Medical and endocrine disease09 / 30
Severe hypercalcaemia from primary hyperparathyroidism with a perforated ulcer56-year-old woman, 64 kg, for an emergency laparotomy: perforated duodenal ulcer
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Know this first
- Severe hypercalcaemia: saline at 250–500 mL/h to keep urine above 200 mL/h; diuretic only if overloaded.
- Calcitonin works within minutes, bridging until hydration and a bisphosphonate act.
- Calcium above 8 mEq/L makes conduction disturbances likely; the PR lengthens and the QT shortens.
- Third-degree block with hypotension: pace without delay; atropine and adrenaline or dopamine only bridge to pacing.
The patient
56-year-old woman, 64 kg, for an emergency laparotomy: perforated duodenal ulcer.
Primary hyperparathyroidism found 2 months ago, awaiting surgery; thirsty, constipated and confused today; renal stones last year.
Drugs: bendroflumethiazide for hypertension.
Labs: Ca 16.4 mg/dL (8.2 mEq/L; albumin normal), creatinine 1.6 mg/dL, K 3.4 mmol/L. ECG: PR 0.24 s, short QT.
Vitals: BP 96/58, HR 112, SpO2 96% on air, RR 22, temp 37.9 °C.
The examiner asks
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Consider
What are the issues?
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- A 56-year-old with severe hypercalcaemia from hyperparathyroidism, with a perforated ulcer needing emergency laparotomy. Patient
- Her calcium touches kidneys, bones, gut and brain: stones, thirst, constipation and today's confusion. Disease
- Her ulcer may itself be calcium-driven, because calcium boosts gastric acid.
- She's likely very dry from calcium-driven polyuria plus peritonitis.
- A PR of 0.24 and a short QT: her conduction is already affected.
- Perforation can't wait long, so I resuscitate hard in the hours before theatre. Surgery
Prepare
How do you prepare her?
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- Ionised calcium, phosphate, magnesium and a 12-lead ECG now. (Disease)
- Her thiazide stops: it pushes calcium up.
- Saline at 250–500 mL/h, targeting urine above 200 mL/h, with her heart watched.
- Furosemide only once she's filled, never before.
- Calcitonin acts within minutes while pamidronate 90 mg IV starts to work.
- If her kidneys fail, dialysis.
Plan
How do you anaesthetise her?
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- Arterial line, pacing pads on, then a rapid sequence with rocuronium 1.2 mg/kg. Airway
- She's drowsy already, so her anaesthetic need may be lower; doses are titrated. Disease
- Relaxant response is unpredictable: weak muscles, but calcium antagonises the block. I monitor and titrate.
- Careful positioning; her bones may fracture. Surgery
- Hyperparathyroidism is the commonest feature of MEN 1, so endocrinology screen her family risk. After surgery
- After her later parathyroidectomy, hungry bone can drop her calcium, lowest at 3–7 days.
Crisis
Two minutes after induction her heart rate falls to 34 in complete heart block. BP 62/30. Your management?
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- Bradycardia algorithm: complete heart block with hypotension, in severe hypercalcaemia. Crisis
- Third-degree block: transcutaneous pacing now, through her pads.
- Atropine 1 mg only while pacing starts; it may fail if the block is below the node.
- Meanwhile adrenaline 2–10 mcg/min or dopamine 2–10 mcg/kg/min by infusion.
- Her cause is treated too: more saline and calcitonin to bring calcium down.
- Transvenous pacing if it persists; surgery goes ahead once rhythm and pressure are controlled. After surgery
Fatal mistakes
- Inducing her while she is dry and severely hypercalcaemic.
- Starting furosemide before her volume is restored.
- No pacing plan for symptomatic heart block.
Checked against: Miller 10e · Stoelting 8e · AHA guidelines: adult advanced life support (2025) · Faust
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