Discussion
Calcium supplementation
Patients presenting with hypocalcaemia can be critical , depending on the severity of the hypocalcaemia . If it goes unnoticed , the clinical signs can have life-threatening effects [ 2 , 4 ] . The patient presented with muscle twitching , weakness , ataxia and seizure activity – all clinical signs associated with hypocalcaemia [ 4 ] – so the team performed the assessment and started treatment swiftly . It was decided to test ionised calcium ( iCa ) over total calcium ( tCa ) as iCa is a more accurate representation of the patient ' s calcium concentration [ 5 ] . Tørnqvist-Johnsen et al . [ 6 ] investigated the relationship between iCa and tCa in dogs presenting with hypercalcaemia . A statistically significant number of dogs ( p < 0.0001 ) had an ionised hypercalcaemia compared with a normal tCa [ 6 ] . Although this study looked at hypercalcaemia , it was able to demonstrate a discordant relationship between iCa and tCa . In contrast , Woods et al . [ 7 ] found a statistically significant positive correlation between iCa and tCa , although it should be noted that the authors determined this significant correlation as weak [ 7 ] . It can be concluded that iCa should be tested alongside tCa to ensure abnormalities are not missed in patients presenting with the correlating clinical signs .
An iCa of 0.8 – 0.9 mmol / l is considered to be moderate hypocalcaemia , whereas an iCa of < 0.8 mmol / l represents severe hypocalcaemia in canine patients [ 2 ] . The patient presented with an iCa of 0.53 mmol / l , which , according to the literature available [ 8 ] , indicates severe hypocalcaemia requiring immediate supplementation [ 2 ] . Calcium gluconate 10 % solution was administered to the patient as a 1 ml / kg IV bolus over 30 min . Calcium gluconate 10 % solution is a common treatment for severe hypocalcaemia [ 9 ] . In a similar case study , the treatment of choice was calcium gluconate 10 % administered with 0.45 % glucose solution during the initial emergency treatment [ 10 ] . There was no discussion by the authors to justify the addition of glucose , and limited literature could be found demonstrating similar administration techniques . Without further evidence describing the effectiveness of additional glucose , a clinical conclusion cannot be made on its use . Currently , calcium gluconate 10 % IV is the more routine choice for treatment of hypocalcaemia in practice .
Contraindication of oral calcium supplementation has been discussed in the literature , with the production of uroliths and excessive hypercalciuria being reported [ 11 ] . It should be noted that the team was aware of this complication and ensured the patient was closely monitored in the hospital and after discharge , reducing the long-term calcium supplementation where appropriate . The author is aware the evidence cited is out of date ; however , on research , there appears to be no current literature on this topic , and there is no current literature to disprove the article ' s findings .
Monitoring and managing bradycardia
Patients with hypocalcaemia commonly present with bradycardia and abnormalities on an ECG [ 10 ] . During calcium supplementation , the patient was closely monitored , with a particular focus on the patient ' s heart rate and ECG trace using continuous ECG monitoring via a multiparameter monitor . Bradycardia can be exacerbated during calcium supplementation , so it is essential that all patients receiving calcium are monitored closely to enable calcium boluses to be stopped immediately if this is noticed [ 12 ] . The VNs in this case monitored the patient frequently , ensuring detailed notes were kept of the patient ' s parameters every 10 – 15 min . Keeping detailed records is important in critical patients , like the one in this case report , to establish a trend in their response to treatment [ 13 ] . The patient had frequent episodes of persistent bradycardia , which were recorded on the patient ' s hospital chart ; when bradycardia became severe , the calcium bolus treatment was stopped .
Communication is key when managing a critically ill patient , including written clinical records and verbal communication with the veterinary team . The RCVS Code of Professional Conduct for Veterinary Nurses ( RCVS CoPCVN ) clearly states that effective communication within the team is vital [ 14 ] . Effective communication and teamwork are especially important with the critical patient [ 15 ] . In this case , the team set clear boundaries , allowing the VNs to act under veterinary direction without the veterinary surgeon ( VS ) being present , particularly in cases of severe tachycardia or bradycardia , and to determine when treatment should be resumed . The team understood the legal limitations of the staff involved [ 14 ] and delegated roles to maximise the expertise and skills of all staff to offer the best care to the patient . The VNs were therefore empowered to advocate for the patient when it was necessary to make any appropriate changes to the treatment .
Hypocalcaemia can influence the ECG trace in some patients [ 10 ] . Changes seen on an ECG trace can include deep T waves , prolonged QT or ST intervals , and bradycardia [ 10 ] . If there is a concern that a patient is at risk of having an abnormal ECG , continuous monitoring should be initiated [ 13 ] . Once the patient in this case had begun a calcium gluconate 10 % infusion , a continuous ECG monitor was placed so that any abnormal ECG traces could be monitored and treated where possible [ 2 , 16 ] . The ECG trace ( Figure 1 , page 27 ) showed deep T waves , consistent with the aforementioned literature [ 10 ] .
For the ECG , initially , three leads were placed using crocodile-clip attachments , which can cause a level of discomfort to the patient [ 17 ] , especially if connected for a long period of time . The VNs replaced the clips with ECG pads that were taped to the paws to provide a better level of comfort for the patient while still allowing the VNs to monitor the ECG consistently . When using ECG pads , there is no reduction in the level
26 Veterinary Nursing Journal