Clinical Question

[Evelyn Hall]

I need someone recommendation. I have a patient 56 years old diagnosed with Crohn’s disease both small & large intestine. The patient on chronic TPN for several years.

The patient continues to have hypomagnesmia, hypokalemia, and hyponatremia.

I increased the NaCl, MgSO4, and KCl several times in Patient’s TPN. The patient recieves only 1200 ml fluids daily and continue to be NPO.

My question is what is your recommendation in fixing Patient’s electrolytes. Patient’s serum phos and Ca are stable. Blood sugar ranges between 225-240 mg/dL was on insulin.

Thanks

[Alchemist]

To provide a recommendation on proper electrolytes management a more information needed. However, generally managing electrolytes in PN is an art rather than a science. The quantity of electrolytes which should be added to PN is determined by several factors:

1. The existence of abnormal sources of electrolyte loss e.g. Diarrhea, nasogastric suction, fistula

2. Renal function

3. Medication profile (don’t forget IV fluids) e.g. Chronic use of PPI =hypomagnesemia

4. Nutrition history

5. Past medical and surgical histories

Remember:

· More dextrose = more electrolytes

· Potassium affected by acid base base disorder (if acidosis exist use acetate) and potassium affected by magnesium level

· Sodium level affected by fluid status

[Willie Kelly]

Patient’s electrolytes profile is affected by many factors
Fistula drainage, uncontrolled glucose level that he may require more insulin, possible on steroids, etc. All these factors lead to electrolytes disturbances. I can’t help you in electrolytes
Adjustments as we don’t complete patient history, Medications, lab profile, electrolytes in IVF or PN patient received, under cardiac monitor or not.
I may help if I have a hint for some information about the case.

[Joyce Phillips]

Also consider Drug-lab interactions for false lab results

[Lois Perry]

What about the adrenal gland function for this patient?

I think it can tell you something.

[Rachel Phillips]

more detailed picture is needed before attempting to fix electrolytes levels through PN. Adding right amount of electrolytes can only happen when you identify the causes. Here are some thoughts:

1. Hypomagnesemia: Drug induced i.e. Insulin, Diuretics? Is it hypomagnesemia induced by Hypokalemia? Extra Dextrose? The key is to reduce dextrose in PN and correct hypokalemia.

2. Hypokalemia: Is it due to Alkalosis induced by Diuretics? Extra dextrose/insulin? Excess GI losses? Try ranitidine 100mg in PN. Lower dextrose. Correct acid-base.

3. Hyponatremia: 90% of Hyponatremia is fluid overload. Check blood and urine Osmolarity and identify why Hyponatremia: R/O Hyperglycemia-induced Hyponatremia. Don’t add more than 155mmol/L.

Note: There is no limit on how much Mg and K can be added to PN assuming the patient has massive GI losses. If not, and if the the case is intracellular shift due to acid-base or drug-induced, then be more conservative.

The key to success with electrolytes correction is identifying the of etiologies.

[Evelyn Hall]

I would like to thank eveyone. I appreciate your feedback. I found out the etiology of her problems with her low serum Na, K, and Mg, it turned out the patient is taking orally 3-4 liters of soft drink coke on daily basis. I had a long discussion with the primary physician and with patient’s skilled nurse at home regarding this issue. The patient wasn’t reporting her abuse to coke to her physician or skilled nurse.

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