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Use of a K⁺-adsorption filter for the massive transfusion of irradiated red blood cells in a child

Tochigi, Japan

To the Editor:

The potassium level in the supernatant of irradiated packed red blood cells (IR-RBCs) increases rapidly and reaches more than 50 mEq•L^–1 one week after irradiation.¹ Such high potassium loads might induce fatal arrhythmias especially in cases of rapid and massive transfusion.² Strategies reducing the potassium load from IR-RBCs are required to make transfusion safer.

Recently, a potassium-adsorption filter (Kawasumi Laboratories, Tokyo, Japan) has become commercially available for the rapid and massive transfusion of IR-RBC. It consists of a chamber containing sodium polystyrene sulfonate beads, which adsorb K⁺ and release Na⁺ in equivalent amounts. It can eliminate more than 80% of the potassium in the supernatant of IR-RBCs at infusion rates less than 50 mL•min^–1.3

Massive bleeding may be observed during liver transplantation (LT), especially in children with congenital biliary atresia (CBA) undergoing a Kasai portoenterostomy. Recently, we experienced massive bleeding during a LT and were able to manage massive transfusion uneventfully using this filter.

A ten-month-old girl (weight 7.3 kg) with CBA was scheduled for LT. The operation lasted 986 min and anesthesia 1,127 min. Total bleeding amounted to 765 g, massive bleeding being observed specially during the dissection and anhepatic phase. Rapid infusions of IR-RBCs (30–200 mL•hr^–1) and fresh frozen plasma (FFP) (40–200 mL•hr^–1) were needed to maintain circulatory stability and total infusion of IR-RBCs and FFP amounted to 665 mL and 950 mL, respectively. All IR-RBCs were transfused using this filter. Mean potassium concentration in the supernatant of IR-RBCs was reduced from 16.3 mEq•L^–1 to 1.9 mEq•L^–1.

The circulating blood volume is 75 mL•kg^–1 in a ten-month-old infant and more than one circulating blood volume was lost in this case. It has been reported that washing of IR-RBCs by using an autotranfusion device can reduce potassium concentration in the supernatant and provide safe transfusion to end-stage renal failure patients.⁴ However, because this method requires a sophisticated device and a dedicated operator, it cannot be used conveniently.

The potassium adsorption filter is an alternative strategy for preventing transfusion induced hyperkalemia. It must be rinsed with 200 mL of saline just before attaching to IR-RBC bags. Compared to the preparation of the autotranfusion device, it is very easy and quick to use. This filter provides a convenient method to prevent transfusion induced hyperkalemia.

References

1 Thorp JA, Plapp FV, Cohen GR, Yeast JD, O’Kell RT, Stephenson S. Hyperkalemia after irradiation of packed red blood cells: possible effects with intravascular fetal transfusion. Am J Obstet Gynecol 1990; 163: 607–9.[Medline]

2 Brown KA, Bissonnette B, McIntyre B. Hyperkalaemia during rapid blood transfusion and hypovolaemic cardiac arrest in children. Can J Anaesth 1990; 37: 747–54.[Abstract/Free Full Text]

3 Inaba S, Nibu K, Takano H, et al. Potassium-adsorption filter for RBC transfusion: a phase III clinical trial. Transfusion 2000; 40: 1469–74.[Medline]

4 Knichwitz G, Zahl M, Van Aken H, Semjonow A, Booke M. Intraoperative washing of long-stored packed red blood cells by using an autotransfusion device prevents hyperkalemia. Anesth Analg 2002; 95: 324–5.[Abstract/Free Full Text]

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