Hypocalcaemia

Hypocalcaemia

Amarendra B Singh090201263

Hypocalcaemia 2

Calcium

Normal total calcium level is 8.5 -10.5mg/dlNormal ionized Ca+2 level is 4.5 – 5.6mg/dl

Hypocalcaemia Total calcium <8.5 mg/dL, if serum protein

is normal ORIonized calcium < 4.5mg/dL

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Role of Mg

• Always measure serum magnesium in a hypocalcaemic patient.

• Hypomagnesemia impairs PTH secretion

• It also causes resistance to the actions of PTH at the level of kidney and bone

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Causes of hypocalcaemia

1) Increased Phosphate levels– Chronic kidney disease– Phosphate therapy

2) Hypoparathyroidism– Post thyroidectomy hypocalcaemia– Congenital deficiency (Di George Syndrome)– Idiopathic hypoparathyroidism– Severe hypomagnesaemia

3) Vitamin D deficiency– Osteomalacia/rickets– Vitamin D resistance

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Causes of hypocalcaemia

4). Resistance to PTH– Pseudohypoparathyroidism

5). Drugs– Calcitonins– Bisphosphanates

6). Other– Acute pancreatitis – Citrate blood in massive transfusion– Low plasma albumin eg. Malnutrition, Chronic liver

disease– Malabsorption eg. Coeliac disease

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Clinical Features• The clinical manifestations of hypocalcaemia

result from increased neuromuscular irritability.

• Paraesthesia (tingling sensation) around mouth, fingers and toes

• Muscle cramps, carpopedal spasms• Tetany • Seizures – focal or generalised• Laryngospasm, stridor and apnoeas (neonates)• Cardiac rhythm disturbances (prolonged QT

interval)• Chvostek’s and Trousseau’s signs – latent

hypocalcemia

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Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins, www.wrongdiagnosis.com/bookimages/14/4721.1.png

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Trousseau sign:(very uncomfortable and painful)

• A blood pressure cuff is inflated to 20mm Hg above systolic blood

pressure level.• arterial blood flow to the hand is occluded for 3 to 5 minutes.• Carpopedal spasm:

* flexion at the wrist * flexion at the MCP joints * extension of the IP joints * adduction thumbs/fingers

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Investigations

• S. Calcium and Phosphate levels• S. Albumin• S. & Urinary Creatinine (for renal disease)• PTH levels in serum• Parathyroid antibodies (present in idiopathic

hypoparathyroidism)• Vitamin D serum level (low in Vitamin D def.)• Magnesium level• X-rays of metacarpals (showing short 4th metacarpals

which occur in pseudo hypoparathyroidism)• ECG

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Pseudohypoparathyroidism

• Phenotype of Albright’s

• NORMAL serum calcium

• NO PTH resistance

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Management

1. Dependent on the underlying cause and severity

2. Administration of calcium alone is only transiently effective.

3. Mild asymptomatic cases: Often adequate to increase dietary calcium by 1000 mg/day

4. Symptomatic: Treat immediately22/06/2013

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Severe Symptomatic:• IV 10% Calcium Gluconate 10 ml over 10

minutes• Continuous IV infusion of Calcium Gluconate

@ 0.1 mmol/kg over 24 hours• Continuous Cardiac monitoring for

Bradycardia

Severe Asymptomatic:

Oral Calcium Supplements @ 0.2 mmol/kg (Max 10 mmols or 400 mg Ca) 4 x a day

Treatment of Hypocalcaemia

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• Aim to keep serum Ca between 8-8.5mg/dl• Oral Calcium supplements• Active preparations of Vitamin D

• 1,25-dihydroxyvitamin D (Calcitriol)• 1‑α‑hydroxyvitamin D (Alfacalcidiol)

@ 50 nanograms/kg (Max ~2 micrograms/day)

• Monitoring• Urine Ca/Cr (<0.7)• Plasma Ca+2

Treatment of Hypoparathyroidism

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Thank You!

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Education

Hypocalcaemia