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Transfusion medicine

Tranfusion side effects

Metabolic effects of transfusion

Reviewer: Huy Phu Pham, M.D. (see Reviewers page)
Revised: 4 December 2011, last major update September 2011
Copyright: (c) 2007-2011, PathologyOutlines.com, Inc.

Metabolic effects - general

● Most often seen in neonates or in massive transfusion
● Typically includes citrate toxicity, hyperkalemia, hypothermia
● Due to preservatives, anticoagulants, other additives, biochemical changes in blood components during storage (Arch Pathol Lab Med 2007;131:708)

Citrate toxicity

● Citrate is part of anticoagulant solution in pRBCs (CPDA-1 is citrate-phosphate-adenine anticoagulant-preservative)
● Metabolized primarily in liver to bicarbonate
● May cause hypocalcemia (transiently decrease in patientís ionized calcium), causing QT interval prolongation, decreased left ventricular function, hypotension, hypomagnesemia, cardiac arrhythmias
● Risk factors: massive transfusion, hypothermia, liver failure, premature infant (cannot metabolize excess citrate)
● Patients with renal failure may get metabolic alkalosis
● May require slowing rate of transfusion or providing calcium / magnesium replacement
● Prevent with continuous calcium-gluconate infusion during large-volume peripheral blood progenitor cell leukapheresis (Transfusion 2003;43:1615)


● Transfusions to neonates may cause hypoglycemia unless continuous glucose infusion of 4-8 mg/kg/min
● Transfusions may cause transient hyperglycemia due to glucose in preservative; this leads to insulin release and may cause hypoglycemia
● Hypoglycemia more common with CPDA-1 red cells than AS-1 or AS-3, because CPD has lower glucose concentration
● Most pRBCs are not currently stored in CPDA-1 solution
● Transfusions usually not a factor in hyperglycemia in liver transplant patients (World J Gastroenterol 2005;11:2789)


● Potassium accumulates in supernatant of whole blood and red cells during storage because ATP pump is impaired at this temperature
● Leakage is accelerated by gamma irradiation of products
● Total potassium in supernatant of most transfusions is clinically insignificant, but rapid infusion of large volumes (> 20 mL/kg) of stored or irradiated red cells may cause fatal hyperkalemia in infants, children and rarely adults
● Increased susceptibility if patients have oliguric renal failure, hepatic failure or poor cardiac function
Case reports: ventricular fibrillation (Anaesth Intensive Care 2007;35:110)
Prevention: washing red cells or reducing volume of additive solution (Transfusion 2007;47:248, Eur J Cardiothorac Surg 2007;31:659), use of autotransfusion devices (Transfus Med 2007;17:89), potassium adsorption filter (Can J Anaesth 2004;51:639)

End of Transfusion Medicine > Tranfusion side effects > Metabolic effects of transfusion

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