Adult Medical Emergency Handbook - Scottish Intensive Care Society

Fluid
• Urgent fluid replacement with 0.9% saline (add potassium chloride
as required) will lower calcium, and enhance renal clearance.
• Check U&E’s and calcium twice daily.
Diuretics
• Loop diuretics (e.g. furosemide 40mg IV bd) will enhance calcium
loss in the urine. DO NOT start until fluid deficits rectified.
• NEVER use thiazides as they cause calcium retention.
Bisphosphonates
• Ensure fluid deficit corrected first.
• A single infusion of pamidronate (see table) will lower calcium
levels within 2 to 4 days (but not acutely).
• Maximal effect is at about 1 week.
• Recurrent hypercalcaemia may be treated with repeated IV
infusions of pamidronate.
• In cancer-related refractory hypercalcaemia, zoledronate may be
given once salt and water deficits have been replenished. Please
discuss with haematology/ oncology.
Other
• If patient is on digoxin, discontinue.
• Steroids should not be used routinely. May be helpful in sarcoidosis,
myeloma and hypervitaminosis-D (prednisolone 60-80mg oral daily).
PAMIDRONATE DOSE TABLE
Serum calcium (mmol/L) Dose of pamidronate
4.0 90mg
If creatinine clearance >30ml/min infuse at rates up to 60mg/hr. If
creatinine clearance