Written by Clark Strunk
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In this single-center retrospective study of trauma patients receiving early whole blood transfusion, calcium chloride administration at a ratio of at least 1 gram per 2 units of whole blood was associated with a reduction in early mortality.
More than just strong bones…
This was a single-center retrospective cohort study that included 273 trauma patients who received low-titer O whole blood (LTOWB) prehospital or within 4 hours after arrival, evaluating the amount and formulation of calcium received and its effects on 24-hour mortality. For a calcium threshold of 1 gram per 2 units, there was an approximately 84% reduction in 24-hour mortality, with an adjusted odds ratio of 0.164 (95%CI 0.034–0.796, p=0.025). There was no significant reduction with calcium gluconate at this threshold. 24-hour mortality was 6.7% in patients that received at least 1 gram of calcium per 2 units of whole blood versus 17.8% in those that did not (p = 0.01), and this effect was strongest at the 1:2 threshold compared to 1:3 and 1:4. There was no significant difference in 4-hour or 30-day mortality.
How does this change my practice?
There is increasing recognition that calcium needs to be aggressively replenished in bleeding patients, whether traumatic, gastrointestinal, obstetrical, etc. This small retrospective observational study looked at only the initial resuscitation of trauma patients, and its results are in line with the approximate ratios that I (and many others, I imagine) already use. This affirms my practice but should not be applied too dogmatically. This study also does not directly inform how to best translate this 1:2 ratio to institutions using component therapy. Ultimately, the study underscores the importance of aggressive calcium administration in bleeding patients, but how best to give calcium to bleeding patients as their clinical course evolves throughout the different stages of resuscitation, from empiric ratios initially to integration with ionized calcium levels, needs prospective investigation.
Source
Aggressive calcium chloride dosing reduces early mortality in trauma patients receiving whole blood resuscitation. J Trauma Acute Care Surg. 2026 Apr 17. doi: 10.1097/TA.0000000000005009. Epub ahead of print. PMID: 41995161.
