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October 10, 1986, Vol 256, No. 14 >
ARTICLE | October 10, 1986

Hypocalcemia in Critical Illness FREE

Gary Paul Zaloga, MD; Bart Chernow, MD
[+] Author Affiliations

The opinions expressed herein are the private views of the authors and are not to be construed as reflecting the views of the Navy Department, the Naval Service at large, or the Department of Defense.

Reprint requests to the Department of Anesthesiology, Massachusetts General Hospital, Boston, MA 02114 (Dr Chernow).


JAMA. 1986;256(14):1924-1929. doi:10.1001/jama.1986.03380140094029
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Article
References

CALCIUM is an essential ion required for many biologic processes, including neuronal conduction, synaptic transmission, hormone secretion, mitotic division, cardiac automaticity, and excitation-contraction coupling in muscle. Calcium is also a major intracellular messenger, is needed for cellular processes that require movement, and is required by many enzymes for full activity. Deficiency of circulating concentrations of this important ion are common in patients with critical illness.

Physiologic Regulation of the Serum Calcium Concentration  The serum calcium concentration is maintained within normal limits by the combined effects of parathyroid hormone (PTH) and vitamin D. Dietary calcium is not required, since these hormones can maintain the serum calcium level via their skeletal effects. A deficiency in either hormone, however, may lead to hypocalcemia. Deficiency in PTH may result from parathyroid gland damage, as may occur after neck surgery, or from parathyroid gland suppression. The parathyroid glands may be suppressed by hypercalcemia, hypomagnesemia, or

REFERENCES

1 +
Zaloga GP, Chernow B:  Calcium metabolism . Clin Crit Care Med 1985;;5:169-204.
2 +
Zaloga GP, Chernow B, Cook D, et al:  Assessment of calcium homeostasis in the critically ill patient: The diagnostic pitfalls of the Mclean Hastings nomogram . Ann Surg 1985;;202:587-594.
3 +
Zaloga GP, Chernow B:  Free fatty acids increase calcium binding to albumin in serum from critically ill patients . Clin Res 1985;;33:296A
4 +
Aguanno JJ, Ladenson JH:  Influence of fatty acids on the binding of calcium to human albumin . J Biol Chem 1982;;257:8745-8748.
5 +
Ladenson JH, Shyong JC:  Influence of fatty acids on the binding of calcium to human serum albumin . Clin Chim Acta 1977;;75:293-302.
6 +
Chopra IJ, Chua Teco GN, Mead JF, et al:  Relationship between serum free fatty acids and thyroid hormone binding inhibitor in nonthyroidal illnesses . J Clin Endocrinol Metab 1985;;60:980-984.
7 +
Ladenson JH, McDonald JM, Bruns DE, et al:  Acute pancreatitis, hyperlipemia and normal amylase . Clin Chem 1978;;24:815-820.
8 +
Howland WS, Schweizer O, Jascott D, et al:  Factors influencing the ionization of calcium during major surgical procedures . Surg Gynecol Obstet 1976;;143:895-900.
9 +
Kahn RC, Jascott D, Carlon GC, et al:  Massive blood replacement: Correlation of ionized calcium, citrate, and hydrogen ion concentration . Anesth Analg 1979;;58:274-278.
10 +
Denlinger JK, Nahrwold ML, Gibbs PS, et al:  Hypocalcemia during rapid blood transfusion in anaesthetized man . Br J Anaesth 1976;;48:995-999.
11 +
Howland WS, Schweizer 0, Carlon GC, et al:  Cardiovascular effects of low levels of ionized calcium during massive transfusion . Surg Gynecol Obstet 1977;;145:581-586.
12 +
Perkins HA, Synder M, Thacher C, et al:  Calcium ion activity during rapid exchange transfusion with citrated blood . Transfusion 1971;; 11:204-212.
13 +
Killen DA, Grogan EL, Gower RE, et al:  Effect of ACD blood prime on plasma calcium and magnesium . Ann Thorac Surg 1972;;13:371-380.
14 +
Stulz PM, Scheidegger D, Drop LJ, et al:  Ventricular pump performance during hypocalcemia: Clinical and experimental studies . J Thorac Cardiovasc Surg 1979;;76:185-194.
15 +
Cooper N, Brazier JR, Hottenrott C, et al:  Myocardial depression following citrated blood transfusion . Arch Surg 1973;;107:756-763.
16 +
Olinger GN, Hottenrott C, Mulder DG, et al:  Acute clinical hypocalcemic myocardial depression during rapid blood transfusion and postoperative hemodialysis . J Thorac Cardiovasc Surg 1976;; 72:503-511.
17 +
Chernow B, Rainey TG, Georges LP, et al:  Iatrogenic hyperphosphatemia: A metabolic consideration in critical care medicine . Crit Care Med 1981;;9:772-774.
18 +
Berger RE, Gomez LS, Mallette LE:  Acute hypocalcemic effects of clinical contrast media injections . Am J Radiol 1982;;138:283-288.
19 +
Caulfield JB, Zir L, Harthorne JW:  Blood calcium levels in the presence of arteriographic contrast material . Circulation 1975;;52:119-123.
20 +
Kutt H, Milhorat TH, McDowell F:  The effect of iodinized contrast media upon blood proteins, electrolytes and red cells . Neurology 1963;;13:492-499.
21 +
Thomson KR, Violante MR, Kenyon T, et al:  Reduction in ventricular fibrillation using calcium-enriched Renografin 76 . Invest Radiol 1978;; 13:238-240.
22 +
Tragardh B, Lynch PR, Vingiguerra T:  Cardiac function during coronary arteriography with calcium enriched diatrizoate and metrizamide . Invest Radiol 1976;;11:569-576.
23 +
Tragardh B, Bove AA, Lynch PR:  Mechanism of production of cardiac conduction abnormalities due to coronary arteriography in dogs . Invest Radiol 1976;;11:563-568.
24 +
Fuchs C, Brasche M, Donath-Wolfram U, et al:  Dialysate calcium and plasma calcium fractions during and after haemodialysis . Klin Wochenschr 1975;;53:39-42.
25 +
Maynard JC, Cruz C, Kleerekoper M, et al:  Blood pressure response to changes in serum ionized calcium during hemodialysis . Ann Intern Med 1986;;104:358-361.
26 +
Henrich WL, Hunt JM, Nixon JV:  Increased ionized calcium and left ventricular contractility during hemodialysis . N Engl J Med 1984;;310:19-23.
27 +
Ladenson JH, Lewis JW, Boyd JC:  Failure of total serum calcium corrected for protein, albumin, and pH to correctly assess free calcium status . J Clin Endocrinol Metab 1978;;46:986-993.
28 +
Chernow B, Zaloga GP, McFadden E, et al:  Hypocalcemia in critically ill patients . Crit Care Med 1982;;10:848-851.
29 +
Nagant De Deuxchaisnes C, Krane SM:  Hypoparathyroidism , in Avioli LV, Krane SM (eds): Metabolic Bone Disease . Orlando, Fla, Academic Press Inc, 1978;, vol 2, pp 217-445.
30 +
Broadus AE:  Mineral metabolism , in Felig P, Baxter JP, Broadus AE, et al (eds): Endocrinology and Metabolism. New York , McGraw-Hill International Book Co, 1981;, pp 963-1079.
31 +
Zaloga GP, Chernow B:  Stress-induced changes in calcium metabolism . Semin Respir Med 1985;;7:52-68.
32 +
Anast CS, Winnacker JL, Forte LR, et al:  Impaired release of parathyroid hormone in magnesium deficiency . J Clin Endocrinol Metab 1976;; 42:707-717.
33 +
Chernow B, Smith J, Rainey TG, et al:  Hypomagnesemia: Implications for the critical care specialist . Crit Care Med 1982;;10:193-196.
34 +
Cholst IN, Steinberg SF, Tropper PJ, et al:  The influence of hypermagnesemia on serum calcium and parathyroid hormone levels in human subjects . N Engl J Med 1984;;310:1221-1225.
35 +
Lee C, Zaloga GP:  Magnesium metabolism . Semin Respir Med 1985;;7:75-80.
36 +
Rude RK, Oldham SB, Singer FR:  Functional hypoparathyroidism and parathyroid hormone end-organ resistance in human magnesium deficiency . Clin Endocrinol 1976;;5:209-224.
37 +
Zaloga GP, Chernow B, Pock A, et al:  Hypomagnesemia is a common complication of aminoglycoside therapy . Surg Gynecol Obstet 1984;; 158:561-565.
38 +
Zaloga GP, Chernow B:  Pathogenic mechanisms for hypocalcemia during gram negative sepsis . Crit Care Med 1986;;14:405.
39 +
Jacobs ML, Daggett WM, Civetta JM, et al:  Acute pancreatitis: Analysis of factors influencing survival . Ann Surg 1977;;185:43-51.
40 +
Hauser CJ, Kamrath RO, Sparks J, et al:  Calcium homeostasis in patients with acute pancreatitis . Surgery 1983;;94:830-835.
41 +
Sibbald WJ, Sardesai V, Wilson RF:  Hypocalcemia and nephrogenous cyclic AMP production in critically ill or injured patients . J Trauma 1977;; 17:677-684.
42 +
Taylor B, Sibbald WJ, Edmonds MW, et al:  Ionized hypocalcemia in critically ill patients with sepsis . Can J Surg 1978;;21:429-433.
43 +
Robertson GM, Moore EW, Switz DM, et al:  Inadequate parathyroid response in acute pancreatitis . N Engl J Med 1976;;294:512-516.
44 +
Condon JR, Ives D, Knight MJ, et al:  The aetiology of hypocalcemia in acute pancreatitis . Br J Surg 1975;;62:115-118.
45 +
Haldimann B, Goldstein DA, Akmal M, et al:  Renal function and blood levels of divalent ions in acute pancreatitis . Mineral Electrolyte Metab 1980;; 3:190-199.
46 +
Michie W, Duncan T, Hamer-Hodges DW, et al:  Mechanism of hypocalcemia after thyroidectomy for thyrotoxicosis . Lancet 1971;;1:508.
47 +
Chesney RW, McCarron DM, Haddad JG, et al:  Pathogenic mechanisms of the hypocalcemia of the staphylococcal toxic shock syndrome . J Lab Clin Med 1983;;101:576-585.
48 +
Kita R, Witoszka MM, Hopkins RW, et al:  Bone marrow pressure and blood flow and resistance in experimental hemorrhagic shock . Am J Surg 1972;;123:380-384.
49 +
Ginsburg R, Esserman LJ, Bristow MR:  Myocardial performance and extracellular ionized calcium in a severely failing heart . Ann Intern Med 1983;;98:603-606.
50 +
Connor TB, Rosen BL, Bleaustein MP, et al:  Hypocalcemia precipitating congestive heart failure . N Engl J Med 1982;;307:869-872.
51 +
Chaimovitz C, Abinader E, Benderly A, et al:  Hypocalcemic hypotension . JAMA 1972;;222:86-87.
52 +
Chopra D, Janson P, Sawin CT:  Insensitivity to digoxin associated with hypocalcemia . N Engl J Med 1977;;296:917-918.
53 +
Johnson JD, Jennings R:  Hypocalcemia and cardiac arrhythmias . AJDC 1968;;115:373-376.
54 +
Drop LJ:  Ionized calcium, the heart and hemodynamic function . Anesth Analg 1985;;64:432-451.
55 +
Chernow B, Roth BL:  Pharmacologic manipulation of the peripheral vasculature in shock: Clinical and experimental approaches . Circ Shock 1986;;18:141-155.
56 +
Bristow MR, Ginsburg R, Minobe W, et al:  Decreased catecholamine sensitivity and β-adrenergic receptor density in failing human hearts . N Engl J Med 1982;;307:205-211.
57 +
Rumancik WM, Denlinger JK, Nanrwold ML, et al:  The QT interval and serum ionized calcium . JAMA 1978;;240:366-368.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Zaloga GP, Chernow B:  Calcium metabolism . Clin Crit Care Med 1985;;5:169-204.
2 +
Zaloga GP, Chernow B, Cook D, et al:  Assessment of calcium homeostasis in the critically ill patient: The diagnostic pitfalls of the Mclean Hastings nomogram . Ann Surg 1985;;202:587-594.
3 +
Zaloga GP, Chernow B:  Free fatty acids increase calcium binding to albumin in serum from critically ill patients . Clin Res 1985;;33:296A
4 +
Aguanno JJ, Ladenson JH:  Influence of fatty acids on the binding of calcium to human albumin . J Biol Chem 1982;;257:8745-8748.
5 +
Ladenson JH, Shyong JC:  Influence of fatty acids on the binding of calcium to human serum albumin . Clin Chim Acta 1977;;75:293-302.
6 +
Chopra IJ, Chua Teco GN, Mead JF, et al:  Relationship between serum free fatty acids and thyroid hormone binding inhibitor in nonthyroidal illnesses . J Clin Endocrinol Metab 1985;;60:980-984.
7 +
Ladenson JH, McDonald JM, Bruns DE, et al:  Acute pancreatitis, hyperlipemia and normal amylase . Clin Chem 1978;;24:815-820.
8 +
Howland WS, Schweizer O, Jascott D, et al:  Factors influencing the ionization of calcium during major surgical procedures . Surg Gynecol Obstet 1976;;143:895-900.
9 +
Kahn RC, Jascott D, Carlon GC, et al:  Massive blood replacement: Correlation of ionized calcium, citrate, and hydrogen ion concentration . Anesth Analg 1979;;58:274-278.
10 +
Denlinger JK, Nahrwold ML, Gibbs PS, et al:  Hypocalcemia during rapid blood transfusion in anaesthetized man . Br J Anaesth 1976;;48:995-999.
11 +
Howland WS, Schweizer 0, Carlon GC, et al:  Cardiovascular effects of low levels of ionized calcium during massive transfusion . Surg Gynecol Obstet 1977;;145:581-586.
12 +
Perkins HA, Synder M, Thacher C, et al:  Calcium ion activity during rapid exchange transfusion with citrated blood . Transfusion 1971;; 11:204-212.
13 +
Killen DA, Grogan EL, Gower RE, et al:  Effect of ACD blood prime on plasma calcium and magnesium . Ann Thorac Surg 1972;;13:371-380.
14 +
Stulz PM, Scheidegger D, Drop LJ, et al:  Ventricular pump performance during hypocalcemia: Clinical and experimental studies . J Thorac Cardiovasc Surg 1979;;76:185-194.
15 +
Cooper N, Brazier JR, Hottenrott C, et al:  Myocardial depression following citrated blood transfusion . Arch Surg 1973;;107:756-763.
16 +
Olinger GN, Hottenrott C, Mulder DG, et al:  Acute clinical hypocalcemic myocardial depression during rapid blood transfusion and postoperative hemodialysis . J Thorac Cardiovasc Surg 1976;; 72:503-511.
17 +
Chernow B, Rainey TG, Georges LP, et al:  Iatrogenic hyperphosphatemia: A metabolic consideration in critical care medicine . Crit Care Med 1981;;9:772-774.
18 +
Berger RE, Gomez LS, Mallette LE:  Acute hypocalcemic effects of clinical contrast media injections . Am J Radiol 1982;;138:283-288.
19 +
Caulfield JB, Zir L, Harthorne JW:  Blood calcium levels in the presence of arteriographic contrast material . Circulation 1975;;52:119-123.
20 +
Kutt H, Milhorat TH, McDowell F:  The effect of iodinized contrast media upon blood proteins, electrolytes and red cells . Neurology 1963;;13:492-499.
21 +
Thomson KR, Violante MR, Kenyon T, et al:  Reduction in ventricular fibrillation using calcium-enriched Renografin 76 . Invest Radiol 1978;; 13:238-240.
22 +
Tragardh B, Lynch PR, Vingiguerra T:  Cardiac function during coronary arteriography with calcium enriched diatrizoate and metrizamide . Invest Radiol 1976;;11:569-576.
23 +
Tragardh B, Bove AA, Lynch PR:  Mechanism of production of cardiac conduction abnormalities due to coronary arteriography in dogs . Invest Radiol 1976;;11:563-568.
24 +
Fuchs C, Brasche M, Donath-Wolfram U, et al:  Dialysate calcium and plasma calcium fractions during and after haemodialysis . Klin Wochenschr 1975;;53:39-42.
25 +
Maynard JC, Cruz C, Kleerekoper M, et al:  Blood pressure response to changes in serum ionized calcium during hemodialysis . Ann Intern Med 1986;;104:358-361.
26 +
Henrich WL, Hunt JM, Nixon JV:  Increased ionized calcium and left ventricular contractility during hemodialysis . N Engl J Med 1984;;310:19-23.
27 +
Ladenson JH, Lewis JW, Boyd JC:  Failure of total serum calcium corrected for protein, albumin, and pH to correctly assess free calcium status . J Clin Endocrinol Metab 1978;;46:986-993.
28 +
Chernow B, Zaloga GP, McFadden E, et al:  Hypocalcemia in critically ill patients . Crit Care Med 1982;;10:848-851.
29 +
Nagant De Deuxchaisnes C, Krane SM:  Hypoparathyroidism , in Avioli LV, Krane SM (eds): Metabolic Bone Disease . Orlando, Fla, Academic Press Inc, 1978;, vol 2, pp 217-445.
30 +
Broadus AE:  Mineral metabolism , in Felig P, Baxter JP, Broadus AE, et al (eds): Endocrinology and Metabolism. New York , McGraw-Hill International Book Co, 1981;, pp 963-1079.
31 +
Zaloga GP, Chernow B:  Stress-induced changes in calcium metabolism . Semin Respir Med 1985;;7:52-68.
32 +
Anast CS, Winnacker JL, Forte LR, et al:  Impaired release of parathyroid hormone in magnesium deficiency . J Clin Endocrinol Metab 1976;; 42:707-717.
33 +
Chernow B, Smith J, Rainey TG, et al:  Hypomagnesemia: Implications for the critical care specialist . Crit Care Med 1982;;10:193-196.
34 +
Cholst IN, Steinberg SF, Tropper PJ, et al:  The influence of hypermagnesemia on serum calcium and parathyroid hormone levels in human subjects . N Engl J Med 1984;;310:1221-1225.
35 +
Lee C, Zaloga GP:  Magnesium metabolism . Semin Respir Med 1985;;7:75-80.
36 +
Rude RK, Oldham SB, Singer FR:  Functional hypoparathyroidism and parathyroid hormone end-organ resistance in human magnesium deficiency . Clin Endocrinol 1976;;5:209-224.
37 +
Zaloga GP, Chernow B, Pock A, et al:  Hypomagnesemia is a common complication of aminoglycoside therapy . Surg Gynecol Obstet 1984;; 158:561-565.
38 +
Zaloga GP, Chernow B:  Pathogenic mechanisms for hypocalcemia during gram negative sepsis . Crit Care Med 1986;;14:405.
39 +
Jacobs ML, Daggett WM, Civetta JM, et al:  Acute pancreatitis: Analysis of factors influencing survival . Ann Surg 1977;;185:43-51.
40 +
Hauser CJ, Kamrath RO, Sparks J, et al:  Calcium homeostasis in patients with acute pancreatitis . Surgery 1983;;94:830-835.
41 +
Sibbald WJ, Sardesai V, Wilson RF:  Hypocalcemia and nephrogenous cyclic AMP production in critically ill or injured patients . J Trauma 1977;; 17:677-684.
42 +
Taylor B, Sibbald WJ, Edmonds MW, et al:  Ionized hypocalcemia in critically ill patients with sepsis . Can J Surg 1978;;21:429-433.
43 +
Robertson GM, Moore EW, Switz DM, et al:  Inadequate parathyroid response in acute pancreatitis . N Engl J Med 1976;;294:512-516.
44 +
Condon JR, Ives D, Knight MJ, et al:  The aetiology of hypocalcemia in acute pancreatitis . Br J Surg 1975;;62:115-118.
45 +
Haldimann B, Goldstein DA, Akmal M, et al:  Renal function and blood levels of divalent ions in acute pancreatitis . Mineral Electrolyte Metab 1980;; 3:190-199.
46 +
Michie W, Duncan T, Hamer-Hodges DW, et al:  Mechanism of hypocalcemia after thyroidectomy for thyrotoxicosis . Lancet 1971;;1:508.
47 +
Chesney RW, McCarron DM, Haddad JG, et al:  Pathogenic mechanisms of the hypocalcemia of the staphylococcal toxic shock syndrome . J Lab Clin Med 1983;;101:576-585.
48 +
Kita R, Witoszka MM, Hopkins RW, et al:  Bone marrow pressure and blood flow and resistance in experimental hemorrhagic shock . Am J Surg 1972;;123:380-384.
49 +
Ginsburg R, Esserman LJ, Bristow MR:  Myocardial performance and extracellular ionized calcium in a severely failing heart . Ann Intern Med 1983;;98:603-606.
50 +
Connor TB, Rosen BL, Bleaustein MP, et al:  Hypocalcemia precipitating congestive heart failure . N Engl J Med 1982;;307:869-872.
51 +
Chaimovitz C, Abinader E, Benderly A, et al:  Hypocalcemic hypotension . JAMA 1972;;222:86-87.
52 +
Chopra D, Janson P, Sawin CT:  Insensitivity to digoxin associated with hypocalcemia . N Engl J Med 1977;;296:917-918.
53 +
Johnson JD, Jennings R:  Hypocalcemia and cardiac arrhythmias . AJDC 1968;;115:373-376.
54 +
Drop LJ:  Ionized calcium, the heart and hemodynamic function . Anesth Analg 1985;;64:432-451.
55 +
Chernow B, Roth BL:  Pharmacologic manipulation of the peripheral vasculature in shock: Clinical and experimental approaches . Circ Shock 1986;;18:141-155.
56 +
Bristow MR, Ginsburg R, Minobe W, et al:  Decreased catecholamine sensitivity and β-adrenergic receptor density in failing human hearts . N Engl J Med 1982;;307:205-211.
57 +
Rumancik WM, Denlinger JK, Nanrwold ML, et al:  The QT interval and serum ionized calcium . JAMA 1978;;240:366-368.

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