Open Access Highly Accessed Open Badges Research

Assessment and clinical course of hypocalcemia in critical illness

Tom Steele1, Ruwanthi Kolamunnage-Dona2, Colin Downey3, Cheng-Hock Toh34 and Ingeborg Welters15*

Author Affiliations

1 Institute of Ageing and Chronic Disease, University of Liverpool, Daulby Street, Liverpool L69 3GA, UK

2 Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool L69 3BX, UK

3 Department of Blood Sciences, Royal Liverpool University Hospital, Prescot Street, Liverpool L3 5PS, UK

4 Institute of Infection and Global Health, University of Liverpool, West Derby Street, Liverpool L69 7BE, UK

5 Intensive Care Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool L3 8XP, UK

For all author emails, please log on.

Critical Care 2013, 17:R106  doi:10.1186/cc12756

Published: 4 June 2013



Hypocalcemia is common in critically ill patients. However, its clinical course during the early days of admission and the role of calcium supplementation remain uncertain, and the assessment of calcium status is inconsistent. We aimed to establish the course of hypocalcemia during the early days of critical illness in relation to mortality and to assess the impact of calcium supplementation on calcium normalization and mortality.


Data were collected on 1,038 admissions to the critical care units of a tertiary care hospital. One gram of calcium gluconate was administered intravenously once daily to patients with adjusted calcium (AdjCa) <2.2 mmol/L. Demographic and outcome data were compared in normocalcemic (ionized calcium, iCa, 1.1-1.3 mmol/L) and mildly and severely hypocalcemic patients (iCa 0.9-1.1 mmol/L and <0.9 mmol/L, respectively). The change in iCa concentrations was monitored during the first four days of admission and comparisons between groups were made using Repeated Measures ANOVA. Comparisons of normalization and outcome were made between hypocalcemic patients who did and did not receive calcium replacement according to the local protocol. The suitability of AdjCa to predict low iCa was determined by analyzing sensitivity, specificity and receiver operating characteristic (ROC) curves. Multivariate logistic regression was performed to determine associations of other electrolyte derangements with hypocalcemia.


55.2% of patients were hypocalcemic on admission; 6.2% severely so. Severely hypocalcemic patients required critical care for longer (P = 0.001) compared to normocalcemic or mildly hypocalcemic patients, but there was no difference in mortality between groups (P = 0.48). iCa levels normalized within four days in most, with no difference in normalization between those who died and survived (P = 0.35). Severely hypocalcemic patients who failed to normalize their iCa by day 4 had double the mortality (38% vs. 19%, P = 0.15). Neither iCa normalization nor survival were superior in hypocalcemic patients receiving supplementation on admission. AdjCa <2.2 mmol/L had a sensitivity of 78.2% and specificity of 63.3% for predicting iCa <1.1 mmol/L. Low magnesium, sodium and albumin were independently associated with hypocalcemia on admission.


Hypocalcemia usually normalizes within the first four days after admission to ICU and failure to normalize in severely hypocalcemic patients may be associated with increased mortality. Calcium replacement appears not to improve normalization or mortality. AdjCa is not a good surrogate of iCa in an ICU setting.

Electrolyte disorders; Ionized calcium; Adjusted calcium; Hypocalcemia; Critical illness; Intensive care