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Wolf J, Geneen LJ, Meli A, Doree C, Cardigan R, New HV. Hyperkalaemia Following Blood Transfusion–a Systematic Review Assessing Evidence and Risks. Transfus Med Rev 2022; 36:133-142. [DOI: 10.1016/j.tmrv.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/09/2022] [Accepted: 04/12/2022] [Indexed: 11/30/2022]
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Burke M, Sinha P, Luban NLC, Posnack NG. Transfusion-Associated Hyperkalemic Cardiac Arrest in Neonatal, Infant, and Pediatric Patients. Front Pediatr 2021; 9:765306. [PMID: 34778153 PMCID: PMC8586075 DOI: 10.3389/fped.2021.765306] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 09/29/2021] [Indexed: 01/05/2023] Open
Abstract
Red blood cell (RBC) transfusions are a life-saving intervention, with nearly 14 million RBC units transfused in the United States each year. However, the safety and efficacy of this procedure can be influenced by variations in the collection, processing, and administration of RBCs. Procedures or manipulations that increase potassium (K+) levels in stored blood products can also predispose patients to hyperkalemia and transfusion-associated hyperkalemic cardiac arrest (TAHCA). In this mini review, we aimed to provide a brief overview of blood storage, the red cell storage lesion, and variables that increase extracellular [K+]. We also summarize cases of TAHCA and identify potential mitigation strategies. Hyperkalemia and cardiac arrhythmias can occur in pediatric patients when RBCs are transfused quickly, delivered directly to the heart without time for electrolyte equilibration, or accumulate extracellular K+ due to storage time or irradiation. Advances in blood banking have improved the availability and quality of RBCs, yet, some patient populations are sensitive to transfusion-associated hyperkalemia. Future research studies should further investigate potential mitigation strategies to reduce the risk of TAHCA, which may include using fresh RBCs, reducing storage time after irradiation, transfusing at slower rates, implementing manipulations that wash or remove excess extracellular K+, and implementing restrictive transfusion strategies.
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Affiliation(s)
- Morgan Burke
- School of Medicine, George Washington University, Washington, DC, United States
| | - Pranava Sinha
- Department of Pediatrics, School of Medicine, George Washington University, Washington, DC, United States.,Division of Cardiac Surgery, Children's National Hospital, Washington, DC, United States.,Children's National Heart Institute, Children's National Hospital, Washington, DC, United States
| | - Naomi L C Luban
- Department of Pediatrics, School of Medicine, George Washington University, Washington, DC, United States.,Department of Pathology, School of Medicine, George Washington University, Washington, DC, United States.,Division of Hematology and Laboratory Medicine, Children's National Hospital, Washington, DC, United States
| | - Nikki Gillum Posnack
- Department of Pediatrics, School of Medicine, George Washington University, Washington, DC, United States.,Children's National Heart Institute, Children's National Hospital, Washington, DC, United States.,Department of Pharmacology & Physiology, School of Medicine, George Washington University, Washington, DC, United States.,Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, DC, United States
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Serrano K, Pambrun C, Levin E, Devine DV. Supernatant reduction of stored gamma-irradiated red blood cells minimizes potentially harmful substances present in transfusion aliquots for neonates. Transfusion 2017; 57:3009-3018. [PMID: 28782124 DOI: 10.1111/trf.14270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/28/2017] [Accepted: 07/03/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND In neonate transfusion, the use of a dedicated red blood cell (RBC) unit decreases donor exposure. A separate safety measure involves gamma irradiation of the RBCs to abrogate the possibility of transfusion-associated graft-versus-host disease. However, in combination, storage of gamma-irradiated RBCs leads to accumulation of potentially harmful substances in the supernatant. STUDY DESIGN AND METHODS For this study, RBCs were pooled and split into three study arms. Centrifugation or gravity was used to pack RBCs of matched units thereby reducing the amount of supernatant that would be present in neonate transfusion aliquots; these were compared to matched control units. Supernatant measurements of potassium, hemoglobin (Hb), RBC microvesicle (RMV) content, and mannitol were made in aliquots prepared weekly up to 21 days after gamma irradiation. RBC morphology and osmotic fragility were also assessed to determine if supernatant reduction methods affected the storage lesion. RESULTS Potassium and mannitol were significantly decreased in transfusion aliquots prepared with either of the supernatant reduction methods. On Day 21, potassium levels from supernatant-reduced aliquots were below those of Day 7 control aliquots. A decrease in free Hb was only detected on Day 21 in centrifuged aliquots. RMVs were significantly reduced in centrifuged aliquots and significantly increased in gravity-settled aliquots. The only measurable effect on storage lesion was a small increase in osmotic fragility of the RBCs subjected to supernatant reduction. CONCLUSION Supernatant reduction by centrifugation effectively reduces potassium, mannitol, and RMVs in aliquots from gamma-irradiated RBCs stored up to 21 days.
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Affiliation(s)
- Katherine Serrano
- Department of Pathology and Laboratory Medicine and Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada.,Canadian Blood Services Centre for Innovation, Vancouver, British Columbia, Canada
| | - Chantale Pambrun
- Canadian Blood Services Donor and Clinical Services, Ottawa, Ontario, Canada.,IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Elena Levin
- Department of Pathology and Laboratory Medicine and Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada.,Canadian Blood Services Centre for Innovation, Vancouver, British Columbia, Canada
| | - Dana V Devine
- Department of Pathology and Laboratory Medicine and Centre for Blood Research, University of British Columbia, Vancouver, British Columbia, Canada.,Canadian Blood Services Centre for Innovation, Vancouver, British Columbia, Canada
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Imashuku Y, Kitagawa H, Mizuno T, Fukushima Y. Hyperkalemia caused by rapid red cell transfusion and the potassium absorption filter. Saudi J Anaesth 2017; 11:114-116. [PMID: 28217070 PMCID: PMC5292834 DOI: 10.4103/1658-354x.197354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of transient hyperkalemia during hysterectomy after cesarean section, due to preoperatively undiagnosed placenta accreta that caused unforeseen massive hemorrhage and required rapid red cell transfusion. Hyperkalemia-induced by rapid red cell transfusion is a well-known severe complication of transfusion; however, in patients with sudden massive hemorrhage, rapid red cell transfusion is necessary to save their life. In such cases, it is extremely important to monitor serum potassium levels. For an emergency situation, a system should be developed to ensure sufficient preparation for immediate transfusion and laboratory tests. Furthermore, sufficient stock of preparations to treat hyperkalemia, such as calcium preparations, diuretics, glucose, and insulin is required. Moreover, a transfusion filter that absorbs potassium has been developed and is now available for clinical use in Japan. The filter is easy to use and beneficial, and should be prepared when it is available.
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Affiliation(s)
- Yasuhiko Imashuku
- Department of Anesthesiology, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Hirotoshi Kitagawa
- Department of Anesthesiology, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Takayoshi Mizuno
- Department of Anesthesiology, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Yutaka Fukushima
- Department of Anesthesiology, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
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Cid J, Villegas V, Carbassé G, Alba C, Perea D, Lozano M. Transfusion of irradiated red blood cell units with a potassium adsorption filter: A randomized controlled trial. Transfusion 2016; 56:1046-51. [PMID: 26923301 DOI: 10.1111/trf.13536] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 01/16/2016] [Accepted: 01/18/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND The irradiation of red blood cells (RBCs) causes damage of the RBC membrane with increased potassium (K) leak during storage compared with nonirradiated RBC units of similar age. A previous in vitro study showed a mean reduction of K of 94 ± 5% with a potassium adsorption filter (PAF). STUDY DESIGN AND METHODS A prospective, single-center, nonblinded, randomized controlled trial (RCT) was designed to evaluate the safety and efficacy of transfusing irradiated RBC units with the PAF. Patients 18 years of age or older who received irradiated RBC units due to chemotherapy-induced anemia were randomly assigned to receive irradiated RBC units with the PAF (PAF group) or with the standard blood infusion set (control group). Primary outcome measures were safety and efficacy of the PAF (absolute change in hemoglobin [Hb] and K, respectively, in patient's blood values after transfusing the irradiated RBC units with or without the PAF). RESULTS A total of 63 irradiated RBC units were transfused to 17 patients in the control group, and a total of 56 irradiated RBC units were transfused to 13 patients in the PAF group. The absolute change of Hb (9.3 ± 6.3 g/L vs. 8.1 ± 5.8 g/L; p = 0.3) and the absolute change of K (-0.01 ± 0.4 mmol/L vs. -0.01 ± 0.3 mmol/L; p = 0.2) were comparable between the two groups of the trial. CONCLUSION The transfusion of 1 irradiated RBC unit with the PAF was as safe and efficacious as the transfusion of 1 irradiated RBC unit with the standard blood infusion set in patients with chemotherapy-induced anemia.
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Affiliation(s)
- Joan Cid
- Department of Hemotherapy and Hemostasis, CDB, IDIBAPS, Hospital Clínic, University de Barcelona, Barcelona, Spain
| | - Vanessa Villegas
- Department of Hemotherapy and Hemostasis, CDB, IDIBAPS, Hospital Clínic, University de Barcelona, Barcelona, Spain
| | - Gloria Carbassé
- Department of Hemotherapy and Hemostasis, CDB, IDIBAPS, Hospital Clínic, University de Barcelona, Barcelona, Spain
| | - Cristina Alba
- Department of Hemotherapy and Hemostasis, CDB, IDIBAPS, Hospital Clínic, University de Barcelona, Barcelona, Spain
| | - Dolores Perea
- Department of Hemotherapy and Hemostasis, CDB, IDIBAPS, Hospital Clínic, University de Barcelona, Barcelona, Spain
| | - Miguel Lozano
- Department of Hemotherapy and Hemostasis, CDB, IDIBAPS, Hospital Clínic, University de Barcelona, Barcelona, Spain
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Washing out potassium absorption filters with normal saline after use. Clin Exp Nephrol 2015; 19:984. [DOI: 10.1007/s10157-015-1093-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 02/03/2015] [Indexed: 10/24/2022]
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O'Leary MF, Szklarski P, Klein TM, Young PP. Hemolysis of red blood cells after cell washing with different automated technologies: clinical implications in a neonatal cardiac surgery population. Transfusion 2010; 51:955-60. [PMID: 21091957 DOI: 10.1111/j.1537-2995.2010.02935.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In subsets of pediatric cardiac surgery patients, red blood cells (RBCs) are often washed to reduce extracellular potassium (K) to avoid hyperkalemia, but mechanical manipulation and time delay in issuing washed products may increase hemolysis and K. This study's purpose was to evaluate the quality of washed RBCs with regard to hemolysis and extracellular K using different cell washers as a function of postprocessing time. STUDY DESIGN AND METHODS Fresh (<4 days old) RBCs were washed on COBE 2991 blood cell processors (Model 1 and Model 2) or the Fresenius Continuous AutoTransfusion System (CATS), and K and hemolysis index (HI) were analyzed. Academic pediatric hospitals were surveyed to ascertain practice trends regarding indications for washing, washing device, and expiration time for washed RBCs. RESULTS K concentration at 24 hours for units washed with the COBE devices met or exceeded prewash values. At 12 hours, there was a significant difference (p < 0.001) in K concentration between all devices, with the CATS maintaining the lowest K concentration. HI increased immediately after wash on all devices and showed a significant difference between the COBE devices and CATS at times of more than 6 hours (p < 0.01). At storage times beyond 4 hours, hemoglobin exceeded 100 mg/dL on the COBE Model 1. Survey of pediatric hospitals indicated that COBE devices are commonly used, and storage time after washing was 12 hours or more in blood banks queried. CONCLUSIONS Hemolysis levels vary among different cell washers. Decreasing the expiration time of units after washing may be warranted.
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Affiliation(s)
- Mandy Flannery O'Leary
- Department of Pathology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
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Xia VW, Obaidi R, Park C, Braunfeld M, Neelakanta G, Nourmand H, Hu KQ, Steadman RH. Insulin therapy in divided doses coupled with blood transfusion versus large bolus doses in patients at high risk for hyperkalemia during liver transplantation. J Cardiothorac Vasc Anesth 2009; 24:80-3. [PMID: 19362017 DOI: 10.1053/j.jvca.2009.01.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess the effectiveness of an insulin regimen in divided doses designed to target risk factors of hyperkalemia in patients undergoing liver transplantation. DESIGN Retrospective comparison of the divided insulin dose regimen with a conventional large-bolus insulin method during liver transplantation. SETTING University-based, academic, tertiary center. PARTICIPANTS Adult patients whose baseline potassium levels were >/=4.0 mmol/L and received insulin therapy during liver transplantation at the authors' medical center between January 2004 and April 2007. INTERVENTIONS Insulin was administered either in divided doses (1-2 units) for each unit of red blood cells transfused or in a large-bolus in patients at high risk for hyperkalemia during liver transplantation. MEASUREMENTS AND MAIN RESULTS Among 717 patients who underwent liver transplantation, 50 patients received insulin in divided doses, and 101 patients received a large-bolus of insulin. Perioperative characteristics were comparable except for higher insulin doses in the large-bolus group. The divided insulin regimen was associated with significantly lower mean potassium levels within 2 hours before reperfusion of the graft compared with the conventional group (p < 0.005). The mean glucose levels in the divided group were significantly lower in both the pre- and postreperfusion periods than in the conventional group (p < 0.05 to <0.001). CONCLUSIONS The divided insulin dose regimen that specifically targets the risk factors for prereperfusion hyperkalemia is associated with significantly lower prereperfusion potassium and pre- and postreperfusion glucose levels and provides a useful alternative to the conventional large-bolus method in management of intraoperative hyperkalemia during liver transplantation.
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Affiliation(s)
- Victor W Xia
- Department of Anesthesiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 3225, Los Angeles, CA 90095-7403, USA.
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Abstract
PURPOSE OF REVIEW The present review describes new trends and ongoing controversies in the anesthetic care of liver transplant recipients. RECENT FINDINGS Recent studies have improved our knowledge of conditions increasing perioperative risk, such as portopulmonary hypertension and renal failure. Improved surgical and anesthetic management has reduced intraoperative blood loss, as more studies identify an independent association between blood transfusion and poor outcome. New concepts in the coagulopathy of liver failure are emerging, with clear implications for clinical practice, including greater awareness of the risks of intraoperative thromboembolism. Less invasive intraoperative hemodynamic monitoring has been advocated, as has wider use of transoesophageal echocardiography. Early extubation is becoming more routinized. SUMMARY Anesthetic management still varies widely between liver transplant centers with little data to indicate best practice. Future research should focus on fluid replacement, prevention and treatment of coagulopathy, care of the acutely ill patient and the safety and benefits of early extubation.
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Cid J, Ramiro L, Bertran S, Martínez N, Claparols M, Maymó RM, Puig L, Pla RP. Efficacy in reducing potassium load in irradiated red cell bags with a potassium adsorption filter. Transfusion 2008; 48:1966-70. [DOI: 10.1111/j.1537-2995.2008.01776.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Smith HM, Farrow SJ, Ackerman JD, Stubbs JR, Sprung J. Cardiac arrests associated with hyperkalemia during red blood cell transfusion: a case series. Anesth Analg 2008; 106:1062-9, table of contents. [PMID: 18349174 DOI: 10.1213/ane.0b013e318164f03d] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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.
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Affiliation(s)
- Hugh M Smith
- Department of Anesthesiology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Shephard DAE. The changing pattern of anesthesia, 1954-2004: a review based on the content of theCanadian Journal of Anesthesia in its first half-century. Can J Anaesth 2005; 52:238-48. [PMID: 15753493 DOI: 10.1007/bf03016057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE In order to review changes and progress in anesthesiology in the second half of the 20th century, and to recognize the first half-century of the Journal's existence. SOURCE The content of the Journal from its inauguration in 1954 through 2004 was reviewed. RESULTS Although the data base is that of the Canadian Journal, many of the contributions were from other countries, and for this reason the findings will have relevance both in Canada and elsewhere. The review suggests that anesthesiology evolved in two phases in this period: from 1954 to 1978 and from 1979 to 2004. The first was characterized by the introduction of new drugs and adaptation to new surgical techniques; the second, by a greater emphasis on clinical excellence, outcome, quality patient care both in the operating room and elsewhere in the hospital, and research. CONCLUSIONS Although profound advances in knowledge, techniques, and relationships, have shaped the pattern and practice of anesthesiology in this half-century, the basic concerns of anesthesiologists relating to the practice of anesthesia and to their patients remained unchanged. At the same time, the many advances that have shaped anesthesiology in this half-century have extended the understanding of the phenomenon of anesthesia and enhanced the quality of patient care, which gives rise to the hope that anesthesiologists will continue to fully achieve these twin goals in the next half-century.
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