What is the proper dilution of 10 milliliters (mml) of calcium gluconate for administration in hyperkalemia?

From the Guidelines

For administration in hyperkalemia, dilute 10 ml of 10% calcium gluconate in 100 ml of 5% dextrose or normal saline solution, as recommended by the most recent guidelines 1. This diluted solution should be administered intravenously over 2-3 minutes for acute treatment. The standard adult dose is 10-20 ml of 10% calcium gluconate (1-2 grams) 1. Key considerations for administration include:

• Monitoring the patient's ECG during administration, as rapid infusion can cause cardiac arrhythmias.
• Understanding that calcium gluconate works by temporarily antagonizing the cardiac membrane effects of hyperkalemia, providing protection to the heart while other measures are taken to reduce serum potassium levels.
• Recognizing that this effect begins within 1-3 minutes but only lasts 30-60 minutes 1.
• Noting that calcium gluconate does not actually lower potassium levels but provides cardiac protection while other treatments (insulin with glucose, sodium bicarbonate, or potassium-binding resins) work to reduce serum potassium.
• Avoiding administration through the same IV line as bicarbonate solutions to prevent precipitation. Given the potential for variable efficacy and significant adverse effects associated with other treatments like sodium polystyrene sulfonate 1, the use of calcium gluconate as part of a comprehensive approach to managing hyperkalemia is supported by recent clinical guidelines 1.

From the FDA Drug Label

Dilute the dose of Calcium Gluconate Injection in 5% dextrose or normal saline to a concentration of 10-50 mg/mL prior to administration. To administer 10 milliliters (mL) of calcium gluconate, it should be diluted to a concentration of 10-50 mg/mL.

• For a bolus administration, the 10 mL of calcium gluconate can be diluted in 100-200 mL of 5% dextrose or normal saline to achieve a concentration within the recommended range.
• For a continuous infusion, the 10 mL of calcium gluconate can be diluted in 50-170 mL of 5% dextrose or normal saline to achieve a concentration within the recommended range of 5.8-10 mg/mL 2.

From the Research

Administration of Calcium Gluconate in Hyperkalemia

• The proper dilution of 10 milliliters (mL) of calcium gluconate for administration in hyperkalemia is not explicitly stated in the provided studies as a specific dilution ratio.
• However, according to 3, calcium gluconate 10% dosed 10 mL intravenously should be provided for membrane stabilization in hyperkalemia, unless the patient is in cardiac arrest.
• Additionally, 4 provides guidance on the administration of calcium gluconate in the context of hypocalcaemia, suggesting an initial dose of 10–20 mL 10% calcium gluconate in 50–100 mL of 5% dextrose i.v. over 10 min with ECG monitoring.

Equivalent Dosing

• 4 also provides information on the dose equivalence of calcium gluconate and calcium chloride, stating that each 10 mL vial of 10% calcium gluconate contains 2.2 mmol of calcium.
• If using calcium chloride in place of calcium gluconate, the required volume should be calculated, aiming to achieve 2.2–4.4 mmol i.v. loading bolus followed by a 1.1–2.2 mmol/h maintenance infusion 4.

Clinical Considerations

• The effectiveness of calcium gluconate in treating hyperkalemia has been studied, with 5 finding that IV Ca-gluconate therapy was effective, albeit to a limited degree, in main rhythm ECG disorders due to hyperkalemia.
• However, the use of calcium gluconate in hyperkalemia is not without controversy, with 6 highlighting the need for clarity in emergency treatment algorithms regarding the amount of calcium in calcium chloride preparations.