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

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.

Chronic periodic fluid redistribution effect on muscle calcium in healthy subjects during prolonged hypokinesia

Studies have shown that chronic periodic fluid shifting upwards is not sensed as excessive fluid volume and excretion mechanisms are not activated. To determine if chronic periodic fluid and volume shifting upwards can affect muscle calcium (Ca(2+)) during hypokinesia (HK) we measured muscle Ca(2+) content, plasma Ca(2+) concentration, and Ca(2+) losses in urine and feces. Studies were conducted on 40 healthy male volunteers. They were divided into four equal groups: active control subjects (ACS), hypokinetic subjects (HKS), periodic fluid redistribution control subjects (PFRCS), and periodic fluid redistribution hypokinetic subjects (PFRHS). Plasma Ca(2+) level decreased (p < 0.05) in Ca(2+) repleted muscle, muscle Ca(2+) level increased (p < 0.05), and Ca(2+) losses in urine and feces decreased (p < 0.05) in the PFRHS group compared with the HKS group. Plasma Ca(2+) level increased (p < 0.05) in Ca(2+) deficient muscle, muscle Ca(2+) level decreased (p < 0.05), and Ca(2+) losses in urine and feces increased (p < 0.05) in the HKS group compared with their pre-experimental levels and the values in their respective control groups (ACS and PFRCS). This study shows that the muscle Ca(2+) content increases and Ca(2+) excretion decreases, suggesting the clinical potential of chronic periodic fluid and volume redistribution in treatment of muscle Ca(2+) deficiency.