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Intravenous Dilution Guidelines

CALCIUM CHLORIDE

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 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]


Alternatively:
[0.5 gram ] [100 ml ]  [1 hour^]
[1 gram ]  [100 ml ]  [2 hours or longer^]
--------------------------------------------

Calculations for continuous infusions^:
Example: 70 kg patient:
-------------------------------------
~2 mg/kg/hr:
[2 grams ]  [250 ml ]  [4 hours]
-------------------------------------
~1 mg/kg/hr:
[2 grams ]  [250 ml ]  [8 hours]
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~0.5 mg/kg/hr:
[2 grams ]  [250 ml ]  [16 hours]
-------------------------------------

^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.).


Remember that there is 20mg of elemental calcium per mEq.


(0.5 grams CaCl2 = ~1.46 grams Calcium Gluc.)
(1.0 gram CaCl2 = ~2.92 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.  

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 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  top of page icon


"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

Example: 1.5 grams added to 100 ml D5W:
The total volume of the final solution is: 115.0 ml, and the total milliosmoles in solution is 55.8 mOsm and the calculated osmolarity of the final solution is 485 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.


Example: 2 grams added to 100 ml D5W:
The total volume of the final solution is: 120.0 ml, and the total milliosmoles in solution is 66.0 mOsm and the calculated osmolarity of the final solution is 550 mOsm/Liter

(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 total volume of the final solution is: 280.0 ml, and the total milliosmoles in solution is 124.2 mOsm and the calculated osmolarity of the final solution is 444 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.



Drug Monograph -  Calcium Chloride

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1 gram= 13.6 meq/10 ml = 273mg elemental calcium.
Normal range: 8.4 to 10.2 mg/dl
Ionized Ca++: 1.19 to 1.29.


DRUG DESCRIPTION
Each mL contains: 100 mg calcium chloride dihydrate in water for injection q.s. pH (range 5.5-7.5) adjusted with Hydrochloric Acid and/or Sodium Hydroxide. Each 10 mL contains 13.6 mEq Calcium and 13.6 mEq Chloride. The molecular weight is 147.02 and the molecular formula is CaCl2•2H20.


Maximum IV rate: 100mg (1 ml)/ min. Too rapid injection may decrease BP/ cardiac syncope.


CONTRAINDICATIONS
Calcium chloride is contraindicated for cardiac resuscitation in the presence of ventricular fibrillation or in patients with the risk of existing digitalis toxicity.

Calcium chloride is not recommended in the treatment of asystole and electromechanical dissociation.

WARNINGS
10% Calcium Chloride Injection, USP is irritating to veins and must not be injected into tissues, since severe necrosis and sloughing may occur. Great care should be taken to avoid extravasation or accidental injection into perivascular tissues.

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.

PRECAUTIONS
Do not administer unless solution is clear and seal is intact. Discard unused portion.

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.


ADVERSE REACTIONS
Rapid injection may cause the patient to complain of tingling sensations, a calcium taste, a sense of oppression or “heat wave”.

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
10% Calcium Chloride Injection, USP is administered only by slow intravenous injection (not to exceed 1 mL/min), preferably in a central or deep vein.

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.

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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