Intravenous Calcium Chloride Research Articles

Efficacy of intraperitoneal calcium for hungry bone syndrome following parathyroidectomy: A case report

A man with hyperparathyroidism secondary to kidney failure on peritoneal dialysis underwent a parathyroidectomy with half-gland reimplantation complicated by severe hungry bone syndrome resulting in severe hypocalcaemia, hypotension and QT prolongation on ECG. He was initially managed with oral calcium and intravenous (IV) calcium chloride. Despite standard supportive treatment, attempts to wean IV therapy were unsuccessful. We report the novel use of intraperitoneal calcium to facilitate the weaning of IV calcium and discharge from hospital. A subsequent peritoneal membrane adequacy study did not demonstrate loss of peritoneal membrane adequacy.

Intravenous Calcium to Decrease Blood Loss During Intrapartum Cesarean Delivery: A Randomized Controlled Trial.

To evaluate whether prophylactic administration of 1 g of intravenous calcium chloride after cord clamping reduces blood loss from uterine atony during intrapartum cesarean delivery. This single-center, block-randomized, placebo-controlled, double-blind superiority trial compared the effects of 1 g intravenous calcium chloride with those of saline placebo control on blood loss at cesarean delivery. Parturients at 34 or more weeks of gestation requiring intrapartum cesarean delivery after oxytocin exposure in labor were enrolled. Calcium or saline placebo was infused over 10 minutes beginning 1minute after umbilical cord clamping in addition to standard care with oxytocin. The primary outcome was quantitative blood loss, analyzed by inverse Gaussian regression. Planned subgroup analysis excluded nonatonic bleeding, such as hysterotomy extension, arterial bleeding, and occult placenta accreta. We planned to enroll 120 patients to show a 200-mL reduction in quantitative blood loss in planned subgroup analysis, assuming up to 40% incidence of nonatonic bleeding (80% power, α<0.05). From April 2022 through March 2023, 828 laboring parturients provided consent and 120 participants were enrolled. Median blood loss was 840 mL in patients allocated to calcium chloride (n=60) and 1,051 mL in patients allocated to placebo (n=60), which was not statistically different (mean reduction 211 mL, 95% CI -33 to 410). In the planned subgroup analysis (n=39 calcium and n=40 placebo), excluding cases of surgeon-documented nonatonic bleeding, calcium reduced quantitative blood loss by 356 mL (95% CI 159-515). Rates of reported side effects were similar between the two groups (38% calcium vs 42% placebo). Prophylactic intravenous calcium chloride administered during intrapartum cesarean delivery after umbilical cord clamping did not significantly reduce blood loss in the primary analysis. However, in the planned subgroup analysis, calcium infusion significantly reduced blood loss by approximately 350 mL. These data suggest that this inexpensive and shelf-stable medication warrants future study as a novel treatment strategy to decrease postpartum hemorrhage, the leading global cause of maternal morbidity and mortality. ClinicalTrials.gov, NCT05027048.

Tissue injury secondary to peripheral xenobiotic administration.

A 57-year-old female with a past medical history of depression was brought in by emergency medical services after intentional ingestion of 400 mg warfarin and 200 mg amlodipine 4 hours before presentation. The patient was started on treatment for calcium channel blocker overdose, including intubation for central nervous system depression, activated charcoal, intravenous calcium and glucagon, high-dose insulin with dextrose infusion, and vasopressor support. On day 2 of hospitalization, a rash was found on the left lower extremity (see Figures 1 and 2). Tissue Injury Due to Peripheral Intravenous Calcium Chloride Administration Intravenous calcium is used to treat acute hypocalcemia, severe hyperkalemia, calcium channel blocker overdose, beta-blocker overdose, and hydrofluoric acid exposure.1 Calcium chloride is preferentially administered via a central venous catheter due to its high osmolarity and its propensity to act as a vesicant.1 Calcium gluconate is preferred over calcium chloride for peripheral administration, as it is less likely to cause tissue injury if extravasation occurs. Adverse effects of both formulations include local tissue injury, skin necrosis, calcium-induced vasoconstriction, and late-onset calcifications or calcinosis cutis.1-4 Treatment for local tissue injury includes stopping the infusion and consideration of intradermal hyaluronidase around the site to diminish tissue injury.1, 4 If tissue necrosis develops, wound care, surgical debridement, and skin grafting may be considered.3 Clinicians should familiarize themselves with local tissue injury, which can be minimized by using calcium gluconate as opposed to calcium chloride when peripheral access is present.

Calcium chloride for the prevention of uterine atony during cesarean delivery: A pilot randomized controlled trial and pharmacokinetic study

Study objectiveTo assess the feasibility, patient tolerance, pharmacokinetics, and potential effectiveness of a randomized controlled trial protocol investigating intravenous calcium chloride for the prevention of uterine atony during cesarean delivery. DesignDouble-blind, randomized controlled pilot trial with nested population pharmacokinetic analysis. SettingThis study was performed at Lucile Packard Children's Hospital, from August 2018 to September 2019. PatientsForty patients with at least two risk factors for uterine atony at the time of cesarean delivery. InterventionsOne gram of intravenous calcium chloride (n = 20 patients) or a saline placebo control (n = 20 patients), in addition to standard care with oxytocin, upon umbilical cord clamping. MeasurementsThe primary efficacy-related outcome was the presence of uterine atony defined as the use of a second-line uterotonic medication, surgical interventions for atony, or hemorrhage with blood loss >1000 mL. Blood loss, uterine tone numerical rating scores, serial venous blood calcium levels, hemodynamics, and potential side effects were also assessed. Main resultsThe study protocol proved feasible. The incidence of atony was 20% in parturients who received calcium compared to 50% in the placebo group (relative risk 0.38, P = 0.07, 95% CI 0.15–1.07, NNT 3.3). Calcium recipients tolerated the drug infusion well, with no adverse events and an equal incidence of potential side effects in the calcium and placebo groups. Ionized calcium concentration rose significantly in all patients who received calcium infusion, from baseline 1.18 mmol/L to peak levels 1.50–1.60 mmol/L. One-compartment population pharmacokinetics established clearance of 0.93 (95% CI 0.63–1.52) L/min and volume of distribution 76 (95% CI 49–94) L. ConclusionsIn this pilot study, investigators found that intravenous calcium chloride was well-tolerated by the 20 patients assigned to receive the study drug and may be effective in prevention of uterine atony. A 1-g dose was sufficient to substantially increase calcium levels without any critically elevated lab values or concern for adverse side effects. These encouraging findings warrant further investigation of calcium as a novel agent to prevent uterine atony with an adequately powered clinical trial.Clinical trial registry NCT03867383 https://clinicaltrials.gov/ct2/show/NCT03867383

Calcium administration In patients undergoing CardiAc suRgery under cardiopulmonary bypasS (ICARUS trial): Rationale and design of a randomized controlled trial

IntroductionWeaning from cardiopulmonary bypass (CPB) is a critical step of any cardiac surgical procedure and often requires pharmacologic intervention. Calcium ions are pivotal elements for the excitation-contraction coupling process of cardiac myocytes. Thus, calcium administration might be helpful during weaning from CPB. MethodsWe describe a multicenter, placebo-controlled, double blind randomized clinical trial to assess the effect of calcium chloride on the need for inotropic support among adult patients during weaning from CPB. The experimental group (409 patients) will receive 15 mg/kg of calcium chloride. The control group (409 patients) will receive an equivalent volume of 0.9% sodium chloride. Both drugs will be administered intravenously as a bolus at the beginning of weaning from CPB. ResultsThe primary outcome will be the need for inotropic support between termination of CPB and completion of surgery. Secondary outcomes will be: duration of inotropic support, vasoactive-inotropic score 30 min after transfer to intensive care unit and on postoperative day 1, plasma alpha-amylase on postoperative day 1, plasma Ca2+ concentration immediately before and 10–15 min after calcium chloride administration, non-fatal myocardial infarction, blood loss on postoperative day 1, need for transfusion of red blood cells, signs of myocardial ischemia on electrocardiogram after arrival to intensive care unit, all-cause mortality at 30 days or during hospital stay if this is longer than 30 days. DiscussionThis trial is designed to assess whether intravenous calcium chloride administration could reduce the need for inotropic support after cardiopulmonary bypass weaning among adults undergoing cardiac surgery.

The Safety of Glucagon use during ERCP in Diabetic Patients with Renal Insufficiency: A Case Discussion and Review of Literature

This is a case report with the use of glucagon during ERCP which resulted in Hyperkalemia. A 45 year old male, ASA 3, with Type 1 diabetes mellitus, hypertension, and chronic kidney disease underwent ERCP with general anesthesia for evaluation of a bile duct stricture. After administration of 0.75 mg glucagon (0.25 mg doses over an hour) tall, peaked T-waves were noted on the ECG. Labs were drawn and potassium was 6.6 mEq/L and glucose was 393 mg/dL. Intravenous calcium chloride, 1000 mg, was titrated. Repeat potassium was 6.1mEq/L and glucose 568 mg/dL. The remainder of the procedure was uneventful and postoperative potassium was 5.2 mEq/dL.

A case of massive atenolol overdose successfully managed with intravenous calcium chloride

A case of massive atenolol overdose successfully managed with intravenous calcium chloride

Ionised calcium levels in major trauma patients who received blood en route to a military medical treatment facility

BackgroundHypocalcaemia is a common metabolic derangement in critically ill patients. Blood transfusion can also contribute to depleted calcium levels. The aims of this study were to identify the incidence of...

The Effect of Co-administration of Intravenous Calcium Chloride and Oxytocin on Maternal Hemodynamics and Uterine Tone Following Cesarean Delivery: A Double-blinded, Randomized, Placebo-controlled Trial

(Int J Obstet Anesth. 2015;24:217–224) Oxytocin administration following cesarean delivery may be associated with significant adverse effects, such as cardiovascular instability (hypotension, tachycardia, myocardial ischemia). Intravenous (IV) calcium chloride (CaCl2) has been shown to increase mean arterial pressure (MAP) and cardiac contractility in patients undergoing anesthesia. Consequently, the authors of the present study hypothesized that IV co-administration of CaCl2 with oxytocin 5 U IV bolus would reduce the risk of hypotension and improve uterine tone in women undergoing elective cesarean delivery under spinal anesthesia. The primary outcome studied was blood pressure change after study drug administration. Secondary outcomes included the effect of CaCl2 on heart rate, uterine tone, need for additional uterotonic agent, vasopressor use, and blood loss.

Initial Observations of the Effects of Calcium Chloride Infusions in Pediatric Patients with Low Cardiac Output.

Myocardial contractility and relaxation are highly dependent on calcium homeostasis. Immature myocardium, as in pediatric patients, is thought to be more dependent on extracellular calcium for optimal function. For this reason, intravenous calcium chloride infusions may improve myocardial function in the pediatric patient. The objectives of this study were to report the hemodynamic changes seen after administration of continuous calcium chloride to critically ill children. We retrospectively identified pediatric patients (newborn to 17 years old) with hemodynamic instability admitted to the cardiac ICU between May 2011 and May 2012 who received a continuous infusion of calcium chloride. The primary outcome was improvement in cardiac output, assessed by arterial-mixed venous oxygen saturation (A-V) difference. Sixty-eight patients, mean age 0.87 ± 2.67 years, received a total of 116 calcium infusions. Calcium chloride infusions resulted in significant improvements in primary and secondary measures of cardiac output at 2 and 6 h. Six hours after calcium initiation, A-V oxygen saturation difference decreased by 7.4 % (32.6 ± 2.1 to 25.2 ± 2.0 %, p < 0.001), rSO2 increased by 5.5 % (63.1 vs 68.6 %, p < 0.001), and serum lactate decreased by 0.9 mmol/l (3.3 vs 2.4 mmol/l, p < 0.001) with no change in HR (149.1 vs 145.6 bpm p = 0.07). Urine output increased 0.66 ml/kg/h in the 8-h period after calcium initiation when compared to pre-initiation (p = 0.003). Neonates had the strongest evidence of effectiveness with other age groups trending toward significance. Calcium chloride infusions improve markers of cardiac output in a heterogenous group of pediatric patients in a cardiac ICU. Neonates appear to derive the most benefit from utilization of these infusions.

The effect of co-administration of intravenous calcium chloride and oxytocin on maternal hemodynamics and uterine tone following cesarean delivery: a double-blinded, randomized, placebo-controlled trial

BackgroundOxytocin administration to prevent uterine atony following cesarean delivery is associated with adverse effects including hypotension, tachycardia, and nausea. Calcium chloride increases mean arterial pressure, systemic vascular resistance, and uterine smooth muscle contractility. This study evaluated whether the co-administration of calcium chloride with oxytocin following cesarean delivery could alter maternal hemodynamics. Secondary outcomes included uterine tone and blood loss. MethodsSixty healthy parturients with singleton, term, vertex pregnancies undergoing elective cesarean delivery under spinal anesthesia were randomized to one of three study solutions given intravenously immediately after umbilical cord clamping: (1) placebo, oxytocin 5U alone; (2) CA-200, oxytocin 5U+calcium chloride 200mg; or (3) CA-400, oxytocin 5U+calcium chloride 400mg. Blood pressure, heart rate, uterine tone, vasopressor or alternate uterotonic use and the incidence of nausea or vomiting were recorded. Baseline and intraoperative plasma concentration of ionized calcium and hematocrit were measured. ResultsPlasma concentration of ionized calcium was elevated in both study groups compared with placebo (P=0.001). Blood pressure decreased and heart rate increased in all groups (P <0.0001), with no differences between groups. No differences were observed between groups in uterine tone, vasopressor use, hematocrit change, estimated blood loss, incision-to-delivery interval, delivery-to-skin closure interval, total intravenous fluid administered or incidence of nausea. ConclusionsThe decrease in blood pressure associated with oxytocin administration following cesarean delivery was not attenuated with co-administration of calcium chloride at the doses evaluated. Vasopressor use, uterine tone, and blood loss were also unaffected.

Sepsis-induced Hypermagnesemia Resulting in Hypotensive Crisis and Bradycardia in an Octogenarian

Hypermagnesemia with potential life-threatening occurs rarely in clinic. We present the case of an 85-year-old man with community acquired pneumonia with sepsis. After antibiotic treatment, fever subsided. Four days later, his blood pressure and heart beat dropped. Follow-up laboratory investigations revealed a serum magnesium level of 8.2 mg/dL (reference range, 1.7-2.55 mg/dL). Computed tomography (CT) of the abdomen demonstrated few small calcific lesions in the descending colon, which were presumed to be undigested magnesium oxide tablets on account of his history of constipation. Hypermagnesemia was successfully treated and hypotension improved after administration of intravenous calcium chloride and gastrointestinal decontamination with a magnesium-free enema. The possibility of hypermagnesemia should not be neglected when patients present with hypotension and bradycardia. Early diagnosis of hypermagnesemia is very important for preventing life-threatening effects of this condition.

Managing the Intravenous Calcium Shortage: Evaluation of Calcium Chloride Stability in 0.9% Sodium Chloride and Dextrose 5% Water Polyvinyl Chloride Bags.

Intravenous calcium chloride (CaCl) is commonly used by inpatient practitioners for a myriad of indications from electrolyte abnormalities to advanced cardiac life support. Currently, a paucity of data is available regarding the stability of CaCl after preparation of intravenous admixtures. This study evaluated the physical and chemical stability of CaCl 10% diluted in 0.9% sodium chloride or dextrose 5% water polyvinyl chloride bags. CaCl 10% solution (1000 mg) was diluted with 0.9% sodium chloride or dextrose 5% water 100 mL for injection to a final concentration of 10 mg/mL. CaCl 10% solution (2000 mg) was diluted with 0.9% sodium chloride or dextrose 5% water 150 mL for injection to a final concentration of 13.3 mg/mL. Each of the preparations were stored at room temperature (23-25°C) and exposed to fluorescent light. Samples of each preparation were analyzed on days 0, 2, 3, 5, and 7. Sterility and physical stability were assessed. Chemical stability of CaCl was evaluated by indirect potentiometry. CaCl 10 mg/mL and 13.3 mg/mL solutions in polyvinyl chloride bags were physically stable during the entire 7-day study period. CaCl retained >90% of the original concentration at 7 days after preparation in 0.9% sodium chloride and dextrose 5% water. CaCl diluted to 10 mg/mL or 13.3 mg/mL with 0.9% sodium chloride or dextrose 5% water for injection is both physically and chemically stable for a period of 7 days with ≤10% degradation under conditions of room temperature with fluorescent lighting.

Verapamil-associated cardiogenic shock in a 71-year-old man with myasthenia gravis: a case report

IntroductionMyasthenia gravis is a rare neuromuscular disorder associated with a reduction in the availability of acetylcholine receptors at the post-synaptic membranes of skeletal muscles. This is caused by the production of anti-acetylcholine receptor antibodies at the neuromuscular junction due to an autoimmune insult, leading to a compromised neuromuscular transmission. Verapamil can influence, in a dose-dependent fashion, the neuromuscular transmission in myasthenia gravis.Case presentationWe report a 71-year-old Caucasian man with myasthenia gravis suffering from a cardiogenic shock following a single dose of verapamil. The patient had uncontrolled atrial fibrillation with a heart rate of 120 beats/min. Atenolol 100 mg was started. The next day, verapamil SR 240 mg was started. Two hours after the first dose of verapamil, the patient complained of weakness and dyspnea with signs of shock; his blood pressure was 70/50 mm Hg and heart rate at 101 beats/min. An echocardiogram showed diffuse hypokinesis of both ventricles with an ejection fraction of 20%. Cardiac catheterization was performed and coronary arteries appeared without significant stenosis, but there was a diffuse hypokinesis. Verapamil was stopped and the patient received intravenous glucagon and calcium chloride. Both the anti-acetylcholine receptor and anti-striated muscle antibodies tested positive. A few hours later, another echocardiogram showed an improvement in the ventricular function, which returned to normal five days later.ConclusionCaution is needed when administering verapamil to patients with myasthenia gravis, especially when the anti-acetylcholine receptor and anti-striated muscle antibodies titres are positive.

Mechanism of Urinary Calcium Regulation by Urinary Magnesium and pH

Urinary magnesium and pH are known to modulate urinary calcium excretion, but the mechanisms underlying these relationships are unknown. In this study, the data from 17 clinical trials in which urinary magnesium and pH were pharmacologically manipulated were analyzed, and it was found that the change in urinary calcium excretion is directly proportional to the change in magnesium excretion and inversely proportional to the change in urine pH; a regression equation was generated to relate these variables (R(2) = 0.58). For further exploration of these relationships, intravenous calcium chloride, magnesium chloride, or vehicle was administered to rats. Magnesium infusion significantly increased urinary calcium excretion (normalized to urinary creatinine), but calcium infusion did not affect magnesium excretion. Parathyroidectomy did not prevent this magnesium-induced hypercalciuria. The effect of magnesium loading on calciuria was still observed after treatment with furosemide, which disrupts calcium and magnesium absorption in the thick ascending limb, suggesting that the effect may be mediated by the distal nephron. The calcium channel TRPV5, normally present in the distal tubule, was expressed in Xenopus oocytes. Calcium uptake by TRPV5 was directly inhibited by magnesium and low pH. In summary, these data are compatible with the hypothesis that urinary magnesium directly inhibits renal calcium absorption, which can be negated by high luminal pH, and that this regulation likely takes place in the distal tubule.

Skin Necrosis After Intravenous Calcium Chloride Administration as a Complication of Parathyroidectomy for Secondary Hyperparathyroidism: Report of Four Cases

Intravenous (i.v.) calcium chloride is usually given to treat symptomatic hypocalcemia; however, the extravasation of calcium solution may cause soft tissue and skin necrosis. After parathyroidectomy and autotransplantation for secondary hyperparathyroidism associated with end-stage renal failure, i.v. calcium infusion is often necessary to treat severe postoperative hypocalcemia. We reviewed 371 patients who underwent parathyroidectomy for secondary hyperparathyroidism between January 2000 and June 2005, 96 of whom received i.v. calcium postoperatively for symptomatic hypocalcemia. We report the cases of three (3%) of our own patients and of one patient referred to our hospital, who suffered skin necrosis after i.v. calcium solution administration. These reports show that i.v. calcium should be administered into large veins, or via a central line, and diluted in an appropriate volume of solution. Moreover, the calcium solution infusion should be ceased if the patient complains of tenderness over the injection site. If skin necrosis develops, we suggest early debridement and a simple split thickness skin graft to repair the skin defect. We report our experience to remind surgeons of the danger of calcium chloride injection and to discuss ways of preventing and treating this complication.

Management of severe hyperkalemia without hemodialysis: Case report and literature review

Purpose To report a case of severe hyperkalemia successfully managed without the use of hemodialysis and to provide a review of the literature regarding the management of severe hyperkalemia. Methods A clinical case report from the medical-surgical intensive care unit of a teaching hospital and a literature review are presented. The case involves a 59-year old man with diabetes mellitus, essential hypertension, and gout, who presented to hospital with severe hyperkalemia (K + = 10.4 mEq/L) and normal renal function. He was treated with intravenous fluids, sodium bicarbonate, calcium chloride, insulin, calcium resonium, and furosemide. Results The hyperkalemia resolved with conservative treatment within 8 hours, and dialytic therapy was not required. The literature review supported an initial conservative management approach in stable patients with intact renal function. Conclusions Hemodialysis is not necessary for all cases of severe hyperkalemia and should be reserved for patients with acute or chronic renal failure or those with life-threatening hyperkalemia unresponsive to more conservative measures.

Successful resuscitation of a verapamil intoxicated child with a dextrose-insulin infusion

Objective: To report the use of dextrose-insulin infusion in the successful resuscitation of an adolescent following an overdose of sustained-release verapamil that was refractory to traditional medical management.Case summary: A 13-year-old female with depression and post-traumatic stress disorder ingested 25–30 120-mg tablets (120–140 mg/kg) of sustained-release verapamil in a suicide attempt. Gastric lavage was performed, and activated charcoal and sorbitol were given for gastric decontamination. She developed atrial-ventricular (A-V) dissociation, bradycardia, hypotension and somnolence. Initial interventions included endotracheal intubation for airway protection, fluid resuscitation, high-dose intravenous calcium chloride, and glucagon. Hypotension and A-V block continued despite the addition of dopamine, epinephrine, and norepinephrine infusions. Normal sinus rhythm and hemodynamic stability occurred only after an infusion of regular insulin (0.1 U/kg/hr) and dextrose (0.5 g/kg/hr) was started. She ...

Imaging and Diagnostic Testing: Diastolic dysfunction after coronary artery bypass grafting: a frequent finding of clinical significance not influenced by intravenous calcium

BackgroundDiastolic dysfunction is common immediately after coronary artery bypass surgery (CABG). The duration of this phenomenon is unknown. Intravenous calcium is frequently administered during separation from cardiopulmonary bypass (CPB). We sought to determine whether intravenous calcium influences perioperative diastolic function and whether diastolic dysfunction persists into the postoperative period. Methods and resultsPatients undergoing first-time elective CABG (n = 29) were randomly assigned to receive intravenous calcium chloride (n = 13) or placebo (n = 16) during separation from CPB. Diastolic function was assessed by the pressure-area relation with transesophageal echocardiography and pulmonary capillary wedge pressure (PCWP) measured simultaneously. Left ventricular end-diastolic area (LVEDA) and Doppler indexes were measured at comparable PCWP (within 2 mm Hg) at baseline, after separation from CPB, after sternal closure, and 3 hours after surgery. After CABG, both groups had a significant decrease in LVEDA and mitral E-wave deceleration time that persisted at 3 hours. Because there were no significant differences between the calcium and control groups at any time point, the data for the entire study cohort was analyzed. The LVEDA decreased (stiffness increased) progressively from 16.9 ± 3.4 cm2 at baseline to 15.8 ± 2.9 cm2 after CPB, 14.9 ± 2.5 cm2 after sternal closure, and 14.3 ± 3.1 cm2 at 3 hours after surgery (P < .0001). The mitral E-wave deceleration time measured at the same time points was 168 ± 47 ms, 136 ± 25 ms, 137 ± 36 ms, and 111 ± 44 ms (P = .0001). ConclusionsAn increase in left ventricular diastolic chamber stiffness is nearly universal after CABG, and it persists for at least 3 hours after surgery. An intravenous bolus of calcium chloride given during separation from CPB has no measurable negative effect on diastolic function. In the setting of increased chamber stiffness, the PCWP alone does not adequately reflect the volume status and effective preload of the left ventricle.

Cultivating Conscience: Learning to Make End-of-Life Decisions in the Emergency Department

Cultivating Conscience: Learning to Make End-of-Life Decisions in the Emergency Department