Users Online: 1219 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  
Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Login 
 

 
Table of Contents
CASE REPORT
Year : 2011  |  Volume : 27  |  Issue : 3  |  Page : 393-394

Tetany: A diagnostic dilemma


Department of Anaesthesiology and Critical Care, Christian Medical College, Ludhiana, India

Date of Web Publication11-Aug-2011

Correspondence Address:
Aparna Williams
Department of Anaesthesiology and Critical Care, Christian Medical College & hospital Ludhiana - 141008, Punjab
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.83691

Rights and Permissions
   Abstract 

Tetany is a disorder of increased neuronal excitability usually associated with hypocalcemia. We report a patient with typical tetanic cramps and carpopedal spasm in the postoperative period, despite normal serum concentrations of calcium, which responded to intravenous infusion of calcium.

Keywords: Alkalosis, hyperventilation syndrome, hypocalcemia, hypomagnesemia, tetany


How to cite this article:
Williams A, Liddle D, Abraham V. Tetany: A diagnostic dilemma. J Anaesthesiol Clin Pharmacol 2011;27:393-4

How to cite this URL:
Williams A, Liddle D, Abraham V. Tetany: A diagnostic dilemma. J Anaesthesiol Clin Pharmacol [serial online] 2011 [cited 2019 May 20];27:393-4. Available from: http://www.joacp.org/text.asp?2011/27/3/393/83691


   Introduction Top


The care of postoperative patients may present unique challenges to anesthesiologists, such as those in the form of various metabolic problems. Tetany is a disorder characterized by enhanced neuromuscular excitability that is caused by various metabolic abnormalities. Irrespective of the causative factors, the variable clinical presentation can range from asymptomatic patients to life-threatening emergencies. We, as anesthesiologists, should be able to not only recognize these metabolic abnormalities but also provide effective treatment. Tetany in various settings has been reported in literature, but its occurrence in a postoperative case, after a minor surgical procedure, has not been reported previously.


   Case Report Top


A 22-year-old (weight 60 kg, height 157 cm) American Society of Anesthesiologists (ASA) physical status 1, male patient presented for incision and drainage of an abscess over his left elbow. There was no history of addiction or self-medication with any drugs. Past surgical interventions included external fixation for fracture of both bones of the left forearm along with left brachial artery repair under general anesthesia. Previous surgery and postoperative recovery had been uneventful. General physical examination was unremarkable, except for the abscess over his left elbow.

The patient was premedicated with Diazepam 10 mg orally two hours prior to the surgery. Preoperatively, he had a heart rate (HR) of 72 beats per minute, respiratory rate (RR) of 14 breaths per minute, and BP 110/70 mm Hg. Anesthesia was induced with glycopyrrolate 0.2 mg, ketamine 100 mg, and propofol 100 mg intravenously. Anesthesia was maintained with a mixture of oxygen: Nitrous oxide (40:60) and 1.5% isoflurane, on spontaneous ventilation using a face mask. Duration of the surgery was 15 minutes. He was transferred to the post anesthesia care unit (PACU) after he regained consciousness and had stable vital signs.

Within half an hour of admission to PACU, the patient complained of pain, and became restless and tachypneic (RR = 34/min). He complained of a tingling sensation all over the body and painful spasms. He was given oxygen by face mask. Electrocardiography (ECG) and pulse oximetry (SpO 2 ) monitoring was initiated. His restlessness and tingling sensations continued to worsen. He complained of inability to move his right hand and soon developed carpal spasm of the right hand. Blood samples were collected immediately for arterial blood gas (ABG) analysis and to determine the serum electrolytes, calcium, albumin, and magnesium (Mg) levels. A 12-lead ECG was also taken.

The patient was given 20 ml of calcium gluconate 10% as a slow intravenous infusion over 15 minutes. He showed dramatic improvement in symptoms after the infusion and his vital signs returned to the preoperative values. He was admitted to the PACU for overnight observation. The ABG revealed alkalosis with a pH 7.49, pCO 2 22 mm Hg, HCO 3 20 meq/L and low serum ionized calcium of 0.70 mmol/L. The serum calcium level was reported as 8 mg%, with an albumin of 2 mg % (corrected calcium of 9.6 mg %). The serum electrolytes and magnesium levels were within the normal range. The patient was discharged the next day from the hospital and was prescribed oral calcium supplements. He was referred to the endocrinology department for further workup of the episode of tetany.


   Discussion Top


Tetany is a disorder with an extremely variable clinical presentation. It includes enhanced neuromuscular activity and associated sensory disturbance. [1] Mild symptoms may include circumoral numbness, muscle cramps, or paresthesias of hands and feet. In severe cases, patients may present with laryngospasm, generalized muscle cramps, seizures, or even myocardial dysfunction. Trousseau sign and Chvostek sign are clinical tests to unmask latent tetany. The increased excitability of the peripheral nerves is due to either a low serum calcium (true hypocalcemia denotes a decrease in the ionized calcium level even though the total serum calcium level may be normal) or alkalosis in which the proportion of the serum calcium in the ionized form is decreased.

Our patient developed tetany even though his total serum calcium was 9.6 mg/dl, which is within the normal range. However, the ionized calcium level on the ABG was low. The etiology of tetany in our patient was probably multifactorial. The patient was hyperventilating due to pain and anxiety in the PACU. The hyperventilation caused alkalosis and decrease in the ionized fraction of serum calcium, which manifested as carpal spasm in the patient. Edmondson et al. have demonstrated that hypocalcemia in combination with alkalosis always produced tetany. [2]

The patient hyperventilated in the PACU, but did not show any signs of preoperative anxiety. He had undergone a previous major surgical procedure without any excessive anxiety, which rules out the diagnosis of hyperventilation (HV) syndrome as the cause of tetany. Tetanic patients with and without HV are characterized by a significant hypocalcemia, but a significant hypomagnesemia is exclusively found in tetanic patients with HV attacks. [3]

Magnesium deficiency could have been a contributory factor but there was no clinical evidence to suspect magnesium deficiency. Magnesium deficiency is usually caused by long-standing etiological factors, which may include inadequate intake during starvation or increased requirement during early childhood, pregnancy, or lactation. Hypomagnesemia may also be caused by malabsorption from the gastrointestinal tract, loss from the kidneys during use of diuretics, or due to a combination of the two, as in alcoholism. Acute hypomagnesemia can occur without previous magnesium deficiency after epinephrine, cold stress, and stress of serious injury or extensive surgery. [4] In this case, the surgical procedure was minor.

Hypokalemia in the absence of alkalosis has also been reported to cause tetany, [5] but our patient did not have hypokalemia. Usually hypokalemia manifests as tetany in association with alkalosis. [5]

In conclusion, tetany can be a manifestation of multiple disorders, viz. hypocalcemia, alkalosis, hypomagnesemia, hypokalemia, and HV syndrome. The clinician should have a high index of suspicion and must investigate and treat the underlying cause rather than treating just the clinical manifestation.

 
   References Top

1.Ito N, Fukumoto S. Symptoms and management of tetany. Clin Calcium 2007;17:1234-9.  Back to cited text no. 1
[PUBMED]    
2.Edmondson JW, Brashear RE, Li TK. Tetany: Quantitative interrelationships between calcium and alkalosis. Am J Physiol 1975; 228:1082-6.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Fehlinger R, Seidel K. The hyperventilation syndrome: A neurosis or a manifestation of magnesium imbalance? Magnesium 1985; 4:129-36.  Back to cited text no. 3
[PUBMED]    
4.Flink EB. Magnesium deficiency. Etiology and clinical spectrum. Acta Med Scand Suppl. 1981; 647:125-37.  Back to cited text no. 4
    
5.Jacob J, De Buono B, Buchbinder E, Rolla AR. Tetany induced by hypokalemia in the absence of alkalosis. Am J Med Sci 1986; 291:284-5.  Back to cited text no. 5
[PUBMED]    



This article has been cited by
1 Dysembrioplastyczny guz nerwowo-nablonkowy (DNT) u 9-letniego chlopca Ė od objawu do rozpoznania
Ewelina Witkowska-Sedek,Monika Krawczyk,Elzbieta Lipska,Beata Pyrzak
Pediatria Polska. 2017;
[Pubmed] | [DOI]
2 Tetany by transfusion of small volume of blood: A rare case report
Tanvi Sood,Kshitija Mittal,Ravneet Kaur Bedi,Kanchan Dogra,Kislay Dimri
Transfusion and Apheresis Science. 2013;
[Pubmed] | [DOI]
3 Pripomienky k neurog√©nnemu tetanick√©mu syndr√≥mu a simult√°nnym stavom zv√ĹŇ°enej neuromuskul√°rnej excitability
Kukumberg, P.
Ceska a Slovenska Neurologie a Neurochirurgie. 2013; 76(1): 119-121
[Pubmed]
4 Falling too Fahr
Merlini, A. and Peruzzotti-Jametti, L. and Bacigaluppi, M. and Mantovani, G. and Spada, A. and Rodegher, M. and Comi, G.
Journal of Neurology. 2012; 259(7): 1483-1484
[Pubmed]
5 Falling too Fahr
Arianna Merlini,Luca Peruzzotti-Jametti,Marco Bacigaluppi,Giovanna Mantovani,Annamaria Spada,Mariaemma Rodegher,Giancarlo Comi
Journal of Neurology. 2012; 259(7): 1483
[Pubmed] | [DOI]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Case Report
   Discussion
    References

 Article Access Statistics
    Viewed2744    
    Printed109    
    Emailed2    
    PDF Downloaded429    
    Comments [Add]    
    Cited by others 5    

Recommend this journal