Introduction
Transfusion of blood components has historically been seen as a low-risk, safe technique. However, in recent years, awareness of the risks associated with blood transfusions and their components has increased. Since it is no longer regarded as a low- or no-risk treatment, stringent rules for transfusing blood products are becoming increasingly necessary to prevent infections and lessen other transfusion-related side effects.
Following large blood transfusions, citrate poisoning is a common consequence that frequently manifests as metabolic alkalosis. This phrase was created due to the liver's primary role in converting citrate, an anticoagulant used in blood bags, to bicarbonate. Therefore, citrate, which chelates calcium and is used to anticoagulant stored blood (3 g/unit of RBC), is used. In a healthy adult, the liver metabolizes 3 g of citrate in 5 minutes. As a result, citrate is elevated, and ionized plasma calcium is decreased by infusion rates of more than 1 unit of RBC per minute or liver failure.
The infusion of hydrochloric acid caused an acute metabolic acidosis that reduced proximal fluid reabsorption and enhanced the fractional transport of sodium and calcium to the distal tubule but not to the final urine.
According to reports, about 30% of the patient need a transfusion in an ICU. Acidosis raises plasma potassium concentrations by causing outflow from the cell into the extracellular compartment through hydrogen exchange.
What Are the Advantages of Citric Acid?
All citrus fruits naturally contain mild acid, known as citric acid. Citric acid can be tasted if you've ever bit into a lemon. Manufacturers artificially add it to processed foods. Citric acid-containing medications cure conditions like kidney stones. Citric acid is not just found in sour citrus fruits. It is present in minute amounts in all plants and animals. Numerous marketed foods and non-food goods, such as cosmetics and cleaning supplies, also include citric acid. However, it's a synthetic form rather than the natural one. Citrus fruits, particularly the juice of lemons and limes, are foods high in natural citric acid. Natural citric acid is also present in various other fruits and vegetables. The uses of citric acid are as follows:
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At least a dozen food and drinks have citric acid added. Foods in jars and cans are kept fresher for longer. It can stop freshly cut vegetables from oxidizing or browning. Foods can benefit from citric acid's thickening or mildly sour flavoring effects. Some ice creams, sorbets, and sodas may mention citric acid as an ingredient.
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The acid in a food or beverage can be balanced out by citric acid. It is occasionally added to wine by winemakers to enhance flavor.
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Citric acid is a component of certain lotions that help treat skin infections. Additional oral citric acid medications can reduce the amount of acid in the urine. This may lessen the risk of kidney stones. People may also take citric acid for metabolic acidosis, a buildup of acid in the body.
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Kidney stones can be avoided by taking calcium citrate supplements, which some people do.
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Alpha hydroxy acid, a substance created when manufacturers combine citric acid with other substances, can help smooth the skin. Additionally, it extends the shelf life of several cosmetics and personal care products like deodorant, lipstick, and hairspray.
What Are the Adverse Health Effects of Citric Toxicity?
The unfavorable effects of citric acid are typically related to the depressed ionization of such cations in extracellular fluid, notably calcium. Citric acid forms weakly dissociated salts with divalent cations. Such depression can affect the body's excitable tissues, with the heart muscle suffering the most significant repercussions. Traditional uses of fresh frozen plasma include:
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Volume replacement.
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The treatment of disseminated intravascular coagulopathy.
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The care of a bleeding newborn.
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The prevention of intraventricular hemorrhage.
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Sepsis.
Citrate has historically been considered a safe blood anticoagulant due to its rapid utilization under normal circumstances. The risk of citric acid poisoning through blood transfusion has been considered minimal. There is strong evidence that citrate concentrations may frequently increase to hazardous levels due to the huge amounts of blood now utilized, the speed with which it must frequently be supplied, and the rising number of patients with liver disease undergoing surgery. It is now widely acknowledged that neonates with erythroblastosis can have dramatic elevations in citrate concentration after exchange transfusions; tetany and fatalities have been documented.
A significant disruption to glucose metabolism occurs during liver donation. The blood glucose level is extremely challenging to manage using standard clinical techniques during this phase. A liver transplant is one surgical operation that necessitates a transfusion of blood products. This causes complex internal milieu changes(changes in the internal environment) that can result in life-threatening intraoperative occurrences. Following orthotopic liver transplantation(The diseased liver is substituted by a normal liver), 40 % to 64% of individuals experienced metabolic alkalosis brought on by large blood infusions between the third and fourth days.
What Are the Complications Associated With Citric Toxicity?
Blood transfusions, a type of tissue implantation, can often save lives, but they also carry several risks. Blood transfusions can save lives. However, there are hazards involved, such as non-viral and infectious consequences. Circulatory overload, transfusion-dependent sepsis, hemosiderosis, problems from anticoagulants, gas embolism, cold-induced homeopathy, and viral transmission are examples of non-immunological consequences. Immunological complications and nonimmunological complications are the two types of transfusion-related problems.
Because cardiac function (relaxation and contraction) rely greatly on plasma concentrations of ionized calcium, neonates are at risk of heart failure due to hypocalcemia after transfusion. In addition, when newborns exhibit liver disease, their citrate metabolism is reduced, and the risk of death is very high. To identify individuals with aplastic anemia or blood cancer, the work suggested counting the link between carbon dioxide emission caused by the action of citrate metabolism and serum electrolytes in those patients.
What Is the Treatment of Citric Toxicity?
Citrate stops blood products from coagulating while being kept (primarily FFP Fresh frozen plasma, platelets, and cell saver). When significant citrate levels are transfused, calcium and magnesium are chelated, resulting in hypocalcemia and hypomagnesemia. Citrate toxicity symptoms include hypotension, myocardial depression, EKG abnormalities (QT prolongation, heart block, arrhythmias), nervous system hyperexcitability (laryngospasm, tetany, Trousseau sign), and coagulopathy.
These symptoms are linked to hypocalcemia and hypomagnesemia. Patients with hepatic dysfunction, hypoalbuminemia, hypothermia, or hyperventilation, as well as pediatric patients, may experience these symptoms that are more pronounced. The main goals of treatment are to replenish magnesium and calcium (IV calcium gluconate or chloride). Additionally, the liver often breaks down citrate quickly. Therefore, reducing the transfusion rate will enable hepatic metabolism in addition to the therapy of hypocalcemia.
Conclusion
As the citrate in the transfused blood binds to calcium in the patient's body, citrate poisoning occurs. Unless the transfusion rate approaches one unit every five minutes, clinically significant hypocalcemia typically does not happen. Arrhythmias, a narrow pulse, severe hypotension, and increased end-diastolic pressure indicate citrate intoxication.
