Cardiac Arrests Associated with Hyperkalemia During Red Blood Cell Transfusion: A Case Series

Department of Anesthesiology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
Anesthesia and analgesia (Impact Factor: 3.47). 05/2008; 106(4):1062-9, table of contents. DOI: 10.1213/ane.0b013e318164f03d
Source: PubMed

ABSTRACT Transfusion-associated hyperkalemic cardiac arrest is a serious complication of rapid red blood cell (RBC) administration. We examined the clinical scenarios and outcomes of patients who developed hyperkalemia and cardiac arrest during rapid RBC transfusion.
We retrospectively reviewed the Mayo Clinic Anesthesia Database between November 1, 1988, and December 31, 2006, for all patients who developed intraoperative transfusion-associated hyperkalemic cardiac arrest.
We identified 16 patients with transfusion-associated hyperkalemic cardiac arrest, 11 adult and 5 pediatric. The majority of patients underwent three types of surgery: cancer, major vascular, and trauma. The mean serum potassium concentration measured during cardiac arrest was 7.2 +/- 1.4 mEq/L (range, 5.9-9.2 mEq/L). The number of RBC units administered before cardiac arrest ranged between 1 (in a 2.7 kg neonate) and 54. Nearly all patients were acidotic, hyperglycemic, hypocalcemic, and hypothermic at the time of arrest. Fourteen (87.5%) patients received RBC via central venous access. Commercial rapid infusion devices (pumps) were used in 8 of 11 (72.7%) of the adult patients, but RBC units were rapidly administered (pressure bags, syringe pumped) in all remaining patients. Mean resuscitation duration was 32 min (range, 2-127 min). The in-hospital survival rate was 12.5%.
The pathogenesis of transfusion-associated hyperkalemic cardiac arrest is multifactorial and potassium increase from RBC administration is complicated by low cardiac output, acidosis, hyperglycemia, hypocalcemia, and hypothermia. Large transfusion of banked RBCs and conditions associated with massive hemorrhage should raise awareness of the potential for hyperkalemia and trigger preventative measures.

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    • "RBC age, preservative reduction status, pt K before ECLS initiation, and K of primed ECLS circuit showed no significant effect on the post-ECLS-initiation pt K even when the prime K was >6 mEq/L. Smith et al. (2008) 22 (United States) "
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    ABSTRACT: Background Hyperkalemic cardiac arrest is a potential complication of massive transfusion in children. Our objective was to identify risk factors and potential preventive measures by reviewing the literature on transfusion-associated hyperkalemic cardiac arrest (TAHCA) in the pediatric population. Study Design and Methods Literature searches were performed in MEDLINE and the Cochrane Database of Systematic Reviews. ResultsWe identified nine case reports of pediatric patients who had experienced cardiac arrest during massive transfusion. Serum potassium concentration was reported in eight of those reports; the mean was 9.21.8mmol/L. Risk factors for TAHCA noted in the case reports included infancy (n=6); age of red blood cells (RBCs; n=5); site of transfusion (n=5); and the presence of comorbidities such as hyperkalemia, hypocalcemia, acidemia, and hypotension (n=9). We also identified 13 clinical studies that examined potassium levels associated with transfusion. Of those 13, five studied routine transfusion, two were registries, and six examined massive transfusion. Conclusions Key points identified from this literature search are as follows: 1) Case reports are skewed toward infants and neonates in particular and 2) the rate of blood transfusion, more so than total volume, cardiac output, and the site of infusion, are key factors in the development of TAHCA. Measures to reduce the risk of TAHCA in young children include anticipating and replacing blood loss before significant hemodynamic compromise occurs, using larger-bore (>23-gauge) peripheral intravenous catheters rather than central venous access, checking and correcting electrolyte abnormalities frequently, and using fresher RBCs for massive transfusion.
    Transfusion 04/2013; 54(1). DOI:10.1111/trf.12192 · 3.23 Impact Factor
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    • "In one reported series, 16 patients who received red blood cell transfusions developed serum potassium levels between 5.9-9.2 mEq/L and sustained cardiac arrest [140]. Hyperkalemia should be treated promptly with insulin, glucose and calcium to protect the myocardium and increase intracellular potassium shifts. "
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    ABSTRACT: Background Care of the polytrauma patient does not end in the operating room or resuscitation bay. The patient presenting to the intensive care unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory, cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented. Methods A non-systematic literature search was conducted using PubMed and the Cochrane Database of Systematic Reviews up to May 2012. Results and conclusion Polytrauma patients with severe shock from hemorrhage and massive tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for “damage control resuscitation” including the use of fixed ratios in the treatment of trauma induced coagulopathy remain controversial. A lack of large, randomized, controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging patients.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 09/2012; 20(1):68. DOI:10.1186/1757-7241-20-68 · 2.03 Impact Factor
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    • "Hyperkalemia, which may have been associated with manipulation of the tumor during resection, especially manipulating the tumor for intra-abdominal resection, and massive transfusion of pRBCs containing high levels of potassium [4]. In addition, metabolic and respiratory acidosis, hypocalcemia, hypothermia and oliguria may worsen hyperkalemia [9]. Hypoxemia and hypovolemia also contributed to cardiac arrest [4]. "
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    ABSTRACT: Resection of large sacrococcygeal teratomas (SCTs) in premature neonates has been associated with significant perinatal mortality, making this a high risk procedure requiring careful anesthetic management. Most deaths during resection of SCTs are due to cardiac arrest caused by electrolyte imbalances, such as hyperkalemia, and massive bleeding during surgery. We describe two premature neonates who experienced cardiac arrest, one due to hyperkalemia and the other not due to hyperkalemia, during excision of large, prenatally diagnosed SCTs. We present here the considerations for anesthesia in premature neonates with huge SCTs.
    Korean journal of anesthesiology 07/2012; 63(1):80-4. DOI:10.4097/kjae.2012.63.1.80
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