Adult Medical Emergency Handbook - Scottish Intensive Care Society

Hypercalcaemia in Palliative Care
Introduction
HYPERCALCAEMIA IN PALLIATIVE CARE
• Hypercalcaemia is the commonest life-threatening metabolic disorder in cancer patients.
• Occurs most frequently in myeloma, and in breast, renal, lung and thyroid cancer.
• 20% of patients with hypercalcaemia do not have bone metastases.
• Common symptoms: malaise, thirst, nausea, constipation, polyuria, delirium.
• Treatment may not be appropriate in a dying patient at the end of life – seek advice.
• To reduce risk of renal toxicity from bisphosphonate treatment, consider withholding
medication that affects renal function (eg. NSAIDs, diuretics, ACE inhibitors).
Patient presents with symptoms suggestive of hypercalcaemia.
Check calcium + urea & electrolytes, eGFR, albumin
Corrected calcium ∗ Corrected calcium ∗ Corrected calcium
> 4.0mmol/L 2.6 - 4.0mmol/L normal ∗
Severe hypercalcaemia
can cause seizures Rehydrate with 1-3litres 0.9% NaCl IV Monitor calcium if
or arrhythmias - seek -check calcium, U & E next morning patient at risk of
consultant advice hypercalcaemia.
Calcium is still raised – treat with pamidronate IV (reduce dose in renal impairment)♦
Corrected calcium (mmol/L) Pamidronate dose Diluent & maximum infusion rate
2.6 – 3.0 30mg 500mls NaCl 0.9% over > 60 minutes
3.0 – 3.5 60mg 500mls NaCl 0.9% over > 60 minutes
3.5 – 4.0 90mg 500mls NaCl 0.9% over > 90 minutes
> 4.0 90mg 500mls NaCl 0.9% over > 90 minutes
If calcium >3.0mmol/l, some units routinely give pamidronate 90mg as a higher dose may
increase response and delay relapse.
Review treatment of Continue IV fluids until patient able
underlying cancer. to maintain oral hydration.
Calcium has Monitor renal function. Calcium normal
increased from
pre-treatment level
after rehydration Recheck calcium after 5 days.
and pamidronate. Maintain good hydration;
recheck calcium after 2-3
Seek advice; review Calcium has decreased from days. Do not repeat
diagnosis and pre-treatment level but is pamidronate until 7 days
treatment plan. still elevated. after first dose to avoid
causing hypocalcaemia.
♦ Pamidronate in renal impairment: seek advice
• GFR >20ml/min: give pamidronate over at least 90 minutes. ∗ Corrected calcium =
• GFR