Ionised calcium levels in major trauma patients who received blood en route to a military medical treatment facility

Kyle, Tony; Greaves, Ian; Beynon, Anthony; Whittaker, Vicky; Brewer, M. Frederick; Smith, Jessi L.

doi:10.1136/emermed-2017-206717

Cited by 28 publications

(25 citation statements)

References 17 publications

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“…Additionally, current massive transfusion protocols dictate transfusion of high ratios of FFP [29] which has also been independently associated with hypocalcaemia [10, 30,31]. We therefore hypothesize that patients with admission ionized hypocalcaemia as observed in this study are likely to become more severely hypocalcaemic during haemostatic resuscitation [25,26].…”

Section: Discussionmentioning

confidence: 81%

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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: 81%

“…Hypocalcaemia was associated with early death mirroring the pattern of death observed in the setting of acute traumatic coagulopathy [23,24]. Early resuscitative measures involving blood transfusion are also likely to further exacerbate hypocalcaemia [25,26].…”

Section: Discussionmentioning

confidence: 84%

Hypocalcaemia and traumatic coagulopathy: an observational analysis

et al. 2019

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“…1 Previous civilian and military studies have shown that hypocalcemia (iCa <1.12) commonly occurs in trauma patients who receive even a small volume of blood products. 2,3 Recently published data demonstrated that the prevalence of hypocalcemia (iCa <1.12 mmol/L) in massively transfused patients was 97% and severe hypocalcemia (iCa < 0.9 mmol/L) was a significant risk factor for mortality. 4 Extreme ionized hypocalcemia (iCa < 0.8 mmol/L) is an independent predictor of mortality in critically ill patients.…”

Section: Introductionmentioning

confidence: 99%

“…Despite using citrate, a well‐known calcium chelator, to preserve blood products for over 100 years, the data behind transfusion‐induced hypocalcemia are lacking 1 . Previous civilian and military studies have shown that hypocalcemia (iCa <1.12) commonly occurs in trauma patients who receive even a small volume of blood products 2, 3 . Recently published data demonstrated that the prevalence of hypocalcemia (iCa <1.12 mmol/L) in massively transfused patients was 97% and severe hypocalcemia (iCa < 0.9 mmol/L) was a significant risk factor for mortality 4 …”

Section: Introductionmentioning

confidence: 99%

Massive transfusions and severe hypocalcemia: An opportunity for monitoring and supplementation guidelines

et al. 2021

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Background Massive transfusion protocols (MTPs) are associated with severe hypocalcemia, contributing to coagulopathy and mortality in severely injured patients. Severity of hypocalcemia following massive transfusion activation and appropriate treatment strategies remain undefined. Study design and methods This was a retrospective study of all MTP activations in adult trauma patients at a Level 1 trauma center between August 2016 and September 2017. Units of blood products transfused, ionized calcium levels, and amount of calcium supplementation administered were recorded. Primary outcomes were ionized calcium levels and the incidence of severe ionized hypocalcemia (iCa ≤1.0 mmol/L) in relation to the volume of blood products transfused. Results Seventy‐one patients had an MTP activated during the study period. The median amount of packed red blood cells (PRBCs) transfused was 10 units (range 1–52). A total of 42 (59.1%) patients had periods of severe hypocalcemia. Patients receiving 13 or more units of PRBC had a greater prevalence of hypocalcemia with 83.3% having at least one measured ionized calcium ≤1.0 mmoL/L (p = .001). The number of ionized calcium levels checked and the amount of supplemental calcium given in patients who experienced hypocalcemia varied considerably. Discussion Severe hypocalcemia commonly occurs during MTP activations and correlates with the number of packed red blood cells transfused. Monitoring of ionized calcium and amount of calcium supplementation administered is widely variable. Standardized protocols for recognition and management of severe hypocalcemia during massive transfusions may improve outcomes.

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“…Calcium levels have been proposed as important in the development of coagulopathy in the trauma patient with hemorrhagic shock. [27][28][29][30][31][32] Low ionized calcium levels are associated with hypotension, coagulopathy, and increased mortality. In particular, platelet dysfunction has been linked to hypocalcemia.…”

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confidence: 99%

Does Gender Matter: A Multi-Institutional Analysis of Viscoelastic Profiles for 1565 Trauma Patients With Severe Hemorrhage

Smith

Duchesne

Marturano

et al. 2021

The American Surgeon™

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Background Viscoelastic tests including thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are being used in patients with severe hemorrhage at trauma centers to guide resuscitation. Several recent studies demonstrated hypercoagulability in female trauma patients that was associated with a survival advantage. The objective of our study was to elucidate the effects of gender differences in TEG/ROTEM values on survival in trauma patients with severe hemorrhage. Methods A retrospective review of consecutive adult patients receiving massive transfusion protocol (MTP) at 7 Level I trauma centers was performed from 2013 to 2018. Data were stratified by gender and then further examined by TEG or ROTEM parameters. Results were analyzed using univariate and multi-variate analyses. Results A total of 1565 patients were included with 70.9% male gender (n = 1110/1565). Female trauma patients were older than male patients (43.5 ± .9 vs 41.1 ± .6 years, P = .01). On TEG, females had longer reaction times (6.1 ± .9 min vs 4.8 ± .2 min, P = .03), increased alpha angle (68.6 ± .8 vs 65.7 ± .4, P < .001), and higher maximum amplitude (59.8 ± .8 vs 56.3 ± .4, P < .001). On ROTEM, females had significantly longer clot time (99.2 ± 13.7 vs 75.1 ± 2.6 sec, P = .09) and clot formation time (153.6 ± 10.6 sec vs 106.9 ± 3.8 sec, P < .001). When comparing by gender, no difference for in-hospital mortality was found for patients in the TEG or ROTEM group ( P > .05). Multivariate analysis showed no survival difference for female patients (OR 1.11, 95% CI .83-1.50, P = .48). Conclusions Although a difference between male and females was found on TEG/ROTEM for certain clotting parameters, no difference in mortality was observed. Prospective multi-institutional studies are needed.

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Ionised calcium levels in major trauma patients who received blood en route to a military medical treatment facility

Abstract: Trauma patients who received blood products were at high risk of hypocalcaemia. Aggressive management of these patients with intravenous calcium during transfusion may be required.

Cited by 28 publications

References 17 publications

Hypocalcaemia and traumatic coagulopathy: an observational analysis

Hypocalcaemia and traumatic coagulopathy: an observational analysis

Massive transfusions and severe hypocalcemia: An opportunity for monitoring and supplementation guidelines

Does Gender Matter: A Multi-Institutional Analysis of Viscoelastic Profiles for 1565 Trauma Patients With Severe Hemorrhage

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