A very effective, precise and focused presentation for Calcium abnormalities and approach towards management. Targeted to teach the to the point diagnosis and treatment. It is requested to download the presentation to run the animation as it is a very interactive presentation

1. Case Presentation
Muhammad Asim Rana

2. After a Long Working Day at 7:10pm
• You are sitting in your room and the bleep buzzes
• You answer the number which is from ER and
simultaneously your cell starts ringing
• You keep ER physician on hold and answer the
cell phone which is from Female Surgical Ward
• ER Physician needs you for a patient urgently as
the GCS is low and they want to intubate.
• Surgical floor needs you as the MROC tells the
patient is seizing constantly.

3. What to do?
• Team Leader is consulted with following…
• Why ER people need us for intubation?
• Can’t MROC control fits? He is a doctor as well
• They should call their seniors or anesthetist?
– Team leader decides to send on ref ICU specialist
to ER and another from bed side to the surgical
floor to attend both the calls simultaneously
Very Bad Senior !!!!

4. Case in ER
• A 66 yrs old woman is evaluated in ER because
of decreased LOC.
• She presented 2 hrs ago…
• There is 2-month history of fatigue, anorexia,
thirst, polydipsia, and polyuria.
• Squamous cell lung cancer was diagnosed 5
months ago; the patient absconded
afterwards
• She takes no medications.

5. On physical examination
• Temperature ...37.5 °C
• BP 90/60 mm Hg
• HR is 118/min
• RR is 22/min
• BMI is 18.
• The patient appears cachectic & dry, and
• The remaining general physical examination
findings are normal

6. Physical Exam cont’
• GCS… E2M5V1
• CVS… Normal
• Abdomen… NAD
• Chest… Decreased expansion on Rt side with
decreased air entry, stony dull percussion note
up to inferior angle of Rt scapula with
bronchial breathing at the upper limit of
dullness.

7. What is your impression?
• Rt sided pleural effusion
• Pneumonia?
• Septic Shock secondry to pneumonia
• Confusion & sepsis due to UTI?
• Brain mets…..
Any thing else?
• First set of labs arrived by this time….
• Would you like to see?

8. Laboratory studies
• BUN 70 mg/dL (25.0 mmol/L)
• Calcium 13.5 mg/dL (3.38 mmol/L)
• Creatinine 2.9 mg/dL (256.4 µmol/L)
• ABGs pH 7.29, PaCO2 52, PO2 55, HCO3 18
• Na 148, K 4.9
• CBC.. Hb 6.8, WBCs 24, Plats 455

9. CXRs
(5 months ago) (Today)
CT Brain Normal Study

10. What would you like to do?
Questions you need to answer as ICU specialist
• 1) Does the patient need intubation?
• 2) What is the reason of hypotension?
• 3)How would you manage this patient?
• 4) ICU or No ICU?
What is the main problem here?
Hypercalcemia

11. Management
• Aggressive volume replacement with intravenous
normal saline is initiated.
• Will IV Saline return Calcium to normal levels?
• NO
• Then why saline?
• What is the reason of dehydration/hypovolumia?
• What Next?
• IV Furosemide !!
• Why?.... We are trying to Rx Dehydration Yes/No?

12. Management
What Else….
• Calcitonin….
• How it acts? What is dose?
• Plicamycin…
• Glucocorticoids..
• Bisphosphonates…

13. Management
• Which of the following drugs is likely to provide
the most sustained benefit in decreasing this
patient’s calcium level?
• A) Calcitonin
• B) Cinacalcet
• C) Prednisone
• D) Zoledronate
• What is the fastest available treatment?
Haemodialysis

14. Causes of Hypercalcemia

15. Causes of Hypercalcemia (ICU)
• Malignancy
– Breast Cancer
– Multiple myeloma
– Non Hodgkins Lymphoma
– Lung Cancer (Sq cell Ca)
• Thiazide Diuretics
• Lithium
• Adrenal Insufficiency
• Immobilization

16. Discussion
• Malignancy is the most common cause of non-
parathyroid hormone (PTH)–mediated
hypercalcemia and the most frequent cause of
hypercalcemia in hospitalized patients.
• Malignancy-associated hypercalcemia is
differentiated into two forms:
– Local osteolytic hypercalcemia
– Humoral hypercalcemia of malignancy.

17. Did you forget the other specialist
you sent to surgical floor?
Let’s see him

18. Case on the floor
• A 55-year-old woman is evaluated by ICU
specialist in the surgical ward at 5:30 pm for
constant seizures as per MROC 1st on call.
• She is a known case of type 2 DM, HTN, IHD.
• Treatment History
– Glucophage & Glibenclamide
– Amlodipine and Lisinopril
– Carbamazepine and Aspirin

19. Case on the floor cont’
• History of psychiatric illness for which she was
taking some medication which she has left by
herself and the name of drug is not available
by that time and MRP has already asked for
file from psychiatry out doors.
• History of hysterectomy 5 yrs ago.

20. Present Problem
• 6 hours ago, she had a large parathyroid
adenoma removed.
• The operation lasted for 2 and a half hours.
• The recovery was uneventful and she was
shifted to ward.
• Pre-Op vitals
• Temp.. 37, BP 145/90, HR 102/min,

21. Present Problem
• The operation was bloody, with massive bleeding
and pt received 4 units of PRBCs during OR.
• The anesthetist notes do not describe any fall of
BP during surgery.
• No CPR or cardiac arrhythmias recorded.
• Saturation recordings are steady, no hypoxia.
• Blood Sugar before OR was 145mg% and when
checked by ICU was…..
• 166mg%

22. Laboratory studies (before OR)
• Albumin 4.2 g/dL (42 g/L)
• Calcium 6.0 mg/dL (1.5 mmol/L)
• Phosphorus 1.8 mg/dL (0.58 mmol/L)
• Parathyroid hormone 20 pg/mL (20 ng/L)
• CBC… Hb% 11, WBCs 6.4, Plats 240
• Sodium and Potassium Normal

23. Preoperative skeletal radiographs showed subperiosteal bone
resorption of the distal phalanges, femoral and spinal
osteopenia, and osteoporosis in the radius.

24. Clinical Examination
• V/S.. T 38.3 C, BP 159/90, HR 110/min
• SpO2 on 2 liters per min O2 96%
• Conscious between episodes but not
responding to verbal commands
• Developed sudden jerky movements of the
body while the nurse was checking BP
preceded by tonic spasm in the arm where BP
was being checked

25. Present Problem Cont’
• The movements were repeated and involved
the face of the patient.
• The patient remained conscious during the
jerks which subsided by them self while the
nurse ran for the Diazepam injection advised
by ICU.
• Other systemic exam was unremarkable

26. How you will handle this patient?
• 1) ETT as she is having repeated seizures?
• 2) Lorazepam, Diazepam IV
• 3) Phenobarbitone IV
• 4) IV Dextrose
• 5) ICU or No ICU?
SENIOR SHOULD BE CALLED…What he is doing?
What is the main problem here?
Acute Hypocalcemia

27. • Which of the following is the most likely
diagnosis?
• A) Hungry bone syndrome
• B) Osteomalacia
• C) Permanent hypoparathyroidism
• D) Vitamin D deficiency

28. Discussion
• Hungry bone syndrome
• The associated hypoparathyroidism is usually
transient
• Treatment with calcium and a short-acting
vitamin D metabolite may be required until the
bones heal.
• Both osteomalacia and vitamin D deficiency
cause secondary hyperparathyroidism with
elevated PTH levels. This patient’s normal serum
PTH level argues against these diagnoses.

29. Intravenous Calcium Replacement
Solution Elemental Calcium Unit Volume Osmolarity
10% Calcium
Chloride
27 mg/ml
1.36mEq/ml
10 ml ampule 2000mOsm/L
10% Calcium
Gluconate
9 mg/ml 0.46
mEq/ml
10 ml amplule 680 mOsm/L
IV Ca should be given in CVL, if N/A; use Ca-gluconate
Give a bolus dose 200 mg elemental Calcium
(8ml of10% Ca-Chloride OR 22 ml of 10% Ca-gluconate)
Follow with continuous infusion of 1-2 mg elemental
Calcium per Kg per hr for 6-12 hrs

30. Causes of Hypocalcemia
• Alkalosis
• Blood Transfusions
• Fat embolism
• Mg Depletion
• Pancreatitis
• Renal Insufficiency
• Sepsis
• Aminoglycosides
• Cimitedine
• Heparin
• Theophylline
• Vit D deficiency
Hypoparathyroidism

31. Thank you very much