Cardiac arrests associated with hyperkalemia during red blood cell transfusion: a case series

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.

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.

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%.

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.