Drugs List

Therapeutic Indications

Uses

In cardiopulmonary resuscitation with co-existing hyperkalaemia or hypocalcaemia or calcium channel block activity.

Hypocalcaemia
Calcium deficiency states
Hypocalcaemic tetany (immediate treatment) with other therapy instituted as appropriate.

As adjunctive therapy in the management of hyperkalaemia, with ECG monitoring.
As adjunctive therapy in the management of overdosage of magnesium sulfate.

Administration

For slow intravenous and intracardiac use only.

The IV injection should be given at a rate not exceeding 1ml/minute.

Inject slowly through a small needle into a large vein to minimise venous irritation and avoid undesirable effects. Calcium chloride is considered to be the most irritant of the injectable calcium salts. Care should be taken to avoid extravasation.

Other routes are contraindicated due to the risk of necrosis.

Infant injections should not be given thorough the scalp.

Incompatibilities

Calcium salts are incompatible with a wide range of drugs. Complexes may form resulting in the formation of a precipitate. Generally the mixing of calcium with carbonates, citrates, oxidising agents, phosphates, sulfates, tartrates, tetracyclines or parenteral mixtures including total parenteral nutrition should be avoided.

In patients of any age ceftriaxone must not be mixed or administered simultaneously with any calcium-containing IV solutions, even via different infusion lines or at different infusion sites. However for patients older than 28 days ceftriaxone and calcium-containing solutions may be administer sequentially one after another if infusion lines at different sites are used.

Contraindications

Patients receiving cardiac glycosides
Hypercalcaemia
Hypercalciuria
Hypervitaminosis D
Renal calculi
History of renal calculi

Patients with respiratory acidosis or respiratory failure - due to it's acidifying nature.

Ventricular fibrillation (when employed in cardiac resuscitation).

For slow intravenous use or intracardiac use only - other routes are contraindicated due to the risk of necrosis.

Precautions and Warnings

Renal impairment (see 'Dosage; Renal impairment' section)

Sarcoidosis

Cardiac disease

A moderate fall in blood pressure due to vasodilatation may accompany the injection.

Not suitable for the treatment of hypocalcaemia caused by renal impairment (due to calcium chloride's acidifying nature).

Calcium chloride is considered to be the most irritant of the injectable calcium salts. Severe tissue necrosis and sloughing may occur. Care should be taken to avoid extravasation or accidental injection into perivascular tissues.

Calcium chloride should not be give to infants orally as it can cause irritation to the gastrointestinal tract. Infant injections should not be given thorough the scalp.

Ceftriaxone is contraindicated in premature newborns up to a corrected age of 41 weeks and full-term newborns if they require IV calcium treatment, because of the risk of precipitation of ceftriaxone-calcium complexes in lungs and kidneys. In patients of any age do not mix or administer both together, even via different infusion lines or at a different infusion sites. However, for patients older than 28 days ceftriaxone and calcium-containing solutions may be administer sequentially one after another if infusion lines at different sites are used.

Monitoring of calcium and serum electrolytes levels is necessary following intravenous administration of calcium.

Pregnancy ( see 'Pregnancy' section)

Breastfeeding ( see 'Lactation' section)

Pregnancy and Lactation

Pregnancy

Evaluate risk / benefit of treatment in pregnancy.

There are no studies on the effects of calcium chloride on pregnant women. No problems have been documented. However calcium crosses the placenta and absorption of calcium is increased during pregnancy.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14-17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use with caution in lactation

Calcium is excreted in breast milk, but there are no data on the effects, if any, on the infant.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Gastro-intestinal symptoms
Bradycardia
Arrhythmias
Irritation (after intravenous injection)
Tissue calcification
Decrease in blood pressure
Distinctive taste
Hot flushes
Peripheral vasodilatation
Symptoms of hypercalcaemia
Hypertension
Venous thrombosis
Burning sensation (local)
Hypercalcaemia
Tingling sensation

Presentation

Sterile aqueous solution of calcium chloride 100mg/ml (10%) for slow intravenous injection (infusion) or intracardiac use.

Each 10 ml pre-filled syringe provides 1g of calcium chloride dihydrate equivalent to 273mg of calcium (6.8mmol of calcium) .

Drugs List

Therapeutic Indications

Uses

In cardiopulmonary resuscitation with co-existing hyperkalaemia or hypocalcaemia or calcium channel block activity.

Hypocalcaemia
Calcium deficiency states
Hypocalcaemic tetany (immediate treatment) with other therapy instituted as appropriate.

As adjunctive therapy in the management of hyperkalaemia, with ECG monitoring.
As adjunctive therapy in the management of overdosage of magnesium sulfate.

Dosage

Adults

Elderly

Children

Patients with Renal Impairment

Administration

For slow intravenous and intracardiac use only.

The IV injection should be given at a rate not exceeding 1ml/minute.

Inject slowly through a small needle into a large vein to minimise venous irritation and avoid undesirable effects. Calcium chloride is considered to be the most irritant of the injectable calcium salts. Care should be taken to avoid extravasation.

Other routes are contraindicated due to the risk of necrosis.

Infant injections should not be given thorough the scalp.

Incompatibilities

Calcium salts are incompatible with a wide range of drugs. Complexes may form resulting in the formation of a precipitate. Generally the mixing of calcium with carbonates, citrates, oxidising agents, phosphates, sulfates, tartrates, tetracyclines or parenteral mixtures including total parenteral nutrition should be avoided.

In patients of any age ceftriaxone must not be mixed or administered simultaneously with any calcium-containing IV solutions, even via different infusion lines or at different infusion sites. However for patients older than 28 days ceftriaxone and calcium-containing solutions may be administer sequentially one after another if infusion lines at different sites are used.

Contraindications

Patients receiving cardiac glycosides
Hypercalcaemia
Hypercalciuria
Hypervitaminosis D
Renal calculi
History of renal calculi

Patients with respiratory acidosis or respiratory failure - due to it's acidifying nature.

Ventricular fibrillation (when employed in cardiac resuscitation).

For slow intravenous use or intracardiac use only - other routes are contraindicated due to the risk of necrosis.

Precautions and Warnings

Renal impairment (see 'Dosage; Renal impairment' section)

Sarcoidosis

Cardiac disease

A moderate fall in blood pressure due to vasodilatation may accompany the injection.

Not suitable for the treatment of hypocalcaemia caused by renal impairment (due to calcium chloride's acidifying nature).

Calcium chloride is considered to be the most irritant of the injectable calcium salts. Severe tissue necrosis and sloughing may occur. Care should be taken to avoid extravasation or accidental injection into perivascular tissues.

Calcium chloride should not be give to infants orally as it can cause irritation to the gastrointestinal tract. Infant injections should not be given thorough the scalp.

Ceftriaxone is contraindicated in premature newborns up to a corrected age of 41 weeks and full-term newborns if they require IV calcium treatment, because of the risk of precipitation of ceftriaxone-calcium complexes in lungs and kidneys. In patients of any age do not mix or administer both together, even via different infusion lines or at a different infusion sites. However, for patients older than 28 days ceftriaxone and calcium-containing solutions may be administer sequentially one after another if infusion lines at different sites are used.

Monitoring of calcium and serum electrolytes levels is necessary following intravenous administration of calcium.

Pregnancy ( see 'Pregnancy' section)

Breastfeeding ( see 'Lactation' section)

Pregnancy and Lactation

Pregnancy

Evaluate risk / benefit of treatment in pregnancy.

There are no studies on the effects of calcium chloride on pregnant women. No problems have been documented. However calcium crosses the placenta and absorption of calcium is increased during pregnancy.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14-17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use with caution in lactation

Calcium is excreted in breast milk, but there are no data on the effects, if any, on the infant.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Effects on Ability to Drive and Operate Machinery

None stated

Side Effects

Gastro-intestinal symptoms
Bradycardia
Arrhythmias
Irritation (after intravenous injection)
Tissue calcification
Decrease in blood pressure
Distinctive taste
Hot flushes
Peripheral vasodilatation
Symptoms of hypercalcaemia
Hypertension
Venous thrombosis
Burning sensation (local)
Hypercalcaemia
Tingling sensation

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Shelf Life and Storage

Store below 25 degrees C.

Further Information

Last Full Review Date: June 2011

Reference Sources

British National Formulary, 61st Edition (2011) Pharmaceutical Press, London.

BNF for Children (2010-2011) Pharmaceutical Press, London.

Martindale: The Complete Drug Reference, 37th edition (2011) ed. Sweetman, S. Pharmaceutical Press, London.

Summary of Product Characteristics: Calcium chloride intravenous infusion 10%. Aurum Pharmaceuticals Ltd. Revised April 2002.

Summary of Product Characteristics: Calcium chloride injection Minijet 10%. IMS(UK) Ltd. Revised January 2010.