Abnormal Calcium Levels During Trauma Resuscitation Are Associated With Increased Mortality, Increased Blood Product Use, and Greater Hospital Resource Consumption: A Pilot Investigation

MacKay, Emily J.; Stubna, Michael D.; Holena, Daniel N.; Reilly, Patrick; Seamon, Mark J.; Smith, Brian P.; Kaplan, Lewis J.; Cannon, Jeremy W.

doi:10.1213/ane.0000000000002312

Cited by 68 publications

(70 citation statements)

References 15 publications

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“…Current massive transfusion protocols generally recommend replacement of calcium only in the setting of severe hypocalcaemia. In addition, there may also be a cohort of patients who may present in a hypercalcaemic state, suggesting caution before pre‐emptive replacement of calcium . However, Mackay et al .…”

Section: Discussionmentioning

confidence: 99%

Hypocalcaemia and traumatic coagulopathy: an observational analysis

et al. 2019

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Background and Objectives Haemorrhage‐associated calcium loss may lead to disruption of platelet function, intrinsic and extrinsic pathway‐mediated haemostasis and cardiac contractility. Among shocked major trauma patients, we aimed to investigate the association between admission hypocalcaemia and adverse outcomes. Materials and Methods Data were extracted from the Alfred Trauma Registry and the Alfred Applications and Knowledge Management Department for all adult major trauma patients presenting directly from the scene with a shock index ≥1 from 1 July 2014 to 30 June 2018. Patients with pre‐hospital blood transfusion were excluded. Ionized hypocalcaemia was defined as <1·11 mmol/l, and acute traumatic coagulopathy was defined as initial INR >1·5. Multivariable logistic regression analysis was used to assess the association between admission hypocalcaemia and acute traumatic coagulopathy that was adjusted for Injury Severity Score, initial GCS, bicarbonate and lactate. Results There were 226 patients included in final analysis with 113 (50%) patients recording ionized hypocalcaemia on presentation prior to any blood product transfusion. Ionized hypocalcaemia was associated with coagulopathy in patients with shock index ≥1 (adjusted OR 2·9; 95% CI: 1·01–8·3, P = 0·048). Admission ionized hypocalcaemia was also associated with blood transfusion requirement in the first 24 h post‐admission in 62·5% of hypocalcaemic patients as compared to 37·5% of normocalcaemic patients (P < 0·001). Admission ionized hypocalcaemia was associated with death at hospital discharge (25·6% among hypocalcaemic patients compared to 15·0% of normocalcaemic patients (P = 0·047)). Conclusion Hypocalcaemia was a common finding in shocked trauma patients and was independently associated with acute traumatic coagulopathy. The early, protocolized administration of calcium to trauma patients in haemorrhagic shock warrants further assessment in randomized controlled trials.

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Section: Discussionmentioning

confidence: 99%

Hypocalcaemia and traumatic coagulopathy: an observational analysis

et al. 2019

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“…Abnormal calcium levels during trauma resuscitation have been associated with increased mortality . Resuscitation protocols for bleeding patients often include careful titration of calcium to compensate for citrated blood products transfused to the recipient .…”

Section: Discussionmentioning

confidence: 99%

Sodium citrate contributes to the platelet storage lesion

2019

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BACKGROUND: Sodium citrate has become the preferred anticoagulant used for apheresis collection and has been included in commercial platelet additive solutions (PASs) since PAS-II. It was suggested that citrate be included in PASs to prevent spontaneous aggregation. Reports in cell lines and cord blood have demonstrated that concentrations of citrate present in PAS formulations (10 mM) cause apoptosis. We evaluated whether the removal of citrate from PAS-III could improve platelet storage. STUDY DESIGN AND METHODS: Study 1 evaluatedthe effects of a citrate dose response on the storage of platelets in 65% PAS containing sodium chloride, sodium acetate, and phosphate. Study 2 compared the cell quality and function of platelets stored in 65% citrate-free PAS-III or PAS-III containing 10 mM of citrate. Measurements included cell count, blood gases, flow cytometry analysis of surface activation markers, and aggregation. RESULTS: Study 1 identified that inclusion of citrate in PAS resulted in a dose-dependent increase in glucose utilization, lactate formation, P-selectin expression, phosphatidylserine (PS) exposure, and reactive oxygen species (ROS) formation. Study 2 showed similar results in which platelets stored in citrate-free PAS-III benefited through better maintenance of glucose utilization with less lactate production, P-selectin expression, PS exposure, and ROS formation compared to citratecontaining PAS-III. Platelets stored in citrate-free PAS-III had aggregation responses that were at least 10% greater than those platelets stored in PAS-III. CONCLUSION: Storage of apheresis platelets incitrate-free PAS-III improved multiple storage parameters including glucose utilization, lactate production, Pselection expression, PS exposure, and ROS formation and resulted in a modest increase in aggregation.ABBREVIATIONS: ACD = anticoagulant citrate dextrose solution; ADP = adenosine diphosphate; CPD = citrate-phosphate-dextrose; PASs = platelet additive solutions; PS = phosphatidylserine; ROS = reactive oxygen species; TRAP6 = thrombin receptor activator peptide 6.* Significantly different than Day 5, 0 mM citrate bicarbonate levels; one-way analysis of variance, p = 0.029. † Significantly different than Day 5, 0 mM citrate bicarbonate levels; one-way analysis of variance, p = 0.003.

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“…We read with great interest the article by MacKay et al, 1 which provides compelling evidence for a concerning correlation between abnormal calcium levels during trauma resuscitation and increased mortality. While we found the article well written and informative, we have several concerns about the authors′ analysis and potential future studies.…”

Section: To the Editormentioning

confidence: 99%