To the Editor:—
Think about hemofiltration in a situation like this. We would like to report the resuscitation of a patient during a multiorgan transplant. During reperfusion, this patient experienced a sudden cardiac arrest associated with a serum potassium concentration of almost 9. Extensive mechanical and chemical resuscitation efforts were started immediately, but no regular heartbeat could be reestablished.
High-flow continuous venovenous hemodiafiltration was instituted (Baxter Blood Monitor 11–Balancing Monitor 14 and Polysulfon Hemofilter 1,200 Renoflo II hemofilter; Baxter Deutschland GmbH, Unterschleißheim, Germany; 200 ml/min blood flow; 3.0 l/h dialyzate flow with Schiwa SH 04; B. Braun Schiwa GmbH & Co. KG, Glandorf, Germany [this solution contains 138 mm sodium, 2 mm potassium, 2 mm calcium, 0.75 mm magnesium, 111.5 mm chloride, and 34 mm lactate]). Ten minutes later, the patient’s cardiac rhythm stabilized, and spontaneous circulation resumed.
Postreperfusion syndrome was the most likely cause of this cardiac arrest. Aggarwal et al. 1described postreperfusion syndrome as a constellation of cardiovascular responses, including hypotension, bradycardia, conduction defects, and low systemic vascular resistance. Several factors contribute to this syndrome. In approximately 30% of the liver transplant recipients studied, profound hypotension (mean arterial pressure < 70% of baseline) developed within 5 min of reperfusion, lasting for more than 1 min. In fact, in the Pittsburgh series, 1the degree of hypothermia and acidosis was similar in patients with or without reperfusion hypotension; severe hyperkalemia (> 7 mm) occurred independent of hypotension, and hypocalcemia did not occur during reperfusion. 2
Why our high-flow continuous venovenous hemodiafiltration worked may be because of the findings that were demonstrated by Marino et al. 3in pigs. This study found a lower incidence of cardiac arrest after recirculation of venous blood pretreated with dialysis, suggesting that the release of unknown vasodilating or myocardial depressant factors from the grafted liver or other viscera may play a major role in the cardiovascular effects of the reperfusion syndrome.
We cannot be certain that the successful resuscitation in this complex situation was related to hemofiltration, but if one encounters cardiac arrest in a situation such as this that cannot be managed conservatively, one should consider and switch to an early continuous venovenous hemodiafiltration.