What is the role of calcium chloride in treating hypovolemic (low blood volume) cardiac arrest?

From the Guidelines

Calcium chloride is not recommended as a routine treatment in hypovolemic cardiac arrest. The standard approach for hypovolemic cardiac arrest focuses on volume resuscitation with isotonic crystalloids (like normal saline or Lactated Ringer's) at 20-30 mL/kg initially, followed by blood products as needed, along with standard ACLS protocols including chest compressions, epinephrine (1 mg IV every 3-5 minutes), and treating the underlying cause of hypovolemia. According to the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1, calcium supplementation, including calcium chloride, may be considered when hyperkalemia or hypermagnesemia is suspected as the cause of cardiac arrest. Key points to consider in the management of hypovolemic cardiac arrest include:

• Volume resuscitation as the first line of treatment
• Use of standard ACLS protocols
• Consideration of calcium chloride (10%, 5-10 mL IV) only in specific situations such as known or suspected hyperkalemia, hypermagnesemia, or other conditions where calcium supplementation is beneficial, as stated in the guidelines 1. In hypovolemic arrest, addressing the underlying volume deficit is paramount, as calcium administration without adequate preload will not improve cardiac output. If calcium is needed, calcium chloride is preferred over calcium gluconate in critical situations because it provides three times more bioavailable calcium, though it requires central venous administration when possible due to its potential to cause tissue necrosis if extravasation occurs.

From the FDA Drug Label

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. The use of calcium chloride in hypovolemic cardiac arrest is not directly addressed in the provided drug label. However, it does mention that calcium chloride is not recommended in the treatment of certain cardiac conditions.

• The label does not provide information on the use of calcium chloride in hypovolemic cardiac arrest. Given the lack of direct information, no conclusion can be drawn about the use of calcium chloride in hypovolemic cardiac arrest 2.

From the Research

Calcium Chloride in Hypovolemic Cardiac Arrest

• There is no direct evidence in the provided studies regarding the use of calcium chloride in hypovolemic cardiac arrest.
• However, the studies discuss the use of crystalloids and colloids for fluid resuscitation in hypovolemic shock, which may be relevant to hypovolemic cardiac arrest.
• A study from 3 found that the use of colloids vs crystalloids did not result in a significant difference in 28-day mortality among ICU patients with hypovolemia.
• Another study from 4 discussed the choice of colloid or crystalloid solutions for fluid resuscitation of critically ill patients and noted that colloidal fluids promptly restore plasma volume and reestablish hemodynamic stability with substantially lesser volumes of fluid.
• A systematic review and meta-analysis from 5 found that crystalloids were less efficient than colloids at stabilizing resuscitation endpoints, but guidance on when to switch is urgently required.
• A study from 6 found that hydroxyethyl starches, gelatins, and albumins had no significant mortality benefit compared to crystalloids in adult patients with hypovolemic shock.
• A study from 7 found that crystalloid resuscitation is not harmful to the lung and is equally as effective as colloid resuscitation, and that crystalloid is markedly less expensive than colloid.

Fluid Resuscitation in Hypovolemic Shock

• The choice of fluid for resuscitation in hypovolemic shock remains controversial, with some studies suggesting that colloids may be more effective at restoring plasma volume and hemodynamic stability 4, 5.
• However, other studies have found that crystalloids are equally effective and less expensive than colloids 3, 7.
• The use of hypertonic saline and other colloids has also been studied, with mixed results 6.

Mortality and Morbidity

• The studies found that the use of colloids vs crystalloids did not result in a significant difference in mortality among ICU patients with hypovolemia 3, 6.
• However, one study found that 90-day mortality was lower among patients receiving colloids compared to crystalloids 3.
• Another study found that crystalloids were associated with a lower risk of pulmonary edema compared to colloids 7.