Ca and hypotension

[loveumms]

Just wondering if anyone else does this. working with one of the super smart attendings the other day. 60 something year old man for routine knee surgery. GA with ETT. About a 1/4 the way through when blood pressure just isn't pleasing. Start titrating in the neo - fixed the problem but, of course having to push it every so often. My attending goes, "give him 1g of Ca++". Did as told and asked why but, he said it works every time but, wasn't exactly sure of any evidence. It worked perfectly - blood pressure came up and I didn't have to use the neo. I've used this three times since then and it's worked quite nicely. Did a quick search and couldn't really find much so, I was curious if anyone else has heard of this or used it.

I'm sure it has something to do with the contractility of the heart muscle but, would like to hear some other thoughts.

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[dfk]

how fast did you push the calcium?
and was it gluconate or chloride?
it seems when i use calcium for intra-op replacement,
i get the opposite--> hypotension and occasional transient arrhythmia.
however, this is usually with chloride pushed slowly.
no problems with gluconate pushed rapidly though.

 

[Jeff05]

hypocalcemia will result in decreased myocardial contractility.

Ca Gluconate is not routinely used in the OR.

 

[Planktonmd]

Calcium is an excellent positive inotrope and it increases the BP regardless of the etiology of hypotension.
It's more pronounced with calcium chloride than gluconate for obvious reasons.
The effect most of the time is temporary unless there is underlying hypocalcemia or a calcium channel blocker.
One thing to keep in mind is that sudden increase of calcium when you inject it fast could trigger coronary spasm and could also cause arrhythmias.

 

[loveumms]

Calcium chloride. I pushed it slowly - over about 10-20 minutes. The effects lasted for the remaining of the case.

 

[Noyac]

Yes, I use it from time to time and it works almost every time. I really like it in peds cases with sick hearts but don't do that many of these anymore.

 

[jetproppilot]

Just wondering if anyone else does this. working with one of the super smart attendings the other day. 60 something year old man for routine knee surgery. GA with ETT. About a 1/4 the way through when blood pressure just isn't pleasing. Start titrating in the neo - fixed the problem but, of course having to push it every so often. My attending goes, "give him 1g of Ca++". Did as told and asked why but, he said it works every time but, wasn't exactly sure of any evidence. It worked perfectly - blood pressure came up and I didn't have to use the neo. I've used this three times since then and it's worked quite nicely. Did a quick search and couldn't really find much so, I was curious if anyone else has heard of this or used it.

I'm sure it has something to do with the contractility of the heart muscle but, would like to hear some other thoughts.

Funny you brought this up.

Did a big back case yesterday....after induction dudes pressure was in the 70s...500mg CaCl worked like a charm

So yes, I use it sometimes.

 

[coprolalia]

Cuidado, mi amigos. No este por usando todo el tiempo.

-copro

 

[jetproppilot]

.

 

[jetproppilot]

Cuidado, mi amigos. No este por usando todo el tiempo.

-copro

Yo usar CaCl a veces, Cop. No todo los dias.

 

[jetproppilot]

Cuidado, mi amigos. No este por usando todo el tiempo.

-copro

Y si, tu eres mi amigo tambien.

 

[Noyac]

Cuidado, mi amigos. No este por usando todo el tiempo.

-copro

Si si este es muy peligroso. Principalment con corazon hipertrofia.

 

[jetproppilot]

Si si este es muy peligroso. Principalment con corizon hipertrofia.

Senor,

Tu espanol es intraducible!

 

[Noyac]

That explains why the spanish folks here just look at me and nod.

 

[coprolalia]

Y si, tu eres mi amigo tambien.

Gracias! Yo tambien!



-copro

 

[coprolalia]

I wish my Spanish was better. I don't know why I should be continuously suprised at the number of Hispanic speaking patients I see here in Philly. If you can't beat 'em, join 'em.

-copro

 

[UTSouthwestern]

Don't be too cavalier with calcium, especially with those patients with high normal levels of calcium.

I have seen two patients in the VA develop hypercalcemic pancreatitis, one of whom later died. The list of problems caused by excess calcium is fairly extensive, although rarely life threatening.

 

[Bertelman]

Yes, I use it from time to time and it works almost every time.

 

[coprolalia]

Don't be too cavalier with calcium, especially with those patients with high normal levels of calcium.

I have seen two patients in the VA develop hypercalcemic pancreatitis, one of whom later died. The list of problems caused by excess calcium is fairly extensive, although rarely life threatening.

You practice in Texas and you don't speak Spanish (apparently)?

-copro

 

[UTSouthwestern]

You practice in Texas and you don't speak Spanish (apparently)?

-copro

Spanglish, Chingrish, and Blaxican only.

 

[coprolalia]

Spanglish, Chingrish, and Blaxican only.

Blaxican. I love it.

-copro

 

[SexPanther]

This has now become my new avatar, thanks homes!

 

[Hockeyguy]

Don't be too cavalier with calcium, especially with those patients with high normal levels of calcium.

I have seen two patients in the VA develop hypercalcemic pancreatitis, one of whom later died. The list of problems caused by excess calcium is fairly extensive, although rarely life threatening.

Really UT - how much CA+ did these guys get? I am very cavalier with it especially when I start transfusing blood - maybe I should rethink that?

Mario

 

[Planktonmd]

Really UT - how much CA+ did these guys get? I am very cavalier with it especially when I start transfusing blood - maybe I should rethink that?

Mario

I have seen hypercalcemic pancreatitis in cases where there is a chronic significant increase in serum calcium like hyperparathyroid, Sarcoidosis and osteolytic bone tumors.
I don't recall ever seeing pancreatitis caused by iatrogenic administration of excessive calcium.

 

[jetproppilot]

I wish my Spanish was better. I don't know why I should be continuously suprised at the number of Hispanic speaking patients I see here in Philly. If you can't beat 'em, join 'em.

-copro

Having acquired the MD from DA U, my spanish was approaching "pretty-fluent" back in the day.

Its majorly deteriorated......and I want my spanish speaking ability back.

S.O. is fluent in spanish which is a major help...

And just got Rosetta Stone.

I'll letcha know how useful the Stone program has been after a cuppla months.

 

[jetproppilot]

Spanglish, Chingrish, and Blaxican only.

CHINGRISH???

HAHAHAHAHAHAHA

HORY CRAP NORM!!! ITS TWO'O-CROCK!!! PREASE RETURN TO CRINIC!!!

 

[UTSouthwestern]

Really UT - how much CA+ did these guys get? I am very cavalier with it especially when I start transfusing blood - maybe I should rethink that?

Mario

Over the course of 12 hours, the one that died received 8 grams along with 37 units of RBC's. Extubated the next day, reintubated 5 hours later, lab work all shot with iCa greater than 2, amylase, lipase through the roof. Died 8 days later.

 

[jetproppilot]

Over the course of 12 hours, the one that died received 8 grams along with 37 units of RBC's. Extubated the next day, reintubated 5 hours later, lab work all shot with iCa greater than 2, amylase, lipase through the roof. Died 8 days later.

Are you attributing the outcome to iatrogenic calcium?

37-divided-by-four.....seems about the right amount of Ca administered from what we learn (a gram of calcium for every 4 prbc)...

whats your take on this UT?

Do you really think pt's demise was from iatrogenic calcium administration, even though it seems said administration was within the limits of clinical use (considering the amount of PRBCs given)?

 

[UTSouthwestern]

Are you attributing the outcome to iatrogenic calcium?

37-divided-by-four.....seems about the right amount of Ca administered from what we learn (a gram of calcium for every 4 prbc)...

whats your take on this UT?

Do you really think pt's demise was from iatrogenic calcium administration, even though it seems said administration was within the limits of clinical use (considering the amount of PRBCs given)?

Unfortunately, the resident never checked a calcium level during the procedure and post op levels were all supraphysiologic by a factor of at least 1.8. Autopsy revealed an inflamed pancreas with multiple hypercalcemic nodular foci of necrosis. The pathologist could not find any other plausible causes of these findings and ruled it due to the hypercalcemia.

 

[militarymd]

Unfortunately, the resident never checked a calcium level during the procedure and post op levels were all supraphysiologic by a factor of at least 1.8. Autopsy revealed an inflamed pancreas with multiple hypercalcemic nodular foci of necrosis. The pathologist could not find any other plausible causes of these findings and ruled it due to the hypercalcemia.

I'm not advocating giving supplemental calcium...because I don't.

However, patients who are hypoperfusing (like this dude who is needing a lot of blood) frequently can and will develop pancreatitis from the shock state that may or maynot be clinically identified before death.

 

[UTSouthwestern]

I'm not advocating giving supplemental calcium...because I don't.

However, patients who are hypoperfusing (like this dude who is needing a lot of blood) frequently can and will develop pancreatitis from the shock state that may or maynot be clinically identified before death.

I would agree however the pathologic findings would be different in a shock state and this patient was kept euvolemic by the resident.

 

[Hockeyguy]

Any of you guys give Calcium gluconate with Oxytocin after a bloody C/S? We have an attending who will do this if after thirty units of pitocin if the uterus is still "boggy". If it is particularry bad will move to methergrin/hemebate but starts with supplementing Ca.

 

[dfk]

Any of you guys give Calcium gluconate with Oxytocin after a bloody C/S? We have an attending who will do this if after thirty units of pitocin if the uterus is still "boggy". If it is particularry bad will move to methergrin/hemebate but starts with supplementing Ca.

in my practice, after 30-40 units of pit, we usually go to methergine first, then to hemabate then cytotec. haven't heard nor seen the use of CaGluc for such.
do you have a reasoning behind it?

 

[Hockeyguy]

do you have a reasoning behind it?

Well the drugs basic mechanism of action I guess would be her reasoning. Oxytocin stimulates contraction of uterine smooth muscle by increasing intracellular calcium concentrations using extracellular calcium. I guess my attendings thought is after a rapid infusion of Pit in addition to brisk bleeding extracellular calcium could be low and supplementing it with Ca Guconate helps it work better. It seems to work but thats coming from a guy with a an n=20 so whatever. Too lazy to do a pub-med search.

 

[Planktonmd]

in my practice, after 30-40 units of pit, we usually go to methergine first, then to hemabate then cytotec. haven't heard nor seen the use of CaGluc for such.
do you have a reasoning behind it?

Calcium improves uterine tone and could be helpful if the patient has been on Magnesium.
It's certainly not a bad idea if it's readily available to you but the usual transition should be: Oxytocin then Injectable Prostaglandin then Ergot derivative.
I am not sure if Cytotec is a practical or effective thing to do in a postpartum hemorrhage that did not respond to Oxytocin + Hemabate + Methergin.

 

[dfk]

Calcium improves uterine tone and could be helpful if the patient has been on Magnesium.
It's certainly not a bad idea if it's readily available to you but the usual transition should be: Oxytocin then Injectable Prostaglandin then Ergot derivative.
I am not sure if Cytotec is a practical or effective thing to do in a postpartum hemorrhage that did not respond to Oxytocin + Hemabate + Methergin.

i can't say that i agree or disagree due to my limited experience.
at that point, can i really argue with the surgeon who wants to digitalize the cytotec?

 

[Planktonmd]

i can't say that i agree or disagree due to my limited experience.
at that point, can i really argue with the surgeon who wants to digitalize the cytotec?

You don't have to agree or disagree based on your experience.
I am just saying that after using an injectable prostaglandin (Hemabate) why would you expect an intravaginal suppository of prostaglandin to work better?
And it's good for you as an anesthesia provider to know if there is any literature support for things that you do.

 

[dfk]

You don't have to agree or disagree based on your experience.
I am just saying that after using an injectable prostaglandin (Hemabate) why would you expect an intravaginal suppository of prostaglandin to work better?
And it's good for you as an anesthesia provider to know if there is any literature support for things that you do.

agree completely, and i do for the most part (sans OB since it's a rarity in my facility).