‘Near‐miss’ hyperkalaemic cardiac arrest associated with rapid blood transfusion

Abstract

SummaryA case is presented in which a relatively modest blood transfusion resulted in acute hyperkalaemia with a 'near-miss' cardiac arrest. While transfusion-related hyperkalaemia usually occurs in association with massive transfusions, several factors may have increased the risk of such an acute reaction. A high index of suspicion is required, especially in patients with risk factors. Anaesthetists should not be lulled into a false sense of security simply because modest volumes of blood are being transfused. Hyperkalaemia is an established complication of blood transfusions. Most cases of significant hyperkalaemia and cardiac arrest have involved neonates [1] or adults receiving massive transfusion [2]. We describe a patient in whom a relatively modest blood transfusion resulted in acute hyperkalaemia with a 'near-miss' cardiac arrest. Case historyA frail 74-year-old woman was scheduled for an exploratory laparotomy for a suspected uterine malignancy. She had a history of longstanding hypertension and hypothyroidism, but no history of ischaemic heart disease. She was a nonsmoker and had, until recently, a good exercise tolerance for her age. Medication on admission included amlodipine 5 mg daily and thyroxine 100 mg daily.On examination she was markedly cachectic, weighing only 42 kg, and had a hard mass protruding from her pelvis into her lower abdomen.Her pre-operative ECG was normal and laboratory investigations showed a haemoglobin of 12.7 g.dl À1 , a normal coagulation profile, potassium of 4.4 mmol.l À1 , albumin of 35 g.dl À1 and normal urea and creatinine levels.After application of routine monitoring, anaesthesia was induced with propofol (1.5 mg.kg À1 ) and fentanyl citrate (3 mg.kg À1 ). Cisatracurium besylate (0.20 mg.kg À1 ) was used to facilitate tracheal intubation and the patient's lungs were ventilated with a 50 : 50% mixture of oxygen, nitrous oxide and 1% isoflurane. A 14G peripheral intravenous, 20G radial arterial cannula and a triple-lumen internal jugular central venous pressure (CVP) line were positioned after the induction of anaesthesia.Laparotomy revealed a large, locally aggressive leiomyosarcoma arising from the uterus, and a radical hysterectomy and a debulking procedure was planned.Approximately 1 h after the start of surgery, during debulking of the tumour mass, a sudden blood loss of approximately 1500 ml caused a sudden decrease in the patient's blood pressure from 130/85 mmHg to 75/ 40 mmHg. This was associated with a tachycardia and rapid decrease in the CVP from 6 mmHg to 0 mmHg.Initial fluid resuscitation with 1000 ml 0.9% saline and 1000 ml Haemaccel® solution produced a temporary improvement in the patient's blood pressure. After further blood loss, a blood transfusion was started with two units (740 ml) of blood, which was transfused rapidly over 5-10 min via a fluid warming system. During the rapid infusion of blood, the ECG was noted to show an increase in the size of the T waves, followed rapidly by a widening of the QRS complexes. The pulse rate decreased from 80

An unusual case of hyperkalaemia‐induced cardiac arrest in a paediatric patient during transfusion of a ‘fresh’ 6‐day‐old blood unit

“…It is now well documented that the potassium concentration of 7‐day‐old blood units (packed RBCs stored in AS‐1) is around 23 mmol L −1 , whereas that of the 42‐day‐old blood units, in AS‐1, is in the 50 mmol L −1 range (Vengelen‐Tyler, 1999). Potassium concentrations as high as 70 mmol L −1 have been reported in 28‐day‐old, irradiated blood units stored in SAG‐M (De Silva & Seghatchian, 1994; Carvalho & Quiney, 1999). Campbell (1955) has reported that 7‐day‐old blood units used in exchange transfusions of infants with haemolytic disease have potassium levels in the range of 6·5–8 mmol L −1 .…”

“…The important factors that play a role in the acute alterations due to potassium are the rate of infusion, the amount transfused and the site of infusion (Carvalho & Quiney, 1999). In our case, where the baby suffered from acute extensive blood loss, rapid transfusion of packed RBCs was an urgent requirement, and 120 mL of blood was pushed through the central line.…”

Red blood transfusion in preterm infants: changes in glucose, electrolytes and acid base balance

“…However, rapid infusion of large volumes of RBCs into neonates or patients with cardiac, hepatic, or renal dysfunction mandates close monitoring. [1011]…”

Intra‐operative hyperkalaemia following extensive muscle dissection

“…The Airtraq has a similar profile to the Bullard laryngoscope and we hope that it will be as successful in grades 3 and 4 Macintosh laryngoscopy [2]. Early indications are good [3].…”