TYK254

A 5-month-old male with complex non-syndromic craniosynostosis is undergoing posterior cranial vault expansion and the surgeon has just raised the scalp flap. Following a rapid bolus of packed red cells, you notice that the ECG rhythm changes from NSR and now there are peaked T waves. What is the likely etiology?

a) Unplugged fluid warmer

b) Accidental air embolism from improperly primed line

c) Administration of blood that has an expiration date four days from now

d) Transfusion-associated circulatory overload (TACO)

e) Administration of blood with an expiration date three weeks from now

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Answer

Answer c. Hyperkalemia is a potential risk following massive transfusion, especially in patients with small circulating blood volumes. Packed cells stored less than one week contain < 20 mM potassium and are thus recommended in this patient. During hyperkalemic episodes, peaked T-waves typically present initially, followed by prolongation of the PR interval, absence of the P wave with QRS prolongation, and eventually ventricular tachycardia and fibrillation. Packed red blood cells are typically stored at 1-6 degrees Celcius. Significant fluid or blood resuscitation via an unplugged fluid warmer can induce hypothermia, but EKG changes typically include sinus bradycardia, junctional rhythm, and QT prolongation.

Notes

This question originally printed in the Pediatric Anesthesiology Review Topics kindle book series, and appears courtesy of Naerthwyn Press, LLC.

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