From the Guidelines
Maintaining normal calcium levels during blood transfusions is crucial to prevent hypocalcemia, which can lead to cardiac arrhythmias, decreased cardiac contractility, and coagulopathy, ultimately affecting morbidity, mortality, and quality of life. The citrate preservative in stored blood binds to calcium, potentially causing hypocalcemia, especially in massive transfusions where citrate load can overwhelm the liver's metabolism capacity 1. Hypocalcemia during transfusion can lead to cardiac arrhythmias, decreased cardiac contractility, hypotension, and neuromuscular symptoms like tetany and paresthesias.
Key Considerations
- Calcium levels should be monitored during massive transfusions, and replacement therapy with calcium chloride may be necessary when symptoms develop or when ionized calcium levels fall below normal 1.
- Patients with liver dysfunction, hypothermia, or those receiving rapid transfusions are at higher risk for transfusion-associated hypocalcemia and require closer monitoring 1.
- Preventive calcium administration is not routinely recommended for all transfusions but should be considered in high-risk scenarios to maintain hemodynamic stability and prevent complications.
- The preferred agent to correct hypocalcaemia is calcium chloride, as it contains more elemental calcium compared to calcium gluconate, and may be preferable in the setting of abnormal liver function 1.
Monitoring and Replacement
- Ionised calcium levels should be monitored and maintained within the normal range following major trauma and especially during massive transfusion 1.
- Replacement therapy with calcium chloride may be necessary when ionised Ca2+ levels fall below 0.9 mmol/L or serum total corrected calcium levels of 7.5 mg/dL or lower 1.
- Calcium chloride is recommended to correct hypocalcaemia, with a dose of 10 mL as a 10% solution containing 270 mg of elemental calcium 1.
From the FDA Drug Label
Maintenance of normal serum calcium levels is important for maternal and fetal well being.
The importance of having normal calcium levels during blood transfusion is not directly addressed in the provided drug labels. However, maintaining normal serum calcium levels is important for overall well being, especially in specific populations such as pregnant women.
- Normal calcium levels are crucial for various bodily functions.
- The provided drug labels do not explicitly discuss the importance of calcium levels during blood transfusion 2, 2.
From the Research
Importance of Normal Calcium Levels in Blood Transfusion
- Normal calcium levels are crucial during blood transfusion to prevent hypocalcemia, which can lead to coagulopathy and mortality in severely injured patients 3.
- Hypocalcemia is common in trauma patients receiving massive transfusion protocol and can worsen coagulopathies 4.
- Severe hypocalcemia can occur during massive transfusion activations and correlates with the number of packed red blood cells transfused 3.
Effects of Hypocalcemia on Coagulation
- Hypocalcemia can affect coagulation by reducing clot strength, making it essential to maintain normal ionized calcium concentrations during critical bleeding 5.
- Ionized calcium concentrations have a concentration-dependent association with in vitro clot strength, and maintaining a normal ionized calcium concentration (>1 mmol L(-1)) is recommended during critical bleeding 5.
Management of Hypocalcemia
- Standardized protocols for recognition and management of severe hypocalcemia during massive transfusions may improve outcomes 3.
- Calcium supplementation is essential in patients with hypocalcemia, and the amount of supplemental calcium given should be carefully monitored 4, 3.
- Disorders that lead to chronic hypocalcemia require careful management, including calcium and vitamin D supplementation, to avoid symptoms of hypocalcemia and hypercalciuria 6.