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Impact of hypocalcemia on mortality in pediatric trauma patients who require transfusion
Elissa Abou Khalil1, Erin Feeney, Katrina M Morgan
1From the Department of Surgery (E.A.K.), Northwestern University, Evanston, IL; University of Pittsburgh Medical Center, Department of Surgery, Pittsburgh, PA (E.F., K.M.M., P.C.S., C.M.L.); and University of Texas Southwestern, Department of Surgery, Dallas, TX (B.A.G.).
Insights
Hypocalcemia in pediatric trauma patients is linked to higher mortality rates and increased blood product transfusions. Further research is needed on the benefits of prompt calcium administration in these critically injured children.
Area of Science:
- Pediatric critical care medicine
- Trauma surgery
- Emergency medicine
Background:
- Admission hypocalcemia is a known predictor of adverse outcomes in adult trauma patients.
- The association between hypocalcemia and mortality in pediatric trauma remains understudied.
Purpose of the Study:
- To investigate the impact of admission hypocalcemia on in-hospital mortality and blood product requirements in pediatric trauma patients.
- To determine if hypocalcemia is an independent predictor of mortality in this population.
Main Methods:
- Retrospective analysis of a pediatric trauma center database (2013-2022).
- Inclusion criteria: children (<18 years) receiving blood transfusion within 24 hours of injury with admission ionized calcium (iCal) levels.
- Exclusion criteria: massive transfusion prior to arrival or calcium administration before testing.
- Hypocalcemia defined as iCal <1.00.
- Outcomes: in-hospital mortality and 24-hour blood product needs.
- Logistic regression adjusted for Injury Severity Score (ISS), shock index, Glasgow Coma Scale (GCS), and transfusion volume.
Main Results:
- 331 children included; 10% were hypocalcemic.
- Hypocalcemic children had higher ISS and lower GCS scores.
- Hypocalcemia associated with significantly increased in-hospital (56% vs. 18%) and 24-hour (28% vs. 5%) mortality (p < 0.001).
- Hypocalcemic cohort received more blood products (22 mL/kg more).
- After adjustment, hypocalcemia independently predicted increased 24-hour (OR 4.93) and in-hospital mortality (OR 3.41).
Conclusions:
- Admission hypocalcemia is an independent risk factor for mortality in pediatric trauma.
- Hypocalcemia is associated with greater blood product transfusion requirements in injured children.
- The potential benefit of early calcium administration in pediatric trauma warrants further investigation.
Background:
Admission hypocalcemia has been associated with poor outcomes in injured adults. The impact of hypocalcemia on mortality has not been widely studied in pediatric trauma.
Methods:
A pediatric trauma center database was queried retrospectively (2013-2022) for children younger than 18 years who received blood transfusion within 24 hours of injury and had ionized calcium (iCal) level on admission. Children who received massive transfusion (>40 mL/kg) prior to hospital arrival or calcium prior to laboratory testing were excluded. Hypocalcemia was defined by the laboratory lower limit (iCal <1.00). Main outcomes were in-hospital mortality and 24-hour blood product requirements. Logistic regression analysis was performed to adjust for Injury Severity Score (ISS), admission shock index, Glasgow Coma Scale (GCS) score, and weight-adjusted total transfusion volume.
Results:
In total, 331 children with median (IQR) age of 7 years (2-3 years) and median (IQR) ISS 25 (14-33) were included, 32 (10%) of whom were hypocalcemic on arrival to the hospital. The hypocalcemic cohort had higher ISS (median (IQR) 30(24-36) vs. 22 (13-30)) and lower admission GCS score (median (IQR) 3 (3-12) vs. 8 (3-15)). Age, sex, race, and mechanism were not significantly different between groups. On univariate analysis, hypocalcemia was associated with increased in-hospital (56% vs. 18%; p < 0.001) and 24-hour (28% vs. 5%; p < 0.001) mortality. Children who were hypocalcemic received a median (IQR) of 22 mL/kg (7-38) more in total weight-adjusted 24-hour blood product transfusion following admission compared to the normocalcemic cohort ( p = 0.005). After adjusting for ISS, shock index, GCS score, and total transfusion volume, hypocalcemia remained independently associated with increased 24-hour (odds ratio, 4.93; 95% confidence interval, 1.77-13.77; p = 0.002) and in-hospital mortality (odds ratio, 3.41; 95% confidence interval, 1.22-9.51; p = 0.019).
Conclusion:
Hypocalcemia is independently associated with mortality and receipt of greater weight-adjusted volumes of blood product transfusion after injury in children. The benefit of timely calcium administration in pediatric trauma needs further exploration.
Level Of Evidence:
Prognostic and Epidemiological; Level III.
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