Calcium and magnesium deficiency in children with acute respiratory failure: a prospective observational cohort study
Background. Severe hypomagnesemia and uncorrected hypocalcemia can lead to severe disorders. The aim of this study was to investigate the prevalence and risk factors of hypomagnesemia and hypocalcemia in children with acute respiratory failure. The study hypothesis was that hypomagnesemia and hypocalcemia prolong weaning from mechanical ventilation (MV) and duration of stay in the intensive care unit (ICU). Materials and methods. We complete a prospective single-center cohort study at the Department of Anesthesiology and Intensive Care of Danylo Halytsky Lviv National Medical University (Department of Anesthesiology and Intensive Care, Lviv Regional Children’s Clinical Hospital “OHMATDYT”). We examined patients from 1 month to 3 years old with acute respiratory failure on invasive MV. Serum magnesium and ionized calcium levels were evaluated on the first (d1), third (d3), fifth (d5), seventh (d7) and ninth (d9) days. Results described in this article is the part of the clinical study “Diaphragm ultrasound and trends in electrolyte disorders and transthyretin level as a method to predict ventilation outcome in children: the prospective observational cohort study”; ISRCTN84734652. We enrolled 57 patients with acute respiratory failure, and the analysis of study results included 53 children. If serum magnesium level was below 0.8 mmol/l, all patients received magnesium sulfate 25% intravenously 50 mg/kg/day to reach the target serum magnesium level above 0.8 mmol/l. In case of hypocalcemia (serum ionized calcium level below 1.1 mmol/l), patients received calcium gluconate 10% intravenously 1 ml/kg/day (equivalent to 0.23 mmol/kg/day). Results. We found normomagnesemia in 29.6 % of patients, hypomagnesemia — in 70.4 %, normocalcemia and hypocalcemia — in 77.8 and 22.2 % of individuals, respectively. In patients with normomagnesemia at admission (0.82–0.06 mmol/l), magnesium level reduced to 0.73 ± 0.08 mmol/l within the first 3 days of treatment and required correction. Subsequently, serum magnesium level gradually increased and by the d9 reached 1.10 ± 0.15 mmol/l. Patients with moderate hypomagnesemia at admission (serum magnesium level of 0.62 ± 0.11 mmol/l) also received magnesium sulfate intravenously, and magnesium level normalized by the d5 and was 0.85 ± 0.07 mmol/l, and on study stages d7 and d9 — 0.92 ± 0.11 mmol/l and 0.95 ± 0.14 mmol/l, respectively. The level of ionized calcium in the group of patients with normocalcemia was 1.13 ± 0.04 mmol/l at admission and did not require correction. However, in the group of patients with hypocalcemia, the level of ionized calcium on the d1 was 0.81 ± 0.08 mmol/l and required correction. As a result, the level of ionized calcium increased on d3 to 1.07 ± 0.03 mmol/l and normalized on the d5 — 1.17 ± 0.08 mmol/l. The most common risk factors for hypomagnesemia in our patients were diuretics, sepsis and antibiotic-associated diarrhea. 39.5 % of patients with hypomagnesemia received loop diuretics within the first 3–5 days after admission, most of them had sepsis. It was interesting that 31.6 % of persons with hypomagnesemia had hypocalcemia, as compared to the incidence of hypocalcemia in the overall cohort at the level of 22.2 %. We have not found differences in the duration of MV among patients with hypomagnesemia and normomagnesemia (12.3 ± 1.8 days versus 14.1 ± 1.1 days, respectively; p = 0.43). In addition, there were no significant differences in duration of MV among patients with hypocalcemia and normocalcemia. However, the length of stay in the ICU was 1.47 times longer (95% confidence interval (CI) 1.2–1.9, p = 0.04) among patients with hypomagnesemia at admission as compared to the patients with normomagnesemia. We have not found differences in mortality rates among patients with hypomagnesemia (23.7 %) and normomagnesemia (25 %), p = 0.27. Conclusions. The incidence of hypomagnesemia in children with acute respiratory failure at admission was 70.4 %, and the incidence of hypocalcemia — 22.2 %. Factors associated with the development of hypomagnesemia might be the use of loop diuretics and sepsis. We have not found differences in duration of MV among patients with and without magnesium and calcium disorders. However, the duration of stay in the ICU among patients with hypomagnesemia was 1.47 times higher (95% CI 1.2–1.9, p = 0.04) as compared to the patients with normomagnesemia.
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