Calcium Gluconate

PRIOR HOLD RESOLVED: the earlier draft was built on a mis-fetched bundle (eMC arm was the 'Calvive 1000 Effervescent Tablets' ORAL SPC, forcing the whole page onto US-only 'Calcium Gluconate in Sodium Chloride' premixed bags). The bundle has since been re-fetched and the eMC arm is now the correct UK SPC for 'Calcium Gluconate 10% solution for injection/infusion BP' (medicines.org.uk/emc/product/6264/smpc). All figures above are from that UK SPC. PRODUCT-STRENGTH SAFETY (SPC section 4.4): calcium gluconate and calcium chloride are both presented in 10 ml ampoules at 10% w/v but are NOT equivalent in calcium content — 10 ml of Calcium Gluconate 10% contains 2.23 mmol calcium, whereas 10 ml of calcium chloride 10% contains 6.8 mmol calcium. The difference must be accounted for when using either salt, to avoid medication errors. OTHER ADULT INDICATIONS (SPC section 4.2). Acute severe hyperkalaemia with or without ECG changes (serum potassium above 6.5 mmol/L): 30 ml of the 10% solution (6.69 mmol calcium) undiluted as a slow intravenous injection over 10 minutes; further doses can be considered after 5 minutes if needed, until ECG improvement is achieved. Cardiac arrest due to hyperkalaemia: 30 ml of the 10% solution (6.69 mmol calcium) undiluted as a rapid intravenous injection; further doses can be repeated if return of spontaneous circulation is not achieved within 5 to 10 minutes, or if the resuscitation attempt is prolonged (onset of action within three minutes, duration of action 30 to 60 minutes). Fluoride (e.g. hydrofluoric acid) or lead poisoning-induced hypocalcaemia: 10 to 30 ml of the 10% solution intravenously (2.23 to 6.69 mmol calcium); in severe hypocalcaemia an infusion may be required, e.g. 40 ml (8.92 mmol calcium) intravenously over 1 hour, with serum calcium monitored if repeated doses are given or if calcium is given as an infusion — the UK National Poisons Information Service should be consulted for further specific advice. ADMINISTRATION WARNINGS (section 4.4): must not be mixed with, or administered through the same intravenous line as, sodium bicarbonate (sometimes used in severe hyperkalaemia) because of the risk of precipitation; physically incompatible with many compounds, and serious complications including fatalities have occurred following microcrystallisation of insoluble calcium salts after separate administration of physically incompatible solutions. PAEDIATRIC (SPC section 4.2 — reproduced for completeness; paedDose is left null because the SPC gives several different per-kg volumes by age band and by indication rather than one clean per-kg dose. Verify against a children's formulary before use.) Close plasma-calcium and ECG monitoring are necessary until normal calcium values are achieved. Acute symptomatic hypocalcaemia by slow intravenous injection: neonates (0 to 27 days) a single dose of 1 ml/kg body weight of the 10% solution (0.22 mmol calcium/kg) undiluted over 5 to 10 minutes, with lower doses of 0.5 ml/kg (0.11 mmol calcium/kg) also shown to be effective in alleviating hypocalcaemic symptoms; children (28 days to under 18 years) a single dose of 0.3 to 0.6 ml/kg (0.07 to 0.13 mmol calcium/kg) undiluted over 5 to 10 minutes. In both bands the rate of administration should not exceed 0.22 mmol calcium/min. Acute symptomatic hypocalcaemia by slow continuous infusion: neonates (0 to 27 days) initially 0.2 to 0.3 ml/kg body weight/hour (0.04 to 0.07 mmol calcium/kg) diluted 1:10, with an initial rate of 0.1 ml/kg/hour (0.02 mmol calcium/kg/hour) also shown to be effective, maximum rate 0.1 ml/kg/hour (0.022 mmol/kg/hour); children (28 days to under 18 years) initially 0.08 ml/kg/hour (0.02 mmol calcium/kg/hour) diluted 1:10, maximum rate 0.2 ml/kg/hour (0.045 mmol/kg/hour). Hyperkalaemic cardiac arrest (and acute severe hyperkalaemia, for which the SPC directs that the cardiac arrest regimen be followed): neonates and children 0.5 ml/kg of the 10% solution (0.11 mmol calcium/kg) by slow intravenous injection over 5 to 10 minutes, repeatable if ECG changes persist after 5 to 10 minutes. Fluoride or lead poisoning: children 0 to under 18 years, 0.5 ml/kg (0.11 mmol calcium/kg) over 5 minutes. In children weighing 20 kg or more a maximum of 20 ml of the 10% solution (4.46 mmol calcium) can be given. An overall maximum dose of 1 ml/kg of the 10% solution (0.22 mmol calcium/kg) is recommended in children from 0 to under 18 years because of the risk of aluminium exposure. HEPATIC IMPAIRMENT: hepatic function does not impact the availability of ionised calcium after intravenous calcium gluconate, and dose adjustment may not be necessary. ELDERLY: no evidence that tolerance is directly affected by advanced age, but impaired renal function and poor diet may indirectly affect tolerance and may require a dose reduction. US CROSS-CHECK ONLY (do not apply to UK ampoules): the openFDA arm is 'Calcium Gluconate in Sodium Chloride Injection' (WG Critical Care), a ready-diluted premixed bag that must NOT be further diluted; it expresses adult dosing as 1,000 to 2,000 mg of calcium gluconate, repeatable every 6 hours, or a continuous infusion initiated at 5.4 to 21.5 mg/kg/hour, with bolus rate not exceeding 200 mg/minute in adults. Those figures are salt (calcium gluconate) mass, not elemental calcium, and do not transfer to the UK 10% (100 mg/ml) ampoule. eMC sections 4.4 and 4.8 were truncated at the source-fetch limit.