1. Respiratory Support

Summary: Hypocalcemia and hypermagnesemia impair neuromuscular transmission, risking respiratory muscle fatigue and failure. Early recognition and ventilatory support prevent hypoxemia and hypercapnia.

1.1 Indications for Mechanical Ventilation

• Vital capacity < 15 mL/kg predicted body weight
• Maximal inspiratory pressure (MIP) < –20 cm H₂O
• Arterial blood gas (ABG): PaCO₂ > 45 mm Hg with pH < 7.30
• Respiratory rate > 35 breaths/min, accessory muscle use, or paradoxical breathing
• Absent or diminished deep tendon reflexes signaling severe neuromuscular compromise

1.2 Ventilator Management Nuances

• Low tidal volume strategy: 6–8 mL/kg predicted body weight; maintain plateau pressure < 30 cm H₂O.
• Mode: Pressure-controlled or volume-controlled modes can be used to minimize barotrauma.
• PEEP: Use conservative positive end-expiratory pressure (PEEP) to prevent alveolar collapse without compromising venous return.
• Sedation: Target a light level of sedation (RASS –2 to –3) and perform daily sedation interruptions to assess neurologic function.
• Neuromuscular Blockade: Reserve for severe patient-ventilator dyssynchrony in the first 48 hours (e.g., cisatracurium infusion 37.5 mg/h).

2. Hemodynamic Support

Summary: Electrolyte abnormalities can induce hypotension through vascular smooth muscle relaxation and reduced myocardial contractility. Management focuses on restoring intravascular volume and the judicious use of vasopressors to maintain end-organ perfusion.

2.1 Recognizing Electrolyte-Induced Hypotension

Hypocalcemia: An ionized calcium level below 1.12 mmol/L can lead to reduced myocardial contractility and hypotension, often accompanied by tachycardia or other arrhythmias.

Hypermagnesemia: The cardiovascular effects of hypermagnesemia are dose-dependent and can progress rapidly.

2.2 Fluid and Vasopressor Management

• Crystalloid Resuscitation: Initiate with a 20 mL/kg bolus of 0.9% NaCl or a balanced salt solution. Maintain infusion at 200–300 mL/h to replace ongoing losses, guided by clinical response.
• Fluid Responsiveness: Use dynamic indices like pulse pressure variation (PPV) or stroke volume variation (SVV) to guide fluid administration and avoid overload.
• Vasopressor Therapy:
  • Norepinephrine: First-line agent. Start at 0.05–0.1 µg/kg/min and titrate to maintain a mean arterial pressure (MAP) ≥ 65 mm Hg.
  • Vasopressin: Add-on therapy (0.03 units/min) for refractory hypotension.
  • Dopamine: Reserved for cases of significant bradycardia contributing to hypotension.

3. Prevention of ICU-Related Complications

Summary: The correction of severe electrolyte disorders can precipitate secondary complications like arrhythmias and renal injury. A structured approach to monitoring and prophylaxis is essential to reduce morbidity.

3.1 Arrhythmia Prophylaxis

• Implement continuous ECG telemetry, paying close attention to the QTc interval, T-wave morphology, and atrioventricular conduction.
• Maintain serum magnesium > 2 mg/dL. Aggressively replete hypomagnesemia, especially in the setting of QT prolongation or torsades de pointes, with magnesium sulfate 2 g IV over 10–15 minutes.
• Scrutinize the medication list and avoid or discontinue agents known to prolong the QT interval.
• Correct concomitant electrolyte abnormalities, particularly hypokalemia.

3.2 Nephrocalcinosis Prevention

• Initiate aggressive IV hydration to achieve and maintain a target urine output > 2 L/day.
• Once euvolemia is established, consider a loop diuretic (e.g., furosemide 20–40 mg IV) to enhance urinary calcium excretion.
• Monitor serum creatinine and electrolytes at least every 24 hours to detect any renal injury or secondary electrolyte shifts.

3.3 Magnesium Toxicity Surveillance

• Check deep tendon reflexes (DTRs) every 8 hours; diminished DTRs are the earliest clinical sign of magnesium excess.
• Monitor respiratory rate and tidal volumes (if ventilated) and assess sedation level every 4 hours.
• If serum Mg > 10 mg/dL or life-threatening symptoms (e.g., respiratory arrest, asystole) occur:
  • Administer calcium gluconate 2–4 g IV as a bolus.
  • Consider emergent hemodialysis for definitive and rapid magnesium removal.

4. Management of Iatrogenic Complications

Summary: Therapies for electrolyte disorders carry their own risks, including procedure-related complications. Prompt recognition and targeted treatment are necessary to mitigate tissue and systemic injury.

4.1 Calcium Chloride Extravasation Injury

Calcium chloride is a vesicant and should be administered via a central line whenever possible. If only peripheral access is available, calcium gluconate is the preferred formulation due to its lower risk of tissue injury.

4.2 Calcitonin Tachyphylaxis

• Onset of Action: Calcitonin begins to lower serum calcium within 4–6 hours, with a maximal effect seen at 24–48 hours.
• Monitoring for Tachyphylaxis: Monitor serum calcium every 6–12 hours. A plateau in the calcium reduction despite continued dosing indicates the development of tachyphylaxis.
• Transitioning Therapy: Plan to transition to a more definitive, long-acting agent such as a bisphosphonate (e.g., pamidronate 60–90 mg IV over 2 hours) or denosumab (60 mg SC).

5. Multidisciplinary Goals of Care Discussions

Summary: The use of high-intensity supportive measures like mechanical ventilation and vasopressors must be aligned with the patient’s values, preferences, and overall prognosis.

5.1 Ethical Considerations and Shared Decision-Making

• Proactively weigh the potential benefits versus the burdens of life-sustaining treatments, especially in the context of advanced underlying disease.
• Engage ethics or palliative care consultants early when the prognosis is poor or when there is conflict about the appropriate course of action.
• Clearly document all conversations, advance directives, and code status preferences in the medical record.

5.2 Communication Strategies

• Schedule structured, dedicated family meetings rather than relying on brief hallway conversations.
• Use clear, non-medical language to explain the clinical situation. Visual aids can help illustrate goals and likely clinical trajectories.
• Revisit decisions regularly, especially as the patient’s clinical status evolves, to ensure care remains aligned with their goals.

6. Monitoring and De-escalation Protocols

Summary: Systematic monitoring with defined criteria is essential for guiding the safe weaning of supportive measures once the underlying electrolyte disturbance is controlled.

6.1 Serial Serum Calcium and Magnesium Timing

• During Active Repletion/Treatment: Check serum calcium and magnesium levels every 6–12 hours until they are within the target range.
• Once Stable: After initial stabilization, monitoring can be extended to once daily.
• Adjustment: Be prepared to adjust infusion rates or hold doses as levels approach the upper limits of normal to prevent overshoot iatrogenic abnormalities.

6.2 ECG Parameter Checks

• Maintain continuous telemetry on all unstable patients.
• Obtain a formal 12-lead ECG every 8–12 hours in acutely ill patients or after any significant clinical change.
• Closely monitor QTc, PR, and QRS durations, and intervene promptly on any significant changes.

6.3 Criteria for Therapy Adjustment and Step-Down