Shortage of supply (23/03/2020) - Calcium chloride 10% pre-filled syringes:
Calcium chloride pre-filled syringes 10% (6.8 mmol in 10 ml) are licensed for use in cardio-pulmonary resuscitation, as well as the treatment of hypocalcaemia and calcium deficiency states.
The 10 ml pre-filled syringe of calcium chloride 10% is the preparation listed in the Resus Council list of drugs for intravenous use for cardiac- and peri-arrest. In cardiac arrest caused by hyperkalaemia, hypocalcaemia, or overdose of calcium channel-blocking drugs, an initial dose of 10 ml of 10% calcium chloride (6.8 mmol Ca2+) is recommended, which may be repeated if necessary.
Calcium chloride 10% pre filled syringes are out of stock, we do not currently have a clear date for resolution.
Alternative agents and management options
Calcium gluconate injection is an alternative to calcium chloride. In order to manage this shortage, some of the cardiac arrest boxes will contain calcium gluconate ampoules instead of calcium chloride pre-filled syringes.
It is important to note that there is a difference in calcium content:
10 ml of 10% calcium chloride pre-filled syringes contains 6.8 mmol calcium whereas 10 ml of 10% calcium gluconate contains 2.26 mmol calcium.
The Resus Council mentions use of calcium gluconate as an alternative, highlighting difference in calcium content, you would need to administer 30mls of calcium gluconate to achieve 6.78 mmol calcium and during CPR, if required, it should be given as a rapid bolus injection followed by a 0.9% sodium chloride flush.
Calcium gluconate can be given as a slow IV injection in an emergency (e.g. severe acute hypocalcaemia, cardiac resuscitation, hypocalcaemic tetany). Give each 10mL of undiluted injection over at least 5 minutes, while monitoring plasma-calcium and ECG. (Resus Council advises can be given as rapid bolus injection during CPR).
Calcium gluconate undiluted has a high osmolarity and may cause venous irritation and tissue damage in cases of extravasation.
There may be certain patients, for example in critical care and those with severe liver impairment, for whom the increased volume of gluconate or the time taken to infuse this additional volume may be problematic, and any remaining stock of chloride may need to be prioritised for this group.