318) A 55 year old woman underwent a debulking surgery with total abdominal hysterectomy, Salpingo-oophorectomy, omentectomy and appendicectomy for a recently diagnosed Stage IIIC Epithelial Ovarian Cancer. Her intra-operative course was complicated by severe blood loss and she received about 15 units of Packed Red Blood Cells. She is currently in the intensive care unit. Six hours after surgery, her blood pressure drops to 80/50 mm Hg. On examination, she is afebrile. She is drowsy but can be awakened. She denies any chest pain or shortness of breath. She has muscle tremors. Chest is clear to auscultation. Abdominal sutures are intact with no clinical evidence of Hematoma. An electrocardiogram is shown below:
Which of the following is the most likely explanation of the patient’s acute findings?
A) Hyperkalemia
B) Acute Myocardial Infarction
C) Circulatory Overload
D) Transfusion Associated Acute Lung injury
E) Citrate Toxicity
E) Citrate Toxicity
In massive blood transfusions citrate used as an anticoagulant in PRBC can chelate calcium resulting in hypocalcemia.EKG hows QT prolongation.
citrate toxicity , EKG shows prlonged QT intervals
eeeeeeeeeeeeeee
a
a)hyperkalemia
old damaged RBCs may release potassium causin hyperkalemia and arrhythmias…
muscle tremors are due to citrate that preserve blood and prevent clotting which causes hypocalcemia and eventually muscle tremors
now am confused
most likely hyperkalemia:)
Why muscle tremors?
And what are some of the complications of Massive Blood Transfusion?
e, citrato cnt b metabolized and produce hypocalcemia and hypo mg hypocalcemia cause arrhythmia w/ prolongation of the qt, and wide QRS.
some complications of blood transfusion are iron overload and haemosiderosis, infection,acute haemolysis and immune reaction..and old damaged RBCs may release potassium causin hyperkalemia and arrhythmias…
muscle tremors are due to citrate that preserve blood and prevent clotting which causes hypocalcemia and eventually muscle tremors
maybe it’s citrate toxicity
What keeps stored blood from clotting ?
citrate
citrate
perfect. Citrate binds calcium and causes hypocalcemia. Citrate is normally metabolized very soon in liver but if you give too much citrate as in massive transfusion , the supply overtakes the metabolism and citrate accumulates binding calcium. Hypocalcemia can lead to arrhythmias, muscle tremors, EKG changes such as prolonged QT interval and wide QRS and eventually, may lead to asystole. It is always important to monitor ionized calcium rather than total calcium because hemodilution from massive transfusion can cause inaccurate total calcium values. If ionized calcium is low, this must be relaced immediately with intravnous calcium gluconate or calcium chloride.
Hyperkalemia can occur when old RBCs are transfused , they lyse and increase Serum K+ . Hyperkalemia may cause Tall T waves and wide QRS. However, hyperkalemia should not cause Hypotension and Muscle tremors. Hypocalcemia causes hypotension secondary to decreased peripheral vascular resistance. Hypocalcemia is often a most commonly overlooked etiology of refractory Hypotension in the Intensive care units.
perfecto…..thank you i got it now:)