Hypocalcemia Management Explained Clearly (Electrolytes — Lecture 10) — Transcript

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1. 0:00a 75-year-old lady is being treated for
2. 0:03UTI and you notice that her calcium
3. 0:06level on her morning lab was 7 MGR per
4. 0:09dcil what's next calcium value on BMP
5. 0:13basic metabolic panel or complete
6. 0:15metabolic panel CMP is actually the
7. 0:18total serum calcium and the total serum
8. 0:20calcium equal or it's made of free
9. 0:23calcium plus the bound calcium the
10. 0:25ionize or free calcium versus total
11. 0:27calcium the ionized free calcium is 4 4
12. 0:30to 45% 40 to 45% of calcium bound to
13. 0:33protein mly albumin and the is 15% is
14. 0:36bound to other anion now any increase or
15. 0:39decrease in total calcium does not equal
16. 0:42or by default mean decrease or increase
17. 0:45in ionized free calcium so total calcium
18. 0:48cannot tell you about the value of
19. 0:50ionized calcium unfortunately the
20. 0:52increase or any decrease in albumin it
21. 0:55will lead to increase or decrease in
22. 0:57total calcium as we said 40 to 45% % of
23. 1:00calcium is bound to albumin ionized free
24. 1:03calcium is the active form is really the
25. 1:06form that works in the body and only
26. 1:08ionized calcium is regulated by pth or
27. 1:11vitamin D so it's not the total calcium
28. 1:14it's the free calcium that regulated by
29. 1:16and vitamin D and as you know we always
30. 1:19correct total calcium to albumin any
31. 1:21increase or decrease by one gram of
32. 1:23albumin roughly lead to increase or
33. 1:25decrease by 0.8 mgram in total calcium
34. 1:29few things here alkalosis increase
35. 1:31albian bound cou calcium which leads to
36. 1:34decrease free calcium example
37. 1:36hyperventilation the opposite is true
38. 1:38which means acidosis decrease the ALB
39. 1:41bound calcium increase the free calcium
40. 1:43pth as you know decrease Albin Bond
41. 1:46calcium increase free calcium and high
42. 1:48phosphorus or hyperphosphatemia
43. 1:51phosphorus as you know binds to calcium
44. 1:53leading to decrease free calcium ionized
45. 1:56calcium level is the best test to
46. 1:58diagnose hypo or hyper calcemia the
47. 2:01problem though it's expensive and not
48. 2:03widely available now total calcium level
49. 2:06obtained routinely as we know with CMP
50. 2:08or BMP and we need to always correct for
51. 2:13album and we always need to correct
52. 2:15total calcium level for albumin level
53. 2:17even if calcium level is normal we need
54. 2:20to correct it to albumin any increase or
55. 2:23decrease in total calcium we need to
56. 2:26correct it for albumin first after that
57. 2:28if there is any evidence of high hyper
58. 2:30or hypocalcemia the next step we need to
59. 2:32confirm it with ionized or free calcium
60. 2:35level if available at your facility very
61. 2:38important to remember the ionized
62. 2:39calcium reference values are say
63. 2:41dependent and may be different from one
64. 2:43facility to another so check your lab
65. 2:45references for a summary of this video
66. 2:47please subscribe to my substack the link
67. 2:50is provided below now hypocalcemia
68. 2:52defined by total calcium less than 8
69. 2:55mgram per dcil after it's corrected for
70. 2:58albumin and remember we need to confirm
71. 3:00it with free calcium level if available
72. 3:02and remember the free calcium level
73. 3:05values to decide hypocalcemia are I say
74. 3:07dependent some lab references I know
75. 3:09they use 4.8 mgram per deciliter but
76. 3:12less than that but some other labs may
77. 3:14use different references so check with
78. 3:16your Labs now back to our example here
79. 3:18calcium was 7 migr per dcil albumin was
80. 3:213.9 so they corrected total calcium was
81. 3:247 MGR per dcil cuz normal alumin is four
82. 3:27is almost there so what's next next is
83. 3:30to check ionized calcium level if
84. 3:32available and for this patient was 2.7
85. 3:35now hypoc calcium can be either acute or
86. 3:38chronic now acute there is acute drop in
87. 3:41total calcium to less than 7.5 G per
88. 3:44deciliter again corrected to albumin or
89. 3:47less than 3 mgram per deciliter in
90. 3:49ionized calcium these kind of patients
91. 3:51needs urgent treatment urgent in patient
92. 3:54treatment so we need to compare to a
93. 3:56basine calcium level and if there is no
94. 3:59is line calcium level to compare to and
95. 4:02the patient has no symptoms to suggest
96. 4:03hypocalcemia we consider that chronic
97. 4:06chronic patients usually asymtomatic or
98. 4:08if they have symptoms usually mild
99. 4:09nonurgent Outpatient Treatment again
100. 4:12always compared to previous Labs now
101. 4:14hypocalcemia can be asymptomatic or mild
102. 4:16symptoms or symptomatic if you see any
103. 4:19of these symptoms that means we need
104. 4:21urgent treatment spasm remember the word
105. 4:23spasm bronos spasm lingos spasm or
106. 4:26carpopedal spasm seizures prolong QTC
107. 4:29irritability anxiety or depression
108. 4:32although these can be non-specific and
109. 4:34hard to tell if they are related to
110. 4:35hypocalcemia I borrow these pictures
111. 4:37from up to date I'm not sure if anyone
112. 4:40does this test anymore so if you see
113. 4:43these signs then the patient needs
114. 4:44urgent in patient treatment so now as
115. 4:47you just saw the treatment urgency is
116. 4:50decided by the severity of symptoms and
117. 4:52or the Acuity of hypocalcemia not by the
118. 4:55absolute calcium level now back to our
119. 4:58patient we found labs done for the same
120. 5:00patient a week ago and calcium was 9
121. 5:03migr per dcil and albumin back then was
122. 5:05four so the corrected one n right
123. 5:08because Albin is normal so total calcium
124. 5:10was nine dropped to seven within one
125. 5:12within one week there is acute drop that
126. 5:14means urgent treatment even if the
127. 5:16patient is symptomatic because acute
128. 5:17drop these patient most likely will
129. 5:20develop symptoms soon if they have not
130. 5:22developed yet again if no Baseline to
131. 5:24compare to and no symptoms to really to
132. 5:26suggest symptomatic hypocalcemia we
133. 5:29consider chronic and our patient
134. 5:31presented with lethargy and decrease
135. 5:33oral intake which can be attributed to
136. 5:36UT but also hypoc can cause that yes so
137. 5:39anyway this is a c drop and I will treat
138. 5:42urgently what do I mean by urgent or
139. 5:44imer treatment which means impatient
140. 5:46treatment with IV calcium bses which
141. 5:48will lead to quick but temporary rise in
142. 5:50calcium for a few hours that means we
143. 5:52need to follow that by continuous or
144. 5:54slow calcium infusion sustained rise
145. 5:57this will lead to sustained rise now now
146. 5:59as you know now IV calcium we have
147. 6:02calcium gluconate or calcium chloride
148. 6:05calcium gluconate which I prefer it's
149. 6:07preferred because it's safe to be given
150. 6:09via peripheral axis while chloride needs
151. 6:11central line we give 1 to2 gram over 10
152. 6:14minutes here we give 1 G over 10 minutes
153. 6:17or half a gram over 10 minutes the
154. 6:19elemental amount of calcium is 90 mgram
155. 6:22in the 1 G of calcium gluconate triple
156. 6:24that in chloride 270 so remember this is
157. 6:28the CH calcium chloride is triple
158. 6:30whatever in calcium gluconate but I
159. 6:33always go for calcium gluconate if
160. 6:35available hypoc calcium with severe
161. 6:37symptoms if I have a patient with that I
162. 6:39usually give 1 to two gram of IV calcium
163. 6:41gluconate or 0.5 to 1 gram of calcium
164. 6:44chloride if you have a central line I
165. 6:46reassess the patient symptoms in 15 20
166. 6:48minutes if symptoms persist I give a
167. 6:51second BS I check if our Pharmacy makes
168. 6:54calcium drip you probably have not heard
169. 6:56of this but yes we can make calcium drip
170. 7:00and usually we mix 11 G of calcium
171. 7:02gluconate remember each gram contain 90
172. 7:05mg so 11 that's
173. 7:07999 we mix it in 1,000 mil of .9 normal
174. 7:11C or D5W the concentration will be each
175. 7:14mil of that solution will have 1 mgram
176. 7:17of Elemental calcium or we can mix 3.5 G
177. 7:20of calcium chloride and then we Infuse
178. 7:23that as 50 mil per hour that means we
179. 7:26get 50 mgram of Elemental calcium per
180. 7:28hour again again this will be slow
181. 7:30infusion and will lead to sus more
182. 7:32sustained rise in calcium unlike the
183. 7:35bullets that will lead to Temporary but
184. 7:37quick rise in calcium to relieve the
185. 7:39symptoms now if you don't have a drip
186. 7:41and I'm not sure if a lot of fac
187. 7:43probably don't have the drip we what we
188. 7:45use scheduled bises we can give bises
189. 7:48every four or every six or every eight
190. 7:50hours time 24 hours now one important
191. 7:54thing I want to mention here that we can
192. 7:56slow down the infusion instead of over
193. 7:5910 minutes we can say over 1 to 2 hours
194. 8:02so we can have a more sustained rise
195. 8:05because we don't have the drip an IV
196. 8:07calcium is stopped once symptoms
197. 8:10resolved and oral calcium is started
198. 8:12we'll come to that soon now acute hypoc
199. 8:15calcemia and the with no symptoms or
200. 8:17mild symptoms we give IV calcium bolus
201. 8:20times one or two boluses and we start
202. 8:22oral calcium and vitamin D because these
203. 8:24patients are asymptomatic now back to
204. 8:27our patient the patient has acute
205. 8:28hypocalcemia we don't know if the
206. 8:30symptoms related to UTI or hypocalcemia
207. 8:33anyway I will give calcium gluconate 2 G
208. 8:35IV over 10 minutes then I will give
209. 8:37calcium gluconate 1 G IV over 60 Minutes
210. 8:40every 6 hour time two doses if I don't
211. 8:42have a calcium drip and most likely I
212. 8:45will use this it's easier and then I
213. 8:47will start oral calcium and vitamin D
214. 8:49level we'll come to that now all these
215. 8:51patients we need to start oral calcium
216. 8:53as soon as we can and we usually give 1
217. 8:56to 2 gam of Elemental calcium per day
218. 8:58including calcium in our diet and start
219. 9:01Vitamin D supplements if warranted and
220. 9:03stop IV calcium on symptoms resolved and
221. 9:06oral calcium is started and start we
222. 9:08start both we'll come to that the
223. 9:10vitamin D and oral calcium in
224. 9:13hypoparathyroidism and this is another
225. 9:15table I borrowed from up to date about
226. 9:18the calcium the elemental calcium in the
227. 9:20different oral formulation that has a
228. 9:22combination of calcium and vitamin D you
229. 9:25don't need to memorize it you can just
230. 9:26look it up now in all patients with
231. 9:28hypoc see check check vitamin D level
232. 9:31check magnesium level why because we
233. 9:33have to replace hypomagnesemia otherwise
234. 9:37it will be very difficult to correct
235. 9:39hypocalcemia similar to hypoc calmia
236. 9:42also check phosphorus level as we said
237. 9:44hyperphosphatemia should be treated
238. 9:46because high phosphorus lead to decrease
239. 9:48free calcium and check AKG and all to
240. 9:51look at the QTC and see if there is a
241. 9:53prolong QTC or not and if there is
242. 9:55prolonged QTC then this needs urgent
243. 9:57treatment as we explained now chronic
244. 10:00hypocalcemia plus no symptoms or mild
245. 10:02symptoms we only treat with oral calcium
246. 10:04and vitamin D if fored if vitamin D
247. 10:07deficient now vitamin D deficiency as
248. 10:09you know we have vitamin D2
249. 10:11ergocalciferol vitamin D3 kic calciferol
250. 10:14these are formulation that still need to
251. 10:16be metabolized to active form so you
252. 10:19need healthy kidney and healthy liver
253. 10:21calcitriol on the other hand is a
254. 10:24vitamin D metabolites that can bypass
255. 10:26the need for liver and and kidney
256. 10:29metabolism or renal metabolism so we can
257. 10:31use them in patients with liver disease
258. 10:34or chronic kidney disease and also we
259. 10:36prefer this in acute hypoparathyroidism
260. 10:39because it's active form and quick
261. 10:41action compared to slow action of
262. 10:43vitamin D2 and vitamin D3 for dozing and
263. 10:47how to replace it uh you can just Lo it
264. 10:49up acute hypoparathyroidism after you
265. 10:52treat with IV calcium as we said you
266. 10:54need long-term oral calcium and
267. 10:56long-term vitamin D deficiency
268. 10:58preferably cetol chronic kidney disease
269. 11:01again because these people has high
270. 11:03phosphorus we give calcium acetate it's
271. 11:06not really to replay the calcium rather
272. 11:08than to bind phosphorus because once you
273. 11:10bind phosphorus and decrease phosphorus
274. 11:11level free calcium will consequently
275. 11:14rise and we replace with vitamin D if
276. 11:17deficient and we give calcitriol which
277. 11:19is vitamin D metabolites because if we
278. 11:22give vitamin D2 or three they will need
279. 11:24to be metabolized in the kidney and the
280. 11:26kidney is impaired already and the same
281. 11:29apply for chronic liver disease now
282. 11:31monitoring check calcium level again in
283. 11:3312 to 24 hours monitor the resolution of
284. 11:36symptoms repeat EKG to make sure the QTC
285. 11:39has returned back to normal discharged
286. 11:41patient One symptom is resolved and
287. 11:43calcium level above 8 migr per DC and
288. 11:46you have start adequate replenishment
289. 11:48with oral calcium and vitamin D if
290. 11:50warranted thanks for watching and if you
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