Magnesium Disturbance

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Magnesium Deficiency/Hypomagnesemia

• Causes: 1. decreased dietary magnesium intake 2. gastrointestinal magnesium losses 3. defects in redistribution of magnesium extracellular to intracellular 4. renal magnesium loss

• Epidemiology

The risk of hypomagnesemia can be summarized as follows:1. 2% in the general population2. 10-20% in hospitalized patients3. 50-60% in intensive care unit (ICU) patients4. 30-80% in persons with alcoholism5. 25% in outpatients with diabetes

• Signs and symptoms

1.Neuromuscular manifestations of hypomagnesemia may include the following :

• Muscular weakness• Tremors• Seizure• Paresthesias• Tetany• Positive Chvostek sign and Trousseau sign• Vertical and horizontal nystagmus

2.Cardiovascular manifestations may include the following electrocardiographic abnormalities and arrhythmias:

• Nonspecific T-wave changes - U waves• Prolonged QT and QU interval• Repolarization alternans• Premature ventricular contractions - Monomorphic

ventricular tachycardia• Torsade de pointes• Ventricular fibrillation• Enhanced digitalis toxicity

3. Metabolic manifestations may include the following:

• Hypokalemia• Hypocalcemia

• Diagnosis

1. The majority of patients with clinical manifestations of magnesium deficiency have hypomagnesemia. Measurement of serum magnesium is relatively easy, and it has become the method of choice to estimate magnesium content, although its use in evaluating total body stores is limited.

2. Magnesium assessment can also be made via red cell, mononuclear cell, or skeletal muscle intracellular content; 24-hour urinary excretion; fractional excretion (FE) of magnesium; and intracellular free magnesium ion concentration with fluorescent dye or nuclear magnetic resonance spectroscopy.

• Management and Treatment

1. Treatment for hypomagnesemia depends on the degree of deficiency and the patient's clinical symptoms and signs.

2. Therapy can be oral for patients with mild symptoms or intravenous for patients with severe symptoms or those unable to tolerate oral administration.

3. Some patients with hypomagnesemia caused by renal magnesium wasting may benefit from certain diuretics that have magnesium-sparing properties, such as spironolactone and amiloride.

Hypermagnesemia

• A condition that arises from abnormally elevated magnesium levels in the blood

• Causes: 1.renal failure 2.excessive intake 3.excessive tissue breakdown (eg; hemolysis) 4.Hypothyroidism, adrenal insufficiency, milk-alkali syndrome, Addison’s Disease

• Epidemiology

1. Occurs quite rarely2. Mostly in patients of renal failure

• Signs and Symptoms

1. Neuromuscular symptoms• deep-tendon reflex attenuation• Facial paresthesias• Muscle weakness

2. Hypotension and bradycardia

3. Hypocalcemia• results from a decrease in the secretion of parathyroid hormone (PTH) or

from end-organ resistance to PTH

• Diagnosis

1. Composition of electrolytes in blood, including potassium, magnesium, and calcium levels

2. BUN and creatinine levels• To assess the kidney’s ability to excrete excess magnesium

3. Thyroid fuction test• In case of absence of other explanations because hyperthyroidism is rare

cause of hypermagnesemia

• Management and Treatment

1. dialysis if the patient is severely hypermagnesemic2. intravenous calcium gluconate, because the actions

of magnesium in neuromuscular and cardiac function are antagonized by calcium

3. intravenous diuretics, in the presence of normal renal function

CHLORIDE

PHYSIOLOGICAL FUNCTION• prominent negatively charged ion of the blood, where it

represents 70% of the body’s total negative ion content• chloride combines with hydrogen in the stomach to make

hydrochloric acid• maintain electrical neutrality across the stomach membrane• The exchange of chloride and bicarbonate, between red blood

cells and the plasma helps to govern the pH balance and transport of carbon dioxide, a waste product of respiration

Chlorine Disturbances

Hyperchloremia

• indicated by a high level of chloride in the blood

• Causes:• Loss of body fluids from prolonged vomiting, diarrhea,

sweating or high fever (dehydration).• High levels of blood sodium.• Kidney failure, or kidney disorders• Diabetes insipidus or diabetic coma• Drugs such as: androgens, corticosteroids, estrogens, and

certain diuretics.

• At risk

1. People with impaired kidneys2. alcoholics

• Signs and Symptoms

• Many people do not notice any symptoms of hyperchloremia, unless they are experiencing very high levels of chloride in their blood.

• Dehydration, fluid loss, or high levels of blood sodium may be noted.

• You may be experiencing other forms of fluid loss, such as diarrhea, or vomiting when suffering from hyperchloremia.

• You may be a diabetic, and have poor control over your blood sugar levels (they may be very high).

• Diagnosis

1. Serum chloride levels > 106 mEq/L confirm the diagnosis.2. Serum pH is under 7.353. Serum carbon dioxide levels < 22 mEq/L.4. Sometimes, a chloride test can be done on a sample of the

total urine collected over a 24-hour period (24-hour urine sample). This finds out how much chloride is excreted in the urine.

• Management and Treatment

1. Just like other electrolyte imbalances, the treatment of high blood chloride levels or hyperchloremia is to correct the underlying cause. It includes the following causes:-

2. For dehydrationEstablish and maintain adequate hydration3. For particular drug treatmentAlter or discontinue the medications4. For kidney diseaseRefer to a nephrologist5. For hormone or endocrine causes

Refer to an endocrinologist

6. Treatmenta) Sodium bicarbonate I.V infusion to raise the bicarbonate level

in blood and for permitting renal excretion of chloride anion, as chloride and bicarbonate compete to combine with sodium.

b) Lactated Ringer’s solution which is administered in mind cases of hyperchloremia. In liver, this gets converted to bicarbonate, thereby increasing the base bicarbonate for correcting the acidosis caused.

c) Low sodium diet, the excess chloride ions may combine with sodium to form hypernatremia.

Hypochloremia

• an electrolyte disturbance in which there is an abnormally low level of the chloride ion in the blood. (The normal serum range for chloride is 97 to 107 mEq/L.)

• Causes

1. Loss of body fluids from prolonged vomiting, diarrhea, sweating or high fevers.

2. Drugs such as: bicarbonate, corticosteroids, diuretics, and laxatives.

3. Dietary changes (low sodium diet)-Hyponatremia4. Medications:• Loop and Thiazide Diuretics• Aldosterone• ACTH• Corticosteroids• Bicarbonates• Laxatives

5. Genetic diseases• Cystic fibrosis• Bartter’s syndrome (is a group of several disorders due to

impaired salt reabsorption in the thick ascending Henle’s loop)

• At risk

1. Older adults may have more contributing factors including age-related changes, taking certain medications and a greater likelihood of developing a chronic disease that alters the body's electrolyte balance

2. Intensive physical activities. People who drink too much water while taking part in marathons, ultramarathons, triathlons and other long-distance, high-intensity activities.

• Signs and Symptoms

1. Many people do not notice any symptoms, unless they are experiencing very low levels of chloride in their blood.

2. Dehydration, fluid loss, or high levels of blood sodium may be noted.

3. You may be experiencing other forms of fluid loss, such as diarrhea, or vomiting.

• Diagnosis

1. Serum chloride levels < 98 mEq/L confirm the diagnosis.2. Serum pH is above 7.453. Serum carbon dioxide levels > 32 mEq/L.4. Serum osmolarity < 280mOsm/L (normal = 280–295 mOsm/L )

– This reflects the decrease in particle’s concentration in ECF.5. Arterial blood gas analysis for identifying any acid base

imbalance.6. Sometimes, a chloride test can be done on a sample of the

total urine collected over a 24-hour period (24-hour urine sample). This finds out how much chloride is excreted in the urine

• Management and Treatment

1. Make sure you tell your doctor, as well as all healthcare providers, about any other medications you are taking (including over-the-counter, vitamins, or herbal remedies). Do not take aspirin or products containing aspirin unless your healthcare provider permits this.

2. Remind your doctor or healthcare provider if you have a history of diabetes, liver, kidney, or heart disease.

3. Keep yourself well hydrated. Drink two to three quarts of fluid every 24 hours, unless you are instructed otherwise.

4. Avoid caffeine and alcohol, as these can cause you to have electrolyte disturbances.

5. Electrolyte replacement therapy• IV administration of normal (0.9 sodium chloride) or half strength

saline (0.45 sodium chloride).• Ammonium chloride (an acidifying agent) – This is for treating the

metabolic alkalosis. Dosage depends up on the serum chloride level and weight of the patient. This is contraindicated in cases of impaired renal or liver functions.

• Oral or intravenous KCl (10-40mEq PO). IV should not exceed 20 mEq/hr

6. Dietary modifications• Consume sodium and potassium rich diet, as hypochloremia causes

deficiency of these nutrients.