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Immobilization Hypercalemia
- 1. Immobilization Hypercalcemia Andrew N. Antonio, OTS University of St. Augustine
- 2. Overview Definition Etiology and pathophysiology Characterize the condition as it relates SCI Prosed Management Case Review Questions
- 3. Hypercalcemia “Hypercalemia results when the accelerated bone resorption exceeds the capacity of the kidneys to filter calcium.” Massagli & Cardenas, 1999
- 4. Calcium Regulation and processes of body functions Regulation ◦ Parathyroid hormone (PTH) ◦ Vitamin D ◦ Calcitonin
- 5. Hypercalcemia Mild (Ca+ <12 mg/dl) Moderate (Ca+ between 12 and 14 mg/dl) Severe (Ca+ >14 mg/dl) Diagnosed via blood test
- 6. Etiology Main cause is hyperparathyroidism (>90%) ◦ Common in women over 50 y/o Malignancies may be associated (20%) Inherited kidney or metabolic conditions Excessive Vitamin D & A Aluminum intoxication Milk-Alkali Syndrome
- 7. Immobilization Hypercalcemia Acute spinal cord injury (10-23%) Often in male adolescents/ young adults Tetraplegia v. paraplegia Increase bone resorption Loss of trabecular bone volume Decreased osteoblastic bone formation Depressed parathyroid hormone
- 8. Immobilization Hypercalcemia cont. Develops within days to months of immobilization ~4 - 8 weeks after Last weeks to months Hypercalciuria ◦ Within 1st week up to 6-18 months
- 9. Signs and Symptoms Fatigue Constipation Anorexia Nausea Alteration in mood Vomiting Lethargy Polydipsia Polyuria Intravascular volume depletion Hypertension Arrythmias
- 10. Treatment Goal: ◦ Decrease serum Ca+ concentration ◦ Underlying disease Hydration Loop Diuretics (i.e. furosemide) Biphosphonates Antineoplastic Drugs Antidote, hypercalcemia agents Glucocorticoids Minerals Calcimimetic Agent Surgical treatment Massagli & Cardenas, 1999
- 11. Zoledronic Acid Biphosphonate Ca+ Regulator Reduces risk for Fx Once-yearly injection 100-850 times more potent than Pamidronate Paget’s disease, osteoporosis Side effects ◦ Flu-like symptoms (within 3 days) ◦ Fever ◦ Headache ◦ Muscle spasm ◦ Severe muscle, joint or bone pain ◦ Decrease urination level and frequency ◦ Hypertension ◦ *Jaw problems
- 12. Rehabilitation Team “Moans”, “Stones”, “Groans” & “Bones” Early Remobilization Active movement Weight bearing Update on medical status Increase fluid intake Patient/ family/ caregiver education Massagli & Cardenas, 1999
- 13. Crown et al. American Journal of Clinical Medicine, 2009 46 y/o female Stopped by airport police for erratic Bx Hx of hypertension, alcohol abuse, Hep B Presenting symptoms: generalized confusion, lethargy, hypertension Physical exam unremarkable with no focal motor or sensory deficits, cont. altered mental status Progressed to abdominal pain, severe constipation, bradycardia, electrolyte imbalance Findings: Altered state & acute pancreatitis due to hypercalcemia Hypomagnesia & acute renal failure due to dehydration
- 14. Massagli et al. Arch Phys Med Rehabilitation, 1999 9 patients with immobilization hypercalcemia ◦ 7 men, 2 women ◦ Mean age 22 y/o ◦ Onset ranged from 3 – 16 weeks Pamidronate Disodium Effectiveness, duration of Tx, and ease of administration appear promising Less interruption of activities Excellent response, with few complications Of 78% of the pts., only one treatment needed
- 15. Summary Acute SCI Difficult to detect early More in male adolescents and younger adults Varying levels of severity Cannot be prevented Aim to restore Ca+ levels, and treat underlying disease Mobilization and weight bearing Medications or injection
- 16. References Agrharkar, M. (2014). Hypercalcemia Medication. Retrieved December 5, 2014, from http://emedicine.medscape.com/ American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683. Crown et. al. (2009) Hypercalcemic crisis: a case study. American Journal of Clinical Rehabilitation. 6(1), 38-40. Kolnick et. al (2011). Hypercalcemia in Pregnancy: A case of milk- alkali syndrome. Retrieved December 1, 2014 from http:// ncbi.nlm.nih.gov/ Massagli, T. & Cardenas, D. (1999) Immobilization hypercalcemia treatment with pamidronate disodium after spinal cord injury. Arch Phys Med Rehabilitation. 80(2), 998-1000 Shane, E. & Berenson, J. (2014). Treatment of Hypercalcemia. Retrieved December 4, 2014, from http://uptodate.com/ Zoldronic Acid (Injection). (2014). Retrieved December 16, 2014, from https://www.ncbi.nlm.nih.gov/pubmedhealth/
- 17. Questions ?
Editor's Notes
- INC breakdown of calcium/ bone and is left in the bloodstream Greater input vs. output
- Ca+ is responsible for hormone release, muscle contraction, nerve and brain function and of course…bone formation.
- MG per deciliter Mild usually asymptomatic Severe require more aggressive therapy, whereas mild and moderate should be advised to avoid factors that can aggravate hypercalcemia (diet, increase fluids), and don’t require immediate therapy *Hypercalcemia is easily diagnosed with a blood test, but the CAUSE requires detailed history and physical examination, PTH level and Vitamin D level, urine evaluation, X-rays, and other imaging procedures. Medicinenet.com
- And is related to their risk of osteoporosis Especially lung and breast cancer. Which is a rare condition consisting of a caused by ingestion of large amounts of calcium together with sodium bicarbonate (antacid). HC is seen in women who are pregnant bc their already INC levels in bone absorption and/or imbalances in the PTHormone
- The increased incidence in older children and adolescents probably is related to the rapid bone turnover that accompanies growth, whereas that in males is possibly because of their greater bone mass. This disorder is more common in patients with tetraplegia than it is in persons with paraplegia Stimulates osteoclastic bone resorption The rate of bone loss is inversely related to age, and ranges from 15% of trabecular bone in elderly women to almost 50% in immobilized adolescents
- HC can Ultimately result in osteoporosis
- May be unrecognized because of nonspecific nature of symptoms. Prolonged HC can lead to nephrocalcinosis, nephrolithiasis, renal failure and other systemic complications which is why it is important to recognize the subtle signs and treat immediately
- 1st therapy is volume repletion or HYDRATION with IV saline B- inhibit bone resorption by blocking action of osteoclasts Antineoplastic- reduce bone turnover Antidote- inhibit bone resorption and INC renal Ca+ excretion Glucoc- inhibit inflammation Minerals- such as Phosphate can inhibit bone resorption and promotes Ca+ deposition Calcimimetric- binds to and modulates Parathyroid Ca+ sensing receptor. INC sensitivity to extracellular Ca+ and reduces PTH secretion
- A specific type of management I wanted to share with you is the use of…. Dr. Garcia It works by slowing bone breakdown, increasing bone density, and decreasing the amount of Ca+ released from the bones into the blood. Pamidronate (also injection BUT, administered multiple times per week) Jaw- May cause osteonecrosis of the jaw (ONJ), a serious condition of the jaw bone. It is recommended that a dentist should examine your teeth and perform any needed treatments, including cleaning, before you start to use zoledronic acid.
- On symptoms/ side effects of medical management Moans- GI conditions Stones- Kidney-related cond Groans- psychological Bones- bone pain and bone-related conditions Muscle activity transmits a bone formation signal through the osteocyte. With immobilization, the mechanical stimulation for bone formation caused by muscle activity is reduced, leaving resorption unopposed. Standing frame, weights, tilt table, functional activities
- Hypercalcemic Crisis: A Case Study To show the unspecific and undercover effects of HC on the body.
- C1-T12 For instance, When pt.s don’t need IV catheters and indwelling urinary drainage to handle the large volume of fluid excreted (from diuretics and INC fluid intake) this allows them more freedom to participate in transfers, mobility, and bladder management, and other functional tasks they need to focus on. (transient pyrexia for 48 hrs.)