RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE.

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / Name of the Candidate and Address
[in block letters] / DR. DHIVIYA M,
POST GRADUATE RESIDENT,
DEPARTMENT OF GENERAL MEDICINE,
KEMPEGOWDA INSTITUTE OF MEDICAL SCIENCES,
BANGALORE – 560004.
2. / Name of the Institution / KEMPEGOWDA INSTITUTE OF
MEDICAL SCIENCES,
BANGALORE – 560004.
3. / Course of study and subject / M.D. GENERAL MEDICINE
4. / Date of admission to Course / 09th May 2011
5. / TITLE OF THE TOPIC:
“HYPOMAGNESEMIA IN CRITICALLY ILL MEDICAL PATIENTS”
6. / BRIEF RESUME OF THE INTENDED WORK:
6.1  NEED FOR THE STUDY:
Magnesium is the fourth most abundant cation in the human body and the second most abundant intracellular cation after potassium. It is a critical ion that is essential for life. It serves as a cofactor for more than 300 enzymatic reactions mainly involving the transfer of phosphate group, for example formation of ATP. It also has important endocrine functions and is required for protein synthesis.4 It also maintains neuromuscular excitability and is important for the maintenance of cardiac function.
It has been estimated that 20 to 65% of critically ill patients develop hypomagnesemia during the course of their ICU stays.1 Hypomagnesemia , though so common in critically ill, is frequently overlooked. Magnesium depletion is described as the most underdiagnosed abnormality in clinical practice.6
Chernow and colleagues found that hypomagnesemia was associated with higher mortality rates in critically ill patients.2
The present study is to find the prevalence of hypomagnesemia in critically ill patients admitted to KIMS ICU and to find its effects on morbidity and mortality.
6.2  REVIEW OF LITERATURE:
International studies:
Rubeiz GJ et al3 found that in a total of 381 consecutive acutely ill medical patients, the normo and hypomagnesemic groups had comparable APACHE II scores but mortality rates were twice in hypomagnesemic than the normomagnesemic patients.
Soliman et al5 measured ionized magnesium levels in 446 consecutive patients admitted to ICU over a 3 month period. They found that, 18% of patients developed ionized hypomagnesemia, 68% had normal ionized magnesium levels, and 14% had ionized hypermagnesemia. A total of 23 patients who developed ionized hypomagnesemia exhibited higher APACHE score (14.9 vs. 11) and SOFA( Sequential Organ Failure Assessment) score (7.1 vs. 3.9) at admission, a higher maximium SOFA score during their ICU stay (10 vs. 4.4), a higher prevalence of severe sepsis and septic shock ( 57% vs. 11%), a longer ICU stay (15.4 vs. 2.8 days) and a higher mortality rate (35 % vs. 12%) than other patients.
Mohammedreza et al7 conducted a retrospective study on 100 critically ill patients and found that development of hypomagnesemia in ICU was associated with a guarded SOFA score, more need for ventilator (58.6% vs. 41.4%) and longer duration of mechanical ventilation( 7.2 vs. 4.7 days).
Santos et al8 found that in hospitalized AIDS patients, hypomagnesemia is a risk factor for nonrecovery of renal function and for in- hospital mortality. The risks for nonrecovery of renal function and for death were 6.94 and 6.92 times greater, respectively, for patients with hypomagnesemia .
Indian studies:
In an observational study conducted by Limaye et al9 on hypomagnesemia in critically ill medical patients, it was found that on admission to MICU, 52% had hypomagnesemia. Patients with hypomagnesemia had higher mortality rates (57.7% vs. 31.7%), more frequent need for ventilatory support (73% vs. 53%), longer duration of mechanical ventilation (4.27 vs. 2.15 days), more frequently had sepsis (38% vs. 19%), hypocalcemia (69% vs. 50%) and hypoalbuminemia (80.76% vs. 70.8%). Patients with diabetes mellitus had hypomagnesemia more frequently (27% vs. 14%).
6.3  OBJECTIVES OF THE STUDY:
1.  To study the serum total magnesium in critically ill medical patients and to correlate it with patient outcome in terms of: length of stay in MICU, need for ventilatory support, duration of ventilatory support, APACHE II score and mortality.
2.  To assess the primary critical medical conditions associated with abnormalities of serum magnesium.
3.  To detect other electrolyte abnormalities associated with hypomagnesemia, if any.
7. / MATERIALS AND METHODS:
7.1 SOURCE OF DATA:
Patients admitted to MICU, Kempegowda Institute of Medical Sciences, meeting the inclusion criteria.
7.2 METHOD OF COLLECTION OF DATA:
Study design:
Prospective observational Case Control study.
Study duration: 2 years
Sampling method:
Purposive sampling technique.
Sample size:
100 ( 50 cases and 50 controls).
Written informed consent will be taken from each patient enrolled in the study.
On admission, serum total magnesium will be measured. History and clinical assessment will be done for each patient admitted .APACHE (Acute Physiological and Chronic Health Evaluation) II score will be done on the day of admission to MICU. Relevant biochemical and radiological investigations will be done as indicated in every patient. The study will not interfere with the patient management in the MICU.
SELECTION CRITERIA
a. Inclusion Criteria:
•  Severe infections including sepsis.
•  Respiratory, cardiac, renal failure.
•  Cerebrovascular accidents
•  Poisonings.
•  Diabetic Keto Acidosis.
b. Exclusion Criteria:
1.  Those who have received magnesium prior to admission to MICU.
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans.
Yes.
Blood investigations :Serum total magnesium, serum electrolytes
and relevant biochemical and radiological investigations as
indicated.
7.4 Has ethical clearance been obtained from your institution ?
Yes.
8. / LIST OF REFERENCES:
1.  Ryzen E, Wagers PW, Singer FR, et al. “Magnesium deficiency in a medical ICU population”. Crit Care Med. 1985; 13:19-21.
2.  Chernow B, Bamberger S, Stroiko M, et al. “Hypomagnesemia in patients in the postoperative intensive care unit”. Chest 1989; 95: 391 – 397.
3.  Rubeiz GJ,Thill-Baharozian M, HadieD, Carlson RW. “Association of hypomagnesemia and mortality in acutely ill medical patients”. Crit Care Med. 1994 Feb; 22(2):372-3.
4.  Toffaletti J. Physiology and Regulation: “Ionised calcium, magnesium and lactate measurements in critical care settings”. Am J Clin Pathol. 1995; 104(suppl 1): 588-594.
5.  Soliman HM, Mercan D, Lobo SS, Melot C, Vincent JL. “Development of ionized hypomagnesemia is associated with higher mortality rates.” Crit Care Med. 2003 Apr; 31(4):1082-7.
6.  Paul Marino. “Fluid and electrolyte disorders – Magnesium”. The ICU book ,2nd ed., Philadelphia, Lippincott, Williams and Wilkins.2004;660-672.
7.  Mohammedreza Safavi, Azim Honarmand. “Admission hypomagnesemia – Impact on Mortality or Mortality in critically ill patients”. Middle East Journal Anesth.2007; 19(3).
8.  Santos MS, Seguro AC, Andrade L. “Hypomagnesemia is a risk factor for nonrecovery of renal function of renal function and mortality in AIDS patients with acute kidney injury”. Braz J Med Biol Res.2010 Mar;43(3):316-23
9.  CS Limaye, VA Londhey, MY Nadkar, NE Borges. “Hypomagnesemia in critically ill medical patients”. J Assoc Physicians India. Jan 2011; 59:19-22.
9. / SIGNATURE OF THE CANDIDATE:
10. / REMARK OF THE GUIDE: / An observational study in critically ill medical patients. This study will help in further management of critically ill.
11. / NAME AND DESIGNATION OF (in block letters)
11.1 GUIDE / DR. H.V.NATARAJU,
PROFESSOR AND UNIT HEAD-II , DEPARTMENT OFGENERAL MEDICINE,
KEMPEGOWDA INSTITUTE OF MEDICAL SCIENCES,
BANGALORE – 560004.
11.2 SIGNATURE
11.3 CO-GUIDE (if any)
11.4 SIGNATURE
11.5 HEAD OF THE
DEPARTMENT / DR. POORNACHANDRA M V,
PROFESSOR AND HOD,
DEPARTMENT OF GENERAL MEDICINE,
KEMPEGOWDA INSTITUTE OF MEDICAL SCIENCES,
BANGALORE – 560004.
11.6 SIGNATURE
12. / 12.1 REMARKS OF THE CHAIRMAN AND DEAN
12.2 SIGNATURE