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Have the ‘Lytes Gone Out

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1 Have the ‘Lytes Gone Out
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 gain approach to treatment of hyponatremia and hypernatremia To list symptoms & prevention of refeeding syndrome To list symptoms & treatment of hypomagnesemia To understand differences in the management of diabetes in the palliative patient To understand ethical issues of treatment

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

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

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

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

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

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

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

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

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


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

14 Classic Formulas Try Hypernatremia: Hyponatremia:
Total H2O deficit (L) =  total body water x ( 1 – (desired Na+ )/ serum Na+) ) 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) 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:
Wet – dry them (diuretics) Dry – wet them (fluids) Neither – fluid restrict them

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

17 Hypernatremia Always Hypertonic
Most often Hypovolemic in palliative care 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 Enteral feeding tube Intravenous Hypodermoclysis


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

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

23 Electrolyte Pattern Nov 18 Nov 19 Nov 27 Dec 29 Jan 5 Jan 7 Na K Cl
135 Feeding tube inserted 138 156 134 G-tube inserted K 2.5 3.7 4.0 Cl 100 103 114 Urea 6.5 4.8 23.1 12.1 Creat 72 69 178 108 PO4 0.66 0.51 1.19 0.97 Corr Ca 1.67 1.91 2.29 Alb 24 28 19 Mg 0.48 0.56 1.10

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

25 Refeeding Syndrome Malnutrition: Carbohydrate load:
loss of lean tissue mass depletes phosphate stores Carbohydrate load: requires phosphorylated glycoloysis further depletes phosphate stores stimulates release of insulin 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: heart failure
neuromuscular impairment diaphragmatic weakness hemolytic anemia (Marinella, Nutr Rev 2003) (Marinella, J Supp Onc, 2009)

27 (Marinella, J Supp Onc, 2009)

28 (Marinella, J Supp Onc, 2009)

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


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

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

33 Case 3 Magnesium 0.2 mmol/L ( )

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

35 Hypomagnesemia (Exton, Pall Med 2000)

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

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

38 Pharmacologic Management
Monitoring Ideal Blood Glucose 10-20 mmol/L Pharmacologic Management Treat only if patient conscious and desiring of treatment Best Oral Hypoglycemic Agents* Name Class Starting Doses Advantages Nataglinide Insulin secretagogue 60-120mg preprandial Short acting Well tolerated in renal & hepatic failure Repaglinide mg preprandial Gliclazide Sulphonylurea 80 mg in morning Well tolerated in mild-moderate renal failure Best Basal Insulins NPH (Neutral Protamine Hagedorn) Basal insulin 10 units in morning Peaks during the day Glargine/Detemir More consistent levels over 24 hours Best Prandial Insulins Lispro/ Aspart/ Glulisine Rapid-acting analog insulin 5 units immediately pre or postprandial Flexibility if unsure of oral intake Regular Human short acting insulin 5 units min preprandial Fuller coverage between meals


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

41 Questions?

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