Early Hypocalcemia in Severe Trauma: An Independent Risk Factor for Coagulopathy and Massive Transfusion

Marco Vettorello, Michele Altomare, Andrea Spota, Stefano Piero Bernardo Cioffi, Marta Rossmann, Andrea Mingoli, Osvaldo Chiara, Stefania Cimbanassi, Marco Vettorello, Michele Altomare, Andrea Spota, Stefano Piero Bernardo Cioffi, Marta Rossmann, Andrea Mingoli, Osvaldo Chiara, Stefania Cimbanassi

Abstract

The rapid identification of patients at risk for massive blood transfusion is of paramount importance as uncontrolled exsanguination may lead to death within 2 to 6 h. The aim of this study was to analyze a cohort of severe trauma patients to identify risk factors associated with massive transfusion requirements and hypocalcemia. All major trauma (ISS > 16) presented directly from the scene to the Niguarda hospital between 1 January 2015 and 31 December 2021 were analyzed. A total of 798 patients were eligible out of 1586 screened. Demographic data showed no significant difference between hypocalcemic (HC) and normocalcemic (NC) patients except for the presence of crush trauma, alcohol intake (27% vs. 15%, p < 0.01), and injury severity score (odds ratio 1.03, p = 0.03). ISS was higher in the HC group and was an independent, even if weak, predictor of hypocalcemia (odds ratio 1.03, p = 0.03). Prehospital data showed a lower mean systolic arterial pressure (SAP) and a higher heart rate (HR) in the HC group (105 vs. 127, p < 0.01; 100 vs. 92, p < 0.001, respectively), resulting in a higher shock index (SI) (1.1 vs. 0.8, p < 0.001). Only retrospective studies such as ours are available, and while hypocalcemia seems to be an independent predictor of mortality and massive transfusion, there is not enough evidence to support causation. Therefore, randomized prospective studies are suggested.

Keywords: hypocalcemia; massive transfusion; trauma; trauma-induced coagulopathy.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Patient enrollment.
Figure 2
Figure 2
Linear regression: crystalloids infusions vs. ionized calcium. (R = 0.25, R2 = 0.065, p < 0.001).
Figure 3
Figure 3
Kaplan–Meier Survival Rates. Hypocalcemic vs. Normocalcemic patients.

References

    1. Magnotti L.J., Bradburn E.H., Webb D.L., Berry S.D., Fischer P.E., Zarzaur B.L., Schroeppel T.J., Fabian T.C., Croce M.A. Admission ionized calcium levels predict the need for multiple transfusions: A prospective study of 591 critically ill trauma patients. J. Trauma. 2011;70:391–397. doi: 10.1097/TA.0b013e31820b5d98.
    1. Vivien B., Langeron O., Morell E., Devilliers C., Carli P.A., Coriat P., Riou B. Early hypocalcemia in severe trauma. Crit. Care Med. 2005;33:1946–1952. doi: 10.1097/01.CCM.0000171840.01892.36.
    1. Laitinen K., Lamberg-Allardt C., Tunninen R., Karonen S.-L., Tähtelä R., Ylikahri R., Välimäki M. Transient hypoparathyroidism during acute alcohol intoxication. N. Engl. J. Med. 1991;324:721–727. doi: 10.1056/NEJM199103143241103.
    1. Molina P.E., Sulzer J.K., Whitaker A.M. Alcohol abuse and the injured host: Dysregulation of counterregulatory mechanisms review. Shock. 2013;39:240–249. doi: 10.1097/SHK.0b013e318285b86d.
    1. Odeh M. The role of reperfusion-induced injury in the pathogenesis of the crush syndrome. N. Engl. J. Med. 1991;324:1417–1422. doi: 10.1056/NEJM199105163242007.
    1. James M.F., Roche A.M. Dose-response relationship between plasma ionized calcium concentration and thrombelastography. J. Cardiothorac. Vasc. Anesth. 2004;18:581–586. doi: 10.1053/j.jvca.2004.07.016.
    1. Wray J.P., Bridwell R.E., Schauer S.G., Shackelford S.A., Bebarta V.S., Wright F.L., Bynum J., Long B. The diamond of death: Hypocalcemia in trauma and resuscitation. Am. J. Emerg. Med. 2021;41:104–109. doi: 10.1016/j.ajem.2020.12.065.
    1. Ho K.M., Leonard A.D. Concentration-dependent effect of hypocalcaemia on mortality of patients with critical bleeding requiring massive transfusion: A cohort study. Anaesth. Intensive Care. 2011;39:46–54. doi: 10.1177/0310057X1103900107.
    1. Peltan I.D., Vusse L.K.V., Maier R.V., Watkins T.R. An international normalized ratio-based definition of acute traumatic coagulopathy is associated with mortality, venous thromboembolism, and multiple organ failure after injury. Crit. Care Med. 2015;43:1429–1438. doi: 10.1097/CCM.0000000000000981.
    1. Baker S.P., O’Neill B., Haddon W., Long W.B. The injury severity score: A method for describing patients with multiple injuries and evaluating emergency care. J. Trauma. 1974;14:187–196. doi: 10.1097/00005373-197403000-00001.
    1. Cherry R.A., Bradburn E., Carney D.E., Shaffer M.L., Gabbay R.A., Cooney R.N. Do early ionized calcium levels really matter in trauma patients. J. Trauma. 2006;61:774–779. doi: 10.1097/01.ta.0000239516.49799.63.
    1. Vasudeva M., Mathew J.K., Fitzgerald M.C., Cheung Z., Mitra B. Hypocalcaemia and traumatic coagulopathy: An observational analysis. Vox Sang. 2020;115:189–195. doi: 10.1111/vox.12875.
    1. Gando S., Igarashi M., Kameue T., Nanzaki S. Ionized hypocalcemia during out-of-hospital cardiac arrest and cardiopulmonary resuscitation is not due to binding by lactate. Intensive Care Med. 1997;23:1245–1250. doi: 10.1007/s001340050493.
    1. Brooke M., Yeung L., Miraflor E., Garcia A., Victorino G.P. Lactate predicts massive transfusion in hemodynamically normal patients. J. Surg. Res. 2016;204:139–144. doi: 10.1016/j.jss.2016.04.015.
    1. Kronstedt S., Roberts N., Ditzel R., Elder J., Steen A., Thompson K., Anderson J., Siegler J. Hypocalcemia as a predictor of mortality and transfusion. A scoping review of hypocalcemia in trauma and hemostatic resuscitation. Transfusion. 2022;62:S158–S166. doi: 10.1111/trf.16965.
    1. MacKay E.J., Stubna M.D., Holena D.N., Reilly P.M., Seamon M.J., Smith B.P., Kaplan L.J., Cannon J.W. Abnormal Calcium Levels During Trauma Resuscitation Are Associated with Increased Mortality, Increased Blood Product Use, and Greater Hospital Resource Consumption: A Pilot Investigation. Anesth. Dig. 2017;125:895–901. doi: 10.1213/ANE.0000000000002312.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe