Magnesium

Disturbance
s

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 population
2. 10-20% in hospitalized patients
3. 50-60% in intensive care unit (ICU) patients
4. 30-80% in persons with alcoholism
5. 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, Addisons Disease

 Epidemiology
1. Occurs quite rarely
2. 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 kidneys 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
hypermagnesemic
2. intravenouscalcium gluconate, because the
actions
ofmagnesiuminneuromuscularandcardiacfun
ction are antagonized bycalcium
3. intravenousdiuretics, in the presence of
normalrenal function

CHLORIDE
PHYSIOLOGICAL FUNCTION
prominent negatively charged ion of the blood, where it
represents 70% of the bodys 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 kidneys

2. 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 7.35
3. 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 24hour 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 dehydration
Establish and maintain adequate hydration
3. For particular drug treatment
Alter or discontinue the medications
4.
For kidney disease
Refer to a nephrologist
5.
For hormone or endocrine causes

Refer to an endocrinologist
6. Treatment
a) 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 Ringers 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
anelectrolyte disturbancein which
there is an abnormally low level of
thechlorideion in the blood. (The
normal serum range for chloride is 97 to
107mEq/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)-Hyponatremia
4. Medications:
. Loop and Thiazide Diuretics
. Aldosterone
. ACTH
. Corticosteroids
. Bicarbonates
. Laxatives

5. Genetic diseases
Cystic fibrosis
Bartters syndrome(is a group of several
disorders due to impaired salt reabsorption in the
thick ascending Henles 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 longdistance, 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.
2.
3.
4.

Serum chloride levels < 98 mEq/L confirm the diagnosis.

Serum pH is above 7.45
Serum carbon dioxide levels > 32 mEq/L.
Serum osmolarity < 280mOsm/L (normal = 280295
mOsm/L ) This reflects the decrease in particles
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.