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Ionized Hypocalcemia after Fresh Frozen Plasma Administration to Thermally Injured Children

Effects of Infusion Rate, Duration, and Treatment with Calcium Chloride

Anesthesia Services of Masschusetts General Hospital and Shriners Burns Institute, and the Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts.

Abstract

A number of cardiac arrests and severe hypotensive episodes have been witnessed associated with the intravenous infusion of fresh frozen plasma (FFP). To clarify the possible role of hypocalcemia, 18 thermally injured anesthetized pediatric patients with massive blood loss were studiedto examine the cardiovascular responses (mean arterial pressure [MAP], heart rate, ECG) to 49 infusions of FFP. Rapid, statistically significant reductions in ionized calcium ([Ca²⁺]) followed each of four rates (1.0, 1.5, 2.0, and 2.5 ml·kg^–1·min^–1 for 5 minutes) of FFP infusion (P < 0.0001). The slowest rate resulted in significantly less reduction in [Ca²⁺] than did the higher infusion rates (P < 0.002). In five children MAP decreased 20% below baseline levels, but this was not correlated with rate of FFP administration or decrease in [Ca²⁺]. The decreases in [Ca²⁺1 and MAP were inversely related to age and unrelated to anesthetic technique. Changes in the Q-oT_c interval were not related to [Ca²⁺]. Adverse cardiovascular responses and reduced [Ca²⁺] were not significantly different between 5– and 10-minute FFP infusions. Fewer fluctuations in MAP occurred when calcium chloride (CaCl₂) was administered; the leastfluctuation in [Ca^–2] occurred when CaCl₂ was administered during the plasma infusion. It is concluded that in thermally injuredchildren 1–17 years old: 1) Rapid infusions of FFP produce sudden but evanescent decreases in [Ca²⁺]; more rapid infusions result in greater reductions in [Ca²⁺]. 2) There is no correlation between [Ca²⁺] and systemic hypotension. 3) Clinically important decreasesin MAP occasionally accompany the rapid infusion of FFP. 4) The duration of FFP infusion does not seem to be a significant factor in causing decreases in [Ca²⁺] or in MAP. 5) Pretreatment with exogenous calciummay reduce the incidence of cardiovascular instability; smaller fluctuations in [Ca² +] occur if exogenous calcium is administered duringthe FFP infusion. 6) Changes in Q-oT_c are not predictive of acute changes in [Ca²⁺].

Key Words: BLOOD, PLASMA—fresh frozen. • IONS, CALCIUM—ionized. • COMPLICATIONS—burns.

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999