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Epstein D, Ben Lulu H, Raz A, Bahouth H. Admission hypocalcemia in pediatric major trauma patients-An uncommon phenomenon associated with an increased need for urgent blood transfusion. Transfusion 2022; 62:1341-1346. [PMID: 35638746 DOI: 10.1111/trf.16936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hemorrhage is a leading cause of death among children. Recent data from adult trauma suggests that early, transfusion-unrelated, hypocalcemia is common and that it is associated with an increased need for blood transfusion, mortality, and coagulopathy. The objectives of this study are to evaluate the prevalence of admission hypocalcemia in severely injured children and its correlation with urgent blood transfusion. STUDY DESIGN AND METHODS This is a retrospective cohort study of all severely injured (Injury Severity Score [ISS] > 15) pediatric (<18 years) trauma patients admitted to Rambam Health Care Campus, Israel between 2012 and 2020. We excluded patients transferred from other facilities and those who received blood before determining calcium levels. Severe hypocalcemia was defined as ionized calcium (Ca++ ) < 1.0 mmol/L and mild hypocalcemia as 1.0 mmol/L ≤ Ca++ < 1.1 mmol/L. The primary outcome was urgent blood transfusion (transfusion in the emergency department [ED]). RESULTS Six hundred seventy-three severely injured children were admitted from the field. Ca++ levels were determined before blood transfusion in 457 patients. Severe hypocalcemia was found in three patients (0.7%) and mild hypocalcemia in additional 21 patients (4.6%). Hypocalcemic patients required more urgent blood transfusion (29.2% vs. 6.5%, p < .001) and had higher ISS (29 [interquartile range, IQR: 22-35] vs. 25 [IQR: 19-34], p = .05). Multivariable logistic regression analysis identified Ca++ < 1.1 mmol/L as an independent predictor of the need for blood transfusion, odds ratio 5.44 (95% confidence interval 1.44-20.58), p = .01. DISCUSSION Contrary to adults, admission hypocalcemia is uncommon in severely injured children. However, it may be associated with an increased risk of blood transfusion in the ED.
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Affiliation(s)
- Danny Epstein
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Hen Ben Lulu
- Trauma and Emergency Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Aeyal Raz
- Ruth and Bruce Rappaport Faculty of Medicine, Haifa, Israel.,Department of Anesthesiology, Rambam Health Care Campus, Haifa, Israel
| | - Hany Bahouth
- Trauma and Emergency Surgery, Rambam Health Care Campus, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Haifa, Israel
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Byerly S, Inaba K, Biswas S, Wang E, Wong MD, Shulman I, Benjamin E, Lam L, Demetriades D. Transfusion-Related Hypocalcemia After Trauma. World J Surg 2020; 44:3743-3750. [PMID: 32734451 PMCID: PMC7391918 DOI: 10.1007/s00268-020-05712-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Hypocalcemia is cited as a complication of massive transfusion. However, this is not well studied as a primary outcome in trauma patients. Our primary outcome was to determine if transfusion of packed red blood cells (pRBC) was an independent predictor of severe hypocalcemia (ionized calcium ≤ 3.6 mg/dL). METHODS Retrospective, single-center study (01/2004-12/2014) including all trauma patients ≥ 18 yo presenting to the ED with an ionized calcium (iCa) level drawn. Variables extracted included demographics, interventions, outcomes, and iCa. Regression models identified independent risk factors for severe hypocalcemia (SH). RESULTS Seven thousand four hundred and thirty-one included subjects, 716 (9.8%) developed SH within 48 h of admission. Median age: 39 (Range: 18-102), systolic blood pressure: 131 (IQR: 114-150), median Glasgow Coma Scale (GCS): 15 (IQR: 10-15), Injury Severity Score (ISS): 14 (IQR: 9-24). SH patients were more likely to have depressed GCS (13 vs 15, p < 0.0001), hypotension (23.2% vs 5.1%, p < 0.0001) and tachycardia (57.0% vs 41.9%, p < 0.0001) compared to non-SH patients. They also had higher emergency operative rate (71.8% vs 29%, p < 0.0001) and higher blood administration prior to minimum iCa [pRBC: (8 vs 0, p < 0.0001), FFP: (4 vs 0, p < 0.0001), platelet: (1 vs 0, p < 0.0001)]. Multivariable analysis revealed penetrating mechanism (AOR: 1.706), increased ISS (AOR: 1.029), and higher pRBC (AOR: 1.343) or FFP administered (AOR: 1.097) were independent predictors of SH. SH was an independent predictor of mortality (AOR: 2.658). Regression analysis identified a significantly higher risk of SH at pRBC + FFP administration of 4 units (AOR: 18.706, AUC:. 897 (0.884-0.909). CONCLUSION Transfusion of pRBC is an independent predictor of SH and is associated with increased mortality. The predicted probability of SH increases as pRBC + FFP administration increases.
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Affiliation(s)
- Saskya Byerly
- Department of Surgery, Division of Trauma and Critical Care, Jackson Memorial Hospital Ryder Trauma Center, University of Miami, Miami, FL, USA
| | - Kenji Inaba
- Department of Surgery, Division of Trauma and Critical Care Surgery, Keck School of Medicine, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA.
| | - Subarna Biswas
- Department of Surgery, Division of Trauma and Critical Care Surgery, Keck School of Medicine, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Eugene Wang
- Department of Surgery, Division of Trauma and Critical Care Surgery, Keck School of Medicine, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Monica D Wong
- Department of Surgery, Division of Trauma and Critical Care Surgery, Keck School of Medicine, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Ira Shulman
- Department of Surgery, Division of Trauma and Critical Care Surgery, Keck School of Medicine, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Elizabeth Benjamin
- Department of Surgery, Division of Trauma and Critical Care Surgery, Keck School of Medicine, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Lydia Lam
- Department of Surgery, Division of Trauma and Critical Care Surgery, Keck School of Medicine, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
| | - Demetrios Demetriades
- Department of Surgery, Division of Trauma and Critical Care Surgery, Keck School of Medicine, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA, 90033, USA
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Zhao Y, Garrity D, Graves M, Linden J, St. Pierre P, Ducharme P, Greene M, Vauthrin M, Weinstein R. Optimization of infusional calcium gluconate for prevention of hypocalcemic reactions during therapeutic plasma exchange. J Clin Apher 2019; 34:656-660. [DOI: 10.1002/jca.21742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 06/27/2019] [Accepted: 07/30/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Yong Zhao
- Transfusion Medicine and Apheresis ServiceUMass Memorial Medical Center Worcester Massachusetts
- Division of Transfusion MedicineUMass Memorial Medical Center Worcester Massachusetts
- Department of MedicineUniversity of Massachusetts Medical School Worcester Massachusetts
- Department of PathologyUniversity of Massachusetts Medical School Worcester Massachusetts
| | - Danielle Garrity
- Transfusion Medicine and Apheresis ServiceUMass Memorial Medical Center Worcester Massachusetts
| | - Molly Graves
- Transfusion Medicine and Apheresis ServiceUMass Memorial Medical Center Worcester Massachusetts
| | - Jeanne Linden
- Transfusion Medicine and Apheresis ServiceUMass Memorial Medical Center Worcester Massachusetts
| | - Patricia St. Pierre
- Transfusion Medicine and Apheresis ServiceUMass Memorial Medical Center Worcester Massachusetts
| | - Paula Ducharme
- Transfusion Medicine and Apheresis ServiceUMass Memorial Medical Center Worcester Massachusetts
| | - Mindy Greene
- Transfusion Medicine and Apheresis ServiceUMass Memorial Medical Center Worcester Massachusetts
| | - Michelle Vauthrin
- Transfusion Medicine and Apheresis ServiceUMass Memorial Medical Center Worcester Massachusetts
| | - Robert Weinstein
- Transfusion Medicine and Apheresis ServiceUMass Memorial Medical Center Worcester Massachusetts
- Division of Transfusion MedicineUMass Memorial Medical Center Worcester Massachusetts
- Department of MedicineUniversity of Massachusetts Medical School Worcester Massachusetts
- Department of PathologyUniversity of Massachusetts Medical School Worcester Massachusetts
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Zhao Y, Linden J, Welch L, St. Pierre P, Graves M, Garrity D, Ducharme P, Bailey JA, Greene M, Vauthrin M, Weinstein R. Prophylactic infusion of calcium gluconate to prevent a symptomatic fall in plasma ionized calcium during therapeutic plasma exchange: A comparison of two methods. J Clin Apher 2018; 33:600-603. [DOI: 10.1002/jca.21648] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 06/29/2018] [Indexed: 01/28/2023]
Affiliation(s)
- Yong Zhao
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
- Division of Transfusion Medicine; UMass Memorial Medical Center; Worcester Massachusetts
- Department of Medicine; University of Massachusetts Medical School; Worcester Massachusetts
- Department of Pathology; University of Massachusetts Medical School; Worcester Massachusetts
| | - Jeanne Linden
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
| | - Linda Welch
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
| | - Patricia St. Pierre
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
| | - Molly Graves
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
| | - Danielle Garrity
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
| | - Paula Ducharme
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
| | - Jeffrey A. Bailey
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
- Division of Transfusion Medicine; UMass Memorial Medical Center; Worcester Massachusetts
- Department of Medicine; University of Massachusetts Medical School; Worcester Massachusetts
- Department of Pathology; University of Massachusetts Medical School; Worcester Massachusetts
| | - Mindy Greene
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
| | - Michelle Vauthrin
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
| | - Robert Weinstein
- Transfusion Medicine and Apheresis Service; UMass Memorial Medical Center; Worcester Massachusetts
- Division of Transfusion Medicine; UMass Memorial Medical Center; Worcester Massachusetts
- Department of Medicine; University of Massachusetts Medical School; Worcester Massachusetts
- Department of Pathology; University of Massachusetts Medical School; Worcester Massachusetts
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