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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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☆
Desk Reference: Endocrinology (pp. 41–47). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199672837.003.0002
2.NewsonL(2020).Hyperthyroidism.Patient.Availableat:https://patient.info/doctor/hyperthyroidism
3.WassJAH,OwenK(eds)(2014).Thyroid.In:OxfordHandbookofEndocrinologyandDiabetes,3rd ed (pp. 1–105). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199644438.003.0001
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Chapter20
Hypocalcaemia
Guideline: Society for Endocrinology Endocrine Emergency Guidance
(Emergency management of acute hypocalcaemia in adult patients):
https://ec.bioscientifica.com/view/journals/ec/5/5/G7.xml
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Hypocalcaemiaisdefinedasanadjustedcalciumlevel<2.1mmol/L(ionized<0.9mmol/L). Hypocalcaemiaraisestherestingmembranepotentialofneurons,bringingthemcloserto thethresholdpotentialfordepolarizationwhichmayleadtospasm,tetany,orseizuresand canbelife-threatening.Thecommonestcauseofhypocalcaemiaisatotalthyroidectomy whichincludesremovaloftheparathyroidglands.
Mildhypocalcaemia:asymptomaticANDadjustedcalcium1.9–2.1mmol/L Severehypocalcaemia:symptomaticORadjustedcalcium<1.9mmol/L.
‘Adjusted’ or ‘corrected’ calcium has been modified to take into account albumin levels (albumin is one ofthe primarycalcium binding proteins). Only unbound ionized calcium is physiologicallyactiveandthereforeitisimportanttousetheadjustedfigure.Exactreference rangesvarybetweenlaboratories,checklocally.
Diagnosis
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History
Establish any past medical history which might indicate an underlying cause of hypocalcaemia.
Causes
Usuallyduetothefailure ofPTH secretion(inappropriatelylow PTH)oraninabilityto releasecalciumfrombone(elevatedPTH).
Hypoparathyroidism:
Surgical:
Postthyroidectomy(maybetemporary/permanent)
Postselectiveparathyroidectomy(usuallytransientandmild) Autoimmune Radiation Failureofdevelopmentoftheparathyroidglands Magnesiumdeficiency
Failureofcalciumreleasefrombone:
SeverevitaminDdeficiency(dietary,malabsorption,low ultravioletlightexposure,chronic renalfailure) Cytotoxicmedications(e.g.foscarnet,gadolinium) Renalfailure ResistancetoPTH(magnesiumdeficiency,pseudohypoparathyroidism)
Complexingofcalciumfromcirculation:
Pancreatitis Largetransfusions(transfusedcitrate‘chelates’calcium) Rhabdomyolysis
Multifactorial:
Sepsis Burns.
Symptoms
Symptomsaremoresevereiftherehasbeenanacutedropintheadjustedcalciumlevel.
Perioraland/ordigitalparaesthesia Laryngospasm(temporarilydifficulttospeakorbreatheduetospasmofvocalcords) Generalizedweakness.
Examination
Centralnervoussystem
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Trousseau’sandChvostek’ssigns(Box20.1) Tetany,cramps,carpopedalspasm Focalorgeneralizedseizures Alteredmentalstate.
Cardiovascularsystem
Arrhythmias(i.e.ventriculartachycardia) Reducedcardiacoutputleadingtohypotensionorheartfailure Bradycardia.
Box20.1Eponymousclinicalsignsinhypocalcaemia
Trousseau’ssign(moresensitive)
Inflate the blood pressure cuff to a level 10–20mmHg greater than the systolic blood pressure for 3 minutes. In hypocalcaemia this unmasks latent neuromuscular hyperexcitability,leadingtocarpalspasm.
Chvostek’ssign
Twitchingoffacialmusclesinresponsetotappingofthefacialnerve(i.e.anteriortothe tragus).
Investigations
Bedside
ECG—prolongedPRandQTintervals,arrhythmias(i.e.ventriculartachycardia).
Bloods
Adjustedcalcium Phosphateandmagnesium PTH U&E VitaminD.
Other
Amylase(ifsuspicionofpancreatitis) Creatinekinase(ifsuspicionofrhabdomyolysis).
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Management
Acutemanagement
Mildhypocalcaemia
Oralsupplements(e.g.Calvive®1000,twotabletsBD) Patientmaybedischargedwhencalciumlevel>2.1mmol/L
Ifthecalciumlevelremains1.9–2.1mmol/L,increasethedose(e.g.Calvive®1000,threetablets BD).
Severehypocalcaemia
This is a medical emergency—getsenior clinician help immediately. This patient may requirecriticalcareadmissionforcardiacmonitoring±inotropicsupport.
ExaminewithanABCDEapproach Give100%oxygenifsignificantlyreducedGCSscoreorpatientisseizing StartECGmonitoring IVcalciumgluconatebolus(Box20.2):
10–20mL10%calciumgluconatein50–100mL5%dextrose Giveover10minuteswithcardiacmonitoring Repeatuntilasymptomatic
FollowedbyIVcalciumgluconateinfusion:
100mL10%calciumgluconatein1L0.9%NaCl/5%dextrose Infuseat50–100mL/hour Titrateuntilcalciumlevelshavenormalized.
Box20.2Useofcalciumgluconate
Calciumgluconatecancausetransientbutdramatichypotensionandarrhythmias It can also cause local vasoconstriction or ischaemia—ideally administer via a central line, otherwiseintoalargeveinwithfast-runningIVfluids CalciuminfusionsshouldbeavoidedinsevereCKD(stage3-5)—seekadvicefromnephrology.
Treatmentafterstabilization
Treatthecause
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VitaminDdeficiency:
300,000unitsofcholecalciferolOR300,000unitsofergocalciferolsplitover6–10weeks
Hypomagnesaemia:
Reviewmedicationsthatmightcausehypomagnesaemia,e.g.omeprazole ReplaceIV,e.g.24mmolover24hours(as6gMgSO4in500mL0.9%NaCl/5%dextrose)
Monitorserummagnesium
Postthyroidectomy:
Recheckcalciumlevelsafter24hours If severe hypocalcaemia or continues to have mild hypocalcaemia after 72 hours—get specialistadvice:willrequiretreatmentwithalfacalcidolorcalcitriol.
Follow-up
If thepatientis startedonalfacalcidol orcalcitriol,recheck serum calcium at1week.Ifstable, recheckat1,3and6months. Thesepatientswilllikelyneedongoingoralcalciumsupplementationand should havespecialist follow-up.
Furtherreading
1. British Association of Endocrine and Thyroid Surgeons. Post thyroidectomy/parathyroidectomy guideline. Available at: https://www.baets.org.uk/wp-content/uploads/BAETS-Post-op-
Hypocalcaemia-Guidance.pdf
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Chapter21
Hypoglycaemia
Guideline: Joint British DiabetesSocieties for Inpatient Care (The hospital
managementof hypoglycaemiainadultswithdiabetesmellitus,5thedition):
https://abcd.care/sites/abcd.care/files/site_uploads/JBDS_Guidelines_Current/JBDS_01_HypoGuideline%20_March_2022.pdf
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Hypoglycaemiarefers toaCBGlevel<4.0mmol/L. Prolongedseverehypoglycaemiacan lead to permanentneurological deficitand death. Patients who have had diabetes for a long time, particularlythose with tight glycaemic control, are more likely to have poor hypoglycaemicawareness, increasingtheirrisk ofrecurrenthypoglycaemiaandasevere hypoglycaemicepisode.
Diagnosis
History
Box21.1listspatientsathigherriskofhypoglycaemia.
Box21.1Whichpatientgroupsareatriskofhypoglycaemia?
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Type1diabetics Type2diabeticsoninsulintreatment Long-termdiabetics Thosewithpoorglycaemicawareness Elderlypeople Thosewithrenalimpairment(duetoreducedclearanceofinsulin) Thosewithhepaticimpairment(duetoreducedglycogenstores).
Source:datafromTheHospitalManagementofHypoglycaemiainAdultswithDiabetesMellitus. March2022.JBDS-IP04.
Causes
Incorrecttype/time/doseofinsulinororalhypoglycaemicagente.g.gliclazide Missed/delayedmeals,vomitingorprolongedstarvation(‘nilbymouth’) Sepsis Alcoholexcess Liverfailure Cortisolinsufficiencyorabruptcessationoflong-termsteroidtherapy.
Symptoms
Autonomic(sweating,shaking,palpitationsandhunger) Neuroglycopenic (confusion, drowsiness, behavioural disturbance, speech difficulties, incoordination,seizures,andcoma).
Examination
Table21.1listspossibleABCDEexaminationfindingsinhypoglycaemicpatients.
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Table21.1Potentialexaminationfindingsinapatientwithhypoglycaemia
C
Tachycardia
D
↓GCSscore
E
Confusion Aggressiveoralteredbehaviour Speechdifficulty Incoordination Sweating Shaking Seizure
Source:datafromTheHospitalManagementofHypoglycaemiainAdultswithDiabetesMellitus.March
2022.JBDS-IP04.
Itisvitaltoconsiderhypoglycaemiainanypatientwhopresentswith↓levelofconsciousness, withalteredbehaviourorwhoappearsintoxicated.
Investigations
CBG Consider the likely cause and investigateappropriately depending on the differential diagnosis, e.g. insulin and C-peptide levels (paired with glucose), urinary sulphonylurea levels, septic screen,9amcortisollevel ConsideraCTheadinthosewhohaveprolonged↓GCSscoretoexcludealternativepathology.
Acutemanagement
Initiate treatment without delay and escalate to a senior clinician if treatment fails in order to considerescalationtointensivecare Inallcases,stopanycausalfactor,e.g.IVinsulininfusionorSCinsulinpump
Mildhypoglycaemia(episodethatcanbeself-treated)
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Give quick acting carbohydrate (15–20g), e.g. 4–5 Glucotabs®/150–200mL fruit juice. Repeat CBGafter10–15minutestoensureimprovement/resolution Giveadditionalshort-actingcarbohydratesifCBGremains<4.0mmol/L IfCBGremains<4.0mmol/Lafterthreetreatmentcycles,escalatemanagementtostep3onsevere hypoglycaemiaprotocol.
Forthosewithsevererenalimpairment,fruitjuicesshouldbeavoidedduetotheirpotassium concentration
Severehypoglycaemia(episodethatrequiresthird-partyassistancetotreat)
If confusedbutconsciousandabletoswallow,2 tubes ofglucosegelcanbe squeezedbetween teethandgums RepeatCBGin10–15minutestoensureimprovement/resolutionandrepeatstep1uptotwotimes ifCBG<4.0mmol/L IfCBGstill<4.0mmol/Lorthepatient’sswallowisunsafe,(e.g.seizingorunconscious)giveIV glucoseover15minutes(200mLof10%or100mLof20%)throughalarge-borecannula RepeatCBGin10minutes.RepeatIVglucoseinfusionif<4.0mmol/L.
Where IV access is not available, 1mg IM glucagon can be administered once only. IM glucagonmaybelesseffectiveinthosewithlowglycogenstores(hepaticimpairment/chronic malnourishment)andslowertoworkthanIVglucose.
IVglucoseisrecommendedtobeprescribed‘asrequired’(PRN)foralldiabeticinpatients
foruseincaseofemergency.
Treatmentafterstabilization
When the CBG is ≥4.0mmol/L, give a long-acting carbohydrate, e.g. one slice of toast or two biscuits Donotomitregularlong-actinginsulin,butthedosemayneedadjustment MonitorCBGregularlyfor24–48hourstoestablishatrendandconsiderregimenalteration Ifnilbymouth,starta10%glucoseinfusion,atarateof100mL/houruntileatingnormallyagain Considerdiabeticspecialistreview Askaboutfrequency,severity,andawarenessofhypoglycaemia.
Concurrent use of the following medications with antidiabetic agents can precipitate hypoglycaemic episodes: warfarin, quinine, salicylates, monoamine oxidase inhibitors, sulphonamidesincludingco-trimoxazole,andNSAIDS.
If the hypoglycaemic episode was due to long-acting insulin or sulphonylurea therapy,
hypoglycaemiamayrecurduringthefollowing24–36hours.
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