Presentation on theme: "Have the ‘Lytes Gone Out"— Presentation transcript:
1 Have the ‘Lytes Gone Out Have the ‘Lytes Gone Out? Electrolyte and Metabolic Abnormality Management In Palliative Care – A case based discussionDr. Jana PilkeyMD, FRCPCInternal Medicine, Palliative MedicineAssistant Professor University of Manitoba
2 Objectives To list symptoms & treatments for hypercalcemia To gain approach to treatment of hyponatremia and hypernatremiaTo list symptoms & prevention of refeeding syndromeTo list symptoms & treatment of hypomagnesemiaTo understand differences in the management of diabetes in the palliative patientTo understand ethical issues of treatment
3 Case 1 Mr. B. was a 42 year old man Morbidly obese – weight around 500 lbsDiagnosed with locally invasive squamous cell penile cancerUnderwent penectomy 2006Referred to palliative care
4 Case 1 Unable to ambulate Multiple perineal wounds Profound leg and scrotal edemaCalcium 4.02 (corrected)
5 Hypercalcemia 30% of patients with cancer 50% die within 30 days Most common cancers:squamous cellbreastrenalMMlymphomas
6 Hypercalcemia Causes: Osteolytic effects of bony mets Humoral – secretion of a PTHrP1,25 (OH)2D – secreting lymphomasEctopic secretion of PTH (very rare)
8 Diagnosis Total serum calcium (corrected for albumin) Ionized calcium If treating must monitor:Renal functionphosphatemagnesiumpotassium
9 How to Treat Antineoplastics - key to maintenance Fluids – Saline hydration and loop diureticsBisphosphonatesDecreases bone resorptionFull efficacy in 2-7 daysLasts 1-3 weeks.Calcitoninsubcut 4U/kg q 12 hours,works immediatelytachyphylaxis 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 shorterSwitched to IV zolendronateTried 4 and then 8 mg dosesContinued to declineDied at home
13 Hyponatremia Hyponatremia Isotonic Hypotonic Hypovolemic Euvolemic (lipids or proteins)HypotonicHypovolemicRenal lossesGI lossesMineralocorticoid DeficiencyEuvolemic-SIADHGlucocorticoid deficiencyHypothyroidismHypervolemic-CHF-Nephrotic/renal failure-CirrhosisHypertonic(glucose or mannitol)(Verbalis, Am J Med, 2007)
14 Classic Formulas Try MedCalc.com 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 + 1Adrogue, 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 correctIs correction appropriate in palliative care?
17 Hypernatremia Always Hypertonic Most often Hypovolemic in palliative careShould palliative patients be treated with fluids?
18 Fluids in Palliative Care When might it be appropriate:Patient unable to take orally & not close to dyingGoal to prolong lifeTreat a cause of deliriumWhen might it not be appropriate:Close to dyingGross edemaProne to pulmonary edema
19 Fluids in Palliative Care OralEnteral feeding tubeIntravenousHypodermoclysis
21 Case 2 78 y.o. female with laryngeal ca Unable to swallow & dehydrated - Hungry2 weeks into admission – pt agrees to a feeding tubeTube placed into stoma connecting tracheostomy with esophagus
22 Case 2 Remains hungry - Feeds increase Chews food for enjoyment Continues to dehydrateTube dislodgedIV fluids startedG- tube inserted
23 Electrolyte Pattern Nov 18 Nov 19 Nov 27 Dec 29 Jan 5 Jan 7 Na K Cl 135Feeding tube inserted138156134G-tube insertedK18.104.22.168Cl100103114Urea6.54.823.112.1Creat7269178108PO40.660.511.190.97Corr Ca1.671.912.29Alb242819Mg0.480.561.10
24 Refeeding Syndrome Occurs when malnourished patients are fed Problem in 25% of advanced cancer patientPalliative patients especially vulnerable (labs)Characterized by:acute development of electrolyte depletionfluid retentiondisruption of glucose homeostasis(Marinella, Nutr Rev 2003)(Marinella, J Supp Onc, 2009)
25 Refeeding Syndrome Malnutrition: Carbohydrate load: loss of lean tissue massdepletes phosphate storesCarbohydrate load:requires phosphorylated glycoloysisfurther depletes phosphate storesstimulates release of insulinleads to a shift in po4, k, mg(Marinella, J Supp Onc, 2009)(Marinella, Nutr Rev 2003)
31 Case 3 52 y.o. Woman with stage 4 cervical cancer Had chemo and radiationBowel obstruction – entero-enterostomy and loop colostomyPersistent hypokalemia and hypocalcemiaAnorexia, diarrhea, muscle weakness, twitching, parasthesia.
32 Case 3 Na – 138 K – 2.9 Urea – 5.3 Creat – 57 Corr Ca – 1.57 Phos – 1.27Any Ideas?
34 Case 3 Given IV MgSO4 - Dramatic Improvement! Ca and K normalize over next weekDischarged home and went on ski tripDied 3 months later of renal failureWas her treatment appropriate?Should we routinely check for this in a palliative patient?
36 Hypomagnesemia 7-11% of hospital patients Common if other electrolytes Causes refractory K+ & Ca++Treat cautiously in:renal failuredehydrationmyastheniabradycardia(Exton, Pall Med 2000)
37 Diabetes in Palliative Care Common in palliative careMonitoringUnsure of best frequency or methodGoal is mmol/L and asymptomaticWRHA - implementing screening if on steroidsInsulin preferred agent for treatmentPrimary goal - prevention of hypoglycemiaStop if patient unconscious
38 Pharmacologic Management MonitoringIdeal Blood Glucose10-20 mmol/LPharmacologic ManagementTreat only if patient conscious and desiring of treatmentBest Oral Hypoglycemic Agents*NameClassStarting DosesAdvantagesNataglinideInsulin secretagogue60-120mg preprandialShort actingWell tolerated in renal & hepatic failureRepaglinidemg preprandialGliclazideSulphonylurea80 mg in morningWell tolerated in mild-moderate renal failureBest Basal InsulinsNPH (Neutral Protamine Hagedorn)Basal insulin10 units in morningPeaks during the dayGlargine/DetemirMore consistent levels over 24 hoursBest Prandial InsulinsLispro/ Aspart/ GlulisineRapid-acting analog insulin5 units immediately pre or postprandialFlexibility if unsure of oral intakeRegularHuman short acting insulin5 units min preprandialFuller coverage between meals
40 SummaryElectrolyte/metabolic abnormalities managed on individual basisIf treatment undertaken - management is similar to management elsewherePalliative care patients are particularly vulnerable to electrolyte abnormalitiesIf questions feel free to consult