Download CALCIUM REPLACEMENT IN ADULT PATIENTS To standardize

HOSPITAL NAME
Department:
INSTITUTIONAL POLICY AND PROCEDURE (IPP)
Manual:
TITLE/DESCRIPTION
Section:
POLICY NUMBER
CALCIUM REPLACEMENT IN ADULT PATIENTS
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PURPOSE
To standardize prescribing, preparation, and administration of calcium replacement products to better ensure
safety of patients.
RESPONSIBILITY
The use of calcium replacement products may easily lead to errors by physicians, pharmacists, and nurses if
detail is not emphasized. There are two intravenous calcium preparation on the Formulary, with differing safety
and efficacy profiles. Extravasations with both calcium chloride and calcium gluconate have been documented,
with outcomes often leading to extensive morbidity secondary to local pain, edema, and induration, progressing
to calcinosis cutis or formation of deep necrotic lesions. Intravenous calcium products are often used for mild
hypocalcemia when oral replacement would be appropriate.
CROSS REFERENCES
POLICY
PROCEDURE
1.Prescription Writing Requirements:
a. All orders for calcium replacement therapy must be written in units of the salt form. For example :give
1 gram calcium gluconate over 30 minutes.
b. Intravenous Calcium Gluconate
i.
The ONLY intravenous calcium to be used on the floors under normal circumstances.
ii.
May be given IV push in the ICU’s, or on all patient care units during Maydays or in
emergency situations once in 12 hours only (refer to IV push chart).
c. Intravenous Calcium Chloride
i.
Infusions may ONLY be given in the ICUs. This does not preclude the use of calcium
gluconate in the ICU’s.
ii.
May be given IV push in the ICU’s, or on all patient care units during Maydays or in
Emergency situations once in 12 hours only (refer to IV push chart).
iii.
May ONLY be given through a central line unless during a Mayday.
d. The maximum concentration that will be dispensed for infusion is 2 grams of calcium gluconate or
chloride / 50 ml. Dextrose 5 % or other appropriate IV fluid if specified.
e. No more than 4 grams of calcium gluconate or chloride will be given over 1 hour.
• For patients receiving plasmapheresis, average orders are for 8 to 10 grams of calcium
gluconate in 250 cc of normal saline to run at 100 cc/hr (4 grams / hr).
• Close monitoring is recommended for all patients receiving the maximum dose.
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Standards
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2. Intravenous Administration
a. The forearm is the ideal peripheral venipuncture for administration of calcium gluconate, provided good
access is available. Calcium should only be given with extreme caution through a hand, foot, finger,
scalp, or joint vein or any area over a bony prominence.This is specially true for patients with poor
peripheral circulation (e.g. diabetics).
b. Larger gauge needles are preferred for all calcium gluconate infusions (preferably 20 gauge or larger).
c. Always assess patency of IV prior to administration of intravenous calcium by checking for blood return.
d. Transparent dressings should be used, and the site of venipuncture should not be obscured with tape.
3.Management of Extravasation
a. If calcium extravasation occurs the following measures should be taken:
i.
Leave the needle in place.
ii.
Aspirate any residual drug and blood in the I.V. catheter, needle, and suspected extravasation
site.
iii.
Remove the I.V.catheter.
iv.
Elevate the affected area.
v.
Apply a cold pack immediately for 15 minutes, reapply for 15 minutes four times a day for
24-48 hours.
vi.
Notify the physician for evaluation as soon as possible.
vii.
Document the date, time, IV catheter size and type, insertion site, drug administration
technique, appropriate amount of drug extravasated, management, patient complaints,
appearance of site, physician notification, and follow-up measures.
viii. For in patients, assess the site every day for pain, erythema, induration, or skin breakdown.
For outpatients, contact the patient daily for 3 days for assessment of site, and weekly
thereafter until the problem is resolved.
ix.
The plastic surgery service may be consulted by the physician if pain and / or tissue
breakdown occur.
4. Miscellaneous Information:
Refer to the calcium dosing card for information regarding dosing of both oral and intravenous products.
The dosing card and policy and procedures can be found on the web in the Pharmacy P&P manual or in the
“Medication Administration” policy .
Guidelines for Calcium Replacement in Adults (F36)
The normal laboratory range for calcium is 8.4 – 10.2 mg./dl. For mild to moderate, asymptomatic hypocalcemia
(corrected calcium > 7.5 mg/dl, oral agents may be used .Oral calcium-containing agents available on the
Formulary of Accepted Drugs include:
Table 1: Calcium – Containing Oral Products
Formulary Product
Dosage Strength
(mg of salt)
648 mg
Calcium Carbonate
1250 mg
Tablet 600 or 1250
mg(e.g.Oscal 500)
Calcium Carbonate
500 mg
Chewable tablet 500 or
750 mg
JCI
Standards
Calcium Content
Elemental Calcium
(mg)
260 mg
500 mg
200 mg
300 mg
Percent
Elemental Calcium
40 %
40 %
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750 mg (Tums®,Tums EX®)
Calcium Carbonate
Suspension 1250 mg/5
ml
Calcium Glubionate
Syrup 1800 mg / 5 ml
(e.g.Neo-Calglucon®)
1250 mg / 5 ml
500 mg / 5 ml
40 %
1800 mg / 5 ml
126 mg / 5 ml
6.5 %
For moderate to severe hypocalcemia (corrected calcium < 7.5 mg/dl or symptomatic), parenteral calcium
replacement is indicated.Parenteral calcium – containing agents available on the Formulary Accepted Drugs:
Table II: Calcium Containing Intravenous Products
Product Name
Calcium Content
mg of the salt
Calcium Gluconate
100 mg / ml
Calcium Chloride
100 mg / ml
Table III: Calcium Replacement in Adults
Indication
Mild, asymptomatic Hypocalcemia (corrected
calcium 8.0 – 8.4 mg / dl)
Moderate hypocalcemia (corrected calcium < 8.0 ≥
7.5 mg/dl)
Severe hypocalcemia (corrected calcium < 7.5
mg/dl.)
mg. Of elemental calcium
9 mg / ml
27 mg / ml
Dose
Oral Replacement:
1000 – 3000 mg of ELEMENTAL CALCIUM
divided into doses of ≤ 1 gram each. This is
equivalent to:
Calcium carbonate 2500 – 7500 mg(2-6 1250 mg
tablets or 2-6 teaspoonful per day)
* The use of calcium carbonate is suggested as it has
the highest amount of elemental calcium per dosing
unit.
Consider Oral replacement as above if
asymptomatic. Otherwise may give parenteral
calcium gluconate
Calcium Gluconate 1 – 2 grams IV in 50 ml
Dextrose 5 % over 30 minutes.
Parenteral Calcium Gluconate
Calcium Gluconate 2 grams IV in 50 ml Dextrose 5
% over 30 minutes.
Recheck levels in 2 hours.
Clinical Practice Points:
1. Intravenous calcium MUST be ordered in mg or grams of the salt,”1 ampule …” is not acceptable.
2. Calcium gloconate is the ONLY intravenous calcium to be used on the floors under normal
circumstances. It may be given IV push in the ICUs, or on all patient care units during Maydays or in
JCI
Standards
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emergency situations once in 12 hours only (refer to iv push chart)
3. Calcium chloride infusions may ONLY be used in the ICUs. It may be given IV push in the ICUs, or on
all patient care units during Maydays or in emergency situations once in 12 hours only (refer to IV push
chart). Calcium chloride may ONLY be given through a central line unless during a Maydsy.
4.The maximum concentration that will be dispensed is 2 grams of calcium gluconate or chloride / 50 ml IV
fluid (Dextrose 5 % will be used unless otherwise specified).
5. No greater than 4 grams calcium gluconate or chloride will be given over 1 hour. “Close monitoring is
recommended of all patients receiving maximum dose.
6. Falsely low levels of calcium due to hypoalbuminaemia should be excluded by calculation of corrected
calcium: Corrected calcium (mg/dl) + 0.8{ 4-serum albumin(g/dl)}
7. Monitor vital signs, being alert for bradycardia, dysrhythmias and postural hypotension.
8.When switching a patient to an alternate calcium salt, remember to calculate the new dose based on equivalent
amount of elemental calcium.
9. Check magnesium level and correct if low.
10. Calcium may potentiate digitals toxicity, careful monitoring of patients on digoxin is advised.
11.Caution in patients with elevated Phosphorus levels. Calcium – phosphorus solubility products > 60-70
mg2/dl2 may produce calcium – phosphate soft tissue deposition. Treatment of hyperphosphatetic /
hypocalcemic patients should generally be aimed at decreasing serum phosphorus.
12. In order to avoid precipitation calcium/ phosphorus in TPN replacement, the maximum amount of Calcium +
Phosphorus is 25/L with Travasol and 40 /l with TrophAmine.
13. Oral calcium may decrease the bioavailability of tetracyclines, fluoroquinolones , iron, and atenolol.
14. Consider checking PTH level in patients resistant o therapy.
15.Chronic oral calcium and vitamin D therapy may be required if underlying condition is not corrected.
16. Do not infuse calcium in the same line as phosphorus (e.g.parenteral nutrition).
17. Give PO calcium after meals to maximize solubility and absorption.
18.Patients may report a metallic or chalky taste when receiving IV calcium.
19. Avoid infusing calcium containing solutions through IV catheters with tenous access or those in veins of the
scalp, hands, or feet if possible.
FORMS
EQUIPMENT
REFERENCES
1.Bushinsky DA and Monk RD, Lancet 1998:352;306 – 311.
2.Eastell R and Heath H. The Hypocalcemic State.In.Favus MJ and Coe FL ed. Disorders of Bone and Mineral
Metabolism, New York; Raven Press 1992: 571-85
3.Institute of Safe Medication Practice (ISMP) Medication Safety Alert May 7,1997.
4.Lee,CAB,Barnet C. and Ignatavicius D. Fluids and Electrolytes: A Practice Approach,4th ed.
Philadelphia,PA;F.A. Davis Company,1996:99-103.
5.Olin,BR,ed.Drug Facts and Comparisons.St Louis,MO:Facts and Comparisons, Inc.2001:27-28
6. Shane E.Hypocalcemia: Pathogenesis; Differential Diagnosis, and Management. In:Murray JF,Christakos S et
al,ed. Primer in the metabolic Bone Diseases and Disorders of Mineral Metabolism, 4th ed. Philadelphia,
PA: Lippincott Williams and wikkins,1999: 223-226.
7. Singer FR. Medical Management of Non-Parathyroid Hypercalcemia and Hypocalcemia. Otolaryngol Clin
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Standards
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North Am 1996;29:701-711.
8. Tohme JF and Bilezikian JP. Hypocalcemic Emergencies. Endocrin Metab Clin North Am 1993;22:363-375.
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