Volume of packed red blood cells and fresh frozen plasma is associated with intraoperative hypocalcaemia during large volume intraoperative transfusion

Abstract

Background: Severe hypocalcaemia is associated with increased transfusion in the trauma population. Furthermore, trauma patients developing severe hypocalcaemia have higher mortality and coagulopathy. Electrolyte abnormalities associated with massive transfusion have been less studied in the surgical population. Here, we tested the primary hypothesis that volume of packed red blood cells and fresh frozen plasma transfused intraoperatively is associated with lower nadir ionised calcium in the surgical population receiving massive resuscitation. Methods:We performed a retrospective observational study at an academic quaternary care centre to characterise hypocalcaemia following large volume (4 or more units packed red blood cells) intraoperative transfusion. We used multivariable linear regression to assess if volume of transfusion with packed red blood cells and fresh frozen plasma were independently associated with a lower ionised calcium. We then used multivariable logistic regressions to assess the association between ionised calcium and transfusion with: (i) mortality, (ii) acute kidney injury, and (iii) postoperative coagulopathy.Results: Hypocalcaemia following large volume resuscitation in the operating room is a very frequent occurrence (70% of cases). After controlling for demographic variables and intraoperative variables, the volume transfused intraoperative was independently associated with hypocalcaemia on multivariable linear regression.Hypocalcaemia, intraoperative transfusion of packed red blood cells, and intraoperative transfusion of fresh frozen plasma were not shown to be associated with clinical outcomes.Conclusions: Hypocalcaemia was associated with increased transfusion volume in this single-centre study. Unlike the trauma population, hypocalcaemia was not associated with increased mortality during surgical care. Our findings suggest that despite improved practice patterns of calcium supplementation, intraoperative hypocalcaemia occurs with relatively high frequency following large volume intraoperative transfusion.

Impact of Transfused Citrate on Pathophysiology in Massive Transfusion

“…With this focus on early administration of blood products, massive transfusion protocols (MTPs, commonly defined as transfusion of at least 10 U of blood in a 24-hr period) have become widely implemented (5). The Prevalence of hypocalcemia in the massively transfused population has become a well-described phenomenon (6–12).…”

“…With this focus on early administration of blood products, massive transfusion protocols (MTPs, commonly defined as transfusion of at least 10 U of blood in a 24-hr period) have become widely implemented (5). The Prevalence of hypocalcemia in the massively transfused population has become a well-described phenomenon (6)(7)(8)(9)(10)(11)(12). This is likely even more pronounced when using component therapy; compared with WB resuscitation, solely using component therapy typically results in transfusion of larger volumes of blood product (2,(13)(14)(15)(16).…”