Citrate intoxication following a rapid massive blood transfusion.

A woman of 27 weighing 60 kg was submitted to surgery for Fallot's tetralogy. She had been an invalid all her life and was unable to walk more than a few steps. At operation dilatation of the pulmonary valve and punch excision of an infundibular stenosis was performed via the left pulmonary artery. This operation was uneventful apart from some considerable blood loss both from the pulmonary artery and from some pleural adhesion at the apex of the left lung. During the operation 1080 ml of blood were given, the second bottle still running on her return to the ward. Two and a half hours later, as she was being sat up, the intercostal drain suddenly delivered 440 ml of almost pure blood and continued so to drain for the next 6 hours. Altogether in the 10 hours following her operation 1100 ml of apparently pure blood had drained into the leak bottle and 1620 ml of blood had been replaced. Radiographic studies of the chest revealed a complete haemothorax. Her general condition at this time remained good; the blood pressure and pulse being steady, it was decided that the chest should be re-opened. On return to the theatre, however, her general condition had deteriorated considerably. The pulse was practically impalDable and the blood pressure unrecordable. This situation responded well to a rapid transfusion of blood with a Martin pump and the chest was reopened. After removing a large quantity of fresh clot the heart was observed to be in normal rhythm, in which state it remained for the next 20 minutes. During this time a large quantity of blood was tFansfused, 2700 ml in all. and the general condition was improving steadily. No obvious bleeding point was found; the pulmonary artery was secure but there was considerable oozing from the raw lung surface at the left apex. Twenty minutes after the commencement of the operation the heart, which had been in normal rhythm, 136 suddenly entered ventricular fibrillation. The use of a defibrillator and intracardiac neostigmine failed to restore normal rhythm, but as a large quantity of blood had been transfused, citrate intoxication was considered. 2 ml of 10 per cent calcium chloride were given intracardially and the heart was immediately restored to normal rhythm. Although cardiac massage had been maintained throughout the period of fibrillation, and despite the use of hypertonic sucrose solution, the patient died 48 hours later as a result of cerebral damage, presumably accounted for by the 8-minute period of fibrillation.