Cardiac arrests associated with hyperkalemia during red blood cell transfusion: a case series

1
Cardiac arrests associated with hyperkalemia
during red blood cell transfusion a case series

• AA 106, No. 4, April 2008

2
Introduction

• RBC membranes are only slightly permeable to K
• Their movement is largely dependent on
  energy-dependent transport
• K level increased
• Storage
• Aging of RBC
• Adenosine triphosphate synthesis
• Potassium pumping decrease

3

• Stored RBC? contain K more than 60meq/L
• Hyperkalemia due to transfusion
• potassium level in RBC unit
• Volume
• Rate of transfusion
• Traditional prevention of hyperkalemia
• ? washing of crystalloid or colloid
• The aim of the presentation
• ? To develop a better understanding of the
  conditions lead to hyperkalemia during RBC
  transfusion

4
Method

• Data collection
• 1988?2006
• Transfusion-associated hyperkalemic cardiac
  arrest
• Temporally large or fast RBC transfusion
• Hyperkalemia(gt5.5meq/L)
• Anesthesiologists note the arrest was due to
  hyperkalemia
• All data was collected
• Additional data lowest BT, ECG of the cardiac
  arrest

5
Results

• 16 patients(11 adult and 5 pediatric)
• Surgery type cancer, major vascular, trauma
• 14 patients BT via CVC
• 2 survival
• 9 yr old? spine OP
• 14 yr old? spine tumor resection

6
(No Transcript)
7

• Analysis 74 blood bank RBC

77.2
7.3
0-7 d 197.8
8-14d 3114
15-28 d 3910
8
Discussion
9

• What can contribute hyperkalemic status?
• What route will you choose to BT?
• What does the sign show first? EKG or?

10

• Transfusion-associated hyperkalemic cardiac
  arrest with rapid RBC administration even with
  modest transfusion volume
• Condition may contributed to K level
• Hemorrhagic shock
• Acidosis
• Hyperglycemia
• Increase the cardiotoxicity
• Hypothermia
• Hypocalcemia

11
Hyperglycemia

• Stress, shock? hyperglycemia
• Acute increase serum osmolality? K to exit cells

12
Hypocalcemia

• Massive transfusion of citrated blood is
  associated with hypocalcemia
• Cardiac membrane instability at lower potassium
  levels
• Contribute to extracellular potassium shift

Metabolic acidosis
13
Hypothermia

• Slows the metabolism of citrate
• Exacerbate hypocalcemic status
• In hypothermia, rat myocardium becomes more
  sensitive to potassium

14
Should we BT via CVC?

• Almost cases BT via CVC with high-pressure
  devices
• Blood component CVC? right heart? pulmonary
  circulation? left heart? coronary circulation
• ? CVC may deliver more concentrated K than
  peripheral venous access
• Pressure infusing devices can traumatize RBC
• Linko hyperkalemia correlated with the rate of
  transfusion not the mount

15
ECG real time monitoring?

• Increases in K levels may or may not produce
  accompanying ECG
• ECK may
• Peak T, bradycardia, ORS morphology at K level
  5.3
• ESRD patient may show no ECG finding even up to 6

16
But in this review
17
Risk of BT to anesthesiologists

• Anesthesiologists rarely know the K contain in
  RBC
• Even one published case BT RBC which K level up
  to 120meq/L

77.2
7.3
0-7 d 197.8
8-14d 3114
15-28 d 3910
18
Pediatric

• Most published cases occurred in pediatric
  patients
• Reviewed the article, about 4 associated with
  hyperkalemia
• Smaller circulating volume
• Immature renal function
• Differences in autonomic tone
• Irradiation PRBC

19
Changes in red blood cell integrity related to
infusion pumps a comparison of three different
pump mechanisms
Ped crit care med 2003 vol.4 no.4
20
Adult

• Low cardiac output
• Hemorrhage? providing that K concentration in
  the rapidly transfused blood? exceeds 10meq/L
• Elevated K typically normalized rapidly ? slow
  transfusion
• Intracellular redistribution of potassium
• Adequate circulating blood volume
• Cardiac output

21
Thanks for your attention