What is the recommended preparation and administration protocol for a calcium gluconate drip in adult and pediatric patients?

Calcium Gluconate Drip Preparation and Administration

For calcium gluconate infusion, dilute 10 vials (100 mL) of 10% calcium gluconate in 1 liter of normal saline or 5% dextrose and infuse at 50-100 mL/hour, which delivers approximately 0.06-0.12 g/kg/hour in adults. 1, 2

Preparation Protocol

Standard Continuous Infusion

• Dilute 100 mL of 10% calcium gluconate (10 vials containing 1000 mg each = 10 grams total) in 1 liter of normal saline or 5% dextrose 2
• This creates a final concentration of approximately 10 mg/mL calcium gluconate 1
• Each 10 mL vial of 10% calcium gluconate contains 2.2 mmol (93 mg) of elemental calcium 1, 2

Alternative Concentration for Continuous Infusion

• The FDA label permits dilution to concentrations of 5.8-10 mg/mL for continuous infusion 1
• For bolus administration, higher concentrations of 10-50 mg/mL are acceptable 1

Administration Rates

Adults - General Hypocalcemia

• Infuse at 50-100 mL/hour of the diluted solution 2
• This delivers approximately 0.5-1 gram of calcium gluconate per hour
• Titrate to achieve normocalcemia and continue until the underlying cause is treated 2

Adults - Calcium Channel Blocker Toxicity

• Infusion rate: 0.6-1.2 mL/kg/hour of 10% calcium gluconate (0.06-0.12 g/kg/hour) 3, 4
• Alternatively, give initial bolus of 30-60 mL (3-6 grams) over 10-20 minutes, then start continuous infusion 3, 4
• For hemodynamically unstable patients, the American Heart Association recommends 0.6 mL/kg of 10% solution over 5-10 minutes, followed by 0.3 mEq/kg per hour (approximately 0.6 mL/kg/hour of 10% solution) 5, 6

Pediatric Patients

• Continuous infusion: 0.3 mEq/kg per hour, titrated to hemodynamic response 5, 6
• For post-parathyroidectomy: 1-2 mg elemental calcium per kg per hour 4

Critical Safety Measures

Vascular Access

• Administer through a secure central venous catheter whenever possible 5, 4
• If peripheral access is necessary, calcium gluconate is strongly preferred over calcium chloride due to significantly less tissue irritation 3, 4, 6
• Extravasation through peripheral IV can cause severe calcinosis cutis and tissue necrosis 1, 7

Maximum Infusion Rates

• Never exceed 200 mg/minute in adults or 100 mg/minute in pediatric patients during bolus administration 1
• For emergency bolus dosing, 10-20 mL of 10% calcium gluconate can be given over 10 minutes with continuous ECG monitoring 2

Cardiac Monitoring

• Continuous ECG monitoring is mandatory during administration 5, 4, 6, 1
• Stop infusion immediately if symptomatic bradycardia occurs or heart rate decreases by 10 beats per minute 4
• Monitor for arrhythmias, particularly in patients receiving cardiac glycosides 4, 6

Laboratory Monitoring

Serum Calcium Levels

• Measure ionized calcium every 1-4 hours during continuous infusion 1
• For intermittent infusions, measure every 4-6 hours 1
• Avoid severe hypercalcemia (ionized calcium >2× upper limits of normal) 5, 6
• Target ionized calcium: 1.15-1.36 mmol/L 4

Renal Impairment

• Start at the lowest recommended dose and monitor calcium every 4 hours 1

Critical Drug Incompatibilities

Absolute Contraindications for Mixing

• Never mix with ceftriaxone - forms fatal precipitates, absolutely contraindicated in neonates ≤28 days 1
• Never mix with bicarbonate-containing fluids - causes precipitation 1, 2
• Never mix with phosphate-containing fluids - causes precipitation 1, 2
• Never mix with minocycline - calcium complexes and inactivates it 1
• Never administer through the same line as sodium bicarbonate 6
• Do not mix with vasoactive amines 4, 6

Sequential Administration

• In patients >28 days old, ceftriaxone and calcium may be given sequentially only if lines are thoroughly flushed between infusions 1

Special Clinical Situations

Calcium Channel Blocker Poisoning

• Calcium is first-line therapy based on improvement in contractility and blood pressure 3
• Use the higher infusion rates: 0.6-1.2 mL/kg/hour of 10% solution 3, 4

Hyperkalemia with Cardiac Manifestations

• Calcium stabilizes myocardial membranes without lowering potassium 6
• Give 100-200 mg/kg/dose via slow infusion with ECG monitoring 6

Elevated Phosphate Levels

• Exercise extreme caution - increased calcium may precipitate calcium phosphate in tissues causing obstructive uropathy 4, 6
• Consider renal consultation before aggressive replacement 4, 6

Practical Preparation Steps

1. Obtain 10 vials of 10% calcium gluconate (10 mL each) 2
2. Add all 100 mL to 1 liter bag of normal saline or 5% dextrose 2
3. Label clearly with final concentration and preparation time 1
4. Use immediately after preparation 1
5. Inspect for clarity - should be clear and colorless to slightly yellow 1
6. Do not use if particulate matter or discoloration present 1