Letters to Editor
Hypocalcaemia‑induced acute
exacerbation of bronchial asthma:
An unusual cause of a common
disorder
Sir,
An acute exacerbation of bronchial asthma may present
abruptly, even without prodromal symptoms. Severe
hypocalcaemia can precipitate bronchospasm which
can mimic asthma exacerbation.[1] A combination of
these conditions poses a diagnostic dilemma and may
prove fatal. We report a case of acute exacerbation of
asthma induced by undiagnosed hypocalcaemia in the
post‑anaesthesia care unit (PACU).
A 22‑year‑old woman (50 kg) with a history of
incomplete spontaneous abortion was planned for
emergency dilatation and curettage. She was a known
case of bronchial asthma since 2 years, was on regular
treatment with salbutamol inhaler but had poor
compliance for the last 5 months, with no other medical,
surgical or drug history. She was asymptomatic with
mild bilateral rhonchi, haemodynamically stable with
normal routine investigations. After nebulisation,
she was taken up for the emergency procedure.
Intravenous (IV) sedation with spontaneous
respiration and supplemental oxygen through a face
mask to avoid any airway manipulation was planned.
Using standard American Society of Anesthesiologists
monitoring, she was induced with intravenous (IV)
propofol 40 mg and ketamine 30 mg. Paracetamol
1 g IV infusion and injection dexamethasone 8 mg
were administered. Anaesthesia was maintained with
continuous propofol infusion at 0.1 mg/kg/min. The
intraoperative period was uneventful, and the patient
shifted to the PACU with stable vitals.
Postoperatively, the patient was fully awake,
pain‑free and haemodynamically stable. After
15 min, she suddenly became restless with laboured
breathing and difficulty in speech followed by
a dip in oxygen saturation (SpO2) to 70%. She
developed tachycardia (heart rate 128/min) and
hypotension (blood pressure 92/54 mm Hg) with
no significant changes in the electrocardiogram.
Immediately, 100% oxygen was administered,
following which her SpO2 increased to 88%. She was
also noted to have bilateral carpal spasm, bilateral
820
Page no. 90
diffuse rhonchi and decreased breath sounds suggesting
bronchospasm. Arterial blood gas (ABG) analysis
showed: pH ‑ 7.473, PaO2‑55.0 mmHg, PaCO2‑38.1
mmHg, HCO3− ‑ 27.3 mmol/L, FiO2‑1.0 with ionised
Ca+2‑0.6 mmol/L (normal levels ‑ 1.16–1.31 mmol/L),
while other electrolytes (Na+, K+, Cl−1, and Mg+2)
were normal. Salbutamol plus ipratropium bromide
puffs, IV hydrocortisone 100 mg and 1 g 10% IV
calcium gluconate, was administered over 10 min,
followed by an IV infusion dose of 1 mg/kg/h of
elemental calcium. Over the next 15 min, SpO2
improved to 95% and mild bilateral rhonchi were
managed with nebulisation. One hour later, repeat
ABG analysis on room air showed normal blood
gas parameters with ionised calcium ‑ 0.85 mmol/L.
Subsequent investigations showed low ionised
Ca+2‑0.98 mmol/L and vitamin D ‑ 20 ng/mL (normal
levels ‑ 25–80 ng/ml). She was discharged on oral
calcium and vitamin D supplementation.
Patients undergoing treatment for asthma may
inadvertently develop hypocalcaemia and other
electrolyte disturbances secondary to pharmacotoxic
effects of beta‑agonist therapy.[2] Our patient, probably
because of the combined effects of long‑term beta‑agonist
therapy and underlying vitamin D deficiency had
undiagnosed hypocalcaemia preoperatively which
could have been exacerbated intraoperatively and
postoperatively because of respiratory alkalosis
caused by hyperventilation.[3] Hypocalcaemia
with resultant bronchospasm is a well‑recognised
paediatric emergency,[4] but has been rarely reported
in adults. Although rare, stridor and intermittent
airway obstruction due to laryngospasm resulting
from hypocalcaemia have been reported in elderly
patients.[5] Severe hypocalcaemia can cause
neuromuscular irritability and bronchospasm which
can mimic an exacerbation of bronchial asthma.[1] Pain,
anxiety and surgical stress can exacerbate bronchial
asthma, but our patient was pain free. Symptomatic
hypocalcaemia commonly occurs with a serum
ionised calcium below 1.1 mmmol/L. Our patient must
have been hypocalcaemic preoperatively with serum
ionised calcium levels somewhere around 0.6 mmol/L,
but surprisingly was asymptomatic.
Our experience underscores the significance of
pre‑operative monitoring of serum calcium levels
and other electrolytes in chronic asthma patients on
treatment with beta‑agonist inhalers and highlights the
importance of swift correction to decrease morbidity
and mortality.
Indian Journal of Anaesthesia | Volume 64 | Issue 9 | September 2020
 Letters to Editor

Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Nidhi Jain, Kamlesh Kumari, Shipra Roy,
Rashmi Syal
Department of Anaesthesiology and Critical Care, All India Institute of
Medical Sciences, Jodhpur, Rajasthan, India
Address for correspondence:
Dr. Kamlesh Kumari,
Department of Anaesthesia and Critical Care,
All India Institute of Medical Sciences, Basni Phase‑2,
JodhpurRajasthan ‑ 342 005, India.
E‑mail: kamlesh.gmch@gmail.com
Submitted: 11-May-2020
Revised: 30-May-2020
Accepted: 12-Jul-2020
Published: 01-Sep-2020
chronic stable asthma and with asthma attacks. Egypt J Chest
Dis Tuberc 2014;63:529‑34.
3. Wadhwa R, Kalra S. Unusual presentation of hypocalcaemia
in a peri‑operative period‑cause unknown. Indian J Anaesth
2010;54:270‑1.
4. Venkatesh C, Chhavi N, Gunasekaran D, Soundararajan P. Acute
stridor and wheeze as an initial manifestation of hypocalcemia
in an infant. Indian J Endocrinol Metab 2012;16:320‑1.
5. Srivastava A, Ravindran V. Stridor secondary to hypocalcemia in the
elderly: An unusual presentation. Eur J Intern Med 2008;19:219‑20.
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DOI:
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REFERENCES
1. Janabi LA, Uchel T, Natheer R. Pancreatic induced
hypocalcemia causing acute bronchospasm. Am J Respir Crit
Care Med 2019;199:A5509.
2. Mohammad HA, Abdulfttah MT, Abdulazez AO, Mahmoud AM,
Emam RM. A study of electrolyte disturbances in patients with
How to cite this article: Jain N, Kumari K, Roy S, Syal R.
Hypocalcaemia-induced acute exacerbation of bronchial asthma:
An unusual cause of a common disorder. Indian J Anaesth
2020;64:820-1.
© 2020 Indian Journal of Anaesthesia | Published by Wolters Kluwer - Medknow

Severe metabolic acidosis no other co‑morbidities. Inside the operating room,

secondary to iatrogenic
hyperglycaemia in
secondary cytoreduction and
hyperthermic intraperitoneal
chemotherapy (HiPEC)
Sir,
Cytoreductive surgery (CRS)‑hyperthermic intraperitoneal
chemotherapy (HiPEC) is a popular topic of
investigation for cancers with diffuse peritoneal
metastasis.[1] Perioperative management for these
patients is challenging for the anaesthesiology team.
We report a case of hyperglycaemia and metabolic
acidosis leading to delayed arousal from anaesthesia
after CRS‑HiPEC.
A 53‑year‑old female patient, weighing 52 kg,
diagnosed with carcinoma ovary was posted for
secondary cytoreduction followed by HiPEC. She had
Indian Journal of Anaesthesia | Volume 64 | Issue 9 | September 2020
Page no. 91
standard American Society of Anesthesiologists (ASA)
monitors were connected, an epidural catheter
inserted and general anaesthesia was induced
with Inj. propofol 2 mg/kg, Inj. fentanyl 2 µg/kg
and Inj. vecuronium 0.1 mg/kg intravenously (IV).
Maintenance of anaesthesia was done on low flow
nitrous oxide, oxygen and sevoflurane (2%) with
intermittent Inj. vecuronium 0.02 mg/kg. This
was followed by the insertion of a nasopharyngeal
temperature probe, central venous catheter and right
radial artery cannula. Warm intravenous fluids and
warming blanket were used to prevent hypothermia.
Secondary cytoreduction was performed for 6.5 hours.
Total blood loss of 1100 ml was combated by 2.5 L of
crystalloids (Ringer lactate), 500 ml colloid, and 2 units
of packed red blood cells (RBCs). Surgery was followed
by HiPEC, lasting another hour. Before commencing
HiPEC, warm intravenous fluids were replaced with
cold ones. Doxorubicin prepared in 5% dextrose at
42° was used as intraperitoneal dialysate. Adequate
analgesia was provided by intravenous fentanyl,
morphine and thoracic epidural infusion. Hourly urine
output was adequate (>0.5 mL/kg/hour) throughout
the surgery, with a desirable increase (3 ml/kg/hour)
821