Citrate & Hypocalcemia in Massive Transfusion
Main Article Content
Abstract
This brief review provides an overview of the role of citrate-containing preservatives in the processing and storage of blood components for transfusion, as well as the physiologic impact of citrate ion on transfusion recipients. Correction of hypocalcemia and other toxicities arising from citrate infusion is being increasingly appreciated in trauma and damage control resuscitation; a review of current practice guidelines regarding the identification and correction of hypocalcemia and citrate toxicity in emergency scenarios is provided. Lack of awareness about the citrate content in any given blood product likely impairs prompt and accurate reversal of hypocalcemia; however, such data is limited in literature and is generally unavailable to the transfusing provider. We offer calculated citrate levels in common blood products, and emphasize that plasma-rich product such as fresh frozen plasma and apheresis platelets contains relatively greater amounts of citrate than packed red blood cells, meriting more nuanced calcium repletion.
Article Details
How to Cite
MEHR, Noah; FONG, Erik; CARLL, Timothy.
Citrate & Hypocalcemia in Massive Transfusion.
Medical Research Archives, [S.l.], v. 13, n. 8, aug. 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6869>. Date accessed: 06 dec. 2025.
doi: https://doi.org/10.18103/mra.v13i8.6869.
Section
Review Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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3. Young PP, Cotton BA, Goodnough LT. Massive Transfusion Protocols for Patients With Substantial Hemorrhage. Transfus Med Rev. 2011;25(4):293-303. doi:10.1016/j.tmrv.2011.04.002
4. Jennings LK, Watson S. Massive Transfusion. In: StatPearls. StatPearls Publishing; 2025. Accessed June 17, 2025. http://www.ncbi.nlm.nih.gov/books/NBK499929/
5. Dzik WH, Kirkley SA. Citrate Toxicity During Massive Blood Transfusion. Transfus Med Rev. 1988;2(2):76-94. doi:10.1016/S0887-7963(88)70035-8
6. Larry J. Dumont, Mona Papari, Collen Aronson, Deborah Dumont. Whole-Blood Collection and Component Processing. In: The Technical Manual. 18th ed. AABB; 2014:136-139.
7. Li K, Xu Y. Citrate metabolism in blood transfusions and its relationship due to metabolic alkalosis and respiratory acidosis. Int J Clin Exp Med. 2015;8(4):6578-6584.
8. Bıçakçı Z, Olcay L. Citrate metabolism and its complications in non-massive blood transfusions: association with decompensated metabolic alkalosis+respiratory acidosis and serum electrolyte levels. Transfus Apher Sci Off J World Apher Assoc Off J Eur Soc Haemapheresis. 2014;50(3):418-426. doi:10.1016/j.transci.2014.03.002
9. Ditzel RM, Anderson JL, Eisenhart WJ, et al. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond? J Trauma Acute Care Surg. 2020;88(3):434-439. doi:10.1097/TA.0000000000002570
10.Schriner JB, Van Gent JM, Meledeo MA, et al. Impact of Transfused Citrate on Pathophysiology in Massive Transfusion. Crit Care Explor. 2023;5(6):e0925. doi:10.1097/CCE.0000000000000925
11.Helsloot D, Fitzgerald M, Lefering R, Verelst S, Missant C. Trauma-induced disturbances in ionized calcium levels correlate parabolically with coagulopathy, transfusion, and mortality: a multicentre cohort analysis from the TraumaRegister DGU®. Crit Care. 2023;27:267. doi:10.1186/s13054-023-04541-3
12.Patil V, Shetmahajan M. Massive transfusion and massive transfusion protocol. Indian J Anaesth. 2014;58(5):590. doi:10.4103/0019-5049.144662
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14.Moore EE, Moore HB, Kornblith LZ, et al. Trauma-induced coagulopathy. Nat Rev Dis Primer. 2021;7(1):30. doi:10.1038/s41572-021-00264-3
15.Vasudeva M, Mathew JK, Groombridge C, et al. Hypocalcemia in trauma patients: A systematic review. J Trauma Acute Care Surg. 2021;90(2):396-402. doi:10.1097/TA.0000000000003027
16.Mills JD. Trauma Diamond of Death: Adding Calcium to the Lethal Triad. J Emerg Nurs. 2024;50(3):330-335. doi:10.1016/j.jen.2023.12.011
17.Srichuachom W, Krintratun S, Chenthanakij B, Wongtanasarasin W. Prevalence and outcomes of hypocalcemia on ED arrival in traumatic patients before blood transfusions: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med. 2025;33(1):43. doi:10.1186/s13049-025-01361-y
18.Cherry RA, Bradburn E, Carney DE, Shaffer ML, Gabbay RA, Cooney RN. Do early ionized calcium levels really matter in trauma patients? J Trauma. 2006;61(4):774-779. doi:10.1097/01.ta.0000239516.49799.63
19.Wang J, Li DF, Sun ZK, Yang DQ, Li H. Influence of hypocalcemia on the prognosis of patients with multiple trauma. World J Clin Cases. 2024;12(19):3800-3806. doi:10.12998/wjcc.v12.i19.3800
20.Spahn DR, Rossaint R. Coagulopathy and blood component transfusion in trauma. Br J Anaesth. 2005;95(2):130-139. doi:10.1093/bja/aei169
21.Alghanem H, Liu NCP, Gupta A, et al. Ratios of calcium to citrate administration in blood transfusion for traumatic hemorrhage: A retrospective cohort study. Transfusion (Paris). 2024;64(11):2104-2113. doi:10.1111/trf.18029
22.Olinger GN, Hottenrott C, Mulder DG, et al. Acute clinical hypocalcemic myocardial depression during rapid blood transfusion and postoperative hemodialysis: A preventable complication. J Thorac Cardiovasc Surg. 1976;72(4):503-511. doi:10.1016/S0022-5223(19)40033-0
23.(PDF) Probable Hypocalcemia Induced Ventricular Fibrillation and Torsades de Pointes following Blood Product Administration. Accessed June 19, 2025. https://www.researchgate.net/publication/329870388_Probable_Hypocalcemia_Induced_Ventricular_Fibrillation_and_Torsades_de_Pointes_following_Blood_Product_Administration?utm_source=chatgpt.com
24.Howland WS, Bellville JW, Zucker MB, Boyan P, Cliffton EE. Massive blood replacement. V. Failure to observe citrate intoxication. Surg Gynecol Obstet. 1957;105(5):529-540.
25.Bunker JP, Bendixen HH, Murphy AJ. Hemodynamic effects of intravenously administered sodium citrate. N Engl J Med. 1962;266:372-377. doi:10.1056/NEJM196202222660802
26.Knutson F, Rider J, Franck V, Joie M, Högman C f., Pamphilon D. A new apheresis procedure for the preparation of high-quality red cells and plasma. Transfusion (Paris). 1999;39(6):565-571. doi:10.1046/j.1537-2995.1999.39060565.x
27.Storage of Blood Components and its Significance,. Accessed June 19, 2025. https://meditropics.com/41-2/
28.Corwin GS, Sexton KW, Beck WC, et al. Characterization of Acidosis in Trauma Patient. J Emerg Trauma Shock. 2020;13(3):213-218. doi:10.4103/JETS.JETS_45_19
29.Vivien B, Langeron O, Morell E, et al. Early hypocalcemia in severe trauma. Crit Care Med. 2005;33(9):1946-1952. doi:10.1097/01.ccm.0000171840.01892.36
30.Rumbaut RE, Thiagarajan P. Platelet Aggregation. In: Platelet-Vessel Wall Interactions in Hemostasis and Thrombosis. Morgan & Claypool Life Sciences; 2010. Accessed June 19, 2025 . https://www.ncbi.nlm.nih.gov/books/NBK53449/
31.Nesbitt WS, Giuliano S, Kulkarni S, Dopheide SM, Harper IS, Jackson SP. Intercellular calcium communication regulates platelet aggregation and thrombus growth. J Cell Biol. 2003;160(7):1151-1161. doi:10.1083/jcb.200207119
32.Mann KG, Whelihan MF, Butenas S, Orfeo T. Citrate anticoagulation and the dynamics of thrombin generation. J Thromb Haemost JTH. 2007;5(10):2055-2061. doi:10.1111/j.1538-7836.2007.02710.x
33.Getz TM, Turgeon A, Wagner SJ. Sodium citrate contributes to the platelet storage lesion. Transfusion (Paris). 2019;59(6):2103-2112. doi:10.1111/trf.15213
34.Isola H, Ravanat C, Rudwill F, et al. Removal of citrate from PAS-III additive solution improves functional and biochemical characteristics of buffy-coat platelet concentrates stored for 7 days, with or without INTERCEPT pathogen reduction. Transfusion (Paris). 2021;61(3):919-930. doi:10.1111/trf.16280
35.McLellan BA, Reid SR, Lane PL. Massive blood transfusion causing hypomagnesemia. Crit Care Med. 1984;12(2):146-147. doi:10.1097/00003246-198402000-00014
36.Toffaletti J, Nissenson R, Endres D, McGarry E, Mogollon G. Influence of continuous infusion of citrate on responses of immunoreactive parathyroid hormone, calcium and magnesium components, and other electrolytes in normal adults during plateletapheresis. J Clin Endocrinol Metab. 1985;60(5):874-879. doi:10.1210/jcem-60-5-874
37.Walser M. Ion association. VI. Interactions between calcium, magnesium, inorganic phosphate, citrate and protein in normal human plasma. J Clin Invest. 1961;40(4):723-730. doi:10.1172/JCI104306
38.Meyer JL. Formation constants for interaction of citrate with calcium and magnesium ions. Anal Biochem. 1974;62(1):295-300. doi:10.1016/0003-2697(74)90391-1
39.Sekiya F, Yoshida M, Yamashita T, Morita T. Magnesium(II) Is a Crucial Constituent of the Blood Coagulation Cascade: POTENTIATION OF COAGULANT ACTIVITIES OF FACTOR IX BY Mg IONS (∗). J Biol Chem. 1996;271(15):8541-8544. doi:10.1074/jbc.271.15.8541
40.Liotta EM, Prabhakaran S, Sangha RS, et al. Magnesium, hemostasis, and outcomes in patients with intracerebral hemorrhage. Neurology. 2017;89(8):813-819. doi:10.1212/WNL.0000000000004249
41.Matsuno K, Koyama M, Takeda H, et al. Cytosolic free magnesium concentration in human platelets. Thromb Res. 1993;69(1):131-137. doi:10.1016/0049-3848 (93)90010-l
42.Serebruany VL, Herzog WR, Schlossberg ML, Gurbel PA. Bolus magnesium infusion in humans is associated with predominantly unfavourable changes in platelet aggregation and certain haemostatic factors. Pharmacol Res. 1997;36(1):17-22. doi:10.1006/phrs.1997.0212
43.Ruttmann TG, Montoya-Pelaez LF, James MFM. The coagulation changes induced by rapid in vivo crystalloid infusion are attenuated when magnesium is kept at the upper limit of normal. Anesth Analg. 2007;104(6):1475-1480, table of contents. doi:10.1213/01.ane.0000261256.88414.e4
44.Choi JH, Lee J, Park CM. Magnesium therapy improves thromboelastographic findings before liver transplantation: a preliminary study. Can J Anaesth J Can Anesth. 2005;52(2):156-159. doi:10.1007/ BF03027721
45.Mutnuri S, Fernandez I, Kochar T. Suppression of Parathyroid Hormone in a Patient with Severe Magnesium Depletion. Case Rep Nephrol. 2016;2016(1):2608538. doi:10.1155/2016/2608538
46.Rude RK, Oldham SB, Sharp CF, Singer FR. Parathyroid hormone secretion in magnesium deficiency. J Clin Endocrinol Metab. 1978;47(4):800-806. doi:10.1210/ jcem-47-4-800
47.Magnesium and the parathyroid | Request PDF. ResearchGate. doi:10.1097/00041552-200207000-00006
48.Rude RK, Oldham SB, Singer FR. Functional hypoparathyroidism and parathyroid hormone end-organ resistance in human magnesium deficiency. Clin Endocrinol (Oxf). 1976;5(3):209-224. doi:10.1111/j.1365-2265.1976.tb01947.x
49.Albert A, Hinkel UP, Bohlender T, Stieger P, Braun-Dullaeus RC, Albert C. Paradoxical Inadequate Parathyroid Hormone Secretion Secondary to Severe Hypomagnesaemia: A Review of the Literature. Kidney Med. 2025;0(0). doi:10.1016/j.xkme.2025.101046
50.Association for the Advancement of Blood & Biotherapies, America’s Blood Centers, American Red Cross, Armed Services Blood Program. Circular of Information for the Use of Human Blood and Blood Components.; 2021.
51.D’Alessandro A, Nemkov T, Yoshida T, Bordbar A, Palsson BO, Hansen KC. Citrate metabolism in red blood cells stored in additive solution‐3. Transfusion (Paris). 2017;57(2):325-336. doi:10.1111/trf.13892
52.Rossaint R, Afshari A, Bouillon B, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care. 2023;27(1):80. doi:10.1186/s13054-023-04327-7
53.American College of Surgeons, Committee on Trauma. TQIP Massive Transfusion in Trauma Guidelines. American College of Surgeons; 2014. Accessed June 19, 2025. https://www.facs.org/quality-programs/trauma/tqp/center-programs/tqip/guidelines/
54.Rushton TJ, Tian DH, Baron A, Hess JR, Burns B. Hypocalcaemia upon arrival (HUA) in trauma patients who did and did not receive prehospital blood products: a systematic review and meta-analysis. Eur J Trauma Emerg Surg. 2024;50(4):1419-1429. doi:10.1007/s00068-024-02454-6
55.Cap AP, Pidcoke HF, Spinella P, et al. Damage Control Resuscitation. Mil Med. 2018;183(suppl_2):36-43. doi:10.1093/milmed/usy112
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2. ISBT. 10. Massive Bleeding Protocols – The Transfusion Service Perspective. Accessed June 17, 2025. https://www.isbtweb.org/isbt-working-parties/clinical-transfusion/resources/patient-blood-management-resources/massive-bleeding-protocols.html?utm_source=chatgpt.com
3. Young PP, Cotton BA, Goodnough LT. Massive Transfusion Protocols for Patients With Substantial Hemorrhage. Transfus Med Rev. 2011;25(4):293-303. doi:10.1016/j.tmrv.2011.04.002
4. Jennings LK, Watson S. Massive Transfusion. In: StatPearls. StatPearls Publishing; 2025. Accessed June 17, 2025. http://www.ncbi.nlm.nih.gov/books/NBK499929/
5. Dzik WH, Kirkley SA. Citrate Toxicity During Massive Blood Transfusion. Transfus Med Rev. 1988;2(2):76-94. doi:10.1016/S0887-7963(88)70035-8
6. Larry J. Dumont, Mona Papari, Collen Aronson, Deborah Dumont. Whole-Blood Collection and Component Processing. In: The Technical Manual. 18th ed. AABB; 2014:136-139.
7. Li K, Xu Y. Citrate metabolism in blood transfusions and its relationship due to metabolic alkalosis and respiratory acidosis. Int J Clin Exp Med. 2015;8(4):6578-6584.
8. Bıçakçı Z, Olcay L. Citrate metabolism and its complications in non-massive blood transfusions: association with decompensated metabolic alkalosis+respiratory acidosis and serum electrolyte levels. Transfus Apher Sci Off J World Apher Assoc Off J Eur Soc Haemapheresis. 2014;50(3):418-426. doi:10.1016/j.transci.2014.03.002
9. Ditzel RM, Anderson JL, Eisenhart WJ, et al. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond? J Trauma Acute Care Surg. 2020;88(3):434-439. doi:10.1097/TA.0000000000002570
10.Schriner JB, Van Gent JM, Meledeo MA, et al. Impact of Transfused Citrate on Pathophysiology in Massive Transfusion. Crit Care Explor. 2023;5(6):e0925. doi:10.1097/CCE.0000000000000925
11.Helsloot D, Fitzgerald M, Lefering R, Verelst S, Missant C. Trauma-induced disturbances in ionized calcium levels correlate parabolically with coagulopathy, transfusion, and mortality: a multicentre cohort analysis from the TraumaRegister DGU®. Crit Care. 2023;27:267. doi:10.1186/s13054-023-04541-3
12.Patil V, Shetmahajan M. Massive transfusion and massive transfusion protocol. Indian J Anaesth. 2014;58(5):590. doi:10.4103/0019-5049.144662
13.Citrate metabolism in blood transfusions and its relationship due to metabolic alkalosis and respiratory acidosis. Accessed June 19, 2025. https://www.researchgate.net/publication/279732385_Citrate_metabolism_in_blood_transfusions_and_its_relationship_due_to_metabolic_alkalosis_and_respiratory_acidosis
14.Moore EE, Moore HB, Kornblith LZ, et al. Trauma-induced coagulopathy. Nat Rev Dis Primer. 2021;7(1):30. doi:10.1038/s41572-021-00264-3
15.Vasudeva M, Mathew JK, Groombridge C, et al. Hypocalcemia in trauma patients: A systematic review. J Trauma Acute Care Surg. 2021;90(2):396-402. doi:10.1097/TA.0000000000003027
16.Mills JD. Trauma Diamond of Death: Adding Calcium to the Lethal Triad. J Emerg Nurs. 2024;50(3):330-335. doi:10.1016/j.jen.2023.12.011
17.Srichuachom W, Krintratun S, Chenthanakij B, Wongtanasarasin W. Prevalence and outcomes of hypocalcemia on ED arrival in traumatic patients before blood transfusions: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med. 2025;33(1):43. doi:10.1186/s13049-025-01361-y
18.Cherry RA, Bradburn E, Carney DE, Shaffer ML, Gabbay RA, Cooney RN. Do early ionized calcium levels really matter in trauma patients? J Trauma. 2006;61(4):774-779. doi:10.1097/01.ta.0000239516.49799.63
19.Wang J, Li DF, Sun ZK, Yang DQ, Li H. Influence of hypocalcemia on the prognosis of patients with multiple trauma. World J Clin Cases. 2024;12(19):3800-3806. doi:10.12998/wjcc.v12.i19.3800
20.Spahn DR, Rossaint R. Coagulopathy and blood component transfusion in trauma. Br J Anaesth. 2005;95(2):130-139. doi:10.1093/bja/aei169
21.Alghanem H, Liu NCP, Gupta A, et al. Ratios of calcium to citrate administration in blood transfusion for traumatic hemorrhage: A retrospective cohort study. Transfusion (Paris). 2024;64(11):2104-2113. doi:10.1111/trf.18029
22.Olinger GN, Hottenrott C, Mulder DG, et al. Acute clinical hypocalcemic myocardial depression during rapid blood transfusion and postoperative hemodialysis: A preventable complication. J Thorac Cardiovasc Surg. 1976;72(4):503-511. doi:10.1016/S0022-5223(19)40033-0
23.(PDF) Probable Hypocalcemia Induced Ventricular Fibrillation and Torsades de Pointes following Blood Product Administration. Accessed June 19, 2025. https://www.researchgate.net/publication/329870388_Probable_Hypocalcemia_Induced_Ventricular_Fibrillation_and_Torsades_de_Pointes_following_Blood_Product_Administration?utm_source=chatgpt.com
24.Howland WS, Bellville JW, Zucker MB, Boyan P, Cliffton EE. Massive blood replacement. V. Failure to observe citrate intoxication. Surg Gynecol Obstet. 1957;105(5):529-540.
25.Bunker JP, Bendixen HH, Murphy AJ. Hemodynamic effects of intravenously administered sodium citrate. N Engl J Med. 1962;266:372-377. doi:10.1056/NEJM196202222660802
26.Knutson F, Rider J, Franck V, Joie M, Högman C f., Pamphilon D. A new apheresis procedure for the preparation of high-quality red cells and plasma. Transfusion (Paris). 1999;39(6):565-571. doi:10.1046/j.1537-2995.1999.39060565.x
27.Storage of Blood Components and its Significance,. Accessed June 19, 2025. https://meditropics.com/41-2/
28.Corwin GS, Sexton KW, Beck WC, et al. Characterization of Acidosis in Trauma Patient. J Emerg Trauma Shock. 2020;13(3):213-218. doi:10.4103/JETS.JETS_45_19
29.Vivien B, Langeron O, Morell E, et al. Early hypocalcemia in severe trauma. Crit Care Med. 2005;33(9):1946-1952. doi:10.1097/01.ccm.0000171840.01892.36
30.Rumbaut RE, Thiagarajan P. Platelet Aggregation. In: Platelet-Vessel Wall Interactions in Hemostasis and Thrombosis. Morgan & Claypool Life Sciences; 2010. Accessed June 19, 2025 . https://www.ncbi.nlm.nih.gov/books/NBK53449/
31.Nesbitt WS, Giuliano S, Kulkarni S, Dopheide SM, Harper IS, Jackson SP. Intercellular calcium communication regulates platelet aggregation and thrombus growth. J Cell Biol. 2003;160(7):1151-1161. doi:10.1083/jcb.200207119
32.Mann KG, Whelihan MF, Butenas S, Orfeo T. Citrate anticoagulation and the dynamics of thrombin generation. J Thromb Haemost JTH. 2007;5(10):2055-2061. doi:10.1111/j.1538-7836.2007.02710.x
33.Getz TM, Turgeon A, Wagner SJ. Sodium citrate contributes to the platelet storage lesion. Transfusion (Paris). 2019;59(6):2103-2112. doi:10.1111/trf.15213
34.Isola H, Ravanat C, Rudwill F, et al. Removal of citrate from PAS-III additive solution improves functional and biochemical characteristics of buffy-coat platelet concentrates stored for 7 days, with or without INTERCEPT pathogen reduction. Transfusion (Paris). 2021;61(3):919-930. doi:10.1111/trf.16280
35.McLellan BA, Reid SR, Lane PL. Massive blood transfusion causing hypomagnesemia. Crit Care Med. 1984;12(2):146-147. doi:10.1097/00003246-198402000-00014
36.Toffaletti J, Nissenson R, Endres D, McGarry E, Mogollon G. Influence of continuous infusion of citrate on responses of immunoreactive parathyroid hormone, calcium and magnesium components, and other electrolytes in normal adults during plateletapheresis. J Clin Endocrinol Metab. 1985;60(5):874-879. doi:10.1210/jcem-60-5-874
37.Walser M. Ion association. VI. Interactions between calcium, magnesium, inorganic phosphate, citrate and protein in normal human plasma. J Clin Invest. 1961;40(4):723-730. doi:10.1172/JCI104306
38.Meyer JL. Formation constants for interaction of citrate with calcium and magnesium ions. Anal Biochem. 1974;62(1):295-300. doi:10.1016/0003-2697(74)90391-1
39.Sekiya F, Yoshida M, Yamashita T, Morita T. Magnesium(II) Is a Crucial Constituent of the Blood Coagulation Cascade: POTENTIATION OF COAGULANT ACTIVITIES OF FACTOR IX BY Mg IONS (∗). J Biol Chem. 1996;271(15):8541-8544. doi:10.1074/jbc.271.15.8541
40.Liotta EM, Prabhakaran S, Sangha RS, et al. Magnesium, hemostasis, and outcomes in patients with intracerebral hemorrhage. Neurology. 2017;89(8):813-819. doi:10.1212/WNL.0000000000004249
41.Matsuno K, Koyama M, Takeda H, et al. Cytosolic free magnesium concentration in human platelets. Thromb Res. 1993;69(1):131-137. doi:10.1016/0049-3848 (93)90010-l
42.Serebruany VL, Herzog WR, Schlossberg ML, Gurbel PA. Bolus magnesium infusion in humans is associated with predominantly unfavourable changes in platelet aggregation and certain haemostatic factors. Pharmacol Res. 1997;36(1):17-22. doi:10.1006/phrs.1997.0212
43.Ruttmann TG, Montoya-Pelaez LF, James MFM. The coagulation changes induced by rapid in vivo crystalloid infusion are attenuated when magnesium is kept at the upper limit of normal. Anesth Analg. 2007;104(6):1475-1480, table of contents. doi:10.1213/01.ane.0000261256.88414.e4
44.Choi JH, Lee J, Park CM. Magnesium therapy improves thromboelastographic findings before liver transplantation: a preliminary study. Can J Anaesth J Can Anesth. 2005;52(2):156-159. doi:10.1007/ BF03027721
45.Mutnuri S, Fernandez I, Kochar T. Suppression of Parathyroid Hormone in a Patient with Severe Magnesium Depletion. Case Rep Nephrol. 2016;2016(1):2608538. doi:10.1155/2016/2608538
46.Rude RK, Oldham SB, Sharp CF, Singer FR. Parathyroid hormone secretion in magnesium deficiency. J Clin Endocrinol Metab. 1978;47(4):800-806. doi:10.1210/ jcem-47-4-800
47.Magnesium and the parathyroid | Request PDF. ResearchGate. doi:10.1097/00041552-200207000-00006
48.Rude RK, Oldham SB, Singer FR. Functional hypoparathyroidism and parathyroid hormone end-organ resistance in human magnesium deficiency. Clin Endocrinol (Oxf). 1976;5(3):209-224. doi:10.1111/j.1365-2265.1976.tb01947.x
49.Albert A, Hinkel UP, Bohlender T, Stieger P, Braun-Dullaeus RC, Albert C. Paradoxical Inadequate Parathyroid Hormone Secretion Secondary to Severe Hypomagnesaemia: A Review of the Literature. Kidney Med. 2025;0(0). doi:10.1016/j.xkme.2025.101046
50.Association for the Advancement of Blood & Biotherapies, America’s Blood Centers, American Red Cross, Armed Services Blood Program. Circular of Information for the Use of Human Blood and Blood Components.; 2021.
51.D’Alessandro A, Nemkov T, Yoshida T, Bordbar A, Palsson BO, Hansen KC. Citrate metabolism in red blood cells stored in additive solution‐3. Transfusion (Paris). 2017;57(2):325-336. doi:10.1111/trf.13892
52.Rossaint R, Afshari A, Bouillon B, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care. 2023;27(1):80. doi:10.1186/s13054-023-04327-7
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