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October 13, 2014
1:00 PM - 3:00 PM
Room Hall B1-Area C
Resuscitation with Washed Old Blood Decreases Hyperkalemic Cardiac Arrest in Hemorrhagic Shock
Joel A. Rocha Filho, M.D., Ph.D., Estela Regina R. Figueira, M.D., Ph.D., Matheus F. Vane, M.D., Alessandro R. Martins, D.V.M., Fernando C. Silva, M.D., Alan S. Ramalho, M.D., Marcio A. Moreira, D.V.M., Maria Jose C. Carmona, M.D., Ph.D., Jose Otavio C. Auler, M.D., Ph.D., Luiz Augusto C. D'Albuquerque, M.D., Ph.D.
University of São Paulo, Sao Paulo, Brazil
Introduction: Transfusion-associated hyperkalemia (TAH) is a life-threatening complication of red blood cell (RBC) transfusion that can results in cardiac arrest. During storage RBCs suffer gradual decomposition and physicochemical changes resulting in increased potassium (K) levels in packed RBC (PRBC) supernatant. The underlying pathophysiology is not fully understood. We aimed to evaluate if transfusion of aged PRBC increases serum K in hemorrhagic shock (HS) and, if so, to determine whether washing PRBCs immediately before transfusion could abolish this effect.

Methods: 24 pigs were submitted to controlled HS and PRBC resuscitation. After anesthesia 50% of total blood volume was withdrawn to reach MAP of 30 to 40 mmHg with a ScvO2 lower than 45% before starting PRBC resuscitation. Animals were allocated into three groups. In PRBC21 group, pigs were resuscitated with 21-day stored PRBC; in PRBCW group, with 21-day stored PRBC and washed before transfusion; and in PRBC5 group, with 5-day stored PRBC.

Results: 2.5min after transfusion, serum K was increased in PRBC21 (9.57 ± 3.38 mEq /L) group compared to PRBCW (6.54 ± 2.29 mEq/L) and PRBC5 (5.40 ± 0.88 mEq /L) groups (Fig 1). The mortality was 50% for the PRBC21, and zero for PRBCW and PRBC5 groups, p= 0.02. All deaths occurred within the first 5 min of PRBC administration. The ECG showed ventricular tachycardia with rapid progression to Torsades de pointes, fibrillation and asystole. In PRBC21 K post-transfusion increased 3.04 ± 3.33 mEq/L, but in PRBCW and PRBC5 groups K did not increase. Post-transfusion serum ionized calcium (iCa) was decreased in PRBC21 (3.74 ± 0.49 mg/dL) and PRBC5 (3.71 ± 0.52 mg/dL) compared to PRBCW (4.78 ± 0.16 mg/dL) group (Fig 2). Supernatant K concentration was increased in transfused PRBC21 (24.75 ± 3.21 mEq/L), compared to PRBC5 (11.12 ± 1.99 mEq/L) and PRBCW (7.47 ± 1.57 mEq/L) groups (Fig 3). Additionally post-transfusion arterio-central venous K difference increased in PRBC21 (1.36 ± 2.01 mEq/L) compared to PRBC5 (-0.51 ± 1.04 mEq/L) and PRBCW (-0.64 ± 0.46), p= 0.0089 (Fig 4).

Conclusion: Rapid transfusion of PRBC stored for 21 days in HS increases serum K to critical levels leading to sudden cardiac arrest. Increased supernatant K may not be the only cause of TAH, suggesting that intravascular hemolysis may play a central whole. Washing PRBC before transfusion decreases TAH and hypocalcemia, reducing transfusion-associated cardiac arrest and mortality in HS resuscitation.
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