From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: i.v. Calcium & severe tissue injury
Date: 1 Jan 1999 10:31:55 GMT

In <sbelknap-3112981624050001@slip6a-15.dialin.uic.edu>
sbelknap@uic.edu (Steven Belknap) writes:

>Just did a literature search on this, but thought I'd ask for any
>suggestions here on sci.med.
>
>Intravenous calcium can cause severe damage to tissues if the i.v.
>infiltrates. Any thoughts on how to prevent this? Obviously, using a
>central line, putting albumin in the i.v. bag, including Magnesium in the
>solution, etc. might be helpful. Any other ideas?



    Always give it amp by amp, by slow push into an IV line you can see
is running fast and freely into a site that is peripheral, and not
hidden by dressings, while you're doing the push.   I can't think of
too many cases demanding a calcium drip, anyway.  Your blood gas
machines now give you the new calcium level after every amp, and you
should be looking at that.  It's all cardiology stuff like dig toxicity
and EM dissociation, where you're standing by pushing amps into fast
running IV's anyway.   All the rest of the chronic stuff is handled by
big doses of vitamin D.

From: jrfox@no.spam.fastlane.net.no.spam (Jonathan R. Fox)
Newsgroups: sci.med
Subject: Re: i.v. Calcium & severe tissue injury
Date: Fri, 01 Jan 1999 14:33:26 GMT

On 1 Jan 1999 10:31:55 GMT, sbharris@ix.netcom.com(Steven B. Harris)
wrote:

>In <sbelknap-3112981624050001@slip6a-15.dialin.uic.edu>
>sbelknap@uic.edu (Steven Belknap) writes:
>
>>Just did a literature search on this, but thought I'd ask for any
>>suggestions here on sci.med.
>>
>>Intravenous calcium can cause severe damage to tissues if the i.v.
>>infiltrates. Any thoughts on how to prevent this? Obviously, using a
>>central line, putting albumin in the i.v. bag, including Magnesium in the
>>solution, etc. might be helpful. Any other ideas?
>
>    Always give it amp by amp, by slow push into an IV line you can see
>is running fast and freely into a site that is peripheral, and not
>hidden by dressings, while you're doing the push.   I can't think of
>too many cases demanding a calcium drip, anyway.  Your blood gas
>machines now give you the new calcium level after every amp, and you
>should be looking at that.  It's all cardiology stuff like dig toxicity
>and EM dissociation, where you're standing by pushing amps into fast
>running IV's anyway.   All the rest of the chronic stuff is handled by
>big doses of vitamin D.

Sound advice for replacement therapy, but unfortunately not practical
for parenteral nutrition.  We frequently do peripheral PN with the
premies in our NICU, as the expected short duration of such therapy
often does not warrant the risk of central venous access.  Thanks to
excellent nursing staff at our institution, however, infiltrated
solution is caught early and treated expeditiously, so severe burns
with eschar formation are rare.

But I would presume that adults receiving calcium-containing IV
solutions on a ward may not have the luxury of hourly IV checks as our
premies do.  I believe, then, that the simplest and least high-tech
method of preventing severe tissue damage is best:  Avoid
calcium-containing IV solutions if possible, or, when they are used,
institute a method to monitor the IV site frequently.

--
Jonathan R. Fox, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: i.v. Calcium & severe tissue injury
Date: 2 Jan 1999 01:13:10 GMT

In
<C1DC6809877ECECF.24F91529193D7F0D.DBEF9A66255B5DC2@library-proxy.airne
s.net> jrfox@no.spam.fastlane.net.no.spam (Jonathan R. Fox) writes:

>Sound advice for replacement therapy, but unfortunately not practical
>for parenteral nutrition.


   Gads, I had no idea the calcium concentration in parenteral
nutrition was high enough to be dangerous to tissue.  Interesting.  Are
you diluting it all you can?

                                    Steve

From: jrfox@no.spam.fastlane.net.no.spam (Jonathan R. Fox)
Newsgroups: sci.med
Subject: Re: i.v. Calcium & severe tissue injury
Date: Sat, 02 Jan 1999 23:18:17 GMT

On 2 Jan 1999 01:13:10 GMT, sbharris@ix.netcom.com(Steven B. Harris)
wrote:

>In
><C1DC6809877ECECF.24F91529193D7F0D.DBEF9A66255B5DC2@library-proxy.airne
>s.net> jrfox@no.spam.fastlane.net.no.spam (Jonathan R. Fox) writes:
>
>>Sound advice for replacement therapy, but unfortunately not practical
>>for parenteral nutrition.
>
>   Gads, I had no idea the calcium concentration in parenteral
>nutrition was high enough to be dangerous to tissue.  Interesting.  Are
>you diluting it all you can?

Actually, quite the opposite!  Fetuses have an enormous calcium and
phosphorus requirement, and unless this is maximized in their PN, they
can develop osteopenia.  We concentrate the calcium and phosphorus as
much as possible, but given the tiny fluid volumes we must use to
avoid overloading their immature kidneys, it is still occasionally not
sufficient to prevent metabolic bone disease.  Using Trophamine, a
more acidic amino acid preparation, allows more calcium and
phosphorus, and rarely we will add cysteine to further acidify the
solution and raise the precipitation point.

But as I said, TPN burns are much less frequent than metabolic bone
disease in premature neonates, so the benefit of concentrated Ca and
Phos far outweighs the risk.

--
Jonathan R. Fox, M.D.