Calcium Chloride vs Calcium Gluconate

[Manurse715]

This week I had and immediate post op emergent aortic valve replacement. He came back on Epi, Dopamine, Levophed and insulin drips. We started amniodarone soon after.

Amongst other interventions we gave an amp of calcium gluconate.

So what the difference between Cagluconate vs CaCl when addressing blood pressure?

[clementinern]

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

[clementinern]

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]

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]

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!!

[offlabel]

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]

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]

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

[calivianya, BSN, RN]

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]

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]

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]

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]

NEVER GIVE CALCIUM CHLORIDE PERIPHERALLY!

Except when all you have is a peripheral iv.