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Hypocalcemia :glass_of_milk: (:glass_of_milk: Treatment (:ear_of_rice:For…
Hypocalcemia
:glass_of_milk:
:earth_americas:Scope
Calcium & Vit. D metabolism
Hypocalcemia Def.
Treatment
Case demonstration
:glass_of_milk:
Calcium & Vit.D metabolism
:glass_of_milk:
Ca
more than 90% in bone
Total calcium in serum
Bind with albumin
Ionized Ca (active form)
:soccer:Calcium
homeostasis
directed by
Parathyroid hormone
Vitamin D
Calcitonin
:meat_on_bone:
Calcium requirement
(between 500 - 3000 mg; :shallow_pan_of_food: avg 1000-1200 mg/day)
Kids 1000 mg/day
Adolescent 1200 mg/day
Adult 1000 mg/day
Pregnancy 1500 mg/day
Breastfeeding 2000 mg/day
:small_red_triangle:
Factors affected serum calcium
Albumin
-- it binds to Ca
'Corrected total Ca = measured Ca + 0.8[4 - Serum albumin (mg/dL)]
:arrow_up: ECF concentration of
Anions
(phosphate, citrate, bicarbonate) ➯ chelating Ca ➯ :arrow_down: ionized Ca2+
Alkalosis
(pH) ➯ :arrow_up:affinity of albumin for Ca ➯ :arrow_down: ionized Ca2+
Increase in pH 0.1 ➯ Decrease Ionized Ca2+ 0.2 mg/dL
Ionized Ca2+
-- usu. 50% of total Ca
Measurement of this
required
for Accurate assessment in
Abnormal circulating proteins
Acid-base disorders
Elyte disorders
Preterm infant
:rainbow:
Definition
Serum total Ca < 8 mg/dL
or
Ionized Ca2+ < 4 mg/dL
Infant - 3 months: serum total Ca < 8.8 mg/dL
or
Serum ionized Ca2+ < 4.9 mg/dL
Neonate: serum total Ca < 7.5 mg/dL
or
Serum ionized Ca2+ < 2.5 mg/dL
*at a normal plasma protein level around 7 - 7.5 mg/dL may seen Hypocalcemia symptoms
:candy:
Signs & Symptoms
:alarm_clock:
Neonatal
period
Jitteriness
Convulsion
Apnea
Myocardial dysfunc.
:alarm_clock:
Childhood & adolescence
Tetany (paresthesia, cramps), Hyperreflexia
Stridor fr Laryngospasm
Chovstek's sign, Trousseau's sign
GI: Abdominal cramping, Persistent diarrhea
Seizures
Papilledema & Psuedotumor cerebri
Extrapyramidal signs due to Basal ganglion calcification, Soft tissue calcification (in hypoPTH)
Pyschiatric disorders (*must R/O organic cause first)
Dermal & dental changes (dry skin, brittle nails, coarse hair)
Cataracts
Cardiovascular problems
Prolonged QT interval
Refractory CHF
Hypotension
:birthday:
Cause
of hypocalcemia
Early
neonatal hypocalcemia :star: - mostly Transient cause
(age < 72 hr)
:mother_christmas::skin-tone-3:
Maternal
cause
DM
PIH (pregnancy-induced HT)
Hyperparathyroidism
:baby::skin-tone-3:
Neonatal
cause
LBW (prematurity, IUGR)
Asphyxia
Respiratory distress
Sepsis
HypoMg
Hyperbilirubinemia/Phototherapy
Administration of Citrated blood products/Alkali
Late
neonatal hypocalcemia
(age > 72 hr)
HypoPTH
DiGeorge syndrome (velocardiofacial syndrome)
PseudohypoPTH
Ingestion of high PO4 milk
HypoMg
Vit.D def
Acute/Chronic renal insufficiency
Childhood & Adolescence
hypocalcemia
HypoPTH
Congenital: DiGeorge syndrome
Acquired
Idiopathic
Resistance to PTH
Vitamin D def & Disorder of Vitamin D metabolism
Others
Ca def:
nutritional deprivation
hypercalciuria
HypoMg
HyperPO4
Renal failure
PO4 administration
Tumor cell lysis
Rhabdomyolysis
Drugs
Furosemide
Calcitonin
Antineoplastic agents
Hungry bone syndrome
Critical illness
:books:
Hx taking
Complete Hx taking
Diet: Type of milk? Each time how many cc given?
FxHx of hypoCa or Rickets
Current medication
U/D: Heart disease, Hearing problem
:mailbox:
PE
Complete PE
Chovstek's sign
Hyperreflexia
Tooth, nail, bone
Eye: cataract
CVS
Syndromic feature
:male-scientist::skin-tone-4:
Inx
:small_red_triangle:
Others
X-ray for Soft tissue calcification
EKG
: Prolonged QT interval
CT scan for Calcified basal ganglion
Hand/wrist radiograph
- ดู bone age
Renal U/S
to look for Neprocalcinosis or CRF (จะเห็นไตเหี่ยว)
:small_red_triangle:
Blood
Total Ca, Ionized Ca, PO4
ALP
Elyte, BUN, Cr
PTH, Mg
Vit D (25-hydroxyvitamin D and 1,25-dihydroxyvitamin D)
Tube serum 2 - 5 mL เผื่ออยากส่ง genetic testing
:small_red_triangle:
Urine
Ca, PO4, Cr
pH
Protein, Glucose
:red_flag:
Diseases
:dango:
DiGeorge
syndrome
:tada:
"CATCH 22"
C - Cardiac
Aortic arch anomalies
Conotruncal
TOF
Truncus arteriosus
Interrupted aorta (
type B only
)
Tricuspid atresia
A - Abnormal facies
Hypertelorism
Ear anomalies
Short down slanting palpebral fissures (Anti-mongoloid)
Short philtrum
*แยกจาก Down's syndrome - มัน upslanting and mongoloid features
T - Thymic hypoplasia
:
Cellular immune deficiency
Abnormal no. of T cells
Abnormal func of T cells
C - Cleft palate
or High arch palate
H - HypoPTH
with
HypoCa
22 - 22 chromosome defect
deletion 22q11 (
dx by FISH :fish:
)
:dango:
Albright hereditary osteodystrophy
Congenital defect: Inactivating mutation of GNAS1 gene
:leaves:
S&S
Short, stocky build
Round face
Mental disability
Short/Absent of metacarpal/metatarsal bones
Target organ unresponsiveness to PTH
:male-scientist::skin-tone-4:
Labs
:arrow_down: Ca
:arrow_up: P
:arrow_up::arrow_up::arrow_up:PTH
:dango:
Rickets
Growing bone (in adult called Osteomalacia instead)
Undermineralization
of bone matrix
must Ddx with Osteogenesis Imperfecta (OI)
Collagen defect
เพราะเสาเข็มไม่แข็งแรง ➯ so CC: Fx of bone
เสาเข็มแข็งแรงดี + แต่ปูน cement ไม่ดี ➯ แตกร้าว แต่ไม่หัก* ➯ so CC: Bone deformity
:birthday:
Causes
Calcipenic rickets
Ca def
Vit.D def
Abnormal in vitamin D metabolism
Hypophosphatemic rickets
Renal tubular loss
Inadequate PO4 intake
:leaves:
PE
Genu varus, genu valgus
Widening of wrist joint
Rachitic rosary
:film_frames:
Labs
Fraying
Flaring
Cupping
:glass_of_milk:
Treatment
:pill:
Forms
of Ca supplement
Oral :grapes:
Intravenous :grapes:
:ear_of_rice:For Symptomatic hypocalcemia
Seizure, Tetany, Laryngospasm, Bronchospasm
10% Calcium gluconate 1-2 mL/kg (not exceed 2 mL/kg) IV drip
in 10 - 30 min (max rate 1 mL/min)
Maximum of 3 g of Calcium gluconate per dose (3 amp)
Monitor EKG & give until symptoms are improved
Avoid to drip with PO4, Bicarbonate
Central catheter should be used
:ear_of_rice:For Restore & maintain Eucalcemic state
IV (ถ้ากินไม่ได้)
10% Calcium gluconate 10 mL + 5% DNSS 100 mL IV continuous drip or divided to 3 - 4 doses/day
Maximum total daily dose = 15 g of Calcium gluconate per dose (15 amp)
Intermittent infusion conc. max conc. 50 mg/mL
Continuous infusion conc 1-3 mg/kg/hr
Infant: 20 - 80 mg of elemental Ca/kg/day
Children 20 - 50 mg of elemental Ca/kg/day
Oral Calcium supplement (ถ้ากินได้ให้แบบ oral)
Newborn: 75-100 mg of elemental Calcium/kg/day
Children: 30-75 mg of elemental Ca/kg/day
:ear_of_rice:For Chronic hypocalcemia
Keep total Ca 7.6-8.4 mg/dL (Low normal lvl to prevent Hypercalciuria)
:ear_of_rice:For Hypoparathyroidism
1,25-alpha vitamin D3 (Calcitriol) 20-60 ng/kg/day
1-alpha vitamin D3 [1/2 - 2/3 potency of calcitriol]
:ear_of_rice:For Hypomagnesemia
impaired PTH secretion & resistance to PTH
25-50 mg of Magnesium/kg/dose IV or IM q 4-6 hr
Newborn: 10-20 mg of Magnesium/kg/day
Pediatrics vitamin D status (25(OH)D level) :grapes:
Vitamin D treatment and supplement :grapes:
:rice_ball: Rec. in giving in
Premie (Preterm), Dark-skinned 800 IU/day (PES)
Obesity, Malabsorption, Antiepileptic drugs(AED), or Ketoconazole: :arrow_up: 2-3 times of requirement
Chronic ds: :arrow_up: requirement
:glass_of_milk:
Cases
Check it out in Slides ka