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|D5W, NS Calcium Gluconate link|
Standard Dilutions [Amount of drug] [Infusion volume] [Infusion rate]
| [ 0 to 1.5 grams] [100 ml*] [See comments]
[ 1.6 - 4 grams] [250 ml*] [See comments]
Calculations for continuous infusions^:
Remember that there is 20mg of elemental calcium per mEq.
(0.5 grams CaCl2 = ~1.46 grams Calcium Gluc.)
*Dilutions assume peripheral line is used as well as D5W as the primary diluent (see comment section below - calculation of solution osmolarity). Calcium gluconate is the preferred agent for peripheral administration as well as for the treatment of acute symptomatic hypocalcemia.
[The injection should be halted if the patient complains of any discomfort; it may be resumed when symptoms disappear. Following injection, the patient should remain recumbent for a short time. 2]
Calcium Chloride: Maximum rate: 1.0 mL/minute = 1.36 meq/minute. 2
See monograph for general dosing.
Smaller volumes may be used in patients with a central line. Actual infusion rates should be based on the severity of the deficit. In non-emergent cases (asymptomatic patients), oral therapy is preferred.
-Serum calcium levels should be measured every 2 to 6 hours to guide continued therapy. If the patient has a low serum albumin level, ionized calcium should be monitored.
-The following patients need continuous ECG monitoring during calcium infusions: (1) Patient's with cardiac arrhythmias or (2) Patients receiving digoxin therapy.
Comments/ Stability / Miscellaneous
"Hypocalcemia is defined as a serum calcium concentration <8.5 mg/dL (or ionized calcium <4.2 mg/dL). Symptoms of hypocalcemia usually occur when ionized levels fall to <2.5 mg/dL. Symptoms include paresthesias of the extremities and face, followed by muscle cramps, carpopedal spasm, stridor, tetany, and seizures. Hypocalcemic patients show hyperreflexia and positive Chvostek and Trousseau signs. Cardiac effects include decreased myocardial contractility and heart failure." [Source].
Example: 1.5 grams added to 100 ml D5W:
Example: 2 grams added to 100 ml D5W:
(HYPERTONIC solution) The osmolarity exceeds 500 mOsm/liter but is less than 900. If infusing peripherally consider using a subclavian vein and/or proximal axillary vein. Monitor patient closely for phlebitis. A slow infusion with a solution with an osmolarity between 500 and 590 mOsm/L generally does not cause a problem, however as the final solution osmolarity increases above 590 mOsm/L the risk increases proportionately. Switch to a central line if there are any complications with peripheral administration. Phlebitis is difficult to defend in a court of law ... in some cases the vein may be irreparably damaged and require surgical removal. An example of a common solution at the lower end of this range is D5NS (osmolarity: 560 mOsm/L). It is recommended that you follow your local IV infusion protocol(s).
Example: 3 grams added to 250 ml D5W:
The osmolarity is between 280 mOsm/L and 500 mOsm/L ...... No problems anticipated. Normal plasma osmolarity: 280-310 mOsm/L. Cephalic and basilic veins in the upper arms can usually be used as long as the final pH is above 5 and under 9.
Drug Monograph - Calcium Chloride
Maximum IV rate: 100mg (1 ml)/ min. Too rapid injection may decrease BP/ cardiac syncope.
Calcium chloride is not recommended in the treatment of asystole and electromechanical dissociation.
WARNING: This product contains aluminum that may be toxic. Aluminum may reach toxic levels with prolonged parenteral administration if kidney function is impaired. Premature neonates are particularly at risk because their kidneys are immature, and they require large amounts of calcium and phosphate solutions, which contain aluminum.
Research indicates that patients with impaired kidney function, including premature neonates, who receive parenteral levels of aluminum at greater than 4 to 5 mcg/kg/day accumulate aluminum at levels associated with central nervous system and bone toxicity. Tissue loading may occur at even lower rates of administration.
Because of its additive effect, calcium should be administered very cautiously to a patient who is digitalized or who is taking effective doses of digitalis or digitalis-like preparations.
Injections should be made slowly through a small needle into a large vein to minimize venous irritation and avoid undesirable reactions. It is particularly important to prevent a high concentration of calcium from reaching the heart because of the danger of cardiac syncope.
Injections of calcium chloride are accompanied by peripheral vasodilatation as well as a local “burning” sensation and there may be a moderate fall in blood pressure.
Should perivascular infiltration occur, I.V. administration at that site should be discontinued at once. Local infiltration of the affected area with 1% procaine hydrochloride, to which hyaluronidase may be added, will often reduce venospasm and dilute the calcium remaining in the tissues locally. Local application of heat may also be helpful.
DOSAGE AND ADMINISTRATION
The usual precautions for intravenous therapy should be observed. If time permits, the solution should be warmed to body temperature. The injection should be halted if the patient complains of any discomfort; it may be resumed when symptoms disappear. Following injection, the patient should remain recumbent for a short time.
The usual adult dosage in hypocalcemic disorders ranges from 200 mg to 1 g (2-10 mL) at intervals of 1 to 3 days depending on the response of the patient and/or results of serum ionized calcium determinations. Repeated injections may be required because of rapid excretion of calcium.
The pediatric dosage in hypocalcemic disorders ranges from 2.7 to 5.0 mg/kg hydrated calcium chloride (or 0.136 to 0.252 mEq elemental calcium per kg, or 0.027 to 0.05 mL of 10% Calcium Chloride Injection per kg). No data from clinical trials is available about repeated dosages, though textbook references recommend repeat dosages q 4 to 6 hours.
Caution: 10% Calcium Chloride Injection consists of 1 gram of calcium chloride in a 10 mL syringe, or 100 mg/mL. This concentration represents 27 mg or 1.4 mEq of elemental calcium per mL. Thus, one 10 mL syringe provides 270 mg of elemental calcium. The dosage recommendation in various references is given either as amount of calcium chloride or amount of elemental calcium, and often it is not specified. Ionized calcium concentrations should be measured, to assist in dosage adjustment.
[1 ] 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 10.1: Life-Threatening Electrolyte Abnormalities. Circulation. 2005;112:IV-121-IV-125. Accessed - revisited: 05/01/11.
[2 ] CALCIUM CHLORIDE injection, solution (10% Calcium Chloride) [Hospira, Inc.] Hospira, Inc., Lake Forest, IL 60045 USA. Revised: November,
[3 ] CALCIUM GLUCONATE injection, solution (10% CALCIUM GLUCONATE). APP Pharmaceuticals, LLC. Schaumburg, IL 60173. Revised:
[4 ] Trissel LA. Handbook on injectable drugs. 14th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2007:245-6.