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Rapid and appropriate investigation and treatment of severe
Peripheral IV infusion of calcium gluconate
Hypocalcaemia is a symptom complex, and can be regarded as:
- Mildly symptomatic (distal parasthesia)
- Severely symptomatic (tetany, seizures)
All children with symptomatic OR severe biochemical hypocalcaemia (usually Ca2+ < 1.7-1.8 mmol/L) should be discussed with and admitted under the Paediatric Endocrinology Team.
Hypocalcaemia itself in children is potentially life-threatening due to cardiac arrhythmias and stridor (usually at values of total Calcium <1.6 mmol/l) - hence the need for cardiac monitoring.
Calcium is vital for most biological functions and hence the serum calcium level is maintained within a narrow range, at the expense of sequestration of bone (potentially leading to rickets), and retention of calcium by kidneys at the expense of phosphate loss. Hypocalcaemia in this setting is therefore a late presentation of a chronic disease process and indicates that a child has significant total body calcium depletion (termed bone hunger).
Large and continuous doses of calcium are normally required for replacement; weaning of calcium infusion is usually over 48 hours as oral calcium is initiated, and stopping infusions usually results in rebound hypocalcaemia. But weaning can normally start once serum Ca2+ is >1.8
Common Causes of Infant and Childhood Hypocalcaemia
|Vitamin D deficiency||↓||↑||↑||↓↓|
|Hypoparathyroidism (transient or permanent)||=||N/↓||N/↓||N|
Critical to draw at time of hypocalcaemia
Serum calcium, ionised calcium, phosphate, ALP, albumin, creatinine, urea, magnesium, PTH, & 25(OH)D3 (25 hydroxyvitaminD)
Calcium, calcium/creatinine ratio & phosphate
Check maternal PTH, 25 hydroxyvitamin D, calcium, phosphate, ALP & HbA1c (maternal diabetes)
Principles of Management
- To stabilize serum calcium to a safe range (>1.7 - 1.8 mmol/L total Calcium or >1.0 mmol/l ionised) quickly and maintain it while transitioning to oral therapy.
- To avoid complications of treatment: in particular extravasations of IV calcium infusion (must have a close watch of IV site).
- To establish the underlying cause.
- Obtain blood for appropriate investigations before commencing treatment.
- Bolus or infusions of IV calcium should ONLY be given in CED, PICU, 23B or 26A HDU with continuous cardiac monitoring, and frequent checks of iv site due to high risk of extravasation.
- Do not give calcium with phosphate or bicarbonate as precipitation will occur.
Symptomatic Hypocalcaemia (Seizures / Tetany / Stridor)
|1||Always perform ABC and basic resuscitation if necessary|
|2||Treat seizures with anti-epileptics as per seizure protocol|
|3||Continuous cardiac monitoring - if arrhythmia discuss with Cardiologist|
Treat hypocalcaemia with IV calcium (See below for dosing)
|5||If serum Mg2+ is ≤ 0.6 mmol/L consider IV
magnesium sulphate (2 mmol/mL).
Dose: 0.2 - 0.4 mmol/kg every 12 hours as slow iv infusion. See Paediatric Medication Administration Guideline ADHB intranet only.
Oral Therapy (Assuming Vitamin D deficient rickets or hypoparathyroidism)
Calcium Infusion via peripheral IV
- Calcium gluconate comes as a 10% standard stock solution.
- For peripheral infusions always make calcium to a 1% solution as follows: 1 part 10% calcium gluconate diluted to 9 parts with "water for injection".
- Also compatible with 5% glucose (makes it less irritant), 0.9% sodium chloride, and glucose saline solutions.
- More concentrated solutions may be used via central lines.
- Only administer if secure IV access is obtained
TETANY or SEIZURES (OR RECENT SEIZURE)
BOLUS IV calcium
Six (6) mL/kg of 1% Calcium gluconate solution (diluted as above) over 2 hours
Ensure cardiac monitoring, followed by an continuous infusion (see below).
This bolus dose equates to ~ 0.13 mmol/kg.
This will ameliorate tetany for ≥ 15 minutes to several hours.
Can repeat if required.
NB: Seizures need treating with anticonvulsants
If ASYMPTOMATIC BUT Ca2+ < 1.8 mmol/L or FOLLOWING ABOVE BOLUS
As above always make calcium to a 1% solution for peripheral administration:
Monitoring and observation
- Monitor ECG in case of arrythmia: unusual with this protocol
- Monitor the IV site for local reaction/redness - must be directly observed regularly as risk of tissue necrosis if any extravasation
- Review IV site if patient complains of pain
- Monitor Blood pressure
- Monitor serum calcium's as described above
- Do not add any other medications as calcium precipitation may occur
Concentrations of Calcium gluconate
- 10% calcium gluconate = calcium gluconate 100 mg/mL = elemental Ca of 0.22 mmol/mL = elemental Ca of 8.9 mg/mL
- The daily elemental calcium estimation requirement is ~73 mg/kg.
- If IV calcium gluconate not available can use calcium
10% CaCl (100 mg/mL) (elemental Ca = 0.68 mmol/mL; 27 mg/mL). This is 3X more elemental calcium.
Sperling MA. Pediatric Endocrinology. 2nd Edition.
Lifshitz F. Pediatric Endocrinology. 3rd Edition.
Hospital for Sick Children Resuscitation Card 2003-2004
Did you find this information helpful?
- Date last published: 26 January 2017
- Document type: Clinical Guideline
- Services responsible: Paediatric Endocrinology
- Author(s): Craig Jefferies
- Owner: Craig Jefferies
- Editor: Greg Williams
- Review frequency: 2 years
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