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# Calcium Gluconate ## Overview Calcium gluconate is an inorganic salt used to treat and prevent hypocalcemia and as an antidote for certain toxicities. It is available in oral and intravenous (IV) formulations. ## Primary Indications * **Hypocalcemia:** Treatment of severe symptomatic hypocalcemia (e.g., tetany, seizures, cardiac arrhythmias). * **Other:** * Antidote for magnesium sulfate overdose. * Antidote for hydrofluoric acid (HF) burns (topical). * Adjunctive treatment in hyperkalemia (intended to stabilize cardiac membranes, not to lower potassium). * Treatment of calcium channel blocker overdose. ## Adult Dosing **Intravenous (IV) Dosing:** * **Hypocalcemia:** * **Acute symptomatic hypocalcemia:** 10 mL of 10% calcium gluconate (equivalent to 90 mg elemental calcium or 4.5 mEq) administered slowly over 5-10 minutes. May be repeated every 10-20 minutes as needed based on clinical response and serum calcium levels. * **Continuous infusion:** 1-3 g of elemental calcium (equivalent to 10-30 g of 10% calcium gluconate) per 1000 mL of dextrose 5% in water (D5W) at a rate of 20-50 mL/hour. *Specific infusion rates and concentrations depend on local protocol and patient's electrolyte needs.* * **Magnesium Sulfate Overdose:** 10 mL of 10% calcium gluconate (90 mg elemental calcium) IV every 1-4 minutes until symptoms improve. * **Calcium Channel Blocker Overdose:** Initial bolus of 10-20 mL of 10% calcium gluconate (90-180 mg elemental calcium) IV, followed by infusion of 1-5 mg/kg/hour. *Dosing can vary significantly; consult advanced toxicology resources.* * **Hyperkalemia:** 10 mL of 10% calcium gluconate (90 mg elemental calcium) IV over 2-5 minutes. *This does not lower potassium levels.* **Oral Dosing:** * **Hypocalcemia prevention/treatment:** Varies based on indication and formulation. Typical elemental calcium doses range from 1-2 g daily, divided into multiple doses. ## Pediatric Dosing **Intravenous (IV) Dosing:** * **Hypocalcemia:** * **Neonates (less than 1 year):** 1-2 mL/kg of 10% calcium gluconate (equivalent to 9-18 mg elemental calcium/kg or 0.45-0.9 mEq/kg) administered slowly over 10-20 minutes. *Infusion rate must be slow given risk of bradycardia.* * **Infants and Children:** 1-2 mL/kg of 10% calcium gluconate (equivalent to 9-18 mg elemental calcium/kg or 0.45-0.9 mEq/kg) administered slowly over 5-10 minutes. May be repeated every 10-20 minutes as needed. * **Continuous infusion:** 1-3 g of elemental calcium (equivalent to 10-30 g of 10% calcium gluconate) per 1000 mL D5W at a rate of 20-50 mL/hour. *Specific infusion rates and concentrations depend on local protocol and patient's electrolyte needs.* * **Magnesium Sulfate Overdose:** 1-2 mL/kg of 10% calcium gluconate (9-18 mg elemental calcium/kg) IV every 1-4 minutes until symptoms improve. Maximum dose not well established, use caution. **Oral Dosing:** * Dosing varies based on indication and formulation. Refer to pediatric-specific guidelines or consult a pediatrician. ## Dose Adjustments * No specific dose adjustments are generally required for hepatic or renal impairment, but serum calcium and electrolyte levels should be closely monitored. In severe renal impairment, caution is advised with IV calcium due to potential for hypercalcemia. ## Contraindications * **Hypercalcemia:** IV calcium gluconate is contraindicated in patients with hypercalcemia. * **Ventricular fibrillation:** In patients with ventricular fibrillation, IV calcium should be used with extreme caution. * **Renal calculi:** Oral calcium may be cautioned in patients with a history of renal calculi, although this is debated. * **Known hypersensitivity:** To calcium gluconate. ## Adverse Effects **Most Common:** * Local irritation, phlebitis (with IV administration). * Hypotension, bradycardia, arrhythmias (especially with rapid IV administration). * Constipation, nausea, vomiting (with oral administration). * Warm sensation, metallic taste. **Serious:** * Hypercalcemia (headache, confusion, anorexia, nausea, vomiting, polyuria, constipation, cardiac arrhythmias, coma). * Extravasation injury (tissue necrosis; monitor IV site closely). ## Key Drug Interactions * **Digoxin:** IV calcium can potentiate digoxin toxicity, especially in patients with hypercalcemia or hypokalemia. * **Tetracyclines and Fluoroquinolones:** Oral calcium can reduce the absorption of these antibiotics; administer at least 2 hours before or 4-6 hours after. * **Bisphosphonates:** Oral calcium can decrease the absorption of bisphosphonates; administer at least 2 hours before or after. * **Thiazide Diuretics:** Can increase serum calcium levels, potentially leading to hypercalcemia. * **Sodium Polystyrene Sulfonate:** Concurrent use may reduce efficacy. ## Monitoring * **Serum Calcium Levels:** Essential for guiding dosing and monitoring efficacy. Correct for albumin levels if needed. * **Electrocardiogram (ECG):** For patients receiving IV calcium, especially those with cardiac conditions or receiving rapid infusions, to monitor for arrhythmias. * **Renal Function:** Monitor for signs of hypercalcemia (e.g., polyuria). * **Magnesium and Phosphate Levels:** These electrolytes can influence calcium balance. * **IV Site:** For signs of extravasation. ## Clinical Pearls * **IV Administration:** Always administer IV calcium gluconate slowly and with continuous cardiac monitoring, especially in neonates and patients with cardiac disease, due to the risk of bradycardia, hypotension, and arrhythmias. * **Extravasation:** If extravasation occurs, stop infusion immediately and consult institutional protocol for management, which may include infiltration with hyaluronidase. * **Compatibility:** Calcium gluconate is incompatible with many medications and solutions, including sodium bicarbonate, phosphates, and fluorouracil. Always check compatibility charts or consult pharmacy. * **Oral vs. IV Elemental Calcium:** Oral calcium gluconate contains less elemental calcium per gram than calcium carbonate (9% vs. 40%). IV calcium gluconate contains approximately 90 mg of elemental calcium per 10 mL of a 10% solution. * **Albumin-Corrected Calcium:** For interpretation of serum calcium levels, especially in patients with altered albumin levels, consider calculating an albumin-corrected calcium level. *** **Disclaimer:** This information is intended for clinical use and does not substitute for professional medical advice. Always consult the most current prescribing information, institutional protocols, and relevant literature before making treatment decisions. Dosing may vary based on individual patient factors and specific clinical circumstances.