The medical director of a hospital transfusion service in California reports that their orthotopic liver transplant program has experienced several cases of unexpected, severe, life-threatening hyperkalemia during liver transplantation that have occurred relatively early during surgery, well before the vascular connection of the graft (when hyperkalemia is expected), and were resistant to insulin/glucose, bicarb, etc and were temporally associated with cardiac arrest. All of these patients were being transfused, and clearly the blood added some K+, albeit little, since the storage times of the administered RBC units were relatively brief. However, as a result of these events, the surgeons request that the transfusion service supply RBC units that are no greater than 2 weeks old (they use AS-1, -3, -5 rbc) and routinely reject RBC units that have been stored for longer times. The inquiring physician is of the opinion that there is no 'standard of care' regarding the age of blood for liver transplantation, and he would like to know the age of RBC units supplied by other transfusion services for liver transplants and/or what agreements, if any, other transfusion services have with their liver transplant surgeons regarding age of the RBC units supplied. It would also be of interest to know if other liver transplant programs employ additional methods to limit K+ administration with blood, e.g. washing products in the blood bank or OR, etc.

The following comments have been received.

ADDENDA April, 14, 2007

1. Colleagues who work at an academic medical center in the Midwest report that during the past 7 years they have had only one cardiac arrest in a liver transplant patient that was not associated with declamping the graft. Last year (2006) they did more than 100 liver transplants, routinely providing blood that was more than 14 days 'old' without incident. They comment that it is highly suspicious that the occurence of cardiac arrests has increased at the California colleague's hospital and they suggests that a change might have occurred in operating room practice. They acknowledge that many years ago at their own hospital, a sudden outbreak of hemolysis was seen with liver transplant patients, and the surgeons attributed the outbreak to the blood transfusions. However, a careful investigation revealed a change in the suction tip of the cell saver that was used for intraoperative blood management. There were no further incidences of hemolysis after discontinuing that tip. The Midwestern colleagues suggest that an epidemiologist should investigate the outbreak of cardiac arrests at the California hospital. They are fairly confident that there is another etiology, other than the blood, will be discovered to explain the adverse events.

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