University of Wisconsin–Madison Medical College of Wisconsin

Maintenance of Ionized Calcium During Prolonged Extreme Massive Transfusion During Liver Transplantation

Ricardo P. Dorantes, BS; Stylianos Voulgarelis, MD; Harvey J. Woehlck, MD

WMJ. 2023;122(4):294-297.

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Introduction: Massive transfusion may cause ionized hypocalcemia, a complication that, when severe, causes hemodynamic instability. Extant literature fails to provide effective guidance on replacement strategies to avoid severe ionized hypocalcemia in the most extreme situations.

Case Presentation: We discuss a liver transplant in which our empiric calcium replacement strategy resulted in no critically low ionized calcium values during the pre-reperfusion phase of a liver transplant with over 140 000 mL of bank blood transfusion, with an average of 10 000 mL per hour for 14 hours.

Discussion: Few comparable reports exist. Most rely upon monitoring with subsequent replacement, but these have not been effective at avoiding severely low ionized calcium values.

Conclusions: Our empiric calcium replacement strategy of 1 gram of calcium chloride per liter of citrated bank blood transfused, in 200 mg/200 mL increments, resulted in successful maintenance of ionized calcium during the anhepatic phase of liver transplantation while on continuous veno-venous hemofiltration.

Author Affiliations: Medical College of Wisconsin (MCW), Milwaukee, Wisconsin (Dorantes); Department of Anesthesiology, Children’s Specialty Group, MCW, Milwaukee, Wis (Voulgarelis); Department of Anesthesiology, MCW, Milwaukee, Wis (Woehlck).
Corresponding Author: Harvey Woehlck, MD, Professor of Anesthesiology, Department of Anesthesiology, Froedtert Memorial Hospital, 9200 W Wisconsin Ave, Milwaukee, WI 53226; phone 414.805.2715; email; ORCID ID 0000-0002-1701-392X
Financial Disclosures: None declared.
Funding/Support: None declared.
Acknowledgements: The patient gave written authorization for publication of this case report.
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