Have the ‘Lytes Have the ‘Lytes Gone Out?Gone Out?

Electrolyte and Metabolic Abnormality Electrolyte and Metabolic Abnormality Management In Palliative Care –Management In Palliative Care –

A case based discussion A case based discussion

Dr. Jana PilkeyDr. Jana PilkeyMD, FRCPC MD, FRCPC

Internal Medicine, Palliative MedicineInternal Medicine, Palliative MedicineAssistant Professor University of Assistant Professor University of

ManitobaManitoba

ObjectivesObjectives

To list symptoms & treatments for hypercalcemiaTo list symptoms & treatments for hypercalcemia To gain approach to treatment of hyponatremia To gain approach to treatment of hyponatremia

and hypernatremiaand hypernatremia To list symptoms & prevention of refeeding To list symptoms & prevention of refeeding

syndromesyndrome To list symptoms & treatment of hypomagnesemiaTo list symptoms & treatment of hypomagnesemia To understand differences in the management of To understand differences in the management of

diabetes in the palliative patient diabetes in the palliative patient To understand ethical issues of treatmentTo understand ethical issues of treatment

Case 1Case 1

Mr. B. was a 42 year old man Mr. B. was a 42 year old man Morbidly obese – weight around 500 Morbidly obese – weight around 500

lbs lbs Diagnosed with locally invasive Diagnosed with locally invasive

squamous cell penile cancersquamous cell penile cancer Underwent penectomy 2006Underwent penectomy 2006 Referred to palliative careReferred to palliative care

Case 1Case 1

Unable to ambulateUnable to ambulate Multiple perineal woundsMultiple perineal wounds Profound leg and scrotal edemaProfound leg and scrotal edema Calcium 4.02 (corrected)Calcium 4.02 (corrected)

HypercalcemiaHypercalcemia

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 lymphomaslymphomas

HypercalcemiaHypercalcemia

Causes:Causes: Osteolytic effects of bony metsOsteolytic effects of bony mets Humoral – secretion of a PTHrPHumoral – secretion of a PTHrP 1,25 (OH)2D – secreting lymphomas1,25 (OH)2D – secreting lymphomas Ectopic secretion of PTH (very rare)Ectopic secretion of PTH (very rare)

Clinical SymptomsClinical Symptoms

BonesBones – bony pain – bony pain

StonesStones - (Renal) – dehydration, polyuria, - (Renal) – dehydration, polyuria, thirst/polydipsia, renal calculithirst/polydipsia, renal calculi

MoansMoans – sedation, delirium, coma – sedation, delirium, coma

GroansGroans – anorexia, nausea, vomiting, abd – anorexia, nausea, vomiting, abd painpain

DiagnosisDiagnosis

Total serum calcium Total serum calcium (corrected for albumin)(corrected for albumin)

Ionized calciumIonized calcium If treating must monitor:If treating must monitor:

Renal function Renal function phosphate phosphate magnesiummagnesium potassium potassium

How to TreatHow to Treat AntineoplasticsAntineoplastics - key to maintenance - key to maintenance

FluidsFluids – Saline hydration and loop diuretics – Saline hydration and loop diuretics

BisphosphonatesBisphosphonates 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.

CalcitoninCalcitonin subcut 4U/kg q 12 hours, subcut 4U/kg q 12 hours, works immediatelyworks immediately tachyphylaxis within a few daystachyphylaxis within a few days

(Siddiqui, J Pall Med 2010)

Should I Treat?Should I Treat?

Ethical IssueEthical Issue Must take into account: Must take into account:

patients goalspatients goals ability to palliate/treatability to palliate/treat ““good death”good death”

Case 1Case 1

Initially responded to pamidronateInitially responded to pamidronate Time between treatments getting Time between treatments getting

shortershorter Switched to IV zolendronateSwitched to IV zolendronate Tried 4 and then 8 mg dosesTried 4 and then 8 mg doses Continued to declineContinued to decline Died at homeDied at home

HyponatremiaHyponatremia

(Verbalis, Am J Med, 2007)

HyponatremiaHyponatremia

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 themNeither – fluid restrict them

HyponatremiaHyponatremia

Most often happened gradually Most often happened gradually Must be very careful to not over Must be very careful to not over

correctcorrect Is correction appropriate in palliative Is correction appropriate in palliative

care?care?

HypernatremiaHypernatremia

Always HypertonicAlways Hypertonic Most often Hypovolemic in palliative Most often Hypovolemic in palliative

carecare Should palliative patients be treated Should palliative patients be treated

with fluids?with fluids?

Fluids in Palliative CareFluids in Palliative Care When might it When might it

be be appropriate:appropriate:

Patient unable to take Patient unable to take orally & not close to orally & not close to dyingdying

Goal to prolong lifeGoal to prolong life Treat a cause of Treat a cause of

deliriumdelirium

When might it When might it not be not be appropriate:appropriate:

Close to dyingClose to dying Gross edemaGross edema Prone to pulmonary Prone to pulmonary

edemaedema

Fluids in Palliative CareFluids in Palliative Care

OralOral Enteral feeding tubeEnteral feeding tube IntravenousIntravenous HypodermoclysisHypodermoclysis

Case 2 Case 2

78 y.o. female with laryngeal ca78 y.o. female with laryngeal ca Unable to swallow & dehydrated - Unable to swallow & dehydrated -

HungryHungry 2 weeks into admission – pt agrees to 2 weeks into admission – pt agrees to

a feeding tubea feeding tube Tube placed into stoma connecting Tube placed into stoma connecting

tracheostomy with esophagus tracheostomy with esophagus

Case 2Case 2

Remains hungry - Feeds increaseRemains hungry - Feeds increase Chews food for enjoymentChews food for enjoyment Continues to dehydrate Continues to dehydrate Tube dislodgedTube dislodged IV fluids startedIV fluids started G- tube insertedG- tube inserted

Electrolyte PatternElectrolyte Pattern

Nov Nov 1818

Nov 19Nov 19 Nov 27Nov 27 Dec Dec 2929

Jan 5Jan 5 Jan 7Jan 7

NaNa 135135

Feeding tube Feeding tube insertedinserted

138138 156156 134134

G-tube G-tube insertedinserted

KK 2.52.5 3.73.7 4.04.0 3.73.7

ClCl 100100 103103 114114

UreaUrea 6.56.5 4.84.8 23.123.1 12.112.1

CreaCreatt

7272 6969 178178 108108

PO4PO4 0.660.66 0.510.51 1.191.19 0.970.97

Corr Corr CaCa

1.671.67 1.911.91 2.292.29

AlbAlb 2424 2828 1919

MgMg 0.480.48 0.560.56 1.101.10 0.970.97

Refeeding SyndromeRefeeding Syndrome

Occurs when malnourished patients are fedOccurs when malnourished patients are fed Problem in 25% of advanced cancer patientProblem in 25% of advanced cancer patient Palliative patients especially vulnerable Palliative patients especially vulnerable

(labs)(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)

Refeeding SyndromeRefeeding Syndrome

Malnutrition:Malnutrition: loss of lean tissue mass loss of lean tissue mass depletes phosphate storesdepletes phosphate stores

Carbohydrate load: Carbohydrate load: requires phosphorylated glycoloysis requires phosphorylated glycoloysis further depletes phosphate storesfurther depletes phosphate stores stimulates release of insulin stimulates release of insulin leads to a shift in po4, k, mgleads to a shift in po4, k, mg

(Marinella, J Supp Onc, 2009)

(Marinella, Nutr Rev 2003)

Refeeding SyndromeRefeeding Syndrome

Decrease po4 leads to decrease ATP:Decrease po4 leads to decrease ATP: heart failure heart failure neuromuscular impairment neuromuscular impairment diaphragmatic weaknessdiaphragmatic weakness hemolytic anemiahemolytic anemia

(Marinella, Nutr Rev 2003)(Marinella, J Supp Onc, 2009)

TreatmentTreatment

Prevent DehydrationPrevent Dehydration Replace phosphate, K, MgReplace phosphate, K, Mg Resume feeding slowlyResume feeding slowly Thiamine and B vitaminsThiamine and B vitamins

(Marinella, J Supp Onc, 2009)

Case 3Case 3 52 y.o. Woman with stage 4 cervical 52 y.o. Woman with stage 4 cervical

cancercancer Had chemo and radiationHad chemo and radiation Bowel obstruction – entero-Bowel obstruction – entero-

enterostomy and loop colostomyenterostomy and loop colostomy Persistent hypokalemia and Persistent hypokalemia and

hypocalcemiahypocalcemia Anorexia, diarrhea, muscle weakness, Anorexia, diarrhea, muscle weakness,

twitching, parasthesia. twitching, parasthesia.

Case 3Case 3

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

Case 3Case 3

Magnesium 0.2 mmol/L (0.65-1.05)Magnesium 0.2 mmol/L (0.65-1.05)

Case 3Case 3

Given IV MgSO4 - Dramatic Given IV MgSO4 - Dramatic Improvement!Improvement!

Ca and K normalize over next weekCa and K normalize over next week Discharged home and went on ski tripDischarged home and went on ski trip Died 3 months later of renal failureDied 3 months later of renal failure

Was her treatment appropriate?Was her treatment appropriate? Should we routinely check for this in a Should we routinely check for this in a

palliative patient?palliative patient?

HypomagnesemiaHypomagnesemia

(Exton, Pall Med 2000)

HypomagnesemiaHypomagnesemia

7-11% of hospital patients7-11% of hospital patients Common if other electrolytesCommon if other electrolytes Causes refractory KCauses refractory K++ & Ca & Ca++++ Treat cautiously in:Treat cautiously in:

renal failure renal failure dehydration dehydration myastheniamyasthenia bradycardiabradycardia

(Exton, Pall Med 2000)(Exton, Pall Med 2000)

Diabetes in Palliative CareDiabetes in Palliative Care

Common in palliative careCommon in palliative care MonitoringMonitoring

Unsure of best frequency or methodUnsure of best frequency or method Goal is 10-20 mmol/L and asymptomaticGoal is 10-20 mmol/L and asymptomatic WRHA - implementing screening if on steroidsWRHA - implementing screening if on steroids

Insulin preferred agent for treatmentInsulin preferred agent for treatment Primary goal - prevention of Primary goal - prevention of

hypoglycemiahypoglycemia Stop if patient unconsciousStop if patient unconscious

Monitoring

Ideal Blood Glucose 10-20 mmol/L

Pharmacologic ManagementTreat only if patient conscious and desiring of treatment

Best Oral Hypoglycemic Agents*

Name Class Starting Doses Advantages

Nataglinide Insulin secretagogue 60-120mg preprandial Short actingWell tolerated in renal & hepatic

failureRepaglinide Insulin secretagogue 0.5 - 1mg preprandial Short acting

Gliclazide SulphonylureaInsulin secretagogue

80 mg in morning Well tolerated in mild-moderate renal failure

Best Basal Insulins

Name Class Starting Doses Advantages

NPH (Neutral Protamine Hagedorn) Basal insulin 10 units in morning Peaks during the day

Glargine/Detemir Basal insulin 10 units in morning More consistent levels over 24 hours

Best Prandial Insulins

Name Class Starting Doses Advantages

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 30-45 min preprandial

Fuller coverage between meals

SummarySummary

Electrolyte/metabolic abnormalities Electrolyte/metabolic abnormalities managed on individual basismanaged on individual basis

If treatment undertaken - If treatment undertaken - management is similar to management is similar to management elsewheremanagement elsewhere

Palliative care patients are particularly Palliative care patients are particularly vulnerable to electrolyte abnormalitiesvulnerable to electrolyte abnormalities

If questions feel free to consultIf questions feel free to consult