Pulseless electrical activity after rapid administration of fresh frozen plasma.

We present two extreme low birthweight preterm neonates who developed pulseless electrical activity during dilutional exchange transfusions with fresh frozen plasma (FFP). Both were polycythaemic recipient twins delivered prematurely because of foetal compromise as a result of twin-to-twin transfusion syndrome. The two events were associated with an acute fall in ionised calcium. We discuss the mechanism of these cardiac arrests and highlight the care required when infusing citrate containing blood products, particularly FFP, in order to avoid causing acute life-threatening hypocalcaemia.

An autopsy case of death due to metabolic acidosis after citric acid ingestion.

A man in his 40s was found unconscious on a sofa in a communal residence for people with various disabilities. He appeared to have drunk 800 ml of undiluted citric acid from a commercial plastic bottle. The instructions on the label of the beverage specified that the beverage be diluted 20- to 30-fold before consumption. The patient was admitted to an emergency hospital with severe metabolic acidosis (pH, 6.70; HCO3(-), 3.6 mEq/L) and a low ionized calcium level (0.73 mmol/L). Although ionized calcium and catecholamines were continuously administered intravenously to correct the acidosis, the state of acidemia and low blood pressure did not improve, and he died 20 h later. Citric acid concentrations in the patient's serum drawn shortly after treatment in the hospital and from the heart at autopsy were 80.6 mg/ml and 39.8 mg/dl, respectively (normal range: 1.3-2.6 mg/dl). Autopsy revealed black discoloration of the mucosal surface of the esophagus. Microscopically, degenerated epithelium and neutrophilic infiltration in the muscle layer were observed. In daily life, drinking a large amount of concentrated citric acid beverage is rare as a cause of lethal poisoning. However, persons with mental disorders such as dementia may mistakenly drink detergent or concentrated fluids, as in our case. Family members or facility staff in the home or nursing facility must bear in mind that they should not leave such bottles in places where they are easily accessible to mentally handicapped persons.

Massive blood transfusion.

Pediatricians in the hospital setting must frequently treat children who require massive transfusion (MT) in a variety of clinical situations ranging from major trauma to neonatal hyperbilirubinemia. After identifying the need for massive transfusion, the pediatrician must select the appropriate blood components. Different blood components have specific temperature, preservative, and time requirements for their storage. Changes, termed storage lesions, occur over time in blood components during storage; biochemical changes include decreased levels of 2,3-DPG, a decrease in pH, and an increase in supernatant potassium (K+) with a concurrent decrease in intracellular K+. These changes may affect the function and the viability of components. Additionally, physical changes such as deformation of the red cell membrane occur during storage. Knowledge of these storage lesions is necessary for the pediatrician to make the most appropriate decisions regarding the preparation and selection of components during MT. Serious complications of MT include hemostatic abnormalities, biochemical/metabolic abnormalities, hypothermia, mechanical injury and the effect of Rh incompatibility, each of which has a specific management response. Pediatricians need to be aware of the potential complications associated with massive transfusion, to take measures to prevent them when possible, to anticipate additional transfusion requirements, and to know how to manage them in the pediatric patient.

[Right subclavian catheterization. Misplaced insertion into the subclavian artery and the ascending aorta]. / Cathétérisme sous-clavier droit. Fausse-route dans l'artère sous-clavière et l'aorte ascendante.

The accidental subclavian artery puncture is usually obvious. We report a case of unrecognized arterial catheterisation. The catheter had been inserted during anaesthesia after return of dark and non pulsatile blood, and not controlled by a chest radiograph. During surgery, the injection of 40 mL isotonic saline containing 4 g of piperacillin for antibiotic prophylaxis resulted in a transient circulatory collapse associated with ECG tracing of myocardial ischaemia. Postoperative chest radiograph showed that the catheter was in a midsternal position, at the level of the ascending aorta. The intracoronary penetration of piperacillin was considered as the cause for the transient cardiocirculatory changes. The various diagnostic tools of the intra-arterial location of the catheter are discussed. All inadvertent subclavian artery catheterisations published in the literature have been carried out with multi-lumen catheters. The latter can contribute to the failure to recognize the arterial puncture and catheter insertion because of the use of a small bore needle (Seldinger's technique) and infusion with electrical pumps.

Lethal iatrogenic hypermagnesemia.

The administration of magnesium is an effective therapeutic option in such conditions as preeclampsia, ischemic heart disease, cardiac arrhythmia, and asthma. It has also been used as a cathartic in the treatment of constipation. As a medical therapy, magnesium enjoys an acceptable safety record. Because magnesium is almost exclusively excreted in the urine, significantly elevated levels of magnesium are typically anticipated only in patients with renal dysfunction. With wider application, emerging reports suggest that additional factors such as intestinal hypomotility and chronic constipation should be considered before using magnesium to avoid toxicity.

Severe lactic acidosis in a diabetic patient after ethanol abuse and floor cleaner intake.

An intoxication with drugs, ethanol or cleaning solvents may cause a complex clinical scenario if multiple agents have been ingested simultaneously. The situation can become even more complex in patients with (multiple) co-morbidities. A 59-year-old man with type 2 diabetes mellitus (without treatment two weeks before the intoxication) intentionally ingested a substantial amount of ethanol along with ~750 mL of laminate floor cleaner containing citric acid. The patient was admitted with severe metabolic acidosis (both ketoacidosis and lactic acidosis, with serum lactate levels of 22 mM). He was treated with sodium bicarbonate, insulin and thiamine after which he recovered within two days. Diabetic ketoacidosis and lactic acidosis aggravated due to ethanol intoxication, thiamine deficiency and citrate. The high lactate levels were explained by excessive lactate formation caused by the combination of untreated diabetes mellitus, thiamine deficiency and ethanol abuse. Metabolic acidosis in diabetes is multi-factorial, and the clinical situation may be further complicated, when ingestion of ethanol and toxic agents are involved. Here, we reported a patient in whom diabetic ketoacidosis was accompanied by severe lactic acidosis as a result of citric acid and mainly ethanol ingestion and a possible thiamine deficiency. In the presence of lactic acidosis in diabetic ketoacidosis, physicians need to consider thiamine deficiency and ingestion of ethanol or other toxins.

National audit of citrate toxicity in plateletpheresis donors.

UNLABELLED: Citrate toxicity complicating plateletpheresis is not uncommon. However, the scale and severity of the problem have never been formally addressed. In order to answer these questions we undertook a national audit of 13 070-platelet procedures throughout 17 apheresis centres in England over a 3-month period from 1 April to 30 June 2000. A standard form was distributed to each centre to record the symptoms/signs of citrate toxicity which were then graded (grades 1-5) according to their severity. The following variables were studied to determine whether they influenced the frequency and severity of citrate toxicity: 1. The type of manufacturer's cell separator used (Cobe Spectra, Haemonetics, Baxter Amicus and Trima). 2 The type of procedure: single needle, dual needle, single, double or triple dose. 3 The way in which donors were instructed to report symptoms of citrate toxicity. OUTCOME: Plateletpheresis is a relatively safe procedure provided that donors who experience severe reactions receive appropriate treatment. The incidence of severe citrate toxicity (0.03% procedures) is comparable to that of severe faints following whole blood donation, indicating a comparable margin of safety. Donors should be warned of the symptoms of citrate toxicity at their first attendance only. More frequent reminders encourage donors to over-report symptoms of mild citrate toxicity.

Adverse events in platelet apheresis donors: A multivariate analysis in a hospital-based program.

OBJECTIVES: This study was designed to review the incidence of adverse events during nearly 20,000 apheresis procedures over a 4-year period in a hospital-based program. METHODS: Data were obtained from a review of: (1) apheresis adverse event forms (2) hospital or emergency room medical records (3) the databank for donor and procedure-related variables. Adverse events during or after the apheresis procedures were analyzed according to the following categories: (1) complications related to citrate toxicity; (2) hypotensive or vasovagal episodes; (3) complications or symptoms consistent with coronary ischemia; (4) complications related to percutaneous needle insertion, and (5) miscellaneous procedure-related events or nonspecific symptoms. Serious adverse events were categorized as persistent or severe hemodynamic changes as well as other events that required further medical evaluation. RESULTS: Of 19,736 apheresis procedures, 159 (0.81%) were associated with adverse events. In 2,376 first-time donations, 26 (1.09%) developed adverse events compared to 133 (0.77%) of 17,360 repeat procedures (p = 0.10). Seventy (0.35%) of 159 donation-related adverse events involved hemodynamic or citrate-related complications and 73 (0.37%) involved venipuncture-related complications, of which 2 required subsequent neurologic consultation. The remaining 23 (0. 12%) adverse events involved procedure-related, nonspecific complications. Forty-seven (0.24%) of the 19,736 apheresis procedures were associated with serious adverse events (SAEs). Seven of these serious adverse events required admission to an emergency department, and 2 required hospitalization for further evaluation. Multivariate analysis revealed that apheresis machine model, donor gender and weight, the concomitant harvesting of plasma, the frequency of donation, and citrate-related symptoms (e.g. paresthesias) were independently associated with severe hypotensive reactions. CONCLUSIONS: Apheresis procedures have a 150-fold higher incidence of SAEs requiring hospitalization compared to whole blood donation. Identification of donors at risk for complications can facilitate modification of the apheresis procedure in order to reduce the likelihood of adverse events. Although our study did not demonstrate a cause-effect relationship between platelet donation and the development of acute coronary syndromes, underlying cardiovascular disease was detected in 2 donors during or after the apheresis who were otherwise asymptomatic.

Citric acid ingestion: a life-threatening cause of metabolic acidosis.

We present a case that illustrates the acute (<6 hours) metabolic and hemodynamic effects of the ingestion of a massive oral citric acid load. The principal findings included metabolic acidosis accompanied by an increase in the plasma anion gap that was not caused by L -lactic acidosis, hyperkalemia, and the abrupt onset of hypotension. A unique feature was a dramatic clinical improvement when ionized calcium was infused. The case illustrates the importance of considering the properties of the conjugate base (anion) of the added acid because, in this instance, the citrate anion had a unique and life-threatening consequence (lower ionized calcium level) that was rapidly reversible.