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Hypercalcemia
Alex Yartsev
Calcium
• Element number 20
• Makes up 3% of the Earths crust
• Calcium ion: Ca2+
• Divalent cation
Wikipedia
Calcium in the human body
• 5th most abundant element in the human body
• After cremation, a third of the remaining mass (1kg)
• Makes up 70% of hydroxyapatite (Ca10(PO4)6(OH)2)
• Most is present in this fixed form: bones and teeth
• A little is in the cytoplasm of all the cells
• A tiny amount circulates bound to albumin
• Miniscule portion is circulating as Ca++ ion
• the only physiologically active form is the Ca++ ion
• Clotting cascade Ca++ is a cofactor required at most factor activation steps, that’s why
blood bank purple top tubes contain a calcium chelator (EDTA)
• Bone integrity
National Health and Medical Research Council. (2006) Executive Summary of Nutrient Reference Values for
Australia and New Zealand Including Recommended Dietary Intakes.
Commonwealth Department of Health and Aging, Australia, Ministry of Health, New Zealand.
Daily calcium requirements in the ICU
• 0.1 mmol/Kg /day - INTRAVENOUSLY
• Thus, a 100kg ICU pt on TPN needs 10mmol
every day
Oh’s Intensive Care Manual, 6th ed. R.Leonard; Chapter 87 Enteral and parenteral nutrition
Usual Sources of Calcium
• Dairy:
– 200ml yoghurt = 10mmol
– 1 litre of milk = 25 mmol
• Spinach
• Baked beans
• Oranges
• Nuts
• Small canned fish with intact bones:
canned sardines = 10mmol per 100g
www.nutritiondata.com
Unusual Sources of Calcium
• Jevity 1cal contains ~23 mmol of calcium per
litre (910 mg)
• One Caltrate tablet = 15 mmol (600mg)
• Calcium resonium: exchanges calcium for
potassium in the gut. Calcium content is 1.6 to 2.4
mmol/g, so each 30g dose = potentially 48 to 72 mmol
• Calcium gluconate: 2.2 mmol per 10ml vial
• Calcium chloride: 6.6 mmol per 10ml vial
Khosla Sundeep, "Chapter 47. Hypercalcemia and Hypocalcemia" (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL,
Longo DL, Jameson JL, Loscalzo J: Harrison's Principles of Internal Medicine, 17th ed.
Consequences of hypercalcemia
• HYPERCALCEMIA = NERVOUS SYSTEM DEPRESSION
• Reduced reflexes or areflexia
• Reduced alertness, depression, confusion, lethargy, coma
• Polyuria, polydipsia (reduced concentrating ability)
• Bradycardia, AV block, short QT interval, widened T wave
• Nausea, anorexia, constipation, abdominal cramps
• Bone pain, pathological fractures
• Pancreatitis
• Peptic ulcers
• Renal calculi
• Symptoms are usually seen at above 3.0mmol/L
• Cardiac arrest is a real possibility at levels above 3.75 mmol/L
Khosla Sundeep, "Chapter 47. Hypercalcemia and Hypocalcemia" (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL,
Longo DL, Jameson JL, Loscalzo J: Harrison's Principles of Internal Medicine, 17th ed.
Diagnostic aids
• Is it the albumin? Whats the corrected Ca++
• PTH levels, or PTHrP levels
• Vitamin D levels
• Phosphate and magnesium are done routinely with calcium
• What is the renal function
• Has anything happened to the neck?
Khosla Sundeep, "Chapter 47. Hypercalcemia and Hypocalcemia" (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL,
Longo DL, Jameson JL, Loscalzo J: Harrison's Principles of Internal Medicine, 17th ed.
Management of mild hypercalcemia
• Consider not doing anything
• Consider stopping calcium replacement
• Consider stopping thiazides
• Consider giving a different variety of resonium
next time
• Rehydration (hypercalcemia inevitably leads to
dehydration by polyuria)
• Loop Diuretics if volume already normal
Khosla Sundeep, "Chapter 47. Hypercalcemia and Hypocalcemia" (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL,
Longo DL, Jameson JL, Loscalzo J: Harrison's Principles of Internal Medicine, 17th ed.
Management of severe hypercalcemia
• GOALS:
– Decrease bone resorption
– Increase calcium excretion
– Then, deal with the primary pathology, if possible
Oh’s Intensive Care Manual, 6th ed. B. Venkatesh; Chapter 54 Acute Calcium Disorders
Management of severe hypercalcemia
• Rehydrate aggressively WHILE giving loop diuretics
• Aim for a daily urine output of 4-5 litres
• If there are no kidneys to work with, go with dialysis.
Oh’s Intensive Care Manual, 6th ed. B. Venkatesh; Chapter 54 Acute Calcium Disorders
Specific strategies
in the management of hypercalcemia
• Chloroquine for sarcoidosis- reduces serum vitamin D levels
• Ketoconazole is also for sarcoidosis-induced hypercalcemia and
vitamin D intoxication
• Hydrocortisone for myeloma, granulomae, Vitamin D intoxication
Oh’s Intensive Care Manual, 6th ed. B. Venkatesh; Chapter 54 Acute Calcium Disorders
Abnormal management of
hypercalcemia
• Gallium Nitrate known to inhibit bone resorption by altering the
structure of hydroxyapatite, equivalent efficacy to pamidronate but
horribly nephrotoxic in 12.5%
• Calcitonin was more popular before bisphosphonates
– For some reason, salmon calcitonin is more powerful than human calcitonin