this salt can be infused peripherally via a large vein The use of calcium gluconate is usually favored as it is less likely to result in tissue damage if extravasation occurs As concentrated forms are irritating to veins, calcium salts should be diluted in dextrose and water or saline The final concentration of calcium gluconate should be 50 mg/mL, and calcium chloride should be diluted to 20 mg/mL Calcium should not be prepared or infused with fluids containing phosphate or bicarbonate given the risk of precipitation of insoluble salts The dose for IV bolus of calcium gluconate in the setting of cardiac disturbance is 50 to 100 mg/kg/dose infused over to minutes and for tetany is 100 to 200 mg/kg/dose infused over to 10 minutes Intravenous calcium should not be infused more rapidly given the risk for cardiac arrhythmia, bradycardia, and arrest Cardiac monitoring and serial monitoring of the serum calcium level should be performed Repeat boluses should be provided until the symptoms resolve, and then a slower infusion should be continued For patients with either chronic hypocalcemia or milder degrees of acute hypocalcemia without severe symptoms, oral calcium is preferred Numerous forms of oral calcium salts are available Calcium carbonate is readily available and well tolerated If either hypoparathyroidism or vitamin D deficiency is suspected, vitamin D replacement should be provided to optimize enteral absorption The overall management goal of chronic hypocalcemia is to achieve acceptable serum calcium while avoiding hypercalcemia and excessive hypercalciuria Hypercalcemia Hypercalcemia results when the influx of calcium into the extracellular space exceeds the rate of deposition into bone or renal capacity for excretion This most commonly results from accelerated bone resorption secondary to increased PTH activity, but may also occur due to excessive absorption from the gastrointestinal tract, or decreased renal excretion Excessive exposure to vitamin D will increase intestinal calcium and phosphate absorption and would be associated with a depressed PTH level In addition to exogenous sources of vitamin D, granulomatous disorders may be associated with increased 1,25-dihydroxyvitamin D activity and promote absorptive hypercalcemia Accelerated bone resorption would be anticipated in primary, secondary, and tertiary hyperparathyroidism Jansen