For adult hospitalized patients with asymptomatic hypocalcemia measured by total albumincorrected or ionized calcium does intravenous IV calcium supplementation guided by ongoing monitoring of blood calcium levels lead to improved clinical outcomes or reduced length of stay

Hypocalcemia is a common finding in hospitalized patients. In critically ill patients hypocalcemia is associated with poor outcomes as measured by arterial blood pressure survival and length of stay although a causeandeffect relationship has not been demonstrated. Current recommendations see UpToDate.com reference suggest IV calcium supplementation only for symptomatic patients carpopedal spasm tetany seizures for patients with a prolonged QT interval and for asymptomatic patients with an acute decrease in serum calcium albumincorrected to 7.5 mgdL 1.9 mmolL. Oral calcium supplementation is recommended for patients with milder symptoms of neuromuscular irritability and corrected calcium concentrations 7.5 mgdL with IV calcium only if symptoms do not improve with oral supplements. However in practice many hospitalized patients found to have mild to moderate hypocalcemia on routine testing but who are asymptomatic are also routinely treated with IV calcium supplements and undergo frequent typically daily laboratory monitoring with calcium measurements during their hospitalization in an attempt to normalize blood calcium concentration and improve hemodynamic function. Although IV calcium replacement venipuncture and laboratory calcium measurements are seemingly relatively inexpensive and lowrisk procedures these activities still consume considerable nursing pharmacy and laboratory resources. More importantly there is a lack of evidence that normalizing blood calcium levels in these patients has any direct benefit in terms of improved clinical outcomes decreased morbiditymortality or reduced length of stay. In fact some studies have shown that the hypocalcemia observed in acutely ill patients is resistant to normalization and it has been postulated that a low serum calcium concentration may actually be an adaptive physiologic response to acute illness that selfresolves as the patient recovers. In addition animal studies have indicated that administering calcium during sepsis and shock increases mortality whereas use of calcium chelators or calcium channel blockers improves survival. Moreover one human study showed that intravenous calcium replacement in mild asymptomatic hypocalcemia of critical illness did not seem to benefit these patients and was associated with longer hospital stays. If this is indeed the case then IV calcium supplementation and blood draws to measure calcium levels may be unnecessary and potentially harmful. Selected References1. Goltzman D. Treatment of hypocalcemia. UpToDate.com. httpwww.uptodate.comcontentstreatmentofhypocalcemiasourcepreviewlanguageenUSanchorH4selectedTitle1150H4. accessed 103015 2. Zivin JR Gooley T Zager RA Ryan MJ. Hypocalcemia a pervasive metabolic abnormality in the critically ill. Am J Kid Dis 200137689698.3. Egi M Kim I Nichol A Stachowski E French CJ Hart GK Hegarty C Bailey M Bellomo R. Ionized calcium concentration and outcome in critical illness. Crit Care Med 201139314321.4. Chen HC. Intravenous Calcium Replacement for Asymptomatic Hypocalcemia of Critical Illness. The Endocrinologist 2001 11 364367.5. Forsythe RM Wessel CB Billiar TR Angus DC Rosengart MR. Parenteral calcium for intensive care unit patients review. Cochrane Database of Systematic Reviews 2008 Issue 4. Art. No. CD006163. DOI 10.100214651858.CD006163.pub2. 6. Baird GS Rainey PM Wener M Chandler W. Reducing routine ionized calcium measurement. Clinical Chemistry 200955533540.

As the American healthcare system moves toward a valuebased model there is an increased emphasis on using evidencebased medicine to guide the use of diagnostic tests and therapeutic procedures and to identify and avoid those that increase cost without adding value. IV calcium replacement and blood calcium monitoring in hospitalized asymptomatic hypocalcemic patients is a common practice that is invasive and resourceintensive with questionable clinical efficacy benefits and safety. A comprehensive and systematic review of the literature on this topic would assist in developing evidencebased guidelines for IV calcium replacement in hospitalized patients and enhance the clinical and cost effectiveness of patient care.

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