Hypocalcaemia

1. Hypocalcaemia Amarendra B Singh 090201263

2. Calcium Normal total calcium level is 8.5 -10.5mg/dl Normal ionized Ca +2 level is 4.5 – 5.6mg/dl Hypocalcaemia Total calcium <8.5 mg/ dL , if serum protein is normal OR Ionized calcium < 4.5mg/ dL 22/06/2013 Hypocalcaemia 2

3. 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 22/06/2013 Hypocalcaemia 3

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7. Causes of hypocalcaemia Increased Phosphate levels Chronic kidney disease Phosphate therapy Hypoparathyroidism Post thyroidectomy hypocalcaemia Congenital deficiency (Di George Syndrome) Idiopathic hypoparathyroidism Severe hypomagnesaemia Vitamin D deficiency Osteomalacia /rickets Vitamin D resistance 22/06/2013 Hypocalcaemia 7

8. 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 22/06/2013 Hypocalcaemia 8

9. 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 22/06/2013 Hypocalcaemia 9

10. Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins, www.wrongdiagnosis.com/bookimages/14/4721.1.png 22/06/2013 Hypocalcaemia 10

11. 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 22/06/2013 Hypocalcaemia 11

12. Investigations S. Calcium and Phosphate levels S. A lbumin 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 4 th metacarpals which occur in pseudo hypoparathyroidism ) ECG 22/06/2013 Hypocalcaemia 12

13. Pseudohypoparathyroidism Phenotype of Albright’s NORMAL serum calcium NO PTH resistance 22/06/2013 Hypocalcaemia 13

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15. Management Dependent on the underlying cause and severity Administration of calcium alone is only transiently effective. Mild asymptomatic cases: Often adequate to increase dietary calcium by 1000 mg/day Symptomatic: Treat immediately 22/06/2013 Hypocalcaemia 15

16. 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 22/06/2013 Hypocalcaemia 16

17. 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 22/06/2013 Hypocalcaemia 17

18. Thank You! 22/06/2013 Hypocalcaemia 18