we are developing a new guideline for Pediatric Stem Cell collection and we have a question regarding the IV Calcium (Ca++).

How can we give it?

How can we calculate the dose?

Calcium Replacement

Attached is our currect protocol which we're happy to share. However it's being updated as we now use prophylaxix for everyone and so the PO calcium need has changed. We will start everyone on the iv infusion [50mg/kg/run] and if symptoms arise will give 1 oral tablet, reduce the anticoagulant infusion & call for MO. The max iv dose is 2gm [this will be appropriate for adult patients who weigh > 40kgs].

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(I) CALCIUM REPLACEMENT - for Hypocalcaemia

1. Oral Therapy

2. I.V. Therapy

1. ORAL

For initial mild hypocalcaemic reactions such as tingling or numb lips, administer as follows

Sandocal 1000mg – one tablet dissolved in a cup of water

*Tip: - break/crush tablet before dissolving to reduce dissolving time.

If symptoms persist or reoccur, administer another Sandocal 1000mg. Symptoms should resolve.

If symptoms reappear again for the third time or are unresolved, there are 2 options to take.

a) Commence i.v. Calcium replacement. (See pt. 2 below i.v. Administration)

Reduce the amount of ACDA going to the patient.

This is achieved by →

Reducing/dropping the inlet flow rate.

Drop the inlet flow rate by 20%. This will not lead to clumping but will drop the total amount of citrate the person is getting.

2. IV ADMINISTRATION

* Calcium Gluconate concentration used = Calcium Gluconate 10% 1g/10 ml

* Calcium Chloride concentration used = Calcium Chloride 10% 1g/10ml

Cautions & Side Effects of Calcium Administration.

~ Avoid Extravasation, avoid using small veins.

~ Rapid administration => Tingling sensation, Chalky taste, Sense of oppression.

~ Vasodilation.

~ Cardiac Arrhythmias, Bradycardia, Hypotension.

For a child 20kg or less, or unable to communicate their signs and symptoms;

Administer a calcium gluconate infusion to run along side the entire procedure, via the return line. This eradicates the need for oral Sandocal.

*Calcium Gluconate 10% is used as a neat infusion.

The infusion runs at 50mg (0.5mls) *Calcium Gluconate/kg/run.

Max = 1g (10mls) over the entire run.

Do not infuse <1 hour.

For patients 20kg - 50kg;

Use oral Sandocal as a first line of choice. If symptoms persist after 2 doses of Oral supplement, then commence i.v. calcium infusion.

*Calcium Gluconate 10% is used as a neat bolus.

The infusion runs at 50mg (0.5mls) *Calcium Gluconate/kg/run.

Max = 2g (20mls) over the entire run.

Do not infuse <1 hour.

For patients over 50kg;

Use oral Sandocal as a first line of choice. If symptoms persist after 2 doses of oral supplement an i.v. bolus dose should be administered.

Bolus = 100mg (1ml)neat *Calcium Gluconate. A Calcium Gluconate infusion is then commenced following the bolus dose.

Note: A hot rush may be experienced by patient with bolus dose.

The infusion runs at 50mg (0.5mls) *Calcium Gluconate/kg over the remainder of run.

Max. = 2g (20mls).

For unresolved symptoms

a) Hypocalcaemia symptoms may reappear frequently or may not resolve. Patient must be reviewed by MO and action’s taken as directed by MO.

In severe cases, the procedure may be temporarily paused allowing for recovery of the patient. On occasions, it may not be possible to continue with the apheresis procedure.