Cardiac failure associated with hypocalcemia

Area of Science:

• Cardiovascular Physiology
• Transfusion Medicine
• Anesthesiology

Background:

• Pelvic exenteration and hemipelvectomy are extensive surgeries requiring significant blood replacement.
• Citrated whole blood is commonly used in massive transfusion protocols.
• Maintaining hemodynamic stability and electrolyte balance is critical during major surgery.

Observation:

• A patient receiving rapid transfusion of citrated whole blood developed acute hypotension and elevated central venous pressure.
• Cardiac failure signs correlated with a sharp drop in serum ionized calcium (Ca++) concentration.
• Slowing the transfusion rate led to the normalization of arterial blood pressure and increased serum Ca++.

Findings:

• Rapid citrated whole blood transfusion can induce hypocalcemia and cardiac dysfunction.
• Hypotension and elevated central venous pressure are associated with these transfusion-related complications.
• Modulating transfusion rate can mitigate adverse cardiovascular events and correct hypocalcemia.

Implications:

• Clinicians should monitor ionized calcium levels closely during rapid blood transfusions, especially with citrated products.
• Adjusting transfusion rates may be a key strategy to prevent or manage transfusion-associated circulatory overload and hypocalcemia.
• This case highlights the physiological impact of citrate metabolism and calcium binding during massive transfusion.