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 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 + 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?