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NHS Lothian

Hypercalcaemia

Electrolyte Disturbance
NHS Lothian

Think

1. Is the patient unwell?

  • ABCDE approach 

2. Is the result a true value?

  • Could the sampling method have affected the result (if red bottle filled before brown bottle EDTA contamination can affect result)?
  • Is there a previous level?
  • Is the level corrected for albumin?

3. Does the patient have any symptoms or signs?

  • May indicate the significance and rapidity of electrolyte change
  • Nausea and constipation, renal stones (+/- renal impairment), muscle weakness, cardiomyopathy, mood disturbance, confusion, coma, pancreatitis
  • ECG - short QT, arrhythmia

4. Are there culprit drugs? - consider stopping them

  • Excess vitamin D or vitamin A, lithium (don’t stop until discussed with psychiatry), theophylline, thiazide diuretics

5. Causes? - treat them

  • Malignancy, primary or tertiary hyperparathyroidism (check PTH, vitamin D, phosphate)
  • More unusual - rhabdomyolysis, thyrotoxicosis, immobilisation, sarcoid, adrenal insufficiency, milk-alkali syndrome, phaeochromocytoma, familial hypocalciuric hypercalcaemia (rarely severe)

 

Treat

Severe (Ca2+ ≥3.0 mmol/L)

  • IV 0.9% Saline – give 4-6 litres over 24 hours
  • Monitor for fluid overload especially if history of cardiac/renal impairment or elderly
  • Consider bisphosphonates (IV zolendronic acid 4 mg over 15 minutes) – this takes 2-4 days to take full effect and does not need to be given urgently
    • If giving bisphosphonates please withhold other nephrotoxic medications
    • If eGFR <30 use pamidronate instead, and discuss with pharmacy for dosing regime
  • Recheck Ca2+ level daily

Mild/Moderate (Ca2+ <3.0 mmol/L)

  • Treat the cause

 

Do I need to Escalate?

Seek senior advice if concerns and in particular if:

  • Ca2+ >3.5 mmol/L, ECG changes or reduced GCS
  • Contact renal if there is severe renal impairment – may need to consider dialysis
  • Contact endocrinology if PTH is not suppressed

Cardiac monitoring or HDU review?

  • Cardiac monitoring needed if Ca2+ >3.5 mmol/L or if ECG changes only if patient a candidate for escalation of care
  • Consider HDU review if Ca2+ >3.5 mmol/L, significant concern regarding fluid balance or reduced GCS