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Liver Transplant Anhepatic Phase — FRCA Final MCQ

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HardGeneral AnaesthesiaLiver Transplant Anhepatic PhaseFRCA Final

An 80-kg man undergoing liver transplantation is in the anhepatic phase and receiving rapid transfusion of citrated blood components. His arterial ionised calcium is 0.72 mmol/L, with hypotension and QT-interval prolongation. A functioning central venous catheter is present. You decide to administer approximately 3.4 mmol of elemental calcium immediately in the smallest practical volume. Which prescription is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Calcium chloride 10%, 5 mL, by slow central intravenous administration

Option E is correct. Citrate in transfused blood components complexes ionised calcium; citrate clearance is markedly reduced during the anhepatic phase. The severe ionised hypocalcaemia, hypotension and QT prolongation therefore require prompt intravenous calcium, with ECG and serial ionised-calcium monitoring. Calcium chloride 10% contains 6.8 mmol calcium per 10 mL, so 5 mL supplies approximately 3.4 mmol in a small volume. It should be administered slowly through secure central access because extravasation can cause tissue injury. Ten millilitres of 10% calcium gluconate supplies only 2.23 mmol. Calcium gluconate does not require hepatic metabolism to make calcium available; the original explanation was incorrect on this point. Oral calcium is too slow, magnesium does not directly correct the measured abnormality, and additional FFP increases the citrate burden.

Reference: Electronic Medicines Compendium, Calcium Gluconate 10% solution for injection/infusion BP, SmPC sections 4.2 and 4.4, revised 2023: https://www.medicines.org.uk/emc/product/6264/smpc