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- Acidemia and Hyperkalemia: from massive transfusions;

- massive transfusion: transfusion of pRBC >6-8 units, must also provide platelets;
- 8 units platelets for ea 10-12 units pRBC's transfused;
- 2 units of FFP
- Ca replacement if hypocalcemic (2nd to citrate)
- references:
- Electrolyte and acid-base disturbances caused by blood transfusions.
- Hyperkalemia after packed red blood cell transfusion in trauma patients.
- Post-Transfusion Alkalosis:
- the early net result of succesful resusitation is post-transfusion alkalosis in the patient;
- the sodium citrate is converted to bicarbonate
- the alkalosis is associatted with increased potassium excretion;
- Hypocalcemia:
- some recommend calcium supplementation for patients receiving greater than 100 ml/min;
- give 0.2 gm of CaCl in a separate line for each 500 ml given;
- some believe that most patients will tolerate 1 unit pRBC q 5 min without requiring calcium supplementation;

Massive Transfusion is usually defined as the need to transfuse from one to two times the patient's normal blood
volume. In a "normal" adult, this is the equivalent of 10-20 units. Potential complications from this include coagulopathy,
citrate toxicity, hypothermia, acid-base disturbances and changes in serum potassium concentration.

Coagulopathy is common with massive transfusion. The most common cause of bleeding following a large volume
transfusion is dilutional thrombocytopenia. This should be suspected and treated first before moving on to factor
deficiencies as the cause of coagulopathy.
Citrate toxicity results when the citrate in the transfused blood begins to bind calcium in the patient's body. Clinically
significant hypocalcemia does not usually occur unless the rate of transfusion exceeds one unit every five minutes or so.
Citrate metabolism is primarily hepatic - so hepatic disease or dysfunction can cause this effect to be more pronounced.
Treatment is with intravenous calcium administration - but identification of the problem requires a high index of suspicion.
Hypothermia should not occur on a regular basis. Massive transfusion is an absolute indication for the warming of all
blood and fluid to body temperature as it is being given.
Acid-Base balance can be seen after massive transfusion. The most common abnormality is a metabolic alkalosis.
Patients may initially be acidotic because the blood load itself is acidic and there may be a prevailing lactic acidosis from
hypoperfusion. However, once normal perfusion is restored, any metabolic acidosis resolves and the citrate and lactate are
then converted to bicarbonate in the liver.
Serum potassium can rise as blood is given. The potassium concentration in stored blood increases steadily with time.
The amount of potassium is typically less than 4 milliequivalents per unit - so you can see that large amounts of blood at a
high rate of delivery is required to raise serum levels of potassium.