Not All Calcium Formulations Are Alike

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We read with great interest the article by MacKay et al,1 which provides compelling evidence for a concerning correlation between abnormal calcium levels during trauma resuscitation and increased mortality. While we found the article well written and informative, we have several concerns about the authors’ analysis and potential future studies.
Ionized calcium levels are influenced by many factors that are likely to be deranged during massive resuscitation, most notably serum pH and serum lactate, neither of which are reported by the authors or factored into their regression.2 More importantly, the authors state that calcium supplementation was provided as both calcium gluconate and calcium chloride, and they report median calcium administered in grams without differentiating between the 2 preparations. As there is a 3-fold difference in cation concentration between these 2 preparations, treating them as equivalent in statistical analysis, as the authors appear to have done, may lead to erroneous conclusions.3
As these compelling data are presented as a pilot investigation, we would suggest that future investigations control for pH, lactate, and the significant difference in cationic concentration between calcium chloride and calcium gluconate when studying the correlation between abnormal calcium levels and outcomes.
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