A 70-year-old male presented with a one-week history of increasing confusion. According to his wife his general health had been deteriorating for about three months. His appetite was reduced. He complained of abdominal discomfort and felt excessively thirsty. He had been a heavy smoker since the age of 16. On examination he had reduced skin turgor. The heart rate was 110 beats/min. Heart sounds were normal. The chest was clear. Abdominal examination revealed a palpable colon with hard faeces. Investigations are shown.
Hb 11 g/dl WCC 11 109/l Platelets 100 109/l Sodium 139 mmol/l Potassium 5 mmol/l Urea 20 mmol/l Creatinine 190 mol/l Calcium 3.2 mmol/l Phosphate 1.4 mmol/l Albumin 32 g/l
What is the immediate step in his management?
a. IV pamidronate.
b. IV furosemide.
c. IV saline (0.9%).
d. IV hydrocortisone.
e. IV calcitonin.
Answer:
The patient has symptomatic hypercalcaemia. In general patients with hypercalcaemia rarely exhibit symptoms if the serum calcium is below 3 mmol/l. Treatment of symptomatic hypercalcaemia has to be instituted before the underlying cause is identified (Table). The most important aspect of management is vigorous rehydration. Most patients are dehydrated owing to fluid loss from the kidneys resulting from nephrogenic diabetes insipidus. Fluid loss may also occur from the gastrointestinal tract owing to vomiting. The general recommendation is to treat with 4 litres of saline over 24 hours and review hydration status. Some guidelines recommend the concomitant use of furosemide, as this promotes hyper calcuria; however, in diuresis it may worsen dehydration and is best reserved for patients who exhibit fluid overload after rehydration.
All patients should receive intravenous bisphosphonates after rehydration. Most patients respond rapidly to bisphosphonate therapy. The drug can cause a bone pain, transient pyrexia, flu-like illness, rashes or iritis. Patients who do not respond to bisphosphonates may benefit from intramuscular calcitonin but the hormone is usually poorly tolerated owing to flushing, nausea and diarrhoea. Some cases of resistant hypercalcaemia respond to high-dose corticosteroid therapy. Following the acute treatment of hypercalcaemia the aim is to identify and treat the underlying cause.
c. IV saline (0.9%).
Management of symptomatic hypercalcaemia Step 1 Rehydration with intravenous saline Step 2 Intravenous bisophosphonate therapy Step 3 Identify and treat underlying cause if possible