Hypokalemia and massive transfusion

Transfusion-associated hyperkalemia in pediatric population: Analyses for risk factors and recommendations

BACKGROUND

Transfusion-associated hyperkalemia (TAH) is a potentially life-threatening complication of red blood cell (RBC) transfusion. Previously, we reported features of RBC transfusions from 35 pediatric patients (TAH group) who had hyperkalemia with RBC transfusion in one-year period at four facilities. In this study, we used multivariate analyses and artificial intelligence to compare the TAH group to newly collected control group (non-TAH group) to identify factors associated with TAH occurrence.

STUDY DESIGN

A review of RBC transfusion with TAH was compared to non-TAH group who did not develop TAH with RBC transfusion at each facility during the same one-year period. The non-TAH group included 12 patients each in 5 age groups. Wilcoxon rank-sum tests recursive feature elimination, least absolute shrinkage, and selection operator (LASSO), and other artificial intelligence techniques were employed to identify the most salient features associated with predicting specific clinical outcomes for TAH occurrence.

RESULTS/FINDINGS

Pre-transfusion creatinine, comorbidities of kidney and/or liver dysfunctions, and total transfused volume within 12 h (tV-12) per kg and per estimated total blood volume (eTBV) showed statistically significant differences between TAH and non-TAH groups. Multivariate analysis revealed the biggest factor in TAH occurrence was tV-12/kg followed by age of RBC units. The thresholds of risks were tV-12/kg of 30 ml/kg, tV-12/eTBV of 30%, and RBC unit age of 7.95 days.

CONCLUSIONS

The study findings suggest that the biggest factor on TAH occurrence is tV-12/kg. More importantly, 30% of eTBV transfusion could cause TAH in patients with multiple comorbidities.

Transfusion-associated hyperkalemia in pediatric population: Prevalence, risk factors, survival, infusion rate, and RBC unit features

BACKGROUND

Hyperkalemia is a rare life-threatening complication of red blood cell (RBC) transfusion. Stored RBCs leak intracellular potassium (K+) into the supernatant; irradiation potentiates the K+ leak. As the characteristics of patients and implicated RBCs have not been studied systematically, a multicenter study of transfusion-associated hyperkalemia (TAH) in the pediatric population was conducted through the AABB Pediatric Transfusion Medicine Subsection.

STUDY DESIGN

The medical records of patients <18 years old were retrospectively queried for hyperkalemia occurrence during or ≤12 h after the completion of RBC transfusion in a 1-year period. Collected data included patient demographics, diagnosis, medical history, timing of hyperkalemia and transfusion, mortality, and RBC unit characteristics.

RESULTS/FINDINGS

A total of 3777 patients received 19,649 RBC units during the study period in four facilities. TAH was found in 35 patients (0.93%) in 37 occurrences. The patient median age and weight were 1.28 years and 9.80 kg, respectively. All patients had multiple serious comorbidities. There were 79 RBC units transfused in the TAH events; 62% were irradiated, and the median age of the units was 10 days. The median total RBC volume transfused ≤12 h before TAH was 24% of patient estimated total blood volume, and the median infusion rate (IR) was19.6 ml/kg/h. Mortality rate within 1 day after the TAH event was 20%.

CONCLUSIONS

The prevalence of TAH in children was low; however, the 1-day mortality rate was 20%. Patients with multiple comorbidities may be at higher risk for TAH. The IR was higher for patients who had TAH than the IR threshold for safe transfusion.

Transfusion-associated hyperkalemia

The supernatant potassium concentration [K+] of red blood cell (RBC) units is frequently much higher than normal human plasma potassium levels, especially in units nearing the end of their storage life. Clinical hyperkalemia resulting from RBC transfusions has been recognized as a transfusion complication for decades, and there have been reported cardiac arrests attributed to transfusion-associated hyperkalemia. This review summarizes the evidence surrounding RBC [K+] levels, effects of irradiation and washing on [K+], the evidence for clinical hyperkalemia and cardiac arrests resulting from transfusion, predictors of post-transfusion hyperkalemia, and their preventative strategies. Key points include: (a) the [K+] (in mmol/L) increases linearly and is approximately equal to the number of days of RBC unit storage; (b) irradiation causes a rapid increase in [K+]; (c) there is potentially sufficient potassium in the supernatant of current RBC preparations to lead to hyperkalemia with large transfusion volumes; (d) any rise in patient potassium after transfusion is usually transient due to the redistribution of the potassium load; (e) transfusion-associated hyperkalemic cardiac arrests probably do occur, although it is difficult to prove this fact conclusively; and (f) promising strategies to combat transfusion-associated hyperkalemia include RBC washing, the use of in-line potassium filters, and the use of traditional treatments for hyperkalemia such as the use of insulin.

Hyperkalemia after packed red blood cell transfusion in trauma patients

BACKGROUND

Published analyses of clinical outcomes for patients requiring large-volume blood transfusion conflict with respect to the impact upon plasma potassium levels. We analyzed a cohort of trauma patients to ascertain the impact of component product transfusion upon plasma potassium values.

METHODS

We performed an observational analysis of previously, prospectively collected clinical data on 131 noncrush trauma patients undergoing resuscitation during the initial 12 hours after admission to a combat support hospital. Comparisons were made between those who received packed red blood cell (PRBC) transfusion and those who did not. Primary outcome was hyperkalemia (plasma potassium level >5.5 mmol/L).

RESULTS

Ninety-six of one hundred thirty-one patients (73.3%) received PRBCs (mean number of PRBC units 11.2, range, 0-55.0). For transfusion versus nontransfusion patients, baseline plasma potassium value (3.7 +/- 0.57 mmol/L vs. 3.6 +/- 0.36 mmol/L, p = 0.22) rose significantly after transfusion (5.3 +/- 1.2 mmol/L, vs. 4.0 +/- 0.78 mmol/L, p < 0.001). During the study period, 38.5% of transfusion patients developed hyperkalemia, versus 2.9% of those who did not (p = 0.003). In multivariate logistic regression analysis, transfusion of greater than 7 units of PRBCs was independently associated with the development of hyperkalemia (RR 4.72, 95% CI 1.01-21.97, p = 0.048). Transfusion of other cell-based products, baseline base deficits, and plasma bicarbonate levels were not. Spearman's rank correlation coefficient for the relationship of number of transfused PRBC units to the highest recorded potassium value was 0.554 (p < 0.001). The predictive accuracy of the logistic regression model for hyperkalemia was 0.824 (95% CI 0.747-0.901, p < 0.001).

CONCLUSIONS

Hyperkalemia is common after PRBC transfusion, and often severe. PRBC transfusion is independently associated with the development of hyperkalemia. The findings suggest the need for interventional studies examining the impact of alternative resuscitative approaches after severe trauma.

Massive transfusion and hyperkalaemic cardiac arrest in craniofacial surgery in a child

Hyperkalaemia is a recognised complication of massive blood transfusion. We present a case of hyperkalaemic cardiac arrest in a male infant of 12 months, who was undergoing craniofacial surgery for sagittal craniosynostosis. At the time of arrest the patient had received a massive transfusion of predominantly irradiated packed red cells over a two-hour period, and had a measured plasma potassium concentration of 10.1 mmol/l. Cardiopulmonary resuscitation was successful after 15 minutes. On the basis of our laboratory data and a review of the available literature, we recommend the use of fresh, non-irradiated packed red cells whenever possible in paediatric surgery.

Anesthetic problems. Venous air embolism, airway difficulties, and massive transfusion

Perioperative anesthetic complications require the coordinated efforts of both the surgical and anesthesia teams. These complications, or their sequelae, have significant influence on the care of the patient in the preoperative, intraoperative, and postoperative periods.

Transfusion therapy in emergency medicine

Volume replacement is critical to the resuscitation of the hemorrhaging patient, but this usually can be accomplished quickly and safely with crystalloid and/or colloid solutions. Red cells should be used in addition to asanguinous fluids in the treatment of tissue hypoxia due to anemia. The need for whole blood as opposed to packed red blood cells is controversial. However, plasma should not be used as a volume expander, and its use to supplement coagulation factors during the massive transfusion of red cells should be guided by laboratory tests that document a coagulopathy. Similarly, platelet transfusions are indicated to correct documented thrombocytopenia or platelet dysfunction, and routine prophylaxis after fixed volumes of red cells results is unwarranted. Many anticipated complications of massive transfusions, including hemostatic abnormalities, acid-base imbalances, hyperkalemia, and hypocalcemia, are uncommon or of limited clinical significance. The risks of immune hemolysis and transfusion-transmitted diseases, on the other hand, are significant, and argue for judicious use of blood components. In emergencies in which blood is required immediately before compatibility testing can be completed, O-negative uncrossmatched blood can be requested. Careful blood specimen collection and patient identification prior to transfusion are critical. Practices that emphasize blood conservation, including the use of autologous salvaged blood, are always to the patient's advantage.

Electrolyte and acid-base disturbances caused by blood transfusions

The effect of blood transfusions on the electrolyte, metabolic and hemodynamic status of 31 patients undergoing major laparotomies was studied. Two groups were compared: Group I, 11 patients receiving continuous intraoperative blood transfusions exceeding 5 units at a rate over 0.3 ml/kg/min, and Group II, 20 patients receiving transfusions of 1-5 units at a rate below the limit. Transiently increased potassium values (5.2 +/- 0.3 mmol/l) were found in Group I during the rapid transfusion phase. The difference was statistically significant (P less than 0.05) when compared to Group II (4.3 +/- 0.2 mmol/l). There was also a significant correlation (r = 0.64; P less than 0.05) between the increase in serum potassium concentrations and the respective potassium load caused by the blood transfused. Most of the hyperpotassemic patients had surgery of the abdominal aorta. During the rapid transfusion, the patients in Group I had significantly lower concentrations of serum ionized calcium (P less than 0.05) and higher central venous pressures (P less than 0.05), but more periods of hypotension when compared to Group II. After the transfusion the massively transfused patients had slight metabolic alcalosis, the BE and pH differing significantly (P less than 0.05) from the values of Group II. It is concluded that hyperpotassemia may occur during rapid transfusions (over 0.4 ml/kg/min) of stored blood, especially in patients undergoing surgery of the abdominal aorta, even without simultaneous shock, acidosis or hypothermia. Calcium administration may be of benefit especially in situations where combined hyperpotassemia and hypocalcemia reduce the myocardial performance.