Ten years ago the possibility of clinical citric acid intoxication during the transfusion of citrated blood was thought to be negligible.1 Shortly thereafter the development of exchange transfusion techniques, with the replacement of two or three times an infant's (or adult's) blood volume, brought attention to this problem again. Wexler and co-workers2 and Ames, Syllm, and Rapoport3 demonstrated high concentrations of serum citrate during the administration of moderate to large amounts of citrated blood and plasma to infants. In each of these investigator's groups of cases there was a death for which citric acid intoxication may have been responsible. More recently, the development of new medical and surgical methods of treating bleeding esophageal varices in patients with portal hypertension and the development of bold techniques in the surgery of the heart and major vessels have created new possibilities for citrate toxicity to develop. To study this problem
Bunker JP, Stetson JB, Coe RC, Grillo HC, Murphy AJ. CITRIC ACID INTOXICATION. JAMA. 1955;157(16):1361–1367. doi:10.1001/jama.1955.02950330001001
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