Calcium Chloride vs Calcium Gluconate

Posted
by Manurse715 Manurse715 Member

Specializes in ICU. Has 2 years experience.

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clementinern

clementinern

Specializes in Critical Care. Has 20+ years experience. 22 Posts

In my facility, we typically use Calcium Gluconate to replace a low ionized ca of

clementinern

clementinern

Specializes in Critical Care. Has 20+ years experience. 22 Posts

the hypocalcemia you see with post op cardiac surgery pts is related to fluid shifting from the actual bypass pump and, as you mentioned, from blood products. also being cold can alter electrolytes. calcium works by increasing the "squeeze" and conduction, so it raises blood pressure and heart rate. chloride is more powerful than gluconate and usually has a bigger response- also in my experience tends to be more transient.

nursingpower

nursingpower

Specializes in Cardiac Critical Care. 66 Posts

While your at it with my last question, here's another. Why is it that open hearts come back with low calciums and sometimes critical low calciums? My guess is that it is due to the amount of blood products they receive and the citrate preservative in them. Also, is there any signs and symptoms that you have noticed in an open heart pt with low Ca? Thank you in advance.

I was told about the citrate thing in blood products from a doctor. At http://www.rch.org.au/bloodtrans/adverse.cfm?doc_id=5323

It states:

Citrate toxicity

Cause: Citrate is the anticoagulant used in blood products. It is usually rapidly metabolised by the liver. Rapid administration of large quantities of stored blood may cause hypocalcaemia and hypomagnesaemia when citrate binds calcium and magnesium. This can result in myocardial depression or coagulopathy. Patients most at risk are those with liver dysfunction or neonates with immature liver function having rapid large volume transfusion.

Management: Slowing or temporarily stopping the transfusion allows citrate to be metabolised. Replacement therapy may be required for symptomatic hypocalcaemia or hypomagnesaemia.

Lwooton

Lwooton

2 Posts

my Standards of Practice Unit Council is developing a Ca++repletion algorithm. I am wanting to know if there is a consideration for elevated sr cr (like for potassium repletion) AND for how many hours post op your standing orders continue the repletion AND if you only follow ionized or if not needing further abg assessment is it in your orders to follow corrected serum Ca. I am in Asheville NC CVRU/CVICU Thanks!!

Edited by Lwooton
i believe we will use gluconate but not sure

offlabel

offlabel

1,374 Posts

Ca is an inotrope and vasopressor- but notoriously short term.

It is also a cofactor in the coag cascade, so it is useful in a postop heart, all of which are coagulaopathic.

The hypoalbuminemia and hemodilution from CPB contribute to postop hypocalcemia.

It is a good rescue drug for acute hemodynamic support but only as an adjunct to other drugs.

Excellent post, for its brevity and accuracy. I'd just refine it by saying that while you may be correct in pointing out that "all" postop heart (cardiopulmonary bypass) patients may be coagulopathic, not nearly as many are bleeding.

calivianya, BSN, RN

Specializes in ICU. 2,418 Posts

my Standards of Practice Unit Council is developing a Ca++repletion algorithm. I am wanting to know if there is a consideration for elevated sr cr (like for potassium repletion) AND for how many hours post op your standing orders continue the repletion AND if you only follow ionized or if not needing further abg assessment is it in your orders to follow corrected serum Ca. I am in Asheville NC CVRU/CVICU Thanks!!

Ours only takes into account the albumin level to get a corrected calcium level, and we replace based on that. We replace anything under a corrected calcium of 8.5, and we use calcium gluconate. Tiers of replacement are Ca++ 7-8.5, and Ca++ under 7.0. 7-8.5 gets 2g IV over 1 hour, under 7.0 gets 4g IV over two hours. We check a level the next day with AM labs with replacement for 7.0-8.5; we check four hours after the end of infusion for a Ca++ under 7.0. I hope that helps.

Lwooton

Lwooton

2 Posts

thank you. do you take into consideration the sr creatinine when replacing calcium?

calivianya, BSN, RN

Specializes in ICU. 2,418 Posts

thank you. do you take into consideration the sr creatinine when replacing calcium?

Nope - we only take creatinine into consideration for K+ replacement. Sorry for the slow response.

PresG33

PresG33

79 Posts

1. Replace Ca based on your ionized calcium from your ABG. This will remove the need to correct for the pt's albumin (do you think the albumin level you have from pre-op is the same as it is post-op? Do you get post-op albumins?). If iCal on the gas is

2. Push the amp slowly. I leave it in line on a runner and give 1 mL every minute or so. Slam the whole amp and you will get hypertension and maybe some arrhythmias.

3. Don't use Ca Gluconate in liver failure. The calcium is attached to a gluconate molecule that requires processing by the liver to convert it into usable Ca. CaCh is immediately useable by the body and this is why it has a faster onset.

4. You should have a very low threshold to give an amp of CaCh to a hypotensive pt, even if you don't know their serum calcium. Most vasopressors work by increasing the release of intracellular calcium, so if your Ca is low your pressors will not work as well. And critically ill patients are almost always hypocalcemic and, even if they aren't, the amp won't hurt them if you push it slow.

Catticus11

Catticus11

Has 3 years experience. 71 Posts

Calcium chloride has three times as much elemental (physiologically available) calcium as calcium gluconate.

And as mentioned earlier, it should also be administered via central line since Calcium's vasoconstrictive effects.

Kimmy_RN

Kimmy_RN

Specializes in CCU/ICU, CVICU, CTICU, CSU. Has 15 years experience. 10 Posts

We've gotten patients back in a code situation after giving CaCl.. we use it as protocol on our unit for anyone with an ionized calcium

offlabel

offlabel

1,374 Posts

NEVER GIVE CALCIUM CHLORIDE PERIPHERALLY!

Except when all you have is a peripheral iv.