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Hypocalcemia in trauma patients receiving massive transfusion

  • Amanda Giancarelli
    Correspondence
    Corresponding author. Department of Pharmacy, Orlando Regional Medical Center, 1414 Kuhl Avenue, MP 180, Orlando, FL 32806. Tel.: +1 321-841-1988; fax: +1 407-649-6839.
    Affiliations
    Department of Pharmacy, Orlando Regional Medical Center, Orlando, Florida
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  • Kara L. Birrer
    Affiliations
    Department of Pharmacy, Orlando Regional Medical Center, Orlando, Florida
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  • Author Footnotes
    1 Present address: Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA.
    Rodrigo F. Alban
    Footnotes
    1 Present address: Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA.
    Affiliations
    Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida
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  • Brandon P. Hobbs
    Affiliations
    Department of Pharmacy, Orlando Regional Medical Center, Orlando, Florida
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  • Author Footnotes
    2 Present address: Department of Pharmacy, Florida Hospital Orlando, 601 E Rollins St, Orlando, FL 32803.
    Xi Liu-DeRyke
    Correspondence
    Corresponding author. Florida Hospital Orlando, 601 E Rollins St, Orlando, FL 32803. Tel.: 407-303-1655; fax: 407-303-5703.
    Footnotes
    2 Present address: Department of Pharmacy, Florida Hospital Orlando, 601 E Rollins St, Orlando, FL 32803.
    Affiliations
    Department of Pharmacy, Orlando Regional Medical Center, Orlando, Florida
    Search for articles by this author
  • Author Footnotes
    1 Present address: Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA.
    2 Present address: Department of Pharmacy, Florida Hospital Orlando, 601 E Rollins St, Orlando, FL 32803.
Published:December 30, 2015DOI:https://doi.org/10.1016/j.jss.2015.12.036

      Abstract

      Background

      Massive transfusion protocol (MTP) is increasingly used in civilian trauma resuscitation. Calcium is vital for coagulation, but hypocalcemia commonly occurs during massive transfusion due to citrate and serum calcium chelation. This study was conducted to determine the incidence of hypocalcemia and severe hypocalcemia in trauma patients who receive massive transfusion and to compare characteristics of patients with severe versus nonsevere hypocalcemia.

      Materials and methods

      This was a retrospective study of trauma patients who received massive transfusion between January 2009 and November 2013. The primary outcome was the incidence of hypocalcemia (ionized calcium [iCa] < 1.12 mmol/L) and severe hypocalcemia (iCa < 0.90 mmol/L). Secondary outcomes included calcium monitoring, calcium replacement, and correction of coagulopathy.

      Results

      There were 156 patients included; 152 (97%) experienced hypocalcemia, and 111 (71%) had severe hypocalcemia. Patients were stratified into iCa ≥ 0.90 (n = 45) and iCa < 0.90 (n = 111). There were no differences in demographics or baseline laboratories except the severe hypocalcemia group had higher baseline activated partial thromboplastin time (29.7 [23.7–50.9] versus 25.8 [22.3–35.9], P = 0.003), higher lactic acid (5.8 [4.1–9.8] versus 4.0 [3.1–7.8], P = 0.019), lower platelets (176 [108–237] versus 208 [169–272], P = 0.003), and lower pH (7.14 [6.98–7.28] versus 7.23 [7.14–7.33], P = 0.019). Mortality was higher in the severe hypocalcemia group (49% versus 24%, P = 0.007). Patients in the iCa < 0.90 group received more blood products (34 [23–58] versus 22 [18–30] units, P < 0.001), and calcium chloride (4 [2–7] versus 3 [1–4] g, P = 0.002), but there was no difference in duration of MTP or final iCa. Neither group reached a median iCa > 1.12.

      Conclusions

      Hypocalcemia is common during MTP, and vigilant monitoring is warranted. Research is needed to effectively manage hypocalcemia during massive transfusion.

      Keywords

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