From the Guidelines
Calcium should only be administered during cardiac arrest for specific indications: hyperkalemia, hypocalcemia, calcium channel blocker overdose, or hypermagnesemia, as recommended by the most recent guidelines 1.
Indications for Calcium Administration
The use of calcium in cardiac arrest management is restricted to certain scenarios where it can provide a therapeutic benefit by stabilizing cardiac cell membranes and improving myocardial contractility. These scenarios include:
- Hyperkalemia
- Hypocalcemia
- Calcium channel blocker overdose
- Hypermagnesemia
Recommended Dose and Administration
The recommended dose of calcium is 10 mL of 10% calcium chloride (1 gram) or 30 mL of 10% calcium gluconate (3 grams) administered intravenously as a slow push, as suggested by studies 1. This dose may be repeated as needed based on clinical response. It is crucial to administer calcium through a large, secure IV line to avoid tissue damage from extravasation, especially with calcium chloride, which is more irritating to veins than calcium gluconate.
Rationale for Restricted Use
The rationale behind the restricted use of calcium in cardiac arrest is to avoid potential harm, such as worsening cellular injury through calcium overload, which can occur when calcium is administered inappropriately. The most recent and highest quality study 1 supports this approach, emphasizing the importance of using calcium only in specific, well-defined scenarios.
Key Considerations
When considering the administration of calcium during cardiac arrest, it is essential to:
- Identify the underlying cause of the cardiac arrest
- Assess the patient's electrolyte balance and cardiac function
- Administer calcium only when indicated, using the recommended dose and administration route
- Monitor the patient closely for potential adverse effects, such as hypercalcemia By following these guidelines and considering the most recent evidence 1, healthcare providers can optimize the use of calcium in cardiac arrest management and improve patient outcomes.
From the FDA Drug Label
2 DOSAGE & ADMINISTRATION
2.1 Important Administration Instructions Calcium Gluconate Injection contains 100 mg of calcium gluconate per mL which contains 9.3 mg (i.e., 0.465 mEq) of elemental calcium.
2.2 Recommended Dosage Individualize the dose of Calcium Gluconate Injection within the recommended range depending on the severity of symptoms of hypocalcemia, the serum calcium level, and the acuity of onset of hypocalcemia.
The FDA drug label does not answer the question.
From the Research
Calcium Administration in Cardiac Arrest
- The routine use of calcium in cardiac arrest is not recommended, as evidence of benefit from this therapy is lacking 2.
- Studies have shown that calcium administration during cardiac arrest does not improve survival or return of spontaneous circulation (ROSC) 3, 4, 5.
- In fact, calcium administration may have detrimental effects on the heart and vascular smooth muscle, particularly in the presence of electromechanical dissociation or asystole 2.
- The use of calcium in cardiac arrest has been evaluated in various studies, including systematic reviews and randomized controlled trials, with no evidence of benefit found 3, 4, 5.
Specific Indications for Calcium Administration
- There is limited evidence to support the use of calcium in specific situations, such as hyperkalemia, calcium channel blocker intoxication, hypocalcemia, and hypermagnesemia 4.
- In cases of hyperkalemia, ionized hypocalcemia may occur during prolonged resuscitative efforts, which may be related to dysfunctional transcellular ionic transport mechanisms 6.
- However, the routine administration of calcium in these situations is not recommended, and its use should be individualized based on the specific clinical context.
Recommended Dose of Calcium
- There is no established recommended dose of calcium for administration during cardiac arrest, as its use is not supported by current evidence.
- The focus should be on providing high-quality cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) interventions, rather than relying on calcium administration 3, 5.