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


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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    • "Additionally, RBCs warmed to 70°C demonstrated increased plasma K + levels. The transfusion of hemolyzed blood can detrimentally affect neonates and small children[4,16]. The K + concentration in the supernatant of hemolyzed RBCs is frequently much higher than that in normal human plasma. Neonates and small children have smaller circulating volumes, immature renal function and K + handling, and differences in autonomic tone[17,18]. "

    Full-text · Article · Jan 2015
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    • "Transf Apheres Sci (2013), Uncommon but very well-recognized complications of the transfusion of irradiated and near-outdating PRBCs are hyperkaliemia-induced cardiac arrythmias and arrest in neonates requiring exsanguinotransfusion and infants requiring cardiopulmonary bypass surgery or extracorporeal membrane oxygenation, in circumstances where transfusion may be massive or administered at high infusion rate via a central venous catheter line flushing the atrioventricular node [12] [13] [14] [15] [16]. The risk of hyperkaliema seems particularly high in hypovolemic, small patients with low cardiac output, metabolic acidosis, hyperglycemia , hypocalcemia and hypothermia. "
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    ABSTRACT: Prevention of transfusion-associated graft versus host disease (TA-GVHD) by gamma irradiation is known to induce increased K+ in supernatant of packed red blood cells (PRBCs) stored in CPDA-1 and SAGM conservative solutions. However, no data exist for PRBCs in AS-3 medium which is considered safe for neonatal transfusion. We evaluated haemolysis and K+ release from irradiated AS-3 PRBCs and compared our results with reported data for SAGM and CPDA-1 PRBCs. Our results indicate that irradiated PRBCs stored in AS-3 after more than 7days post-irradiation should not be used in massive and/or rapidly infused transfusions in neonates and infants.
    Full-text · Article · May 2013 · Transfusion and Apheresis Science
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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.
    Preview · Article · Apr 2013 · Transfusion
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