Electrolyte Replacement

Significant electrolyte depletion can result in serious complications. These guidelines are meant to assist with empiric dosing of electrolytes for inpatients. Doses may need to be adjusted based on patient-specific factors, including creatine & cardiac status; & responses to initial doses.

• Goal serum potassium concentration 4.0 – 5.0 mEq/L
• Goal serum ionized calcium concentration 1.12 – 1.3 mmol/L
• Goal serum magnesium concentration 2.0 – 2.4 mg/dL
• Goal serum phosphorus concentration 2.7 – 4.6 mg/dL

IV electrolyte replacement can produce life-threatening complications, serious arrhythmias & phlebitis; therefore, supplementation must be carefully monitored.  There are multiple underlying factors for electrolyte disorders in adult inpatients, including alterations in absorption, distribution, hormonal, and/or homeostatic mechanisms that can all cause disturbances. Treating the underlying cause and prescribing adequate therapy is essential for repletion. In addition, the intracellular vs. extracellular electrolyte concentrations must be considered. Due to distribution variances, labs may not directly correlate with true electrolyte levels. Therefore, continuous monitoring is essential to properly replete patients.

 

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Fluid Analysis

A systematic approach to the analysis of the fluid in conjunction with the clinical presentation helps to understand the etiology, narrow the differential diagnoses, & design a management plan. Includes biochemistry, microscopic examinations & infectious disease tests.

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Myasthenia gravis

 

 Chronic, constantly progressive disease. Initially, it affects the muscle tissues of the face, then spreads to the trunk. The following types of MG are distinguished:

• Ocular – the nerve endings in the cranial region are affected, and the eyelids fall asymmetrically. The patient complains of double vision and deterioration in visual acuity. Gradually focusing on one subject becomes difficult.
• Bulbar – the lesion extends to the masticatory muscles and tissues of the larynx. The patient’s voice changes, speech becomes quieter and nasal. Some consonants are very difficult to pronounce, and stuttering develops. Due to the penetration of fluid into the respiratory tract, the risk of pneumonia increases.
• Lambert-Eaton – the muscles of the arms, legs, and neck do not receive nerve impulses. It is difficult for the patient to coordinate these areas of the body. This form is diagnosed in the elderly and is characterized by rapid progression.
• Generalized – the muscles of the eyes are immediately affected, then the process spreads to the larynx, arms, legs, and hips. The main danger of this form is that the respiratory muscles are affected over time.

The disease is characterized by constant progression. 

Plasma exchange (PLEX) is first-line for severe exacerbation & usually causes improvement in a few days. It directly removes anti-acetylcholine receptor antibody from the body. May be more effective in MuSK+ patients.

IVIG may be useful for less severe exacerbations; takes longer to work (e.g., 2-3 weeks), but the efficacy may be more sustained. The dose of IVIG is 2 grams/kg, usually divided over 2 or 5 days.

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Drug-induced thrombocytopenia

1. Immune-mediated: Some drugs can trigger an immune response in the body, leading to the production of antibodies that attack and destroy platelets. This immune-mediated destruction of platelets is one of the common mechanisms in drug-induced thrombocytopenia. Examples of drugs associated with immune-mediated DITP include certain antibiotics (such as penicillin and sulfonamides), anti-inflammatory drugs (such as nonsteroidal anti-inflammatory drugs, or NSAIDs), and anticonvulsants.

2. Non-immune-mediated: Other drugs can cause thrombocytopenia through non-immune mechanisms, such as direct toxicity to the bone marrow where platelets are produced. Chemotherapy drugs, for example, can suppress bone marrow function and lead to a decrease in platelet production.

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