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PHARMACY GUIDELINES

Adult Intravenous Calcium Replacement Therapy

General Information:
• Reference Calcium Levels:
1. Total serum calcium: 2.1-2.55 mmol/L or 8.42-10.22 mg/dL
2. Ionized serum calcium: 1.19-1.31 mmol/L or 4.76-5.24 mg/dL
• Corrected Calcium According to Albumin Levels:
1. Corrected Calcium (mg/dL)= Measured Calcium (mg/dL) + 0.8 (4-Serum
Albumin[g/dL])
2. Corrected Calcium (mmol/L)= Measured Calcium (mmol/L) + 0.02 (40-
Serum Albumin[g/L])
• Formulary IV Calcium Preparations:
1 mEq of Calcium = 0.5 mmol
Calcium (mg/dL) x 0.25 = Calcium (mmol/L)
Salt Elemental Calcium mmol Calcium/mL mEq Calcium/mL
Calcium Chloride 27 mg Calcium/mL 0.68 mmol 1.36 mEq
10% (100 mg/mL)
Calcium Gluconate 9 mg Calcium/mL 0.23 mmol 0.46 mEq
10% (100 mg/mL)

Hypocalcaemia: Corrected serum calcium < 1.75 mmol/L or ionized serum calcium of less
than 1.025 mmol/L. Hypocalcaemia could be asymptomatic (requires maintenance calcium
through oral supplementation) or symptomatic (Tetany, ECG changes, Convulsions) which
requires bolus replacement by IV calcium:

Intravenous Calcium Replacement (Bolus Dose):


• By default, if the calcium salt for infusion is not mentioned in the order, calcium
gluconate will be used as it causes less phlebitis (Calcium chloride is acidifying; it
should not be used when acidosis coincides with hypocalcaemia)
Ionized Serum Calcium Replacement Guidelines
0.8-1 mmol/L (Mild/Symptomatic) 2 g (4.6 mmol) calcium gluconate IV
0.6-0.79 mmol/L (Moderate) 3 g (6.9 mmol) calcium gluconate IV
< 0.59 mmol/L (Severe) 4 g (9.2 mmol) calcium gluconate IV
Dilution & Infusion Rate:
• 1-2 g (2.3-4.6 mmol) of calcium gluconate to be diluted in 50 ml dextrose 5% or
0.9% sodium chloride and infused over 30 minutes.
• 3-4 g (6.9-9.2 mmol) of calcium gluconate to be diluted in 100 ml dextrose 5% or
0.9% sodium chloride and infused over 60 minutes.
• Maximum allowable concentration: 0.23 mmol/mL (100 mg/mL)
i.e. 5 g in 50 mL diluent
• Maximum allowable rate: 0.35 mmol/min (150 mg/min)
Continuous Infusion:
• 0.0125-0.05 mmol/kg/hr reduced to 0.0007-0.0125 mmol/kg/hr for further infusions.
Maximum total daily dose 34.5 mmol (15 g of calcium gluconate 10%)
Precautions:
• Calcium salts are irritating to tissues, especially calcium chloride. Close observation
is essential during infusion of calcium via a peripheral vein in order to detect any
extravasation at the earliest possible moment.
• Intravenous calcium should not be administered to patients receiving digoxin. The
inotropic and toxic effects of the two drugs are synergistic and arrhythmias may occur
if they are given together.

Monitoring:
• Check for extravasation if calcium is given through a peripheral line.
• Check patient's heart rate; calcium may cause bradycardia.
• Check serum magnesium level; hypomagnesaemia is a cause of hypocalcemia due to
end organ resistance to parathyroid hormone and possibly impaired PTH secretion.
• Check serum phosphate level; hyperphosphatemia can induce hypocalcemia due to
metastatic calcification of calcium phosphate in the soft tissues and lungs. (usually
associated with renal disease)

References:

1. Guidelines for Calcium Replacement, King Faisal Specialist Hospital & Research
Center
2. Hypocalcaemia: Treatment Guidelines, Kingston General Hospital, Ontario-Canada;
http://www.kgh.on.ca/pharmacy/Guidelines.pdf
3. Guidelines for Calcium Replacement in Adults, Medical University of South Carolina
Pharmacy Services:
www.musc.edu/pharmacyservices/medusepol/Adult_Calcium_Guidelines.pdf
4. Calcium Administration Guidelines, Massachusetts General Hospital, Department of
Pharmacy & Department of Nursing Critical Care:
http://www.massgeneral.org/pharmacy/icu%20Guidelines/calcium.htm
5. Calcium Chloride & Calcium Gluconate-IV Dilution, GlobalRPh Inc.
http://www.globalrph.com/calcium_dilution.htm
6. Electrolyte Replacement Protocol, Oregon Health & Science University
www.ohsu.edu/medicine/residency/handouts/pharmpearls/Nephrology/ElectrolyteRe
placementProtocol.pdf
7. Adult Electrolyte Replacement Protocols;
www.surgicalcriticalcare.net/Guidelines/electrolyte_replacement.pdf
8. Monitored Unit Electrolyte Replacement Protocols;
www.emcrit.org/misc/electrolyte_replacement.pdf
9. Electrolyte Infusion Guidelines at University of Kentucky Hospital;
http://www.hosp.uky.edu/Pharmacy/formulary/criteria/electrolyte.htm