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Intravenous Dilution Guidelines

CALCIUM GLUCONATE

The authors make no claims of the accuracy of the information contained herein; and these suggested doses are not a substitute for clinical judgment. Neither GlobalRPh Inc. nor any other party involved in the preparation of this program shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material.  PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER.

Usual Diluents

D5W, NS     Calcium chloride link

Standard Dilutions   [Amount of drug] [Infusion volume] [Infusion rate]

[1 to 4 grams] [50 - 100 ml] [See comments]*

Alternatively:
[1 gram ] [50 ml ] [1 hour ^]
[2 grams ] [100 ml ] [2 hours ^]

*Dilutions assume peripheral line is used as well as D5W as the primary diluent (see comment section below - calculation of solution osmolarity). 

^Actual infusion times should be based on serial calcium levels, severity of the deficit, current phosphate level (possible metastatic calcification), and the clinical presentation of the patient (acute versus chronic; symptoms present; etc.).


Treatment of emergent (acute symptomatic) patient.  1.

[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 Gluconate: Maximum rate: 1.5 mL/minute = 0.7 meq/minute. 3


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.

Continuous infusion: Initially multiply ( 0.5 x Wt (kg) X 24 ) / 93 mg = number of grams of calcium gluconate needed. Add calculated amount to 500 to 1000 ml D5W or NS. A continuous infusion may be used in symptomatic patients with hypocalcemia. Infusion rate: 0.3 to 2 mg/kg/hr based on elemental calcium. The actual rate should be based on serial plasma calcium levels.

Comments / Stability / Miscellaneous   top of page icon

1 gram= 4.65 meq (93 mg) 10 ml.


"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].


Treatment of ACUTE SYMPTOMATIC hypocalcemia,  maximum rates, etc:

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Asymptomatic patients should be treated with oral calcium
.
For additional information see the following page:
http://www.globalrph.com/calcium_supplements.htm



"Hypocalcemia is defined as a serum calcium concentration <8.5 mg/dL (or ionized calcium <4.2 mg/dL). Hypocalcemia may develop with toxic shock syndrome, with abnormalities in serum magnesium, after thyroid surgery, with fluoride poisoning, and with tumor lysis syndrome (rapid cell turnover with resultant hyperkalemia, hyperphosphatemia, and hypocalcemia). 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. Hypocalcemia can exacerbate digitalis toxicity.". 1.

Intravenous calcium should be restricted to acute symptomatic patients that require prompt therapy.


"Treatment of Hypocalcemia: Treatment of hypocalcemia requires administration of calcium.
Treat acute, symptomatic hypocalcemia with 10% calcium gluconate, 93 to 186 mg of elemental calcium (10 to 20 mL) IV over 10 minutes. Follow this with an IV infusion of 540 to 720 mg of elemental calcium (58 to 77 mL of 10% calcium gluconate) in 500 to 1000 mL D5W at 0.5 to 2 mg/kg per hour (10 to 15 mg/kg)". 1.

"Alternatively, administer 10% calcium chloride, giving 5 mL (136.5 mg of elemental calcium) over 10 minutes, followed by 36.6 mL (1 g) over the next 6 to 12 hours IV. Measure serum calcium every 4 to 6 hours. Aim to maintain the total serum calcium concentration at 7 to 9 mg/dL. Correct abnormalities in magnesium, potassium, and pH simultaneously. Note that untreated hypomagnesemia will often make hypocalcemia refractory to therapy. Therefore, evaluate serum magnesium when hypocalcemia is present and particularly if hypocalcemia is refractory to initial calcium therapy." 1.


Maximum rates, equivalents, etc:
Calcium Chloride: Maximum rate: 1.0 mL/minute = 1.36 meq/minute. 2
Calcium Gluconate: Maximum rate: 1.5 mL/minute = 0.7 meq/minute. 3
Trissel: Maximum rate (calcium injections): 0.7 to 1.8 mEq/minute. 4



Calcium Conversions:

Calcium Chloride 1 gram (10ml)
= 273 mg elemental calcium
= 13.6 mEq
=  6.8 mmol.
20mg of elemental calcium per mEq. 
0.5 mmol of elemental calcium = 1.0 mEq. 
Calcium Gluconate 1 gram (10ml)
= 93 mg elemental calcium
= 4.65 mEq
=  2.325 mmol.
20mg of elemental calcium per mEq. 
0.5 mmol of elemental calcium = 1.0 mEq. 
Example conversion: 0.075 mmol elemental calcium/kg/hr = 0.15 mEq/kg/hr = 3 mg/kg/hr.



Osmolarity calculations:

  top of page icon     source:    http://www.globalrph.com/osmocalc_valid.htm

Osmolarity calculations:  source:    http://www.globalrph.com/osmocalc_valid.htm
Example: 3 grams added to 50 ml D5W:
The total volume of the final solution is: 80.0 ml, and the total milliosmoles in solution is 33.0 mOsm and the calculated osmolarity of the final solution is 412 mOsm/Liter. 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.



Maximum IV rate: 1.5 ml/min or approximately 1 gram/ 7 minutes.

Too rapid injection may decrease blood pressure or cause cardiac syncope. Calcium administration: (Onset: rapid Duration: 30min to 2 hours. ).

Recommended only in cases of hyperkalemia, hypocalcemia, or calcium antagonist blockade.
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Treatment of hypocalcemia: Acute hypocalcemic tetany (unless induced by alkalosis): give 1 gram calcium gluconate IV over 5 - 15 minutes. After 1-2 hours may be necessary to repeat dose or add 2-3 grams calcium gluconate to 250-500ml and infuse over 12-24hours.

----Alternatively----
Symptomatic patient: give 1 gram calcium gluconate over 5 - 15 minutes q1-2hours. If Tetany returns after 6 hours (3 grams calcium gluconate given) start continuous infusion [5-10g of calcium gluconate /1000 ml D5W infused at rate to prevent tetany-usually 30 to 100 ml/hr]. Make sure magnesium levels are corrected first - patients with hypocalcemia and hypomagnesemia will not respond to calcium replacement. Alternative therapy: give 0.3 to 2 mg elemental calcium/kg/hour as a continuous infusion.

Asymptomatic patient: 1 gram calcium gluconate IV q6-12h with careful monitoring of Ca++ levels. Monitoring: during intensive therapy, monitor calcium levels at least twice daily.


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Differentiation of hypoparathyroidism vs Vitamin D deficiency:
Hypoparathyroidism: Decreased serum Ca++/serum PO4 increased/Alk phos normal.
Vitamin D deficiency: decreased Ca++ & PO4/ Alk phos increased.



Drug Monograph -  Calcium Chloride

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DRUG DESCRIPTION
Calcium Gluconate is the calcium salt of gluconic acid, an oxidation product of glucose, and contains 9.3% calcium, which is about one-third of the calcium in strength of calcium chloride USP. Since it is soluble to the extent of only one part in 30 parts of cold water, the 10% solution is supersaturated and is stabilized by the addition of calcium saccharate tetrahydrate 0.46% w/v (which supplies calcium 6.2%). Each mL contains 98 mg of calcium gluconatemonohydrate, 4.6 mg of calcium saccharate tetrahydrate, and Water for Injection USP, q.s. Each mL provides 9.3 mg (0.465 milliequivalents) of calcium.


INDICATIONS
Calcium gluconate is used to treat conditions arising from calcium deficiencies such as hypocalcemic tetany, hypocalcemia related to hypoparathyrodism and hypocalcemia due to rapid growth or pregnancy. It is also used in the treatment of black widow spider bites to relieve muscle cramping and as an adjunct in the treatment of rickets, osteomalacia, lead colic and magnesium sulfate overdosage. Calcium gluconate has also been employed to decrease capillary permeability in allergic conditions, nonthrombocytopenic purpura and exudative dermatoses such as dermatitis herpetiformis and for pruritus of eruptions caused by certain drugs. In hyperkalemia, calcium gluconate may aid in antagonizing the cardiac toxicity provided the patient is not receiving digitalis therapy.

Precautions
General

To avoid undesirable reactions that may follow rapid intravenous administration of calcium gluconate, the drug should be given slowly, e.g., approximately 1.5 mL over a period of one minute. When injected intravenously, calcium gulconate should be injected through a small needle into a large vein in order to avoid too rapid an increase in serum calcium and extravasation of calcium solution into the surrounding tissue with resultant necrosis.

Rapid injection of calcium gluconate may cause vasodilation, decreased blood pressure, bardycardia, cardiac arrhythmias, syncope and cardiac arrest.

Because of the danger involved in simultaneous use of calcium salts and drugs of the digitalis group, a digitalized patient should not receive an intravenous injection of a calcium compound unless indications are clearly defined.

Drug Interactions
The inotropic and toxic effects of cardiac glycosides and calcium are synergistic, and arrhythmias may occur if these drugs are given together (particularly when calcium is given together particularly when calcium is given intravenously). Intravenous administration of calcium should be avoided in patients receiving cardiac glycosides; if necessary, calcium should be given slowly in small amounts.

Calcium complexes tetracycline antibiotics rendering them inactive. The two drugs should not be given at the same time orally nor should they be mixed for parenteral administration.

Calcium gluconate injection has been reported to be incompatible with intravenous solutions containing various drugs. Published data are too varied and/or limited to permit generalizations, and specialized reference should be consulted for specific information.

Adverse Reactions
Patients may complain of tingling sensations, a sense of oppression or heat waves and a calcium or chalky taste following the intravenous administration of calcium gluconate.

Rapid intravenous injection of calcium salts may cause vasodilation, decreased blood pressure, bardycardia, cardiac arrhythmias, syncope and cardiac arrest. Use in digitalized patients may precipitate arrhythmias.

Local necrosis and abscess formation may occur with intramuscular injection.


DOSAGE AND ADMINISTRATION
Calcium Gluconate should be administered intravenously either directly or by infusion. The dose is dependent upon the individual requirements of the patient. Calcium Gluconate may also be administered by intermittent infusion at a rate not exceeding 200 mg/min, or by continuous infusion.

Usual Dosage
Adults: 500 mg - 2 grams (5-20 mL)

Children: 200-500 mg (2-5 mL)

Infants: not more than 200 mg (not more than 2 mL)

HOW SUPPLIED
Calcium Gluconate Injection, USP 10%

NDC 0517-3910-25 10% 10 mL Single Dose Vials packed in boxes of 25
NDC 0517-3950-25 10% 50 mL Single Dose Vials packed in boxes of 25
NDC 0517-3900-25 10% 100 mL Pharmacy Bulk Package packed in boxes of 25


Supersaturated solutions are prone to precipitation.

NOTE: If crystallization has occurred, warming in a 60°C water bath for 15-30 minutes with occasional shaking, may dissolve the precipitate. Cool to body temperature before use. The injection must be clear at the time of use. Parenteral drug products should be inspected visually for particulate matter and discoloration, whenever solution and container permit.

No preservative added. Unused portion of vial should be discarded. Use only if solution is clear and seal intact.

Store at controlled room temperature 15º- 30ºC (59º- 86ºF) (See USP).



References:  top of page icon


[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.
http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-121

[2 ] CALCIUM CHLORIDE injection, solution (10% Calcium Chloride) [Hospira, Inc.] Hospira, Inc., Lake Forest, IL 60045 USA. Revised: November,
2009. [Package Insert: accessed: 05/01/11]

[3 ] CALCIUM GLUCONATE injection, solution (10% CALCIUM GLUCONATE). APP Pharmaceuticals, LLC. Schaumburg, IL 60173. Revised:
February 2009. [Package Insert: accessed: 05/01/11]

[4 ] Trissel LA. Handbook on injectable drugs. 14th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2007:245-6.

Disclaimer
The authors make no claims of the accuracy of the information contained herein; and these suggested doses are not a substitute for clinical judgment. Neither GlobalRPh Inc. nor any other party involved in the preparation of this program shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material.  PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER.
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