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Maintenance of Ionized Calcium During Prolonged Extreme Massive Transfusion During Liver Transplantation. WMJ 2023 Sep;122(4):294-297



Pubmed ID


Scopus ID

2-s2.0-85172878782 (requires institutional sign-in at Scopus site)


INTRODUCTION: Massive transfusion may cause ionized hypocalcemia, a complication that, when severe, causes hemodynamic instability. Extant literature fails to provide effective guidance on replacement strategies to avoid severe ionized hypocalcemia in the most extreme situations.

CASE PRESENTATION: We discuss a liver transplant in which our empiric calcium replacement strategy resulted in no critically low ionized calcium values during the pre-reperfusion phase of a liver transplant with over 140 000 mL of bank blood transfusion, with an average of 10 000 mL per hour for 14 hours.

DISCUSSION: Few comparable reports exist. Most rely upon monitoring with subsequent replacement, but these have not been effective at avoiding severely low ionized calcium values.

CONCLUSIONS: Our empiric calcium replacement strategy of 1 gram of calcium chloride per liter of citrated bank blood transfused, in 200 mg/200 mL increments, resulted in successful maintenance of ionized calcium during the anhepatic phase of liver transplantation while on continuous veno-venous hemofiltration.

Author List

Dorantes RP, Voulgarelis S, Woehlck HJ


Harvey J. Woehlck MD Professor in the Anesthesiology department at Medical College of Wisconsin