Hypercalcemia is when the blood has HIGH CALCIUM LEVELS, which can lead to deadly hypercalcemia complications. These complications can be severe and potentially LIFE-THREATENING if not identified and managed promptly.
As healthcare professionals who may have to care for patients with hypercalcemia, nurses need to be aware of the potential complications associated with this condition.
In this article, we will discuss levels of hypercalcemia, causes, treatment, complications, and monitoring parameters that nurses need to know about.
NORMAL CALCIUM LEVELS & HYPERCALCEMIA
Normal calcium levels can range from 8.5 – 10.5 mg/dL.
- Normal Levels: 8.5 – 10.5 mg/dL
- Mild Hypercalcemia: 10.5 – 12 mg/dL
- Moderate Hypercalcemia: 12 – 14 mg/dL
- Severe Hypercalcemia: > 14 mg/dL
- Ionized Hypercalcemia: > 5.4 mg/dL
CAUSES OF HYPERCALCEMIA:
There are multiple causes of hypercalcemia, including:
- PRIMARY HYPERPARATHYROIDISM
Primary hyperparathyroidism is the MOST COMMON CAUSE OF HYPERCALCEMIA, accounting for about 80% OF CASES. It occurs when the parathyroid glands produce too much parathyroid hormone (PTH), increasing calcium levels in the blood.The most common cause of this is a BENIGN TUMOR called a parathyroid adenoma, which develops in one of the parathyroid glands.
Other less common causes include parathyroid hyperplasia, parathyroid cancer, and inherited genetic disorders.
- MALIGNANCYSome types of cancer, such as MULTIPLE MYELOMA, lung cancer, breast cancer, and kidney cancer, can cause hypercalcemia by releasing substances that increase calcium levels in the blood.
- EXCESSIVE VITAMIN DTaking too much vitamin D supplements or having a disease that increases vitamin D levels in the body, such as SARCOIDOSIS, can lead to hypercalcemia.
- IMMOBILIZATIONProlonged immobilization, such as when a patient is bed-bound, can cause hypercalcemia by INCREASING BONE RESORPTION and calcium release.
- MEDICATIONSCertain medications can cause high calcium levels, including:
- Certain supplements in excess (Vitamin D, Calcium, Vitamin A)
- Thiazide diuretics
- Theophylline toxicity
- OTHER CONDITIONSOther generic and acquired positions can lead to hypercalcemia complications, including hyperthyroidism, acromegaly, pheochromocytoma, adrenal insufficiency, and TPN.
NURSING ASSESSMENT OF HYPERCALCEMIA
Hypercalcemia can cause a wide range of symptoms, most NON-SPECIFIC. The severity and type of symptoms depend on the calcium level in the blood, the underlying cause of hypercalcemia, and how quickly the levels change.
- Mild Hypercalcemia (10.5 – 12 mg/dL): Usually asymptomatic
- Moderate hypercalcemia (12 – 14 mg/dL): polyuria, polydipsia, anorexia, nausea, and constipation
- Severe Hypercalcemia (> 14 mg/dL): worsened above symptoms, ALTERED MENTAL STATUS, and even CARDIAC ARRHYTHMIAS.
Common symptoms of hypercalcemia include:
GI SIDE EFFECTS
Hypercalcemia can cause anorexia, constipation, nausea, and vomiting.
WEAKNESS AND FATIGUE
Patients with hypercalcemia often feel tired and weak, just like with many other electrolyte abnormalities.
High calcium levels lead to decreased concentration ability of the kidneys and subsequent urinary frequency/dehydration.
Chronic high calcium levels in the urine can lead to nephrolithiasis (kidney stones).
ALTERED MENTAL STATUS
Hypercalcemia can affect the central nervous system, leading to cognitive impairment and even CONFUSION, STUPOR, or COMA.
S/S OF ARRHYTHMIAS
Hypercalcemia can affect the heart’s electrical conductivity, leading to ARRHYTHMIAS, which may cause palpitations, chest pain, shortness of breath, dizziness, or syncope. This is generally not as common with hypercalcemia as with other electrolyte abnormalities.
Chronic hypercalcemia can lead to the deposition of calcium in heart valves, coronary arteries, and the heart muscle itself. This can also lead to hypertension and heart failure.
Bone pain can be a symptom of high calcium due to malignancy or primary hyperparathyroidism.
When performing a physical exam for a patient suspected of having hypercalcemia, the nurse should assess for the following:
- HR: May be irregular (indicating an arrhythmia)
- BP: May be increased
- General: May appear weak or fatigued
- Heart: May be irregular if arrhythmia present
- Lungs: Clear to auscultation
- Abdomen: May have abdominal tenderness
- Extremities: May have bone pain or tenderness, may have extremity weakness
TREATMENT FOR HYPERCALCEMIA
The treatment of hypercalcemia depends on the severity of the condition and the underlying cause.
- TREATING DEHYDRATION
- Decreasing bed rest
- Avoiding high-calcium diets
- Avoiding medications that increase calcium levels
- THIAZIDE DIURETICS
- Calcium supplements
- Vitamin D supplements
Patients who have moderate to severe hypercalcemia often are volume depleted. This helps to correct the hypovolemia and increase calcium excretion in the urine. NS OR LR GIVEN AT 200-300ML/HR and then adjusted to a urine output of 100-150ml/hr is recommended for 24-48 hours until the volume depletion is corrected.
What About Lasix?
Loop diuretics aren’t traditionally recommended, however, patients with heart or kidney failure may benefit/require loop diuretics in addition to fluid.
Calcitonin is a hormone that can lower calcium levels in the blood by decreasing bone resorption. This is usually RESERVED FOR SEVERE HYPERCALCEMIA with neurologic symptoms like decreased mental status. The recommended dose is 4 units/kg SQ or IM every 12 hours for 24-48 hours.
These medications can reduce bone resorption and lower calcium levels in the blood. Bisphosphonates are used for LONGER-TERM CONTROL OF HYPERCALCEMIA, especially when related to MALIGNANCY. If given IV for severe hypercalcemia in the hospital, Zalendronic acid is recommended 4mg IV over 15 minutes. This can be repeated in 7 days if needed.
Denosumab is a monoclonal antibody that is sometimes used if Bisphosphonates are not effective or not able to be used. There is a higher risk of hypocalcemia occurring with this medication, so it is avoided when possible.
This is primarily only given if the hypercalcemia is caused by lymphoma, sarcoidosis, or other granulomatous disease that increases calcitriol production and subsequently increases calcium absorption.
In severe cases, dialysis may be needed to remove excess calcium from the blood, ESPECIALLY IF THEY ALSO HAVE HEART FAILURE OR SEVERE RENAL FAILURE.
TREAT UNDERLYING CONDITIONS
Underlying conditions, such as cancer, may need to be treated to improve calcium levels.
MONITORING OF HYPERCALCEMIA COMPLICATIONS
As a nurse, it is essential to monitor patients with hypercalcemia closely to identify and manage any potential complications. The following parameters should be observed:
SERUM CALCIUM LEVELS
Serum calcium levels should be monitored regularly to assess treatment response and to identify potential complications such as hypocalcemia.
SERUM PTH LEVELS
Measuring parathyroid hormone helps determine the etiology of the high calcium levels. If PTH is elevated, this points to primary hyperparathyroidism. If it is low, it is likely not from hyperparathyroidism.
The nurse should monitor laboratory values such as serum calcium, magnesium, and phosphate levels and liver and kidney function tests to assess for complications and monitor treatment progress.
Possible hypercalcemia complications include arrhythmias, so continuous telemetry monitoring, as well as occasional 12-lead ECGs are indicated.
Patients with severe hypercalcemia that warrants significant calcium-reducing therapies should have a NEPHROLOGY CONSULT on board!
HYPERCALCEMIA AND CARDIAC ARRHYTHMIAS
Hypercalcemia can cause a variety of ECG changes, including:
- ST-Segment: ST ELEVATION can occur, especially in the INFERIOR LEADS (II, III, aVF), and can be shortened as well.
- QT interval: Shortened, which can increase the risk of arrhythmias like VTACH
- T-waves: Biphasic or widened
- Other: J waves (osborn waves), which are typically associated with hypothermia, but severe hypercalcemia can mimic this.
ARRHYTHMIAS ARE LESS COMMON with hypercalcemia than with other electrolyte abnormalities but still can cause them including:
- ATRIAL FIBRILLATION (AFIB): Hypercalcemia can cause AFib, a rapid and irregular heart rhythm caused by abnormal electrical activity in the atria.
- VENTRICULAR FIBRILLATION (VFIB): In rare cases, hypercalcemia can cause VFib, a potentially life-threatening arrhythmia that occurs when the ventricles quiver instead of contracting.
- VENTRICULAR TACHYCARDIA
- AV BLOCKS
These ECG changes are thought to be due to altered myocardial repolarization caused by hypercalcemia.
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