Management When hypercalcemia is mild, no specific therapy is warranted and efforts should focus on identifying the underlying condition Chronic moderate hypercalcemia (12 to 14 mg/dL) may be well tolerated and not require immediate intervention, though thorough evaluation should be pursued If hypercalcemia is severe (greater than 14 mg/dL) or associated with clinically significant symptoms, prompt intervention is warranted Given the gastrointestinal and renal manifestations associated with hypercalcemia, patients may present with hypovolemia Initial efforts should focus on restoring adequate intravascular volume with isotonic IV fluids, which will increase GFR and increase renal excretion of calcium Agents that inhibit osteoclasts, such as calcitonin and bisphosphonates, may be used to treat hypercalcemia secondary to increased bone resorption Calcitonin has rapid onset of action but resistance develops rapidly; bisphosphonates such as pamidronate and zoledronic acid have delayed onset but long duration of action, so may be useful when combined with calcitonin Loop diuretics such as furosemide are no longer routinely recommended due to risk of hypovolemia and electrolyte imbalance, but may be used judiciously if necessary to prevent fluid overload in patients with renal failure or CHF If the patient is in renal failure or efforts with saline diuresis and first-line agents are not sufficient, renal replacement therapy (RRT) may be necessary Consultation with a pediatric nephrologist or endocrinologist is advised DISORDERS OF ACID–BASE HOMEOSTASIS Goals of Treatment Maintenance of normal acid–base balance involves expiration of carbon dioxide, metabolism of organic acids, and buffering and renal excretion of nonvolatile acids Severe uncompensated acid–base disorders are associated with a variety of cardiovascular, metabolic, neurologic, and respiratory consequences General goals include treatment of the underlying etiology and maintenance of normal pH in order to prevent potentially fatal sequelae CLINICAL PEARLS AND PITFALLS