From the Guidelines
Calcium supplementation should be administered to correct hypocalcaemia in patients receiving massive transfusions, as recommended by the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1.
Calcium Monitoring and Supplementation
For patients receiving massive transfusions, defined as more than 4-6 units of blood within 24 hours, calcium levels should be monitored to prevent hypocalcemia. The citrate preservative in stored blood can bind calcium, potentially causing hypocalcemia, which can lead to symptoms such as tingling, muscle cramps, seizures, and cardiac arrhythmias.
Preferred Agent for Correction
The preferred agent to correct hypocalcaemia is calcium chloride, as it contains more elemental calcium than calcium gluconate, with 10 mL of 10% solution containing 270 mg of elemental calcium 1.
Rationale for Monitoring and Supplementation
Ionised calcium levels should be maintained within the normal range, as hypocalcaemia can negatively impact the coagulation cascade, platelet function, and cardiac contractility 1. The normal range of ionised calcium is 1.1–1.3 mmol/L, and levels below 0.9 mmol/L should be corrected promptly to prevent cardiac dysrhythmias.
Clinical Considerations
Patients with liver dysfunction may be at higher risk for developing hypocalcemia after transfusions, as they metabolize citrate more slowly. Therefore, close monitoring of calcium levels and prompt correction of hypocalcaemia are crucial in these patients.
Key Recommendations
- Monitor ionised calcium levels in patients receiving massive transfusions
- Administer calcium chloride to correct hypocalcaemia
- Maintain ionised calcium levels within the normal range to prevent negative impacts on the coagulation cascade, platelet function, and cardiac contractility.
From the Research
Calcium Administration After Massive Blood Transfusions
- Massive blood transfusions, defined as exceeding 50 units of blood products, can lead to hypocalcemia due to the citrate preservative in blood products, which binds to calcium ions 2.
- Hypocalcemia is a serious condition that can affect the transmission of nerve impulses, contraction and relaxation of muscles, and hormone secretion 3.
- The administration of calcium, typically in the form of calcium gluconate or calcium chloride, is essential to prevent or treat hypocalcemia in patients receiving massive blood transfusions 3, 4.
Prevention and Treatment of Hypocalcemia
- Calcium gluconate is often preferred over calcium chloride due to its lower irritation potential and better compatibility with other nutrients in parenteral nutrition 3.
- The optimal dose and infusion rate of calcium gluconate for preventing hypocalcemic reactions during therapeutic plasma exchange have been studied, with a dose of 1.6 g/h showing promise 4.
- Intravenous calcium infusion is essential to raise calcium levels and resolve symptoms in acute hypocalcemia, while oral calcium and/or vitamin D supplementation is used to treat chronic hypocalcemia 5, 6.
Clinical Considerations
- The management of hypocalcemia requires careful consideration of the underlying cause, as well as the patient's individual needs and response to treatment 5, 6.
- In patients with hypoparathyroidism, calcium and vitamin D supplementation must be carefully titrated to avoid symptoms of hypocalcemia while minimizing the risk of hypercalciuria and renal dysfunction 5, 6.
- The use of recombinant human parathyroid hormone (rhPTH) has been approved for the treatment of hypoparathyroidism, offering a new therapeutic option for patients with this condition 6.