Calcium chloride is available for intravenous use and is indicated for the treatment of symptomatic or asymptomatic hypocalcemia. Symptomatic hypocalcemia may present as carpopedal spasm, tetany, seizures, and arrhythmias. It is also indicated for the treatment of severe hypermagnesemia.

Off-label uses of calcium chloride in adults include:

• Treatment of Beta-blocker overdose
• For Calcium channel blocker overdose
• For severe Hyperkalemia
• For the treatment of malignant arrhythmias, such as the hypermagnesemia-related cardiac arrest

Calcium chloride Dose in Adults

 Note:

• 1 gm of calcium chloride salt = 270 mg of elemental calcium.
• Calcium ion is present in 1.4 mEq (27 mg)/mL in a 100 mg/mL (10%) solution.

Off label use for treating Beta-blocker overdose: 

• 20 mg/kg Intravenous over 5 - 10 minutes to a maximum of 1 to 2 g/dose using a 10% solution.
• For a total of three or four doses, the dose may be given again every 10 to 20 minutes, or a continuous infusion of 20 to 40 mg/kg/hour may be  started and titrated in accordance with the patient's reaction.

Off label use in the treatment of Calcium channel blocker overdose:

• 20 mg/kg Intravenous over 5 - 10 minutes to a maximum of 1 to 2 g/dose using a 10% solution.
• The dose may be repeated every 10 - 20 minutes for 3 or 4 additional doses or
• a continuous infusion of 20 - 40 mg/kg/hour may be administered and titrated according to the patients' response.

Use for treating Cardiac arrest or cardiotoxicity due to hyperkalemia, hypocalcemia, or hypermagnesemia:

• 500 - 1,000 mg Intravenous over 2 - 5 minutes
• Repeat the dose according to the patients' response.

Use in the treatment of Hypocalcemia:

• Symptomatic acute hypocalcemia:
  • 200 - 1,000 mg Intravenous every 1 - 3 days
• Severe hypocalcemia manifested by seizures and tetany:
  • 1,000 mg intravenous over 10 minutes.
  • If the symptoms don't go away after 60 minutes, the dose can be given again.

Note: Calcium gluconate is the preferred agent in asymptomatic patients.

Calcium chloride Dose in Childrens

 Note: 1 gm of calcium chloride salt = 270 mg of elemental calcium.

Daily maintenance calcium:

• Infants and Children less than 25 kgs:
  • 1-2 mEq/kg/day intravenous
• Children 25-45 kg:
  • 5 - 1.5 mEq/kg/day intravenous
• Children more than 45 kgs and Adolescents:
  • 2 - 0.3 mEq/kg/day or 10-20 mEq/day intravenous

For maintaining requirement of Parenteral nutrition:

• Infants and Children 50 kg or less:
  • 5-4 mEq/kg/day
• Children more than 50 kg and Adolescents:
  • 10-20 mEq/day

Use in the treatment of Hypocalcemia:

• Infants, Children, and Adolescents:
  • 2.7 - 5 mg/kg/dose every 4-6 hours intravenous to a maximum dose of 1000 mg (according to the manufacturer) OR
  • 10-20 mg/kg/dose to a maximum dose of 1000 mg intravenous. Repeat the dose every 4 - 6 hours if needed

Note: Calcium gluconate is the preferred formulation

Use for treating Cardiac arrest with hyperkalemia or hypocalcemia, hypermagnesemia, or calcium channel antagonist toxicity:

• Infants, Children, and Adolescents:
  • 20 mg/kg/dose intravenous to a maximum dose of 2000 mg
  • The dose may be repeated in 10 minutes or it may be given as an intravenous infusion at 20-50 mg/kg/hour

Use for treating Calcium channel blocker toxicity:

• Infants, Children, and Adolescents:
  • 20 mg/kg/dose intravenous infused over 5-10 minutes
  • Intravenous infusion of 20-50 mg/kg/hour may also be given.

Use for treating Hypocalcemia secondary to citrated blood infusion:

• Infants, Children, and Adults:
  • 0.45 mEq of elemental calcium for each 100 mL citrated blood infused.

Use for treating Tetany:

• Infants, Children, and Adults:
  • 10 mg/kg intravenous over 5-10 minutes
  • After six hours, the dose can be repeated, or a 200 mg/kg/day maximum infusion dose can be used.

Calcium chloride pregnancy risk factor: C

• It has not yet been tested in pregnant women.
• Calcium chloride crosses over the placental boundary
• Calcium requirements for pregnant and unpregnant women are identical.
• It should only be used if indicated for cardiac arrhythmias.

Calcium Chloride use during breastfeeding:

• It can be found in breastmilk and can also be used by lactating mothers.
• Both lactating and nonlactating females require calcium.

Calcium chloride Dose in Renal Disease:

• Dose adjustment is not necessary initially.
• The next dose should be changed in accordance with the serum calcium levels.

Calcium chloride Dose in Liver Disease:

• Dose adjustment is not necessary initially.
• The next dose should be changed in accordance with the serum calcium levels.

Common Side effects of Calcium Chloride Include:

• Cardiovascular (with rapid intravenous injection):
  • Cardiac arrest
  • Bradycardia
  • Cardiac arrhythmia
  • Syncope
  • Hypotension
  • Vasodilatation
• Central nervous system:
  • Tingling sensation (with rapid intravenous injection)
  • Feeling abnormal (sense of oppression especially with rapid intravenous injection)
• Endocrine & metabolic:
  • Hypercalcemia
  • Hot flash (with rapid intravenous injection)
• Gastrointestinal:
  • Gastrointestinal irritation
  • chalky taste
  • Increased serum amylase
• Local:
  • Local tissue necrosis (following extravasation)
• Renal:
  • Nephrolithiasis

Contraindication to Calcium Chloride include:

• Digoxin toxicity, known or suspected.

Warnings and Precautions

• Extravasation:
  • Before and during infusion, ensure that the needle, cannula, or line is correctly placed.
  • Extravasation can cause severe necrosis or sloughing, so be sure to monitor the infusion site.
• Acidosis:
  • It can cause acidosis. Patients with respiratory impairment, respiratory acidosis or respiratory failure should not use it.
• Hyperphosphatemia
  • It can cause soft tissue calcium-phosphate precipitation in patients with hyperphosphatemia.​​​​​​​
• Hypokalemia
  • Patients who have severe hypokalemia may develop life-threatening arrhythmias if it is not treated.
• Hypomagnesemia:
  • Patients with refractory hypocalcemia should be treated for hypomagnesemia, a common kind of hypocalcemia.

• Renal impairment
  • Patients with impaired renal function should not use it. The levels of the drug should be closely monitored.

• Ceftriaxone
  • Ceftriaxone may precipitate when combined with calcium. This can cause a calcium-ceftriaxone precipitate, which can damage the lungs, kidneys and reproductive systems, particularly in neonates.
  • It should be administered at separate times and infusion sites.

• Digoxin:
  • Hypercalcemia may precipitate cardiac arrhythmias. This should be avoided in digitalized patients.

• Aluminium:
  • Aluminum can accumulate in calcium chloride products if it is given in high doses to patients with kidney impairment and for a prolonged period.
  • Aluminum can cause CNS and bone toxicity.

Calcium chloride: Drug Interaction

Monitor:

• Serum calcium and ionized calcium
• Serum albumin
• Serum phosphate
• Serum magnesium
• ECG when appropriate
• the infusion site.

When used for the treating Calcium channel blocker and beta-blocker overdose:

• Observe vital signs
• Levels of serum ionized calcium every half-an-hour initially and then every two hours (maintain ionized calcium to about twice the ULN)
• Avoid severe hypercalcemia

How to administer Calcium Chloride injection: 

It is recommended for intravenous administration only. Intramuscular and subcutaneous administration may result in severe necrosis and skin damage. Rapid administration exceeding 100 mg/minute should be avoided except in emergency situations. Preferably through a central or deep vein, the solution should be  infused as a diluted solution over the course of an hour,  up to a maximum rate of 90 mg/kg/hour (1.2 mEq/kg/hour).

Small veins in the hand or foot shouldn't be used for intravenous delivery since they could experience significant necrosis and sloughing.

If calcium is administered more quickly than 2.5 mEq/minute, the ECG should be watched, and the infusion should be discontinued if the  patient complains of pain or discomfort. Before administering, the fluid should be warmed to body temperature. Phosphate-containing solutions shouldn't be given in the same intravenous line as it. Refrain from letting the liquids leak out. Extravasation should be  carefully aspirated after the infusion is stopped right away (leave the needle or cannula in place).

Management of Early calcium extravasation:

• Start the hyaluronidase antidote medication. Use a 25-gauge needle to inject a total of 1 to 1.7 mL (15 units/mL) as  five separate 0.2 to 0.3 mL intradermal or subQ injections into the region of extravasation at the leading edge. The catheter that generated  the infiltration may also be used to inject hyaluronidase.

• Take out the cannula or needle

• Use cold, dry compresses.

• Raising the extremity

Management of delayed calcium extravasation:

• Keep an eye on the website (as most calcifications will spontaneously resolve). Start administering sodium thiosulfate antidote at a dose of 12.5 gm over 30 minutes in cases of severe calcinosis cutis presentation.  The dosage can be raised gradually to 25 gm three times per week.

• Keep an eye out for severe nausea, hypocalcemia, and non-anion gap acidosis.

Mechanism of action of Calcium chloride:

• It controls the action potential excitation, and is essential for optimal neuronal performance and muscle performance.

40% of the drug is Protein-bound (albumin-bound)It isexretedPrimarily via feces

Calcium Chloride International brands:

• Calciclo
• Calcium chloratum
• Solural

Calcium Chloride Brands in Pakistan: