Nutrition Support Pharmacist features issues pertinent to the practice of clinical pharmacy in the area of nutritional support. The column is edited by Dr. Roland Dickerson, Professor of Pharmacy, University of Tennessee Health Science Center; Memphis, TN. Address correspondence to Dr. Roland N. Dickerson, University of Tennessee Health Science Center, 26 South Dunlap St., Memphis, TN 38163.
This article provides a summary of our approach to the management of acute hypocalcemia in critically ill patients receiving specialized nutrition support. It must be pointed out that there are other alternative effective approaches to managing this complication. Additionally, there are exceptions to the outlined treatment guidelines that the astute clinical must be able to identify. However, this approach will provide a sound foundation upon which to build your practice in the management of these difficult patients.
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References
1.
DickersonRN, AlexanderKH, MinardG, CroceMA, BrownRD.Accuracy of methods to estimate ionized and “corrected” serum calcium concentrations in critically ill multiple trauma patients receiving specialized nutrition support. JPEN J Parenter Enteral Nutr.2004;28:133–134.
2.
ZalogaGP, ChernowB, CookD, SnyderR, ClapperM, O'BrianJT.Assessment of calcium homeostasis in the critically ill surgical patient. The diagnostic pitfalls of the McLean-Hastings nomogram. Ann Surg.1985;202:587–594.
3.
ZivinJR, GooleyT, ZagerRA, RyanMJ.Hypocalcemia: a pervasive metabolic abnormality in the critically ill. Am J Kidney Dis.2001;37:689–698.
4.
VivienB, LangeronO, MorellE, et al. Early hypocalcemia in severe trauma. Crit Care Med.2005;33:1946–1952.
5.
OrrellDH.Albumin as an aid to the interpretation of serum calcium. Clin Chim Acta.1971;35:483–489.
6.
EndresDB, RudeRK.Mineral and bone metabolism. In: BurtisCA, AshwoodER, eds. Tietz Textbook of Clinical Chemistry.Philadelphia, PA: W. B. Saunders Company; 1999:1395–1406.
7.
LindL, CarlstedtF, RastadJ, et al. Hypocalcemia and parathyroid hormone secretion in critically ill patients. Crit Care Med.2000;28:93–99.
8.
ZalogaGP, ChernowB.The multifactorial basis for hypocalcemia during sepsis. Studies of the parathyroid hormone-vitamin D axis. Ann Intern Med.1987; 107:36–41.
9.
LinkoK, SaxelinI.Electrolyte and acid-base disturbances caused by blood transfusions. Acta Anaesthesiol Scand.1986;30:139–144.
10.
WilsonRF, BinkleyLE, SaboFMJr., et al. Electrolyte and acid-base changes with massive blood transfusions. Am Surg.1992;58:535–544.
11.
RansonJH, RifkindKM, RosesDF, FinkSD, EngK, SpencerFC.Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet.1974;139:69–81.
12.
McMahonMJ, WoodheadJS, HaywardRD.The nature of hypocalcaemia in acute pancreatitis. Br J Surg.1978; 65:216–218.
13.
DickersonRN, BrownRO.Hypomagnesemia in hospitalized patients receiving nutritional support. Heart Lung.1985;14:561–569.
14.
SuhSM, TashjianAHJr., MatsuoN, ParkinsonDK, FraserD.Pathogenesis of hypocalcemia in primary hypomagnesemia: normal end-organ responsiveness to parathyroid hormone, impaired parathyroid gland function. J Clin Invest.1973;52:153–160.
15.
VelentzasC, MeindokH, OreopoulosDG, et al. Visceral calcification and the CaXP product. Adv Exp Med Biol.1978;103:195–201.
16.
KleinCJ, Moser-VeillonPB, SchweitzerA, et al. Magnesium, calcium, zinc, and nitrogen loss in trauma patients during continuous renal replacement therapy. JPEN J Parenter Enteral Nutr.2002;26:77–92.
17.
WangS, McDonnellEH, SedorFA, ToffalettiJG.pH effects on measurements of ionized calcium and ionized magnesium in blood. Arch Pathol Lab Med.2002;126:947–950.
18.
FalkoJM, BushCA, TzagournisM, ThomasFB.Case report. Congestive heart failure complicating the hungry bone syndrome. Am J Med Sci.1976;271:85–90.
AlegreM, VincentJL.Dopamine dependence in hypocalcemic patients. Intensive Care Med.1990;16:463–465.
21.
GinsburgR, EssermanLJ, BristowMR.Myocardial performance and extracellular ionized calcium in a severely failing human heart. Ann Intern Med.1983;98:603–606.
22.
ChopraD, JansonP, SawinCT.Insensitivity to digoxin associated with hypocalcemia. N Engl J Med.1977;296:917–918.
23.
LangRM, FellnerSK, NeumannA, BushinskyDA, BorowKM.Left ventricular contractility varies directly with blood ionized calcium. Ann Intern Med.1988;108:524–529.
24.
VincentJL, BredasP, JankowskiS, KahnRJ.Correction of hypocalcaemia in the critically ill: what is the haemodynamic benefit?Intensive Care Med.1995;21:838–841.
25.
PorterDL, LedgerwoodAM, LucasCE, HarriganCM.Effect of calcium infusion on heart function. Am Surg.1983;49:369–372.
26.
EryolNK, ColakR, OzdogruI, et al. Effects of calcium treatment on QT interval and QT dispersion in hypocalcemia. Am J Cardiol.2003;91:750–752.
27.
RecalcatiP, PoglianiE, PragaC.Hypocalcemia and bleeding disorders in a uremic patient. Atti Accad Med Lomb.1975;30:91–98.
28.
ShilsME.Magnesium. In: Shils ME OJA, ShikeM, RossAC, ed. Modern Nutrition in Health and Disease.Philadelphia, PA: Lippincott, Williams & Wilkins; 1999:169–192.
29.
DickersonRN.Guidelines for the intravenous management of hypophosphatemia, hypomagnesemia, hypokalemia, and hypocalcemia. Hosp Pharm.2001;36:1201–1208.
30.
DickersonRN, MorganLG, CauthenAD, et al. Treatment of acute hypocalcemia in critically ill multiple-trauma patients. JPEN J Parenter Enteral Nutr.2005;29:436–441.
31.
ZalogaGP, SagerA, BlackKW, PrielippR.Low dose calcium administration increases mortality during septic peritonitis in rats. Circ Shock.1992;37:226–229.
32.
CarlstedtF, ErikssonM, KiiskiR, LarssonA, LindL.Hypocalcemia during porcine endotoxemic shock: effects of calcium administration. Crit Care Med.2000;28:2909–2914.
33.
KovacsA, CourtoisMR, BarzilaiB, KarlIE, LudbrookPA, HotchkissRS.Reversal of hypocalcemia and decreased afterload in sepsis. Effect on myocardial systolic and diastolic function. Am J Respir Crit Care Med.1998;158:1990–1998.
34.
SteinhornDM, SweeneyMF, LaymanLK.Pharmacodynamic response to ionized calcium during acute sepsis. Crit Care Med.1990;18:851–857.
35.
DesaiTK, CarlsonRW, GehebMA.Hypocalcemia and hypophosphatemia in acutely ill patients. Crit Care Clin.1987;3:927–941.
36.
ZalogaGP.Hypocalcemic crisis. Crit Care Clin.1991;7:191–200.
37.
ReberPM, HeathH, 3rd. Hypocalcemic emergencies. Med Clin North Am.1995;79:93–106.
38.
BodyJJ, BouillonR.Emergencies of calcium homeostasis. Rev Endocr Metab Disord.2003;4:167–175.
