Fluids and Electrolytes abnormalities:

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Fluids and Electrolytes abnormalities

• Rafat Mosalli MD, FRCPC, FAAP

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Objectives

• What is the abnormal?
• Who is at risk?
• How it could present clinically?
• Why I should Bother?
• What is the treatment?

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Approach to Fluids Electrolytes problems

• Is it a problem?
• What is the problem?
• What is the cause of the problem?
• What is the treatment of the problem?
• How I can prevent problem recurrences?

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Approach to Fluids Electrolytes problems

• Is it a problem?
• True vs false sample
• Know the normal neonatal level
• Benefit/risk
• What is the problem?
• HYPO-HYPER
• Clinical stability and neonatal course

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Approach to Fluids Electrolytes problems

• What is the cause of the problem?
• -Need for investigation!
• What is the treatment of the problem?
• -Life threatening vs stable( benefit/risk)
• How I can prevent problem recurrences?
• -Cause of the problem ,maintain treatment
• -Communicate with the team

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Case 1

• A term infant was born following a difficult
  delivery with shoulder dystocia. extensive
  resuscitation at birth, with Low Apgar scores, He
  started to make irregular breathing efforts at 10
  min, MBP 30 , serum Na 126
• What is your hemodynamic assessment?
• At what rate ,what type of the fluid you will
  start ?
• How you monitor the fluid and electrolytes
  balance?
• Mention three other electrolytes abnormalities
  that this baby is at risk of, and your approach
  to treat?

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Case2

• 1h old 25 w in good condition but requiring
  ventilation for respiratory distress. His birth
  weight 600g, MBP 23
• What is your hemodynamic assessment?
• How you would assess ,manage Fluid
• Humidity status?
• How you would monitor the fluid and electrolytes
  balance?

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Case3

• 2h old ,34 w with antenataly undiagnosed Large
  Gastroschesis, born at the periphery ,had
  peripheral IV with shallow RR, CRF 5 sec.
• What is your initial assessment action ?
• At what rate of the fluid ? And what type?
• How you monitor the fluid and electrolytes
  balance?

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Case3 Post operative

• Baby had gastroschisis repair, Ladds procedure,
  Had a total of 60ml/kg at the OR. came Intubated
  and ventilated?
• What is your TFI target?
• How you will monitor and manage the fluid and
  electrolytes status?

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Case 3 12h Post op

• At 12 hours post operative , on D 10, MBP
  29mmHg , TFI 120ml/kg/h and 30ml/kg Ns Boluses.
  Mottled looking
• UOP 0.8ml/kg/h, serum Na 129
• What other blood investigations you will ask?
• What is you clinical assessment and treatment
  approach?

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In normal term Infants

• In general, fluid management in the first few
  days is adjusted primarily on urine output,
  serum sodium values and changes in weight.
• Term infants have a lower requirement for fluids
  and calories
• After the first week Fluid volumes are high to
  ensure good caloric intake and growth in
  Term/preterm infants

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What is the role of volume expansion in the Sick
term baby

• More heterogeneous diseases.
• Resuscitation, pulmonary hypertension ,and septic
  shock,HIE.
• No formal hemodynamic studies
• No data to show whether a large amount of volume
  expansion is useful in this vasodilated situation
  
• No data to document the physiologic responses to
  volume expansion in these situations.
• No data on clinical outcomes.

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What is the role of volume expansion in the Sick
term baby

• In severe HIE
• Pale Colour Not Hypovolemic !
• myocardial effects of hypoxia and acidosis.
• Only a few are truly hypovolemic.
• Reasonable to give 10 ml/kg volume, If there is
  no physiologic response to volume further volume
  expansion should be approached with caution!.

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1-HIE fluid electrolytes issues

• Oligo / anuria.
• Hpo Natremia/ Calcemia/ Magnesemia
• Hyperkalemia
• Hypo/hyperglycemia
• Acidosis

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HIE fluid electrolytes issues

• At the resuscitation
• Volume expanders? Rarely indicated
• Post resuscitation treatment
• - Oligo / anuria (pre-renal-post)
• must check Echo, BP, serum ,urine Na
  osmolality, renal function.

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HIE fluid Na pathophysiology

• -Prerenal /- parenchymal injury (less common)
• -myocardial failure (common)
• -Volume depletion (uncommon)
• Rx? Fluid challenge vs inotropes /- steroid
• -Renal (most common)
• -Fluid restriction, renal failure protocol /-
  inotropes/steroid (if hypotension coexist)
• - Postrenal (rare)
• Urinary catheter.

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HIE other electrolytes issue

• Must Maintain Normal
• Glucose , ca, Mg, K

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2-Fluid balance in preterm infants
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Where are we now?

• The fluid Na management of preterm infants
  continue to be controversial topic. !!
• whether babies should be given high fluid
• volumes to aid nutrition, or should they be
  fluid restricted to try to reduce the incidence
  of BPD,PDA and NEC.
• -Na balance High or Low ,early or late ?

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First few days Restrict or generous what is the
evidence?

• There is evidence that restricting fluid volumes
  in preterm infants in the first few days of life
  reduces the incidence of PDA, NEC, and may
  decrease mortality rates.
• Restricting sodium intake in preterm infants in
  the first few days may also reduce the incidence
  of BPD

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Restrict or generous when?

• Fluid restriction asphyxia, renal impairment or
  PDA.
• Higher fluid intakes Infants receiving
  phototherapy!, or with high insensible losses.
• In general, fluid management in the first few
  days is adjusted grossly on serum sodium values
  and changes in weight.
• High serum sodium values usually indicate that
  the infant requires more fluid.
• Low serum sodium values may indicate that the
  infant requires less fluid, or that the infant
  has high sodium losses.

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The main determinants of Fluid management in
preterm

• (1) an estimation of trans-epidermal water losses
• (2) an awareness of GFR and how this is
  influenced by age, respiratory distress and
  medical intervention
• (3) knowledge of tubular function maturation.
• This knowledge and appropriate monitoring are the
  mainstay of management of neonatal fluid balance

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1-GFR

• low in utero, but increases rapidly in the few
  hours immediately after delivery.
• Not influenced by postnatal age once completed
  period of postnatal adaptation given minimum
  water intake for IWL
• Compromised by a PDA mechanical ventilation,
  (increasing by 15 after
• Extubation)

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2-Renal tubualr function

• After delivery All babies undergo a diuresis
  natriuresis, triggered by ANP ?contraction of
  the ECF volume.
• Initial negative sodium balance, followed by
  retaining sodium for growth.
• Overall Preterm infants have a limited ability
  to excrete retain Na as effectively as Term

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3-Transepidermal water loss
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Humidity IWL
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3-Transepidermal water loss

• Greatest in most preterm infants,
• as much as 15 times higher in infants at 25
  weeks than in the term infants, and remains
  significant till 4 weeks after.

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TEWL can be substantially reduced

• Maximum ambient humidity?
• Routine humidification of inspired gases.
• Skin care Topical agents.

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Humidity protocol

• Ambient humidity is to be maintained at 85 for
  first 7D
• Gradually reduce humidity and ambient temperature
  as tolerated. Humidity should remain at least
  70-75 during first 3 weeks of life.
• At 21 days (if temperature is stable) slowly
  reduce humidity to 60 and leave till infant
  reaches 1500grammes.

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The main determinants of Fluid management in
preterm

• (1) an estimation of trans-epidermal water losses
• (2) an awareness of GFR and how this is
  influenced by age, respiratory distress and
  medical intervention
• (3) knowledge of tubular function maturation.
• This knowledge and appropriate monitoring are the
  mainstay of management of neonatal fluid balance

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II- Monitoring fluid balance
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3-RDS fluid electrolytes issues

• Delayed diuresis? low Na
• Delayed diuresis ? chronic lung disease.
• Restrict sodium intake until diuresis.

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4-Post surgical and abdominal wall defect

• Preload SIRS (third spacing)
• SIADH
• IWL
• Salinuresis.
• Check in-out ,Lactate, Na,Cr., osm. And urine Na
  osmolality, acid base balance
• Rx? Cause type of surgery
• Colloid vs crystalloids ?
• Avoid Hypotonic solution

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More facts in neonates

• Hypotension Hypovolumia
• The mechanism of hypotension is different
• Blood pressure and blood flow are not the same
  thing
• ?BP response to fluid is inconsistent,
  neither sustained
• Neither pH nor base excess are good markers of
  circulatory compromise no study showed any
  correlation with measures of SBF

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How much Bolus volume?

• The benefits of giving more than 20 ml/kg in any
  but the most obvious hypovolemic situations must
  be questioned!!
• the Michelin Man appearance of many of these
  babies the day after repeated volume infusions
  would suggest that the fluid is not staying long
  in the vascular compartment

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crystalloid or colloid

• There is insufficient evidence to make firm
• recommendations
• No comparative data on the effects on blood
  flow or important clinical outcomes.
• Use Normal saline for circulatory support
• cheaper, it is not a blood product and
• Lack of evidence of any advantage form using
• colloid.

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Future research in this area needs to

• Focus on more accurate ways to diagnose
  hypovolemia
• whether volume expansion used for circulatory
  support produces sustained hemodynamic
  improvement (not just improved blood
• pressure) and whether it improves clinical
  outcomes.

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Back to our cases

• Case 1? 25 w premature
• Case 2?severe HIE
• Case3? gastroschesis

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Case 4

• 12 h old Term with Meconium aspiration on CMV
  ,had 2 boluses of NS and TFI 80kg/d serum Na
  128.
• What is your clinical approach and likely
  diagnosis?

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Hyponatraemia

• Serum Na lt130
• 1-Inadequate Na intake.
• 2-Excessive water.
• Indomethacin
• Reduces free water clearance and fractional
  excretion of sodium, with the lower free water
  clearance
• SIADH

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Hyponatraemiacauses

• 3-Na Loss
• Renal
• -Prematurity
• Renal Na loss from a high fractional excretion
  of Na.
• - Diuretic therapy ( loop diuretics)
• -Acute tubular necrosis  (tubular Na loss) and
  other causes of renal failure.
• GIT other
• Diarrhoea, Gastric, pleural, CSF, 17OH
  progesterone deficiency

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Investigation

• Repeat the sample.
• Urinary Na ( sodium replacement )
• Serum and urine osmolality.

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Hyponatraemia

• Reduce the water (fluid) intake.
• Sodium supplements
• IV/Oral
• (1ml Po NaCl 2mmol NaCl).
• Usually start at 3mmol/kg/day additional NaCl.
• Occasional infants will require 12mmol/kg/day
• -

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Case 5

• 15 h old 25w Preterm with HMD on CMV
• Serum Na 155. UOP 5ml/kg/h TFI 80ml/kg
• What is your assessment and treatment approach?

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Hypernatraemia

• Na gt150mmol/L.
• Excessive water loss.
• Very preterm esp. insensible water loss.
• Urinary, GIT loss
• Excess Na intake.
• Relatively common with sodium bicarbonate
  infusions.
• infusions may contain large quantities of
  sodium.  (e.g. arterial line containing 0.9
  NaCl and running at 1ml/hour will give 3.6
  mmol/day of NaCl )

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HypernatraemiaTreatment

• Increase Fluid intake.
• Reduce Na intake

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Case 6Cardiac monitor

• - 48 hours Infants born lt 27 weeks gestation,
  serum K is 7.8mEq/L , What is this rhythm? What
  is your immediate treatment

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Hperkalemia

• Case 6-b
• 48 hours Infants born lt 27 weeks gestation,
  capillary sample K is 8.8mEq/L
• Baby looks stable ,EKG is normal?
• What is your treatment?

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Hyperkalemia

• What is the level?
  gt6.7mEq/L .
• Why I bother?
• Hyperkalaemia is a potentially life-threatening
  condition.

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Hyperkalemia

• WHO IS AT RISK?
• Extreme Prematurity (lt 27 weeks gestation)
• Acute renal failure (most commonly perinatal
  asphyxia)
• Chronic renal failure multiple causes
• Haemolysis (eg incompatible blood transfusion)
• Double volume transfusion / use of old blood
  (K rises after 4 days in stored blood) .
• Sepsis .

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Hyperkalemia Consequences

• Usually minimal, /- arrythmias
• EKG Tall peaked T waves, ventricular
  arrhythmias, widening of QRS then sine wave QRS
  complex (before cardiac arrest).
• Reported mortality of infants with hyperkalaemia
  (K gt 7.0 mmol/L) has ranged from 17-30 despite
  appropriate treatment.

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ECG changes Hyperkalemia

• tall peaked T waves, ventricular arrhythmias,
  widening of QRS, then sine wave QRS complex
  (before cardiac arrest).
• Haemolysis commonly occurs in blood collected by
  heel-prick and this results in falsely high serum
  potassium .

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What are the available treatments?

• 1- Antagonism of membrane actions of potassium
• Calcium gluconate.
• 2-Shift potassium intracellularly
• -Insulin infusion, supply glucose
• -Salbutamol infusion.
• -Sodium Bicarbonate .
• 3-Removal of potassium from the body
• Non of the above studied rigorously or proven to
  be effective! neither superior than the other.

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Hyperkalemia

• Key Points
• Avoid potassium in all infusions in the first day
  of life in infants born prematurely
• Monitor the serum potassium 8-12 hourly for the
  1st 48 hours of infants born lt 27 weeks
  gestation
• Insulin/dextrose and Salbutamol are effective.

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Back to the cases

• Case 6
• 48 hours Infants born lt 27 weeks gestation,
  serum K is 7.8mEq/L , what I should do?
• Case 6-b
• 48 hours Infants born lt 27 weeks gestation,
  capillary sample K is 8.8mEq/L
• Baby looks stable ,EKG is normal?
• What is your treatment?

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Case 6 Treatment

• Remove K from IV (i.e. hang 10 dextrose with
  Na)
• 10 Calcium gluconate 0.5ml/kg IV (0.1mmol/kg)
• Sodium bicarbonate 2mmols/kg IV given over 30
  minutes.
• IV dextrose so blood glucose gt12mmol/L.with
  Insulin 0.3 unit/gram of glucose.
• Salbutamol 4micrograms/kg IV over 10 minutes .
  May be repeated after 2 hours.
• Peritoneal dialysis

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Case 7

• -Day 1 Postoperative Bowel resection due to mid
  gut Volvolus with stoma
• K 2.5 mmol/L
• - Case 7-b
• 25w preterm (36w CGA) , BPD
• K 3.2mmol/L
• What is the cause and treatment if any?

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Hypokalaemia

• K lt3.5mmol/L
• Inadequate intake
• Distributional
• Alkalosis (sodium bicarbonate infusions,
  over-ventilation, or loss of acid from gastric
  secretions)
• Losses
• Renal causes
• GIT loss ( NGT, postop, short gut)
• Medications (including diuretic therapy, sodium
  bicarbonate infusions, salbutamol, and insulin

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Hypokalaemia treatment

• Cause and the severity of the hypokalaemia ?
• Oral potassium supplements
• 2 Molar KCl supplements (1ml 2mmol KCl).
• start at 2mmol/kg/day
• Monitor the serum K carefully and adjust dose
  accordingly.
• Intravenous potassium infusion

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IV caution

• Administer IV slowly, maximum infusion rate,
  0.5-1mmol/kg/hour.
• Monitor K /4h-8h.
• Dilute potassium before intravenous
  administration. The literature recommends
  dilution to 40mmol/L, i.e, 1mmol/25ml. As this
  may cause volume overload dilute to 1mmol/12.5ml
  and piggyback with IV fluids to achieve further
  dilution.
• Adequate renal function must be confirmed.

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IV Adverse Effects

• Venous irritation, pain, soft tissue injury at
  the injection site.
• Gastrointestinal disturbances common (diarrhoea,
  vomiting, bleeding, abdominal discomfort).
• Hyperkalaemia, indicated by weakness,
  listlessness, flaccid paralysis, hypotension,
  cardiac arrhythmias including heart block and
  cardiac arrest
• Altered sensitivity to digoxin

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Case 7

• 2 days old premature baby with Ca level 1.7
  mmol/l asymptomatic.
• Case7-b
• A 14 days ,full term infant with Ca 1.0 and
  seizures
• What is your assessment ?

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Hypocalcemia

• What is the level?
  lt1.75mmol/L(7.0mg/dl)
• ionized Ca lt 1mmol/L
• What is the manifestation?
• asymptomatic or non specific, Jitteriness and
  seziures.(most common).
• High pitch cry, laryngospasm, Chvosteks sign,
  Trousseaus sign

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Hypcalcemia causes

• Early (first 3 days)
• 1-Premature infants.
• 2-Birth asphyxia.
• 3-Infant of diabetic mothers.
• 4-Maternal Hyperparathyroidism.
• 5-Congenital parathyroid absence.

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Hypocalcemia

• Late (after end of first week)
• 1-High phosphate cow milk formula.
• 2-Intesinal malabsorbtion.
• 3-Hypoparathyrodism.
• 4-Hypomagnesemia.
• 5-Rickets.

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Hypocalcemia

• Decreased ionized fraction of calcium
• Intralipid.
• Alkalosis.
• Citrate (exchange transfusion)

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Hypocalcemia

• When I should intervene?
• -Symptomatic or seizure /- lt 1.5 mmol/L
• Maintain Ca level to achieve 75mg elemental Ca
  /Kg/d.
• follow up every 8 hours.
• Try to avoid IV avoid bolus.!

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Hypocalcemia

• What I should give?
• 10 Calcium gluconate (1gm/10ml)
• IV 200mg/kg/d.
• Bolus 50-100 mg/kg/dose (5-10mg/kg of elemental
  Ca) 0.5-1ml/kg/dose .
• Maintenance dose is 1 mmol/kg/day ( 1ml of 10
  0.23mmol/Ca)

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Hypocalcemia

• Be aware of IV Ca complications!
• Cardiac arrhythmia.
• Skin ulceration , Burn.
• Block the normal physiological adaptation in
  asymptomatic premature infant.

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Back to the Cases

• Case1
• 2 days old premature baby with Ca level 1.7
  mmol/l a symptomatic. what should I do?
• Case2
• A 14 days ,full term infant with Ca 1.0 and
  seizures, what should I do?

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Hypomagnesemia

• second most abundant intracellular cation.
• Regulate cellular metabolism.
• 1 extracellular conc. Is critical for muscle
  and nerve electrical potentials, and for the
  impulse transmission across NMJ (synergistically
  with Ca).
• Regulated by PTH.

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Hypomagnesemia

• What is the level?
  lt1.5mg/dl, sign lt1.2 mg/dl
• What is the causes?
• Maternal diabetes.
• Maternal deficiency.
• Prematurity,IUGR.
• Renal loss (Acidosis, Tubular defect)
• GIT loss (NGT,Emesis,Diarrhea)
  

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Hypomagnesemia

• What is the clinical pictures?
• Rarely symptomatic.
• Non specifics
• sign of hypocalcemia!