Sign In
CPSI Share                                                                  
​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​ ​​
Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 4/17/2018 12:00:00 AM
Country: United Kingdom
Organization: NHS Commissioning Board

This alert relates to perfusion fluids that are mainly used in solid organ transplantation to perfuse and preserve organs. These perfusion fluids are not intended for intravenous administration. If they are, the high potassium content of some of these fluids can cause cardiac arrest. Several patient safety incidents are described. One, more detailed describes a patient undergoing a live donor kidney transplant where 500 mLs of perfusion fluid were infused into the patient via the kidney by the surgical team. The solution was mistakenly assumed to be saline. The perfusion fluid contained 80 mmol potassium per 1000 mLs. The patient was therefore given a rapid bolus of 40 mmol potassium. The patient became asystolic and ALS [advanced life support] immediately commenced for cardiac arrest. Spontaneous output returned after two rounds of CPR [cardiopulmonary resuscitation]. Recommendations to prevent similar incidents are provided.

Additional Details

Medication/Gas/Fluid:
perfusion fluids, potassium, saline (0.9% sodium chloride)


Risk of death or severe harm from inadvertent intravenous administration of solid organ perfusion fluids