The Role of Calcium in Augmenting the Efficacy of Primary Homeostasis after Hemorrhagic Shock

Research Article

Ann Hematol Onco. 2023; 10(1): 1415.

The Role of Calcium in Augmenting the Efficacy of Primary Homeostasis after Hemorrhagic Shock

Thacker JM, Ledgerwood AM, and Lucas CE*

Department of Surgery, Wayne State University School of Medicine, USA

*Corresponding author: Charles E LucasDepartment of Surgery, Wayne State University School of Medicine, 4201 St. Antoine, Detroit, MI, 48201, USA

Received: December 22, 2022; Accepted: January 24, 2023; Published: January 31, 2023


Background: Traumatic Hemorrhagic Shock (THS) causes hypocalcemia (Ca). This study assesses how low Ca affects platelet (Plt) function.

Study Design: A research registry was queried for 555 studies on 341 patients (pts) with THS requiring 14.2 units RBC, 8.4 units FFP, 3.6 units Plt, and 18.9 mEq Ca by end of O.R. (7.3 hours). Factors analyzed included Plt count, Ca, Bleeding Time (BT), Plt aggregation with ADP (PAadp) and collagen (PAcol), including Max PA, T1/2 PA, and rate PA, plus platelet release factors, beta thromboglobulin (BTG) and Plt PF-4. Studies were made in O.R. (26 pts) during fluid uptake phase II at 29 hours (216 pts), during fluid mobilization phase III at 56 hours (283 pts), and as outpatients (30 pts).

Results: THS caused low Plts (1x10 SD) in O.R (107 ± 43), in phase II (96 ± 35), and in phase III (105 ± 59) and low Ca in O.R. (1.6 ± 0.3), in phase II (1.8 ± 0.2), and in phase III (2.1 ± 0.2). Low Plt and Ca correlated (p=<0.05) with PAadp and PAcol in O.R., phase II, and phase III. Ca correlated directly with Plt count, aggregation, BTG and PF-4, and inversely with BT. All outpatient studies were normal.

Conclusion: THS causes Ca which leads to low Plt and impaired function. Routine Ca supplementation is recommended for THS.

Keywords: Hypocalcemia; Hemorrhagic Shock; PlateletDysfunction


The severely injured patient with Hemorrhagic Shock (HS) requiring Massive Transfusion (MT) presents multiple challenges to successful treatment. Following the control of airway and assurance of adequate breathing, the prime focus rests with stopping hemorrhage and restoring circulation. The traditional restoration of circulation incorporates the balanced replacement of depleted blood, plasma and interstitial fluid with Packed Red Blood Cells (PRBC), plasma (FFP), Platelets (Plt), and Balanced Electrolyte Solution (BES) [1]. Recent studies suggest that a more aggressive use of FFP as part of a balanced FFP/PRBC resuscitation ratio may reduce serum ionized calcium as the increased plasma proteins, especially albumin, bind with free calcium, which is vital for primary hemostasis (formation of a platelet plug) and secondary hemostasis (formation of a fibrin plug) [2,3]. This study looks at the effects of HS requiring MT on calcium levels and the association of calcium levels on primary hemostasis.

Calcium is the most abundant element within the body, with the vast majority located within the skeletal system [4]. Most (88%) non-skeletal calcium is in the serum where it is measured as total serum calcium and includes bound calcium (50%) and ionized calcium (38%); the remaining extra-skeletal calcium is in soft tissues. Circulating ionized calcium has many functions and binds at about 30 sites to different protein molecules and is altered by pH; all ionized Ca measurements, herein, are corrected for pH [4].


The analyses reported herein were derived from a prospectively compiled trauma registry in which all patient data were de-identified [1]. Entrance into this registry was limited to those patients who had severe injury causing HS, which required a minimum of 8 PRBC transfusions by the end of immediate operation if the patient’s Systolic Blood Pressure (SBP) never went below 80 torr, or a minimum of 6 PRBC transfusions if the SBP was below 80 torr during the emergency department resuscitation or immediate operation (phase I) [1]. During the period of data collection, the average EMS run time was seven minutes and these severely injured patients were typically in the operating room within 30 minutes of injury. Data stored on these patients included admitting SBP, Pulse Rate (PR), shock time (minutes that SBP was below 80 torr), and amount of PRBC, FFP, Plt, BES, and Ca given during phase I, during the subsequent fluid uptake period (phase II), and during the first four days of the later fluid mobilization period (phase III) [1].

Based upon prior measurements of electrolytes and coagulation parameters, a guideline for a balanced resuscitation regimen was created. This included 2 units FFP and 13.7 mEq calcium for every 5 units PRBC and 5 units’ platelets for every 10 units PRBC. The actual balanced resuscitation regimen administered to these 341 patients included 2.7 units FFP and 7.4 mEq calcium for every 5 units PRBC and 2.3 unit’s platelets for every 10 units PRBC (Table 2).

From 1972 through 1983, 341 patients met the criteria for evaluation and underwent a total of 555 assessments during phase I, phase II, phase III, and/or convalescence (Table 1). The dedicated surgical research team worked closely with the Wayne State University Department of Physiology Coagulation Division. All blood specimens were measured immediately after collected. The times of study were designed to monitor sequential changes in the three physiological phases during and after resuscitation from HS.