Case Presentation

Muhammad Asim Rana

After a Long Working Day at 7:10pm

• You are sitting in your room and the bleep buzzes

• You answer the number which is from ER and simultaneously your cell starts ringing

• You keep ER physician on hold and answer the cell phone which is from Female Surgical Ward

• ER Physician needs you for a patient urgently as the GCS is low and they want to intubate.

• Surgical floor needs you as the MROC tells the patient is seizing constantly.

What to do?

• Team Leader is consulted with following…

• Why ER people need us for intubation?

• Can’t MROC control fits? He is a doctor as well

• They should call their seniors or anesthetist?– Team leader decides to send on ref ICU specialist

to ER and another from bed side to the surgical floor to attend both the calls simultaneously

Very Bad Senior !!!!

Case in ER

• A 66 yrs old woman is evaluated in ER because of decreased LOC.

• She presented 2 hrs ago…

• There is 2-month history of fatigue, anorexia, thirst, polydipsia, and polyuria.

• Squamous cell lung cancer was diagnosed 5 months ago; the patient absconded afterwards

• She takes no medications.

On physical examination

• Temperature ...37.5 °C

• BP 90/60 mm Hg

• HR is 118/min

• RR is 22/min

• BMI is 18.

• The patient appears cachectic & dry, and

• The remaining general physical examination findings are normal

Physical Exam cont’

• GCS… E2M5V1

• CVS… Normal

• Abdomen… NAD

• Chest… Decreased expansion on Rt side with decreased air entry, stony dull percussion note up to inferior angle of Rt scapula with bronchial breathing at the upper limit of dullness.

What is your impression?

• Rt sided pleural effusion• Pneumonia?• Septic Shock secondry to pneumonia• Confusion & sepsis due to UTI?• Brain mets…..

Any thing else?

• First set of labs arrived by this time….• Would you like to see?

Laboratory studies

• BUN 70 mg/dL (25.0 mmol/L)

• Calcium 13.5 mg/dL (3.38 mmol/L)

• Creatinine 2.9 mg/dL (256.4 µmol/L)

• ABGs pH 7.29, PaCO2 52, PO2 55, HCO3 18

• Na 148, K 4.9

• CBC.. Hb 6.8, WBCs 24, Plats 455

CXRs (5 months ago) (Today)

CT Brain Normal Study

What would you like to do?

Questions you need to answer as ICU specialist

• 1) Does the patient need intubation?

• 2) What is the reason of hypotension?

• 3)How would you manage this patient?

• 4) ICU or No ICU?

What is the main problem here?

Hypercalcemia

Management

• Aggressive volume replacement with intravenous normal saline is initiated.

• Will IV Saline return Calcium to normal levels?

• NO

• Then why saline?

• What is the reason of dehydration/hypovolumia?

• What Next?

• IV Furosemide !!

• Why?.... We are trying to Rx Dehydration Yes/No?

Management

What Else….

• Calcitonin….

• How it acts? What is dose?

• Plicamycin…

• Glucocorticoids..

• Bisphosphonates…

Management

• Which of the following drugs is likely to provide the most sustained benefit in decreasing this patient’s calcium level?

• A) Calcitonin• B) Cinacalcet• C) Prednisone• D) Zoledronate

• What is the fastest available treatment?Haemodialysis

Causes of Hypercalcemia

Causes of Hypercalcemia (ICU)

• Malignancy– Breast Cancer

– Multiple myeloma

– Non Hodgkins Lymphoma

– Lung Cancer (Sq cell Ca)

• Thiazide Diuretics

• Lithium

• Adrenal Insufficiency

• Immobilization

Discussion

• Malignancy is the most common cause of non-parathyroid hormone (PTH)–mediated hypercalcemia and the most frequent cause of hypercalcemia in hospitalized patients.

• Malignancy-associated hypercalcemia is differentiated into two forms:

– Local osteolytic hypercalcemia

– Humoral hypercalcemia of malignancy.

Did you forget the other specialist you sent to surgical floor?

Let’s see him

Case on the floor

• A 55-year-old woman is evaluated by ICU specialist in the surgical ward at 5:30 pm for constant seizures as per MROC 1st on call.

• She is a known case of type 2 DM, HTN, IHD.

• Treatment History

– Glucophage & Glibenclamide

– Amlodipine and Lisinopril

– Carbamazepine and Aspirin

Case on the floor cont’

• History of psychiatric illness for which she was taking some medication which she has left by herself and the name of drug is not available by that time and MRP has already asked for file from psychiatry out doors.

• History of hysterectomy 5 yrs ago.

Present Problem

• 6 hours ago, she had a large parathyroid adenoma removed.

• The operation lasted for 2 and a half hours.

• The recovery was uneventful and she was shifted to ward.

• Pre-Op vitals

• Temp.. 37, BP 145/90, HR 102/min,

Present Problem

• The operation was bloody, with massive bleeding and pt received 4 units of PRBCs during OR.

• The anesthetist notes do not describe any fall of BP during surgery.

• No CPR or cardiac arrhythmias recorded.

• Saturation recordings are steady, no hypoxia.

• Blood Sugar before OR was 145mg% and when checked by ICU was…..

• 166mg%

Laboratory studies (before OR)

• Albumin 4.2 g/dL (42 g/L)

• Calcium 6.0 mg/dL (1.5 mmol/L)

• Phosphorus 1.8 mg/dL (0.58 mmol/L)

• Parathyroid hormone 20 pg/mL (20 ng/L)

• CBC… Hb% 11, WBCs 6.4, Plats 240

• Sodium and Potassium Normal

Preoperative skeletal radiographs showed subperiosteal bone resorption of the distal phalanges, femoral and spinal

osteopenia, and osteoporosis in the radius.

Clinical Examination

• V/S.. T 38.3 C, BP 159/90, HR 110/min

• SpO2 on 2 liters per min O2 96%

• Conscious between episodes but not responding to verbal commands

• Developed sudden jerky movements of the body while the nurse was checking BP preceded by tonic spasm in the arm where BP was being checked

Present Problem Cont’

• The movements were repeated and involved the face of the patient.

• The patient remained conscious during the jerks which subsided by them self while the nurse ran for the Diazepam injection advised by ICU.

• Other systemic exam was unremarkable

How you will handle this patient?

• 1) ETT as she is having repeated seizures?• 2) Lorazepam, Diazepam IV• 3) Phenobarbitone IV• 4) IV Dextrose• 5) ICU or No ICU?

SENIOR SHOULD BE CALLED…What he is doing?

What is the main problem here?

Acute Hypocalcemia

• Which of the following is the most likely diagnosis?

• A) Hungry bone syndrome

• B) Osteomalacia

• C) Permanent hypoparathyroidism

• D) Vitamin D deficiency

Discussion

• Hungry bone syndrome

• The associated hypoparathyroidism is usually transient

• Treatment with calcium and a short-acting vitamin D metabolite may be required until the bones heal.

• Both osteomalacia and vitamin D deficiency cause secondary hyperparathyroidism with elevated PTH levels. This patient’s normal serum PTH level argues against these diagnoses.

Intravenous Calcium ReplacementSolution Elemental Calcium Unit Volume Osmolarity

10% Calcium Chloride

27 mg/ml 1.36mEq/ml

10 ml ampule 2000mOsm/L

10% Calcium Gluconate

9 mg/ml 0.46 mEq/ml

10 ml amplule 680 mOsm/L

IV Ca should be given in CVL, if N/A; use Ca-gluconateGive a bolus dose 200 mg elemental Calcium (8ml of10% Ca-Chloride OR 22 ml of 10% Ca-gluconate)Follow with continuous infusion of 1-2 mg elemental Calcium per Kg per hr for 6-12 hrs

Causes of Hypocalcemia

• Alkalosis

• Blood Transfusions

• Fat embolism

• Mg Depletion

• Pancreatitis

• Renal Insufficiency

• Sepsis

• Aminoglycosides

• Cimitedine

• Heparin

• Theophylline

• Vit D deficiency

Hypoparathyroidism

Thank you very much