{Disarmed} [ccm-l] HyperK arrest w. PRBCs ?

Wed Mar 19 14:04:31 GMT 2008

I've seen hyperkalemic cardiac arrest from massive blood transfusions
three times, once in a ruptured AAA, once in a massive liver
hemangioma and once in a malignant pheochromocytoma when the surgeon
went through the IVC  around which the tumour was wrapped. In all
cases the pateints had a preterminal K of 9 or 10 and died with sine
waves. It could ,of course be argued that if they hadnt died of
hyperkalemia then they would have died of hypothermia coagulopathy
acidosis.
rangraj

On Wed, Mar 19, 2008 at 7:18 PM, A M Batchelor
<a.m.batchelor at newcastle.ac.uk> wrote:
> Hmmm
>
>  I thought every anaesthetist on the planet ...and indeed medical students too knew about this.
>
>  Another one of those bits of information that everyone knows and in fact is a vanishingly rare problem ....rather like hypoxic drive .....
>
>  An average of less than 1 patient per year in the Mayo clinic which cannot have a small case load rather puts it in perspective.
>
>  In 25 years in anaesthesia and intensive care ....with my fair share of massive transfusions I have yet to see it.
>
>  We used to give Ca or HCO3 to prevent this until we worked out that in fact as soon as the cells warm up they take the K back up and it really isn't much of a problem.  Confirmed by in theatre measurements of blood gases and electrolytes.
>
>  Haven't read the paper but their conclusion in the abstract about other conditions eg hypothermia and low cardiac output are I think important.
>
>  I would hate to return to the days when people religiously gave HCO3 for this potential problem and the patients then spent 5 days alkalotic because they cannot clear an alkaline (or Na) load very easily.
>
>  Anna
>  Oh G-d I am now old enough to see the wheels being re-invented ........
>
>
>
>  -----Original Message-----
>  From: ccm-l-bounces at ccm-l.org [mailto:ccm-l-bounces at ccm-l.org] On Behalf Of Ivan Hronek
>  Sent: 19 March 2008 01:24
>  To: ccm-l at ccm-l.org; Anesthideas at yahoogroups.com
>  Cc: trauma-list at trauma.org; sprung.juraj at mayo.edu
>  Subject: {Disarmed} [ccm-l] HyperK arrest w. PRBCs ?
>
>  Anesth Analg 2008; 106:1062-1069  complete article anyone ?
>
>  Cardiac Arrests Associated with Hyperkalemia During Red Blood Cell Transfusion: A Case Series
>
>  Hugh M. Smith, MD, PhD*, Stacy J. Farrow, SRNA*, Joel D. Ackerman, MD*, James R. Stubbs, MD {dagger}<http://www.anesthesia-analgesia.org/math/dagger.gif> , and Juraj Sprung, MD, PhD*
>
>  >From the Departments of *Anesthesiology and  {dagger}<http://www.anesthesia-analgesia.org/math/dagger.gif> Transfusion Medicine, College of Medicine, Mayo Clinic, Rochester, Minnesota.
>
>  Address correspondence and reprint requests to Juraj Sprung, MD, PhD, Department of Anesthesiology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. Address e-mail to sprung.juraj at mayo.edu .
>
>  Abstract
>
>  BACKGROUND: 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.
>
>  METHODS: 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.
>
>  RESULTS: 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%.
>
>  CONCLUSION: 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.
>
>
>
>
>
>  Ivan Hronek MD
>
>  SFMC, Los Angeles
>
>  cell: 310 487-3288
>
>  http://health.groups.yahoo.com/group/Anesthideas/
>
>  Don't fight darkness. Bring the light, and darkness will disappear.
>
>  Maharishi Mahesh Yogi
>
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-- 
Lt Col Rangraj Setlur
Associate Professor
Department of Anaesthesiology and Critical Care
Armed Forces Medical College
Pune
India