevention of refeeding syndrome To list symptoms & treatment of hypomagnesemia To list symptoms & treatment of hypomagnesemia To understand differences in the management of diabetes in the palliative patient To understand differences in the management of diabetes in the palliative patient To understand ethical issues of treatment To understand ethical issues of treatment

3 Case 1 Mr. B. was a 42 year old man Mr. B. was a 42 year old man Morbidly obese – weight around 500 lbs Morbidly obese – weight around 500 lbs Diagnosed with locally invasive squamous cell penile cancer Diagnosed with locally invasive squamous cell penile cancer Underwent penectomy 2006 Underwent penectomy 2006 Referred to palliative care Referred to palliative care

4 Case 1 Unable to ambulate Unable to ambulate Multiple perineal wounds Multiple perineal wounds Profound leg and scrotal edema Profound leg and scrotal edema Calcium 4.02 (corrected) Calcium 4.02 (corrected)

5 Hypercalcemia 30% of patients with cancer 30% of patients with cancer 50% die within 30 days 50% die within 30 days Most common cancers: Most common cancers: squamous cell squamous cell breast breast renal renal MM MM lymphomas lymphomas

6 Hypercalcemia Causes: Causes: Osteolytic effects of bony mets Osteolytic effects of bony mets Humoral – secretion of a PTHrP Humoral – secretion of a PTHrP 1,25 (OH)2D – secreting lymphomas 1,25 (OH)2D – secreting lymphomas Ectopic secretion of PTH (very rare) Ectopic secretion of PTH (very rare)

7 Clinical Symptoms Bones – bony pain Bones – bony pain Stones - (Renal) – dehydration, polyuria, thirst/polydipsia, renal calculi Stones - (Renal) – dehydration, polyuria, thirst/polydipsia, renal calculi Moans – sedation, delirium, coma Moans – sedation, delirium, coma Groans – anorexia, nausea, vomiting, abd pain Groans – anorexia, nausea, vomiting, abd pain

8 Diagnosis Total serum calcium (corrected for albumin) Total serum calcium (corrected for albumin) Ionized calcium Ionized calcium If treating must monitor: If treating must monitor: Renal function Renal function phosphate phosphate magnesium magnesium potassium potassium

9 How to Treat Antineoplastics - key to maintenance Antineoplastics - key to maintenance Fluids – Saline hydration and loop diuretics Fluids – Saline hydration and loop diuretics Bisphosphonates Bisphosphonates Decreases bone resorption Decreases bone resorption Full efficacy in 2-7 days Full efficacy in 2-7 days Lasts 1-3 weeks. Lasts 1-3 weeks. Calcitonin Calcitonin subcut 4U/kg q 12 hours, subcut 4U/kg q 12 hours, works immediately works immediately tachyphylaxis within a few days tachyphylaxis within a few days (Siddiqui, J Pall Med 2010)

10 Should I Treat? Ethical Issue Ethical Issue Must take into account: Must take into account: patients goals patients goals ability to palliate/treat ability to palliate/treat “good death” “good death”

11 Case 1 Initially responded to pamidronate Initially responded to pamidronate Time between treatments getting shorter Time between treatments getting shorter Switched to IV zolendronate Switched to IV zolendronate Tried 4 and then 8 mg doses Tried 4 and then 8 mg doses Continued to decline Continued to decline Died at home Died at home

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13 Hyponatremia Hyponatremia Isotonic (lipids or proteins) Hypotonic Hypovolemic Renal losses GI losses Mineralocorticoid Deficiency Euvolemic -SIADH Glucocorticoid deficiency Hypothyroidis m Hypervolemic -CHF -Nephrotic/renal failure -Cirrhosis Hypertonic (glucose or mannitol) (Verbalis, Am J Med, 2007)

14 Classic Formulas Try MedCalc.com Try MedCalc.com Hypernatremia: Hypernatremia: Total H 2 O deficit (L) = total body water x ( 1 – (desired Na + )/ serum Na + ) ) Total H 2 O deficit (L) = total body water x ( 1 – (desired Na + )/ serum Na + ) ) Hyponatremia : Hyponatremia : Na + requirement (mmol) = total body water x (desired Na + - serum Na + ) Rate of infusion (cc/hr) = Na + requirement (mmol) x 1000 infusate Na + (mmol/L) x time (hours) Na + requirement (mmol) = total body water x (desired Na + - serum Na + ) Rate of infusion (cc/hr) = Na + requirement (mmol) x 1000 infusate Na + (mmol/L) x time (hours) Adrogue Formula : Change in serum Na + = ( (infusate Na + + infusate K + ) - serum Na + ) / total body water + 1 Adrogue Formula : Change in serum Na + = ( (infusate Na + + infusate K + ) - serum Na + ) / total body water + 1 Adrogue, HJ; and Madias, NE. Primary Care: Hypernatremia. New England Journal of Medicine 2000; 342(20): Adrogue, HJ; and Madias, NE. Primary Care: Hyponatremia. New England Journal of Medicine 2000; 342(21):

15 Hyponatremia Assuming Hypotonicity if they are: Assuming Hypotonicity if they are: Wet – dry them (diuretics) Wet – dry them (diuretics) Dry – wet them (fluids) Dry – wet them (fluids) Neither – fluid restrict them Neither – fluid restrict them

16 Hyponatremia Most often happened gradually Most often happened gradually Must be very careful to not over correct Must be very careful to not over correct Is correction appropriate in palliative care? Is correction appropriate in palliative care?

17 Hypernatremia Always Hypertonic Always Hypertonic Most often Hypovolemic in palliative care Most often Hypovolemic in palliative care Should palliative patients be treated with fluids? Should palliative patients be treated with fluids?

18 Fluids in Palliative Care When might it be appropriate: Patient unable to take orally & not close to dying Goal to prolong life Treat a cause of delirium When might it not be appropriate: Close to dying Gross edema Prone to pulmonary edema

19 Fluids in Palliative Care Oral Oral Enteral feeding tube Enteral feeding tube Intravenous Intravenous Hypodermoclysis Hypodermoclysis

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21 Case 2 78 y.o. female with laryngeal ca 78 y.o. female with laryngeal ca Unable to swallow & dehydrated - Hungry Unable to swallow & dehydrated - Hungry 2 weeks into admission – pt agrees to a feeding tube 2 weeks into admission – pt agrees to a feeding tube Tube placed into stoma connecting tracheostomy with esophagus Tube placed into stoma connecting tracheostomy with esophagus

22 Case 2 Remains hungry - Feeds increase Remains hungry - Feeds increase Chews food for enjoyment Chews food for enjoyment Continues to dehydrate Continues to dehydrate Tube dislodged Tube dislodged IV fluids started IV fluids started G- tube inserted G- tube inserted

23 Electrolyte Pattern Nov 18 Nov 19 Nov 27 Dec 29 Jan 5 Jan 7 Na135 Feeding tube inserted G-tube inserted K Cl Urea Creat PO Corr Ca Alb Mg

24 Refeeding Syndrome Occurs when malnourished patients are fed Occurs when malnourished patients are fed Problem in 25% of advanced cancer patient Problem in 25% of advanced cancer patient Palliative patients especially vulnerable (labs) Palliative patients especially vulnerable (labs) Characterized by: Characterized by: acute development of electrolyte depletion acute development of electrolyte depletion fluid retention fluid retention disruption of glucose homeostasis disruption of glucose homeostasis (Marinella, J Supp Onc, 2009) (Marinella, Nutr Rev 2003)

25 Refeeding Syndrome Malnutrition: Malnutrition: loss of lean tissue mass loss of lean tissue mass depletes phosphate stores depletes phosphate stores Carbohydrate load: Carbohydrate load: requires phosphorylated glycoloysis requires phosphorylated glycoloysis further depletes phosphate stores further depletes phosphate stores stimulates release of insulin stimulates release of insulin leads to a shift in po4, k, mg leads to a shift in po4, k, mg (Marinella, J Supp Onc, 2009) (Marinella, Nutr Rev 2003)

26 Refeeding Syndrome Decrease po4 leads to decrease ATP: Decrease po4 leads to decrease ATP: heart failure heart failure neuromuscular impairment neuromuscular impairment diaphragmatic weakness diaphragmatic weakness hemolytic anemia hemolytic anemia (Marinella, Nutr Rev 2003) (Marinella, J Supp Onc, 2009)

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29 Treatment Prevent Dehydration Prevent Dehydration Replace phosphate, K, Mg Replace phosphate, K, Mg Resume feeding slowly Resume feeding slowly Thiamine and B vitamins Thiamine and B vitamins (Marinella, J Supp Onc, 2009)

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31 Case 3 52 y.o. Woman with stage 4 cervical cancer 52 y.o. Woman with stage 4 cervical cancer Had chemo and radiation Had chemo and radiation Bowel obstruction – entero-enterostomy and loop colostomy Bowel obstruction – entero-enterostomy and loop colostomy Persistent hypokalemia and hypocalcemia Persistent hypokalemia and hypocalcemia Anorexia, diarrhea, muscle weakness, twitching, parasthesia. Anorexia, diarrhea, muscle weakness, twitching, parasthesia.

32 Case 3 Na – 138 Na – 138 K – 2.9 K – 2.9 Urea – 5.3 Urea – 5.3 Creat – 57 Creat – 57 Corr Ca – 1.57 Corr Ca – 1.57 Phos – 1.27 Phos – 1.27 Any Ideas? Any Ideas?

33 Case 3 Magnesium 0.2 mmol/L ( ) Magnesium 0.2 mmol/L ( )

34 Case 3 Given IV MgSO4 - Dramatic Improvement! Given IV MgSO4 - Dramatic Improvement! Ca and K normalize over next week Ca and K normalize over next week Discharged home and went on ski trip Discharged home and went on ski trip Died 3 months later of renal failure Died 3 months later of renal failure Was her treatment appropriate? Was her treatment appropriate? Should we routinely check for this in a palliative patient? Should we routinely check for this in a palliative patient?

35 Hypomagnesemia (Exton, Pall Med 2000)

36 Hypomagnesemia 7-11% of hospital patients 7-11% of hospital patients Common if other electrolytes Common if other electrolytes Causes refractory K + & Ca ++ Causes refractory K + & Ca ++ Treat cautiously in: Treat cautiously in: renal failure renal failure dehydration dehydration myasthenia myasthenia bradycardia bradycardia (Exton, Pall Med 2000) (Exton, Pall Med 2000)

37 Diabetes in Palliative Care Common in palliative care Common in palliative care Monitoring Monitoring Unsure of best frequency or method Unsure of best frequency or method Goal is mmol/L and asymptomatic Goal is mmol/L and asymptomatic WRHA - implementing screening if on steroids WRHA - implementing screening if on steroids Insulin preferred agent for treatment Insulin preferred agent for treatment Primary goal - prevention of hypoglycemia Primary goal - prevention of hypoglycemia Stop if patient unconscious Stop if patient unconscious

38 Monitoring Ideal Blood Glucose mmol/L Pharmacologic Management Treat only if patient conscious and desiring of treatment Best Oral Hypoglycemic Agents* NameClassStarting DosesAdvantages NataglinideInsulin secretagogue60-120mg preprandial Short acting Well tolerated in renal & hepatic failure RepaglinideInsulin secretagogue mg preprandialShort acting Gliclazide Sulphonylurea Insulin secretagogue 80 mg in morning Well tolerated in mild-moderate renal failure Best Basal Insulins NameClassStarting DosesAdvantages NPH (Neutral Protamine Hagedorn)Basal insulin10 units in morningPeaks during the day Glargine/DetemirBasal insulin10 units in morning More consistent levels over 24 hours Best Prandial Insulins NameClassStarting DosesAdvantages Lispro/ Aspart/ GlulisineRapid-acting analog insulin 5 units immediately pre or postprandial Flexibility if unsure of oral intake RegularHuman short acting insulin5 units min preprandial Fuller coverage between meals

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40 Summary Electrolyte/metabolic abnormalities managed on individual basis Electrolyte/metabolic abnormalities managed on individual basis If treatment undertaken - management is similar to management elsewhere If treatment undertaken - management is similar to management elsewhere Palliative care patients are particularly vulnerable to electrolyte abnormalities Palliative care patients are particularly vulnerable to electrolyte abnormalities If questions feel free to consult If questions feel free to consult

41 Questions?


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