How to administer IV calcium chloride?

How to Administer IV Calcium Chloride

Administer calcium chloride 10% solution at 2000 mg (20 mL) for adults or 20 mg/kg (0.2 mL/kg) for pediatric patients by slow IV push not exceeding 1 mL/min, preferably through a central venous line with continuous ECG monitoring. 1, 2

Standard Dosing and Administration Rate

Adult Dosing

• Give 2000 mg (20 mL of 10% solution, equivalent to 28 mEq Ca²⁺) as the standard dose 1
• The FDA-approved dosing range for hypocalcemic disorders is 200-1000 mg (2-10 mL) at intervals of 1-3 days depending on patient response 2
• Never exceed 1 mL/min administration rate 1, 2

Pediatric Dosing

• Administer 20 mg/kg (0.2 mL/kg of 10% solution, equivalent to 0.28 mEq Ca²⁺/kg) 1
• FDA-approved range is 2.7-5.0 mg/kg (0.027-0.05 mL/kg of 10% solution) 2
• Repeat dosing every 4-6 hours may be necessary 2

Route of Administration: Central vs Peripheral Access

Strongly Prefer Central Venous Access

• Central line administration is strongly recommended, especially in pediatric patients, to prevent severe tissue necrosis from extravasation 1, 3
• The American Heart Association specifically recommends central line use for calcium chloride in children with calcium channel blocker toxicity 3
• Extravasation through peripheral IV can cause severe skin and soft tissue injury requiring debridement and skin grafting 4, 3, 5

When Peripheral Access Is the Only Option

• If central access is unavailable in emergent situations, peripheral administration may be considered with extreme caution 6
• A retrospective study showed 6% incidence of infusion-related adverse events with peripheral 10% calcium chloride, though none resulted in permanent tissue injury 6
• However, calcium gluconate is strongly preferred over calcium chloride for peripheral administration due to significantly less tissue irritation 4, 3
• If using peripherally, administer into large veins and dilute appropriately 5

Critical Monitoring Requirements

Continuous ECG Monitoring

• Maintain continuous ECG monitoring throughout the entire infusion 1
• Stop infusion immediately if symptomatic bradycardia occurs or heart rate decreases by 10 beats per minute 1
• Enhanced monitoring is required in patients on cardiac glycosides due to increased arrhythmia risk 1

Laboratory Monitoring

• Monitor ionized calcium levels during infusion to avoid severe hypercalcemia (>2 times upper limit of normal) 1
• Ionized calcium concentrations should guide dosage adjustments 2

Patient Monitoring During Administration

• Halt injection if patient complains of any discomfort at the injection site; resume only when symptoms disappear 2, 5
• Patient should remain recumbent for a short time following injection 2
• If time permits, warm solution to body temperature before administration 2

Specific Clinical Indications and Dosing

Cardiac Arrest

• Calcium chloride is the preferred calcium salt during cardiac arrest due to more rapid increase in ionized calcium concentration compared to calcium gluconate 1, 3
• Standard adult dose: 2000 mg IV push 1

Calcium Channel Blocker Toxicity

• Initial bolus: 2000 mg for adults, 20 mg/kg for pediatric patients 1
• Maintenance infusion: 20-40 mg·kg⁻¹·h⁻¹ (0.28-0.56 mEq·kg⁻¹·h⁻¹) for both adults and pediatric patients 1
• Titrate to hemodynamic response and ionized calcium levels 1

Hyperkalemia with Cardiac Manifestations

• Administer IV calcium immediately as part of standard ACLS care 4
• Standard adult dose: 2000 mg 1

Critical Safety Considerations

Absolute Contraindications for Administration Method

• Never inject intramuscularly or subcutaneously 2
• Do not mix with vasoactive amines 4
• Never administer through the same line as sodium bicarbonate or phosphate-containing fluids 4

Special Populations

• Patients on cardiac glycosides require enhanced monitoring due to increased risk of arrhythmias 1
• Exercise caution when phosphate levels are elevated, as calcium may precipitate causing obstructive uropathy 4

Concentration Awareness

• 10% calcium chloride = 100 mg/mL = 27 mg elemental calcium/mL = 1.4 mEq/mL 2
• One 10 mL syringe provides 270 mg of elemental calcium 2
• Be aware that dosing recommendations may reference either calcium chloride amount or elemental calcium amount 2

Common Pitfalls to Avoid

• Do not confuse calcium chloride with calcium gluconate dosing: Calcium chloride contains approximately 2.3 times more elemental calcium than calcium gluconate per volume 7
• Do not administer rapidly: Rapid infusion can cause hypotension, bradycardia, and cardiac arrhythmias 4
• Do not ignore patient complaints of injection site discomfort: This may indicate extravasation requiring immediate cessation 2, 5
• Do not use peripheral access in pediatric patients unless absolutely unavoidable: Central access is strongly preferred 1, 3