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Wang L, Dixon C, Nhan J, Kakajiwala A. A balancing act: drifting away from the reflexive use of "ab"normal saline. Pediatr Nephrol 2024; 39:2325-2335. [PMID: 38233719 DOI: 10.1007/s00467-023-06271-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/19/2024]
Abstract
Maintenance intravenous fluids are the most frequently ordered medications for hospitalized children. Since the American Association of Pediatrics published national guidelines, there has been an increased reflexive use of isotonic solutions, especially 0.9% saline, as a prophylaxis against hyponatremia. In this educational review, we discuss the potential deleterious effects of using 0.9% saline, including the development of hyperchloremia, metabolic acidosis, acute kidney injury, hyperkalemia, and a proinflammatory state. Balanced solutions with anion buffers cause relatively minimal harm when used in most children. While the literature supporting one fluid choice over the other is variable, we highlight the benefits of balanced solutions over saline and the importance of prescribing fluid therapy that is individualized for each patient.
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Affiliation(s)
- Linda Wang
- Department of Pediatrics, Division of Nephrology, Children's National Hospital, Washington, DC, USA.
| | - Celeste Dixon
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Jennifer Nhan
- Department of Pediatrics, Division of Nephrology, Children's National Hospital, Washington, DC, USA
| | - Aadil Kakajiwala
- Department of Pediatrics, Division of Nephrology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
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2
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Ng PK, Yoeli D, Huang JL, Luo Y, Wang Y, Li B, Wang Z, Schold J, Jain S, Su AJA, Mathes DW, Washington KM, Farkash E, Jani AH, Huang CA. Successful Extension of Vascularized Composite Allograft Perfusion Cold Storage to 24 h in a Rat Hindlimb Transplant Model. Transplant Direct 2024; 10:e1623. [PMID: 38757052 PMCID: PMC11098188 DOI: 10.1097/txd.0000000000001623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 05/18/2024] Open
Abstract
Background Vascularized composite allograft transplantation is a treatment option for complex tissue injuries; however, ischemia reperfusion injury and high acute rejection rates remain a challenge. Hypothermic machine perfusion using acellular storage perfusate is a potential solution. This study evaluated the University of Wisconsin Kidney Preservation Solution-1 (KPS-1) compared with normal saline (NS) for preservation of donor rat hindlimbs subjected to 24 h of ex vivo perfusion cold storage. Methods Hindlimbs were subjected to 24-h perfusion cold storage with heparinized KPS-1 (n = 6) or heparinized NS (n = 6). Flow, resistance, and pH were measured continuously. At the end of the 24-h period, tissue was collected for histological analysis of edema and apoptosis. Results KPS-1 perfused limbs showed significantly less edema than the NS group, as evidenced by lower limb weight gain (P < 0.001) and less interfascicular space (P < 0.001). KPS-perfused muscle had significantly less cell death than NS-perfused muscle based on terminal deoxynucleotidyl transferase dUTP nick-end labeling (P < 0.001) and cleaved caspase-3 staining (P = 0.045). During hypothermic machine perfusion, a significant decrease in pH over time was detected in both groups, with a significantly greater decline in pH in the KPS-1 group than in the NS group. There were no significant differences overall and over time in flow rate or vascular resistance between the KPS and NS groups. Conclusions Perfusion with KPS-1 can successfully extend vascularized composite allograft perfusion cold storage for 24 h in a rat hindlimb model without significant edema or cell death.
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Affiliation(s)
- Po’okela K. Ng
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Dor Yoeli
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Joy L. Huang
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Yuhuan Luo
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Yong Wang
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Bing Li
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Zhaohui Wang
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jesse Schold
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Swati Jain
- Department of Medicine, University of Colorado Anschutz Medical Campus , Aurora, CO
| | - An-Jey A. Su
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - David W. Mathes
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Kia M. Washington
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Evan Farkash
- Department of Pathology, University of Michigan School of Medicine, Ann Arbor, MI
| | - Alkesh H. Jani
- Department of Medicine, University of Colorado Anschutz Medical Campus , Aurora, CO
| | - Christene A. Huang
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
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Akasaka H, Naora H. Revisiting the Use of Normal Saline for Peritoneal Washing in Ovarian Cancer. Int J Mol Sci 2023; 24:16449. [PMID: 38003636 PMCID: PMC10671679 DOI: 10.3390/ijms242216449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/09/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
The omentum is the predominant site of ovarian cancer metastasis, but it is difficult to remove the omentum in its entirety. There is a critical need for effective approaches that minimize the risk of colonization of preserved omental tissues by occult cancer cells. Normal saline (0.9% sodium chloride) is commonly used to wash the peritoneal cavity during ovarian cancer surgery. The omentum has a prodigious ability to absorb fluid in the peritoneal cavity, but the impact of normal saline on the omentum is poorly understood. In this review article, we discuss why normal saline is not a biocompatible solution, drawing insights from clinical investigations of normal saline in fluid resuscitation and from the cytopathologic evaluation of peritoneal washings. We integrate these insights with the unique biology of the omentum and omental metastasis, highlighting the importance of considering the absorptive ability of the omentum when administering agents into the peritoneal cavity. Furthermore, we describe insights from preclinical studies regarding the mechanisms by which normal saline might render the omentum conducive for colonization by cancer cells. Importantly, we discuss the possibility that the risk of colonization of preserved omental tissues might be minimized by using balanced crystalloid solutions for peritoneal washing.
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Affiliation(s)
| | - Honami Naora
- Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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4
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Lorente JV, Hahn RG, Jover JL, Del Cojo E, Hervías M, Jiménez I, Uña R, Clau-Terré F, Monge MI, Llau JV, Colomina MJ, Ripollés-Melchor J. Role of Crystalloids in the Perioperative Setting: From Basics to Clinical Applications and Enhanced Recovery Protocols. J Clin Med 2023; 12:5930. [PMID: 37762871 PMCID: PMC10531658 DOI: 10.3390/jcm12185930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/04/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
Perioperative fluid management, a critical aspect of major surgeries, is characterized by pronounced stress responses, altered capillary permeability, and significant fluid shifts. Recognized as a cornerstone of enhanced recovery protocols, effective perioperative fluid management is crucial for optimizing patient recovery and preventing postoperative complications, especially in high-risk patients. The scientific literature has extensively investigated various fluid infusion regimens, but recent publications indicate that not only the volume but also the type of fluid infused significantly influences surgical outcomes. Adequate fluid therapy prescription requires a thorough understanding of the physiological and biochemical principles that govern the body's internal environment and the potential perioperative alterations that may arise. Recently published clinical trials have questioned the safety of synthetic colloids, widely used in the surgical field. A new clinical scenario has arisen in which crystalloids could play a pivotal role in perioperative fluid therapy. This review aims to offer evidence-based clinical principles for prescribing fluid therapy tailored to the patient's physiology during the perioperative period. The approach combines these principles with current recommendations for enhanced recovery programs for surgical patients, grounded in physiological and biochemical principles.
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Affiliation(s)
- Juan V. Lorente
- Department of Anesthesiology and Critical Care, Juan Ramón Jiménez University Hospital, 21005 Huelva, Spain
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
| | - Robert G. Hahn
- Karolinska Institute, Danderyds Hospital (KIDS), 171 77 Stockholm, Sweden
| | - José L. Jover
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Verge del Lliris Hospital, 03802 Alcoy, Spain
| | - Enrique Del Cojo
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Don Benito-Villanueva de la Serena Health District, 06400 Don Benito, Spain
| | - Mónica Hervías
- Department of Anesthesiology and Critical Care, Gregorio Marañón General University Hospital, 28007 Madrid, Spain
- Paediatric Anaesthesiology Section, Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
| | - Ignacio Jiménez
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Virgen del Rocío University Hospital, 41013 Seville, Spain
| | - Rafael Uña
- Department of Anesthesiology and Critical Care, La Paz University General Hospital, 28046 Madrid, Spain
| | - Fernando Clau-Terré
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Vall d’Hebron Institut Recerca, Vall d’Hebrón University Hospital, 08035 Barcelona, Spain
| | - Manuel I. Monge
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
| | - Juan V. Llau
- Department of Anesthesiology and Critical Care, Doctor Peset Hospital, 46017 Valencia, Spain
| | - Maria J. Colomina
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Bellvitge University Hospital, University of Barcelona, 08907 Barcelona, Spain
| | - Javier Ripollés-Melchor
- Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain
- Department of Anesthesiology and Critical Care, Infanta Leonor Hospital, 28031 Madrid, Spain
- Department of Toxicology, Universidad Complutense de Madrid, 28040 Madrid, Spain
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5
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Kim D, Kim J, Han S, Jung H, Park HD, Ko JS, Gwak MS, Kim GS. Effects of 20% albumin infusion therapy during liver transplantation on plasma neutrophil gelatinase-associated lipocalin level: A randomized controlled trial. Liver Transpl 2023; 29:861-870. [PMID: 36749856 DOI: 10.1097/lvt.0000000000000089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 12/30/2022] [Indexed: 02/09/2023]
Abstract
The risk of acute kidney injury (AKI) after liver transplantation was lower in patients with serum albumin levels ≥3.0 mg/dL during surgery. We tested whether intraoperative infusion of 20% albumin affects neutrophil gelatinase-associated lipocalin (NGAL) level, a reliable indicator of AKI. We randomly assigned 134 patients undergoing liver transplantation into albumin group (n=70, 20% albumin 200 mL) and the control group (n=66, crystalloid solution 200 mL). The 2 study fluids were infused at 100 mL/h from the start of the anhepatic phase. The primary outcome was plasma NGAL level at 1 hour after graft reperfusion. Albumin level at the start of graft reperfusion was significantly greater in albumin group than in the control group [2.9 (2.4-3.3) g/dL vs. 2.3 (2.0-2.7) g/dL, p <0.001]. The NGAL level at 1 hour after graft reperfusion was not significantly different between the 2 groups [100.2 (66.7-138.8) ng/mL vs. 92.9 (70.8-120.6) ng/mL, p =0.46], and the AKI risk was not either (63.9% vs. 67.8%, adjusted p =0.73). There were no significant differences between the 2 groups regarding hospital readmission within 30 days/90 days after transplantation (32.6% vs. 41.5%, adjusted p =0.19 and 55.0% vs. 55.7%, adjusted p =0.87). Graft survival probability at 30 days/90 days/1 year after transplantation was 90.0%/84.3%/78.6% in albumin group and 97.0%/90.9%/89.4% in the control group [HR=1.6 (0.6-4.0), adjusted p =0.31]. In conclusion, intraoperative infusion of 20% albumin 200 mL increased the albumin level but failed to maintain serum albumin ≥3.0 mg/dL during surgery. The hypertonic albumin therapy did not significantly affect plasma NGAL level and clinical outcomes including AKI.
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Affiliation(s)
- Doyeon Kim
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, Pochun CHA University School of Medicine, Seongnam, Republic of Korea
| | - Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sangbin Han
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyunjoo Jung
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University School of Medicine, Seoul, Republic of Korea
| | - Hyung-Doo Park
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Justin S Ko
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Mi Sook Gwak
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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6
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Akasaka H, Lee W, Ko SY, Lengyel E, Naora H. Normal saline remodels the omentum and stimulates its receptivity for transcoelomic metastasis. JCI Insight 2023; 8:e167336. [PMID: 37345662 PMCID: PMC10371238 DOI: 10.1172/jci.insight.167336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 05/04/2023] [Indexed: 06/23/2023] Open
Abstract
The omentum contains immune cell structures called milky spots that are niches for transcoelomic metastasis. It is difficult to remove the omentum completely, and there are no effective strategies to minimize the risk of colonization of preserved omental tissues by cancer cells that circulate in the peritoneal fluid. Normal saline is commonly administered into the peritoneal cavity for diagnostic and intraoperative lavage. Here we show that normal saline, when administered into the peritoneal cavity of mice, is prominently absorbed by the omentum, exfoliates its mesothelium, and induces expression of CX3CL1, the ligand for CX3CR1, within and surrounding the omental vasculature. Studies using CX3CR1-competent and CX3CR1-deficient mice showed that the predominant response in the omentum following saline administration is an accumulation of CX3CR1+ monocytes/macrophages that expand milky spots and promote neoangiogenesis within these niches. Moreover, saline administration promoted the implantation of cancer cells of ovarian and colorectal origin onto the omentum. By contrast, these deleterious effects were not observed following i.p. administration of lactated Ringer's solution. Our findings suggest that normal saline stimulates the receptivity of the omentum for cancer cells and that the risk of colonization can be minimized by using a biocompatible crystalloid for lavage procedures.
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Affiliation(s)
- Hironari Akasaka
- Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - WonJae Lee
- Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Song Yi Ko
- Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ernst Lengyel
- Department of Obstetrics and Gynecology, Section of Gynecologic Oncology, University of Chicago, Chicago, Illinois, USA
| | - Honami Naora
- Department of Molecular and Cellular Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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7
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Sreenivasan S, Rathore AS. Combined Presence of Ferrous Ions and Hydrogen Peroxide in Normal Saline and In Vitro Models Induces Enhanced Aggregation of Therapeutic IgG due to Hydroxyl Radicals. Mol Pharm 2023. [PMID: 37189260 DOI: 10.1021/acs.molpharmaceut.3c00051] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Therapeutic monoclonal antibodies (mAb) are known to form aggregates and fragments upon exposure to hydrogen peroxide (H2O2) and ferrous ions (Fe2+). H2O2 and Fe2+ react to form hydroxyl radicals that are detrimental to protein structures. In this study, aggregation of mAb in the combined presence of Fe2+ and H2O2 was investigated in saline and physiologically relevant in vitro models. In the first case study, forced degradation of mAb in saline (a fluid used for administration of mAb) was carried out at 55 °C in the combined presence of 0.2 mM Fe2+ and 0.1% H2O2. The control and stressed samples were analyzed using an array of techniques including visual observation, size-exclusion chromatography (SEC), dynamic light scattering (DLS), microscopy, UV-vis, fluorescence, Fourier transform infrared spectroscopy, and cell-based toxicity assays. At the end of 1 h, samples having the combined presence of both Fe2+ and H2O2 exhibited more than 20% HMW (high molecular weight species), whereas samples having only Fe2+, H2O2, or neither resulted in less than 3% HMW. Aggregate-rich samples also exhibited altered protein structures and hydrophobicity. Aggregation increased upon increasing the time, temperature, and concentration of Fe2+ and H2O2. Samples having both Fe2+ and H2O2 also showed higher cytotoxicity in red blood cells. Samples of mAb with chlorides of copper and cobalt with H2O2 also resulted in multifold degradation. The first case study showed enhanced aggregation of mAb in the combined presence of Fe2+ and H2O2 in saline. In the second case study, aggregation of mAb was investigated in artificially prepared extracellular saline and in vitro models such as macromolecule free fraction of serum and serum. In the presence of both Fe2+ and H2O2, %HMW was higher in extracellular saline compared to macromolecule free fraction of serum. Further, in vitro models having the combined presence of Fe2+ and H2O2 resulted in enhanced aggregation of mAb compared to models that had neither.
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Affiliation(s)
- Shravan Sreenivasan
- Department of Chemical Engineering, Indian Institute of Technology Delhi, New Delhi 110016, India
| | - Anurag S Rathore
- Department of Chemical Engineering, Indian Institute of Technology Delhi, New Delhi 110016, India
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8
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Blumberg N, Heal JM. How do we forecast tomorrow's transfusion? - Next generation transfusion practices to improve recipient safety. Transfus Clin Biol 2023; 30:31-34. [PMID: 36096445 DOI: 10.1016/j.tracli.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Recipient safety measures play a key role in overall transfusion efficacy. The key advances in safety over the first century of transfusion medicine have been the development of techniques to prevent hemolytic transfusion reactions, hemolytic disease of the newborn and transmission of viral pathogens. While these risks remain important, they affect many fewer patients than previously. We propose that some of the most important current safety issues relate to toxicities broadly encompassed by the immunomodulatory effects of allogeneic transfusion. These include (1) universal leukoreduction to mitigate nosocomial infections, inflammation and organ injury, (2) removal of stored supernatant and its attendant toxic contents that cause dysfunctional immunity and organ injury, (3) avoiding infusing ABO incompatible antigen and antibody that can lead to bleeding, platelet refractoriness and inflammation, (3) minimizing prophylactic transfusions (particularly of plasma and platelets) except where benefit is proven, and (4) avoiding use of normal saline which is linked to renal failure and possibly hemolysis. Accompanying these safety measures will be the continued growth of one of the most important safety measures, patient blood management, which has as one benefit the avoidance of unnecessary and harmful transfusions. Reducing the toxicity of transfusions will enhance the improved clinical outcomes seen with patient blood management.
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Affiliation(s)
- Neil Blumberg
- Transfusion Medicine, Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Box 608, 601 Elmwood Avenue, Rochester, NY 14642, USA
| | - Joanna Mary Heal
- Transfusion Medicine, Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Box 608, 601 Elmwood Avenue, Rochester, NY 14642, USA
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9
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How do we forecast tomorrow's transfusion? Prehospital transfusion. Transfus Clin Biol 2023; 30:39-42. [PMID: 35914700 PMCID: PMC9371791 DOI: 10.1016/j.tracli.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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10
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Holloway MR, Fountaine T, Henrichs K, Feeney T, Andolina J, O'Dwyer K, Liesveld J, Blumberg N, Huselton E. Association of crystalloid fluid infusion with intravascular hemolysis and organ dysfunction in hematopoietic stem cell transplant patients. Transfus Apher Sci 2023:103641. [PMID: 36653255 DOI: 10.1016/j.transci.2023.103641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 12/11/2022] [Accepted: 01/12/2023] [Indexed: 01/14/2023]
Abstract
Endothelial cell activation and injury is common after hematopoietic stem cell transplant (HSCT) and is associated with many post-transplant complications. An underexplored mechanism of endothelial cell damage in this population is the infusion of normal saline (NS, 0.9 % sodium chloride) and other crystalloids, as NS use is associated with adverse outcomes in other patient populations. We hypothesized that the infusion of unbalanced crystalloids during HSCT may lead to changes in biomarkers commonly associated with red blood cell (RBC) hemolysis in patients before and after infusion, and that markers of endothelial and end-organ damage during admission may be associated with markers of hemolysis and total crystalloid use. Samples were collected from 97 patients. From pre-fluid infusion to post-fluid infusion, mean haptoglobin decreased (11.7 ug/ml vs 8.4 ug/ml; p < 0.0001), hemopexin decreased (549 vs 512 μg/ml; p = 0.005), and red cell distribution width (RDW) decreased (15.7 vs 15.6; p = 0.0009). During admission (mean 19.4 days, SD 9.9), all markers of tissue and organ damage, including mean creatinine, lactate dehydrogenase (LDH), blood urea nitrogen (BUN), total bilirubin, AST, and ALT, increased from admission to peak levels (p < 0.0001). On linear regression, fluid volume (ml/kg) of crystalloid infusion positively predicted post-fluid infusion cell-free hemoglobin (r(96) = 0.34, p < 0.0001), free heme (r(96) = 0.36, p < 0.0001), and peak LDH during admission (r(75) = 0.23, p = 0.041), and negatively predicted post-fluid infusion hemopexin (r(96) = - 0.34, p < 0.0001). Unbalanced crystalloids may contribute to hemolysis and endothelial damage in HSCT patients. Alternatives such as buffered crystalloid solutions (PlasmaLyte, Lactated Ringer's) may be worth investigating in this population.
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Affiliation(s)
- Melissa R Holloway
- University of Rochester School of Medicine & Dentistry, 601 Elmwood Ave., PO Box 255, Rochester, NY 14642, USA.
| | - Thomas Fountaine
- Department of Medicine, Division of Hematology-Oncology, University of Rochester Medical Center, James P. Wilmot Cancer Center, 90 Crittenden Blvd., Rochester, NY 14642, USA; Tmunity Therapeutics Inc., 3020 Market Street, Suite 535, Philadelphia, PA 19104, USA.
| | - Kelly Henrichs
- Department of Pathology and Laboratory Medicine (Transfusion Medicine), University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY 14642, USA.
| | - Tate Feeney
- Department of Medicine, Division of Hematology-Oncology, University of Rochester Medical Center, James P. Wilmot Cancer Center, 90 Crittenden Blvd., Rochester, NY 14642, USA.
| | - Jeffrey Andolina
- Department of Medicine, Division of Hematology-Oncology, University of Rochester Medical Center, James P. Wilmot Cancer Center, 90 Crittenden Blvd., Rochester, NY 14642, USA.
| | - Kristen O'Dwyer
- Department of Medicine, Division of Hematology-Oncology, University of Rochester Medical Center, James P. Wilmot Cancer Center, 90 Crittenden Blvd., Rochester, NY 14642, USA.
| | - Jane Liesveld
- Department of Medicine, Division of Hematology-Oncology, University of Rochester Medical Center, James P. Wilmot Cancer Center, 90 Crittenden Blvd., Rochester, NY 14642, USA.
| | - Neil Blumberg
- Department of Pathology and Laboratory Medicine (Transfusion Medicine), University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY 14642, USA.
| | - Eric Huselton
- Department of Medicine, Division of Hematology-Oncology, University of Rochester Medical Center, James P. Wilmot Cancer Center, 90 Crittenden Blvd., Rochester, NY 14642, USA.
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11
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Eiby YA, Wright IMR, Stark MJ, Lingwood BE. Red cell infusion but not saline is effective for volume expansion in preterm piglets. Pediatr Res 2022:10.1038/s41390-022-02403-2. [PMID: 36509847 DOI: 10.1038/s41390-022-02403-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/10/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND A common first-line treatment for supporting cardiovascular function in preterm infants is volume expansion using saline, but this does not improve outcomes. This study aimed to determine if volume expansion with saline increases blood volume, blood pressure and cerebral oxygenation; and if volume expansion with packed red blood cells (RBC) is more effective. We hypothesized that RBC infusion is more effective than saline for increasing blood volume and maintaining cardiovascular function and cerebral oxygenation. METHODS Five groups of preterm piglets (98/115d gestation) were infused with saline (10 or 20 mL/kg) or RBC (10 or 20 mL/kg) or no treatment. Blood volume, blood pressure, central venous pressure, heart rate, carotid flow, cerebral oxygenation, arterial pH, base excess, and lactate levels were assessed for 6 h after treatment started. RESULTS Both RBC groups had significant increases in blood volume, and improved measures of cardiovascular function, cerebral oxygenation and metabolic acidosis. Saline infusion did not increase blood volume or measures of cardiovascular function, cerebral oxygenation or metabolic acidosis. CONCLUSIONS The results suggest that the deteriorating cardiovascular function in the hours after birth in preterm piglets, and possibly in premature babies, may be reversed or halted by more effective support of blood volume. IMPACT Blood volume decreases after birth in preterm piglets and this decrease is associated with deteriorating cardiovascular function and cerebral oxygenation. Infusion of saline does not increase blood volume nor prevent deterioration in cardiovascular function. Infusion of packed red blood cells results in an increase in blood volume and improvements in cardiovascular function and cerebral oxygenation. Deteriorating cardiovascular function in the hours after birth in preterm piglets, and possibly in human preterm neonates, may be reversed or halted by more effective support of blood volume.
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Affiliation(s)
- Yvonne A Eiby
- Perinatal Research Centre and UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.
| | - Ian M R Wright
- Perinatal Research Centre and UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Australian Institute of Tropical Health and Medicine and The College of Medicine and Dentistry, James Cook University, Cairns, QLD, Australia
| | - Michael J Stark
- Department of Neonatal Medicine, Women's and Children's Hospital Adelaide, Adelaide, SA, Australia.,Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Barbara E Lingwood
- Perinatal Research Centre and UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Neonatology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
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12
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Nawrocki PS, Mulcahy B, Shukis M, Poremba M. Prehospital Use of Whole Blood for Ill and Injured Patients During Critical Care Transport. Air Med J 2022; 41:451-457. [PMID: 36153142 DOI: 10.1016/j.amj.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 05/06/2022] [Accepted: 05/15/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Hemodynamic instability and hemorrhagic shock are frequently encountered by emergency medical services providers managing ill and injured patients during critical care transport. Although many critical care transport services commonly transfuse crystalloids and/or packed red blood cells (PRBCs), the administration of whole blood (WB) in prehospital care is currently limited. WB contains PRBCs, plasma, and platelets in a physiologic ratio to aid in oxygen delivery to tissue as well as hemostasis. This study describes a single critical care transport program's experience using WB for critically ill and injured patients and reports important clinical and safety outcomes. METHODS This study was a retrospective review of patients who were transported by a single rotor wing-based critical care transport service to 1 of 2 tertiary care receiving hospitals within a single health system. Patients who were transported between November 1, 2018, and November 30, 2019, and who received at least 1 unit of low-titer group O WB during critical care transport were included. The primary outcomes of interest included 24-hour mortality and the total 24-hour transfusion requirement. The safety outcomes included transfusion reactions, acute lung injury, acute kidney injury, and the incidence of venous thromboembolism. RESULTS During the study period, there were 3,084 total patients transported by our critical care transport service. There were 71 patients who received prehospital WB, 64 of whom met the inclusion criteria. The top 3 indications for WB administration included blunt trauma (n = 27, 42.2%), gastrointestinal hemorrhage (n = 15, 23.4%), and penetrating trauma (n = 11, 17.2%). The median total number of blood components transfused within 24 hours was 4.0 (interquartile range, 2.0-9.5), and the overall 24-hour mortality rate was 21.9%. CONCLUSIONS The administration of WB by emergency medical services providers to critically ill and injured patients in the prehospital setting is feasible and is associated with low incidences of adverse events and transfusion reactions. Further research is needed to elucidate the benefits of WB relative to current prehospital standards of care.
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Affiliation(s)
- Philip S Nawrocki
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA.
| | - Brendan Mulcahy
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA
| | - Michael Shukis
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA
| | - Matthew Poremba
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA
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13
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Catahay JA, Polintan ET, Casimiro M, Notarte KI, Velasco JV, Ver AT, Pastrana A, Macaranas I, Patarroyo-Aponte G, Lo KB. Balanced electrolyte solutions versus isotonic saline in adult patients with diabetic ketoacidosis: A systematic review and meta-analysis. Heart Lung 2022; 54:74-79. [PMID: 35358905 DOI: 10.1016/j.hrtlng.2022.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Current guidelines suggest the use of isotonic saline (IS) infusion as the preferred resuscitation fluid in the management of diabetic ketoacidosis (DKA). However, balanced electrolyte solutions (BES) have been proposed as an alternative due to a lower propensity to cause hyperchloremic metabolic acidosis. Evidence regarding the use of BES in DKA remains limited. OBJECTIVES To determine if the use of BES in fluid resuscitation leads to faster resolution of DKA compared to IS. METHODS The study involves a comprehensive search of literature from PubMed, Cochrane CENTRAL, Google Scholar, and Science Direct of clinical trials addressing the use of BES vs IS in fluid resuscitation in DKA. The time to resolution of DKA was examined as the primary endpoint. Pooled hazard ratios (HR) and Mean Difference (MD) in hours with their 95% confidence intervals (CI) were calculated using a random-effects model. RESULTS The literature search included 464 studies that were screened individually. A total of 9 studies were identified but 6 studies were excluded due to irrelevance in the outcome of interest and target population. The pooled hazard ratio HR significantly revealed 1.46 [1.10 to 1.94] (p = 0.009) with 12% heterogeneity while MD was -3.02 (95% CI -6.78-0.74; p = 0.12) with heterogeneity of 85%. CONCLUSION Considering the evidence from pooled small randomized trials with moderate overall certainty of evidence, the use of BES in DKA was associated with faster rates of DKA resolution compared to IS.
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Affiliation(s)
| | | | - Michael Casimiro
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - Kin Israel Notarte
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | | | | | - Adriel Pastrana
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - Imee Macaranas
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - Gabriel Patarroyo-Aponte
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Kevin Bryan Lo
- Department of Medicine, Einstein Medical Center, Philadelphia, USA
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14
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In Vitro Biodegradation of a-C:H:SiO x Films on Ti-6Al-4V Alloy. MATERIALS 2022; 15:ma15124239. [PMID: 35744297 PMCID: PMC9231245 DOI: 10.3390/ma15124239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/01/2022] [Accepted: 06/11/2022] [Indexed: 11/17/2022]
Abstract
This paper focuses mainly on the in vitro study of a five-week biodegradation of a-C:H:SiOx films of different thickness, obtained by plasma-assisted chemical vapor deposition onto Ti-6Al-4V alloy substrate using its pulsed bipolar biasing. In vitro immersion of a-C:H:SiOx films in a solution of 0.9% NaCl was used. It is shown how the a-C:H:SiOx film thickness (0.5-3 µm) affects the surface morphology, adhesive strength, and Na+ and Cl- precipitation on the film surface from the NaCl solution. With increasing film thickness, the roughness indices are reducing a little. The adhesive strength of the a-C:H:SiOx films to metal substrate corresponds to quality HF1 (0.5 µm in thickness) and HF2-HF3 (1.5-3 µm in thickness) of the Rockwell hardness test (VDI 3198) that defines strong interfacial adhesion and is usually applied in practice. The morphometric analysis of the film surface shows that on a-C:H:SiOx-coated Ti-6Al-4V alloy surface, the area occupied by the grains of sodium chloride is lower than on the uncoated surface. The reduction in the ion precipitation from 0.9% NaCl onto the film surface depended on the elemental composition of the surface layer conditioned by the thickness growth of the a-C:H:SiOx film. Based on the results of energy dispersive X-ray spectroscopy, the multiple regression equations are suggested to explain the effect of the elemental composition of the a-C:H:SiOx film on the decreased Na+ and Cl- precipitation. As a result, the a-C:H:SiOx films successfully combine good adhesion strength and rare ion precipitation and thus are rather promising for medical applications on cardiovascular stents and/or friction parts of heart pumps.
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15
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Horcharoensuk P, Yang-en S, Narkwichean A, Rungsiwiwut R. Proline-based solution maintains cell viability and stemness of canine adipose-derived mesenchymal stem cells after hypothermic storage. PLoS One 2022; 17:e0264773. [PMID: 35231072 PMCID: PMC8887718 DOI: 10.1371/journal.pone.0264773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 02/17/2022] [Indexed: 11/18/2022] Open
Abstract
Transportation of mesenchymal stem cells (MSCs) under hypothermic conditions in 0.9% normal saline solution (NSS) might increase cell death and alter the stemness of MSCs. The present study aimed to evaluate the effect of proline-based solution (PL-BS) on cell viability and the stemness of newly established canine adipose-derived mesenchymal stem cells (cAD-MSCs) under hypothermic conditions. Characterized cAD-MSCs were stored in 1, 10, and 100 mM PL-BS or NSS at 4°C for 6, 9, and 12 hours prior to an evaluation. The results demonstrated that storage in 1 mM PL-BS for 6 hours decreased cell apoptosis and proliferation ability, but improved cell viability and mitochondrial membrane potential. cAD-MSCs maintained their high expression of CD44 and CD90, but had a low expression of CD34 and MHC class II. Trilineage differentiation ability of cAD-MSCs was not affected by storage in 1 mM PL-BS. Gene expression analysis demonstrated that immunomodulatory genes, including IDO, HGF, PGE-2, and IL-6, were upregulated in cAD-MSCs stored in 1 mM PL-BS. In conclusion, PL-BS can be effectively applied for storing cAD-MSCs under hypothermic conditions. These findings provide a new solution for effective handling of cAD-MSCs which might be promising for clinical applications.
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Affiliation(s)
| | - Sunantha Yang-en
- Department of Anatomy, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand
| | - Amarin Narkwichean
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Srinakharinwirot University, Nakhon Nayok, Thailand
| | - Ruttachuk Rungsiwiwut
- Department of Anatomy, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand
- * E-mail:
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16
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Zhu Y, Deng H, She H, Zhou Y, Wu Y, Zhang J, Liu L, Tao L. Protective Effect of Moderate Hypotonic Fluid on Organ Dysfunction via Alleviating Lethal Triad Following Seawater Immersion With Hemorrhagic Shock in Rats. Front Physiol 2022; 13:827838. [PMID: 35185622 PMCID: PMC8854799 DOI: 10.3389/fphys.2022.827838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/06/2022] [Indexed: 01/06/2023] Open
Abstract
Previous studies found that seawater immersion combined with hemorrhagic shock (SIHS) induced serious organ function disorder, and lethal triad was a critical sign. There were no effective treatments of SIHS. Fluid resuscitation was the initial measurement for early aid following hemorrhagic shock, while the proper fluid for SIHS is not clear. Effects of different osmotic pressures [lactated Ringer’s (LR) solution, 0.3% saline, 0.6% saline, and 0.9% normal saline] on the lethal triad, mitochondrial function, vital organ functions, and survival were observed following SIHS in rats. The results showed that SIHS led to an obvious lethal triad, which presented the decrease of the body temperature, acidosis, and coagulation functions disorder in rats. Fluid resuscitation with different osmotic pressures recovered the body temperature and corrected acidosis with different levels; effects of 0.6% normal saline were the best; especially for the coagulation function, 0.6% normal saline alleviated the lethal triad significantly. Further studies showed that SIHS resulted in the damage of the mitochondrial function of vital organs, the increase of the vascular permeability, and, at the same time, the organ function including cardiac, liver, and kidney was disordered. Conventional fluid such as LR or 0.9% normal saline could not improve the mitochondrial function and vascular leakage and alleviate the damage of the organ function. While moderate hypotonic fluid, the 0.6% normal saline, could lighten organ function damage via protecting mitochondrial function. The 0.6% normal saline increased the left ventricular fractional shortening and the left ventricular ejection fraction, and decreased the levels of aspartate transaminase, alanine transferase, blood urea nitrogen, and creatinine in the blood. The effects of fluids with different osmotic pressures on the mean arterial pressure (MAP) had a similar trend as above parameters. The survival results showed that the 0.6% normal saline group improved the survival rate and prolonged the survival time, the 72 h survival rate was 7/16, as compared with the LR group (3/16). The results indicate that appropriate hypotonic fluid is suitable after SIHS, which alleviates the lethal triad, protects the mitochondrial function and organ functions, and prolongs the survival time.
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17
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Nguyen TT, Kamyingkird K, Phimpraphai W, Inpankaew T. Viability of Toxoplasma gondii tachyzoites in different conditions for parasite transportation. Vet World 2022; 15:198-204. [PMID: 35369589 PMCID: PMC8924386 DOI: 10.14202/vetworld.2022.198-204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 12/31/2021] [Indexed: 11/20/2022] Open
Abstract
Background and Aim: Toxoplasma gondii tachyzoite is the infective stage that causes acute infection, leading to severe toxoplasmosis. The tachyzoite stage has been extensively used for several inoculation purposes, including antigen production, immunological studies, nutrition mechanisms, and in vitro drug trials. The use of fresh tachyzoites is required for inoculation in either in vitro or in vivo studies. However, there is a lack of information on preserving live tachyzoites during transportation from laboratories to inoculation sites. Therefore, this study aimed to validate suitable preservative conditions for maintaining live parasites by determining the survival and viability of T. gondii tachyzoites on the basis of different media, temperatures, and incubation times. Materials and Methods: The free live T. gondii tachyzoites were evaluated on their viability when maintained in different media without 5% Carbon dioxide (CO2). The purified tachyzoites of the RH and PLK strains were individually suspended in normal saline (NS), phosphate-buffered saline (PBS), minimum essential medium (MEM), and MEM with 10% fetal bovine serum (MEM-FBS) and incubated for 6 h at ice-cold (IC; 3-9°C) and room temperature (RT; 25°C). Parasite survival was measured at the 0, 1st, 2nd, 3rd, 4th, 5th, and 6th h post-incubation using the trypan blue exclusion test. Results: The viability was in the range of 85.0%–91.0% for IC using NS and 81.0%–85.1% (IC) and 75.3%–77.5% (RT) using PBS. The viability was approximately 75.0%–83.0% (IC) and 70.0%–79.0% (RT) using MEM and MEM-FBS. There was a significant difference in the viability between the seven periods on the basis of one-way repeated Analysis of variance and Friedman analyses. Parasite survival slightly reduced (20.0%–30.0%) in NS and MEM-FBS at both temperatures during incubation. Notably, PBS could not support tachyzoite viability after 3 h post-incubation. Conclusion: NS was a suitable preservative for maintaining purified T. gondii tachyzoites during transportation at IC and RT without 5% CO2 supplementation. This could be a valuable medium for parasite transportation, especially when there is a large distance between the laboratory and inoculation site.
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Affiliation(s)
- Thi Thuy Nguyen
- Department of Parasitology, Faculty of Veterinary Medicine, Kasetsart University, Bangkok 10900, Thailand; Department of Veterinary Medicine, Faculty of Animal Science and Veterinary Medicine, University of Agriculture and Forestry, Hue University, Hue, Vietnam
| | - Ketsarin Kamyingkird
- Department of Parasitology, Faculty of Veterinary Medicine, Kasetsart University, Bangkok 10900, Thailand
| | - Waraphon Phimpraphai
- Department of Veterinary Public Health, Faculty of Veterinary Medicine, Kasetsart University, Bangkok 10900, Thailand
| | - Tawin Inpankaew
- Department of Parasitology, Faculty of Veterinary Medicine, Kasetsart University, Bangkok 10900, Thailand
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18
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Jackson BP, Sperry JL, Yazer MH. Prehospital Plasma Transfusion: What Does the Literature Show? Transfus Med Hemother 2022; 48:358-365. [PMID: 35082567 DOI: 10.1159/000519627] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/08/2021] [Indexed: 11/19/2022] Open
Abstract
Background Early initiation of blood products transfusion after injury has been associated with improved patient outcomes following traumatic injury. The ability to transfuse patients' plasma in the prehospital setting provides a prime opportunity to begin resuscitation with blood products earlier and with a more balanced plasma: RBC ratio than what has traditionally been done. Published studies on the use of prehospital plasma show a complex relationship between its use and improved survival. Summary Examination of the literature shows that there may be a mortality benefit from the use of prehospital plasma, but that it may be limited to certain subgroups of trauma patients. The likelihood of realizing these survival benefits appears to be predicted by several factors including the type of injury, length of transport time, presence of traumatic brain injury, and total number of blood products transfused, whether the patient required only a few products or a massive transfusion. When taken as a whole the evidence appears to show that prehospital plasma may have a mortality benefit that is most clearly demonstrated in patients with blunt injuries, moderate transfusion requirements, traumatic brain injury, and/or transport time greater than 20 min, as well as those who demonstrate a certain cytokine expression profile. Key Messages The evidence suggests that a targeted use of prehospital plasma will most likely maximize the benefits from the use of this limited resource. It is also possible that prehospital plasma may best be provided through whole blood as survival benefits were greatest in patients who received both prehospital plasma and RBCs.
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Affiliation(s)
- Bryon P Jackson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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19
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Son M, Lee YS, Lee MJ, Park Y, Bae HR, Lee SY, Shin MG, Yang S. Effects of osmolality and solutes on the morphology of red blood cells according to three-dimensional refractive index tomography. PLoS One 2021; 16:e0262106. [PMID: 34972199 PMCID: PMC8719701 DOI: 10.1371/journal.pone.0262106] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 12/16/2021] [Indexed: 11/18/2022] Open
Abstract
Phosphate-buffered saline (PBS) and Alsever's solution (AS) are frequently used as media in blood-related studies, while 0.9% normal saline (NS) is frequently used in transfusion medicine. Despite the frequent use, the effects of these solutions on the shape and volume of red blood cells (RBCs) have not been reported. We collected blood samples from five healthy adults and used three-dimensional refractive index tomography to investigate the changes in the morphology of RBCs caused by changes in osmolality and solutes at the single-cell level. After diluting 2 μL of RBCs 200-fold with each solution (PBS, AS, and 0.9% NS), 40 randomly selected RBCs were microscopically observed. RBC shape was measured considering sphericity, which is a dimensionless quantity ranging from 0 (flat) to 1 (spherical). RBCs in plasma or AS showed a biconcave shape with a small sphericity, whereas those in 0.9% NS or PBS showed a spherical shape with a large sphericity. Moreover, we confirmed that sodium chloride alone could not elicit the biconcave shape of RBCs, which could be maintained only in the presence of an osmotic pressure-maintaining substance, such as glucose or mannitol. Although 0.9% NS solution is one of the most commonly used fluids in hematology and transfusion medicine, RBCs in 0.9% NS or PBS are not biconcave. Therefore, as the debate on the use of NS continues, future clinical studies or applications should consider the effect of glucose or mannitol on the shape of RBCs.
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Affiliation(s)
- Minkook Son
- Department of Biomedical Science and Engineering, Gwangju Institute of Science and Technology, Gwangju, Republic of Korea
| | - Ye Sung Lee
- School of Mechanical Engineering, Gwangju Institute of Science and Technology, Gwangju, Republic of Korea
| | - Mahn Jae Lee
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - YongKeun Park
- Department of Physics, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Hae-Rahn Bae
- Department of Physiology, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Seung Yeob Lee
- Department of Laboratory Medicine, Jeonbuk National University Medical School and Hospital, Jeonju, Republic of Korea
| | - Myung-Geun Shin
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hwasun Hospital, Hwasun, Republic of Korea
| | - Sung Yang
- Department of Biomedical Science and Engineering, Gwangju Institute of Science and Technology, Gwangju, Republic of Korea
- School of Mechanical Engineering, Gwangju Institute of Science and Technology, Gwangju, Republic of Korea
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20
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Huber JL, Berger S, Löllgen RM. Balanced Electrolyte Solutions or Normal Saline? Resuscitative Fluid Administration Practice in Swiss Pediatric Acute Care: A Cross-Sectional Study. Pediatr Emerg Care 2021; 37:e812-e816. [PMID: 31045958 DOI: 10.1097/pec.0000000000001813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The ideal asanguineous intravenous fluid for volume resuscitation in children is controversially debated and clinical practice guidelines are scarce. Administration of large amounts of normal saline has been associated with complications including hyperchloremic acidosis, dysnatremia, neurologic damage, and fatality. AIM We examined the current practice of intravenous fluid and blood product administration in acutely ill and injured children among pediatric acute care physicians in Switzerland. METHODS For this descriptive, cross-sectional study, pediatric emergency departments, pediatric and neonatal intensive care units were surveyed by means of an online questionnaire. RESULTS Sixty of 66 departments and 47 of 87 participants returned the survey. Normal saline (NS) was most commonly administered (n = 42/46, 91.3%) and twice as many times as balanced electrolyte solutions (n = 20/46, 43.5%). The mean fluid volumes ranged from 7.9 to 19.1 mL/kg. Hypertonic saline/NS were selected most often for shock with severe head injury. Half of participants administered colloids (48.9%). Packed red blood cells (97.7%) and fresh frozen plasma (88.4%) were most frequently given blood products. CONCLUSION There is a distinct practice variation in intravenous fluid and blood product administration in children in Switzerland. Although NS is most frequently given, we observed a trend toward the use of balanced electrolyte solutions. Prospective studies are warranted to compare NS with balanced electrolyte solution (BES) in the pediatric acute care setting. We suggest that pediatric fluid administration guidelines and mass transfusion protocols are implemented to standardize this frequent intervention and minimize complications.
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Affiliation(s)
| | | | - Ruth M Löllgen
- Pediatric Emergency Department, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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21
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Spiegel MC, Simpson AN, Philip A, Bell CM, Nadig NR, Ford DW, Goodwin AJ. Development and implementation of a clinical decision support-based initiative to drive intravenous fluid prescribing. Int J Med Inform 2021; 156:104619. [PMID: 34673308 DOI: 10.1016/j.ijmedinf.2021.104619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/01/2021] [Accepted: 10/09/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Studies suggest superior outcomes with use of intravenous (IV) balanced fluids compared to normal saline (NS). However, significant fluid prescribing variability persists, highlighting the knowledge-to-practice gap. We sought to identify contributors to prescribing variation and utilize a clinical decision support system (CDSS) to increase institutional balanced fluid prescribing. MATERIALS AND METHODS This single-center informatics-enabled quality improvement initiative for patients hospitalized or treated in the emergency department included stepwise interventions of 1) identification of design factors within the computerized provider order entry (CPOE) of our electronic health record (EHR) that contribute to preferential NS ordering, 2) clinician education, 3) fluid stocking modifications, 4) re-design and implementation of a CDSS-integrated IV fluid ordering panel, and 5) comparison of fluid prescribing before and after the intervention. EHR-derived prescribing data was analyzed via single interrupted time series. RESULTS Pre-intervention (3/2019-9/2019), balanced fluids comprised 33% of isotonic fluid orders, with gradual uptake (1.4%/month) of balanced fluid prescribing. Clinician education (10/2019-2/2020) yielded a modest (4.4%/month, 95% CI 1.6-7.2, p = 0.01) proportional increase in balanced fluid prescribing, while CPOE redesign (3/2020) yielded an immediate (20.7%, 95% CI 17.7-23.6, p < 0.0001) and sustained increase (72% of fluid orders in 12/2020). The intervention proved most effective among those with lower baseline balanced fluids utilization, including emergency medicine (57% increase, 95% CI 0.7-1.8, p < 0.0001) and internal medicine/subspecialties (18% increase, 95% CI 14.4-21.3, p < 0.0001) clinicians and substantially reduced institutional prescribing variation. CONCLUSION Integration of CDSS into an EHR yielded a robust and sustained increase in balanced fluid prescribing. This impact far exceeded that of clinician education highlighting the importance of CDSS.
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Affiliation(s)
- Michelle C Spiegel
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States.
| | - Annie N Simpson
- Department of Health Care Leadership and Management, Medical University of South Carolina, Charleston, SC, United States
| | - Achsah Philip
- Department of Information Solutions, Medical University of South Carolina, Charleston, SC, United States
| | - Carolyn M Bell
- Department of Pharmacy, Medical University of South Carolina, Charleston, SC, United States
| | - Nandita R Nadig
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Dee W Ford
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Andrew J Goodwin
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
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22
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Yazer MH, Gorospe J, Cap AP. Mixed feelings about mixed-field agglutination: A pathway for managing females of childbearing potential of unknown RhD-type who are transfused RhD-positive and RhD-negative red blood cells during emergency hemorrhage resuscitation. Transfusion 2021; 61 Suppl 1:S326-S332. [PMID: 34269449 DOI: 10.1111/trf.16459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/12/2021] [Accepted: 01/17/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jose Gorospe
- San Antonio Military Medical Center, JBSA-FT Sam Houston, San Antonio, Texas, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, JBSA-FT Sam Houston, San Antonio, Texas, USA.,Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
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23
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N M, Lukose J, Mohan G, Shastry S, Chidangil S. Single cell spectroscopy of red blood cells in intravenous crystalloid fluids. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2021; 257:119726. [PMID: 33848954 DOI: 10.1016/j.saa.2021.119726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/06/2021] [Accepted: 03/15/2021] [Indexed: 06/12/2023]
Abstract
Crystalloid fluids, a subset of intravenous (IV) fluid solutions are commonly used in clinical settings. The influence of these fluids on the functions of blood components are least explored. Raman spectroscopy combined with optical trapping has been widely used to evaluate the impact of external stress agents on red blood cells. The present study investigates the impact of commonly used crystalloid fluids on red blood cells in comparison with that of blood plasma using Raman Tweezers spectroscopy. The red blood cells suspended in crystalloid fluids undergo deoxygenation readily than that in blood plasma. In addition, cells in blood plasma were able to withstand laser induced deoxygenation comparatively better than that in crystalloid fluids at higher laser powers. Principle component analysis of the Raman spectral data has clearly demonstrated the discrimination of cells in plasma with that of crystalloid fluids demonstrating the effect of external induced stress on RBCs.
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Affiliation(s)
- Mithun N
- Centre of Excellence for Biophotonics, Department of Atomic and Molecular Physics, Manipal Academy of Higher Education, Manipal, Karnataka 576104, India
| | - Jijo Lukose
- Centre of Excellence for Biophotonics, Department of Atomic and Molecular Physics, Manipal Academy of Higher Education, Manipal, Karnataka 576104, India
| | - Ganesh Mohan
- Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Karnataka 576104, India
| | - Shamee Shastry
- Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Karnataka 576104, India
| | - Santhosh Chidangil
- Centre of Excellence for Biophotonics, Department of Atomic and Molecular Physics, Manipal Academy of Higher Education, Manipal, Karnataka 576104, India.
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Erstad BL. Normal saline or balanced salt solutions for fluid administration with a focus on critical care and emergency medicine settings. Am J Health Syst Pharm 2021; 79:199-203. [PMID: 34351364 DOI: 10.1093/ajhp/zxab319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
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Woodley WD, Morel DR, Sutter DE, Pettis RJ, Bolick NG. Clinical Evaluation of Large Volume Subcutaneous Injection Tissue Effects, Pain, and Acceptability in Healthy Adults. Clin Transl Sci 2021; 15:92-104. [PMID: 34268888 PMCID: PMC8742644 DOI: 10.1111/cts.13109] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 11/30/2022] Open
Abstract
Determining feasibility and tolerability of large volume viscous subcutaneous injection may enable optimized, intuitive delivery system design. A translational early feasibility clinical study examined large volume subcutaneous injection viability, tolerability, acceptability, tissue effects and depot location for ~1, 8, and 20 cP injections at volumes up to 10 ml in the abdomen and 5 ml in the thigh in 32 healthy adult subjects. A commercial syringe pump system delivered 192 randomized, constant rate (20 µl/s) injections (6/subject) with in‐line injection pressure captured versus time. Deposition location was qualified via ultrasound. Tissue effects and pain tolerability were monitored through 2 hours post‐injection with corresponding Likert acceptability questionnaires administered through 72 hours. All injection conditions were feasible and well‐tolerated with ≥79.3% favorable subject responses for injection site appearance and sensation immediately post‐injection, increasing to ≥96.8% at 24 hours. Mean subject pain measured via 100 mm visual analog scale increased at needle insertion (6.9 mm, SD 10.8), peaked during injection (26.9 mm, SD 21.7) and diminished within 10 minutes post‐removal (1.9 mm, SD 4.2). Immediate injection site wheal (90.9%) and erythema (92.6%) formation was observed with progressive although incomplete resolution through 2 hours (44.6% and 11.4% remaining, respectively). Wheal resolution occurred more rapidly at lower viscosities. Most subjects (64.5%) had no preference between abdomen and thigh. Correlations between tissue effects, injection pressure and pain were weak (Pearson’s rho ± 0–0.4). The large volume injections tested, 1–20 cP viscosities up to 10 ml in the abdomen and 5 ml in the thigh, are feasible with good subject acceptability and rapid resolution of tissue effects and pain.
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Affiliation(s)
- Wendy D Woodley
- BD Technologies & Innovation, Research Triangle Park, NC, USA
| | - Didier R Morel
- BD Medical- Pharmaceutical Systems, Le Pont de Claix, France
| | - Diane E Sutter
- BD Technologies & Innovation, Research Triangle Park, NC, USA
| | - Ronald J Pettis
- BD Technologies & Innovation, Research Triangle Park, NC, USA
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26
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Barlow A, Barlow B, Tang N, Shah BM, King AE. Intravenous Fluid Management in Critically Ill Adults: A Review. Crit Care Nurse 2020; 40:e17-e27. [PMID: 33257968 DOI: 10.4037/ccn2020337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
TOPIC This article reviews the management of intravenous fluids and the evaluation of volume status in critically ill adults. CLINICAL RELEVANCE Intravenous fluid administration is one of the most common interventions in the intensive care unit. Critically ill patients have dynamic fluid requirements, making the management of fluid therapy challenging. New literature suggests that balanced salt solutions may be preferred in some patient populations. PURPOSE OF PAPER The bedside critical care nurse must understand the properties of various intravenous fluids and their corresponding impact on human physiology. The nurse's clinical and laboratory assessments of each patient help define the goals of fluid therapy, which will in turn be used to determine the optimal patient-specific selection and dose of fluid for administration. Nurses serve a vital role in monitoring the safety and efficacy of intravenous fluid therapy. Although this intervention can be lifesaving, inappropriate use of fluids has the potential to yield detrimental effects. CONTENT COVERED This article discusses fluid physiology and the goals of intravenous fluid therapy, compares the types of intravenous fluids (isotonic crystalloids, including 0.9% sodium chloride and balanced salt solutions; hypotonic and hypertonic crystalloids; and colloids) and their adverse effects and impact on hemodynamics, and describes the critical care nurse's essential role in selecting and monitoring intravenous fluid therapy.
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Affiliation(s)
- Ashley Barlow
- Ashley Barlow is an oncology pharmacy resident, Department of Pharmacy Services, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brooke Barlow
- Brooke Barlow is a critical care pharmacy resident at the University of Kentucky HealthCare, Lexington, Kentucky
| | - Nancy Tang
- Nancy Tang is a clinical pharmacist at MedStar Washington Hospital Center, Washington, DC
| | | | - Amber E King
- Bhavik M. Shah and Amber E. King are associate professors at Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, Pennsylvania
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Mosieri C, Chandler D, Reed DS, Craig MK, Hyatali F, Kallurkar A, Cornett EM, Urman RD, Kaye AD. Managing preoperative anemia: Evolving concepts and strategies for improving patient outcomes. Best Pract Res Clin Anaesthesiol 2020; 34:183-197. [PMID: 32711828 DOI: 10.1016/j.bpa.2020.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/07/2020] [Indexed: 01/28/2023]
Abstract
Anemia is the most common hematological disease, and is defined by the World Health Organization as a condition in which the number of red blood cells and consequently oxygen-carrying capacity is insufficient to meet the physiological needs of the body. Anemia can occur throughout the perioperative period and has important clinical consequences. Preoperative anemia is usually regarded as no more than a surrogate marker of a patient's physical status, and it is not always adequately addressed before surgery. Postoperative anemia is a common event and occurs in 80-90% of patients who have undergone major surgery. This manuscript discusses the detection and management of preoperative anemia, the three pillars of patient blood management, perioperative anemia management, and risk stratification for anemia in the surgical setting.
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Affiliation(s)
- Chizoba Mosieri
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Debbie Chandler
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Devin S Reed
- Department of Anesthesiology, LSU Health Science Center New Orleans, 1542 Tulane Avenue, New Orleans, LA, 70112, USA.
| | - Madelyn K Craig
- Department of Anesthesiology, LSU Health Science Center New Orleans, 1542 Tulane Avenue, New Orleans, LA, 70112, USA.
| | - Farees Hyatali
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Anusha Kallurkar
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA; Provost, Chief Academic Officer, and Vice Chancellor of Academic Affairs, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
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28
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Hemodynamic Changes in the Carotid Artery after Infusion of Normal Saline Using Computational Fluid Dynamics. Diagnostics (Basel) 2020; 10:diagnostics10070473. [PMID: 32664658 PMCID: PMC7400695 DOI: 10.3390/diagnostics10070473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/26/2020] [Accepted: 07/09/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose: To study the effect of the infusion of normal saline on hemodynamic changes in healthy volunteers using computational fluid dynamics (CFD) simulation. Methods: Eight healthy subjects participated and 16 carotid arteries were used for the CFD analysis. A one-liter intravenous infusion of normal saline was applied to the participants to observe the hemodynamic variations. Blood viscosity was measured before and after the injection of normal saline to apply the blood properties on the CFD modeling. Blood viscosity, shear rate, and wall shear stress were visually and quantitatively shown for the comparison between before and after the infusion of normal saline. Statistical analyses were performed to confirm the difference between the before and after groups. Results: After the infusion of normal saline, decreased blood viscosity was observed in the whole carotid artery. At the internal carotid artery, the recirculation zone with low intensity was found after the injection of normal saline. Increased shear rate and reduced wall shear stress was observed at the carotid bifurcation and internal carotid artery. The hemodynamic differences between before and after groups were statistically significant. Conclusions: The infusion of normal saline affected not only the overall changes of blood flow in the carotid artery but also the decrease of blood viscosity.
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29
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Lanza F, Seghatchian J. Reflection on passive immunotherapy in those who need most: some novel strategic arguments for obtaining safer therapeutic plasma or autologous antibodies from recovered COVID-19 infected patients. Br J Haematol 2020; 190:e27-e29. [PMID: 32407543 PMCID: PMC7272917 DOI: 10.1111/bjh.16814] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 12/28/2022]
Affiliation(s)
- Francesco Lanza
- Hematology Unit, Romagna Transplant Network, Ravenna Hospital & University of Ferrara-I, London, UK
| | - Jerard Seghatchian
- International Consultancy in Strategic Advices on Safety Improvements of Blood-Derived Bioproducts and Suppliers Quality Audit/Inspection, London, UK
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Seghatchian J, Lanza F. Convalescent plasma, an apheresis research project targeting and motivating the fully recovered COVID 19 patients: A rousing message of clinical benefit to both donors and recipients alike. Transfus Apher Sci 2020; 59:102794. [PMID: 32448638 PMCID: PMC7177094 DOI: 10.1016/j.transci.2020.102794] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- J Seghatchian
- International Consultancy in Strategic Advice on Safety Improvements of Blood-Derived Bioproducts and Suppliers Quality Audit / Inspection, London, UK.
| | - F Lanza
- Romagna Transplant Network, Hematology Unit, Ravenna-I, Italy
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Abstract
The important scientific and clinical advances of the last century in transfusion medicine include methods for avoiding hemolytic transfusion reactions and preventing transmission of viral infectious diseases. The next great clinical advances will require improving the efficacy and safety of transfusions, as well as acknowledgement of the now proven serious complications of transfusion, including nosocomial infection, thrombosis, inflammation and multi-organ failure. Possible strategies include (1) universal leukoreduction to mitigate transfusion immunomodulation effects and improve storage conditions, (2) minimizing transfusion of ABO incompatible antibodies and cellular/soluble antigens, (3) substituting use of safer solutions for normal saline during apheresis, component infusion and washing (4) new techniques to improve the efficacy and safety of blood components, including improved storage solutions/conditions, supernatant removal by washing, and rejuvenation and (5) maximizing the risk to benefit ratio of transfusions by employing more restrictive and physiologic indications for transfusion (including patient blood management) and improving clinical decision making through novel laboratory and bedside tests such as thromboelastography.
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32
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Seheult JN, Bahr MP, Spinella PC, Triulzi DJ, Yazer MH. The Dead Sea needs salt water… massively bleeding patients need whole blood: The evolution of blood product resuscitation. Transfus Clin Biol 2019; 26:174-179. [PMID: 31262629 DOI: 10.1016/j.tracli.2019.06.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 06/09/2019] [Indexed: 01/30/2023]
Abstract
Whole blood, that is blood that is not manufactured into its component red blood cells (RBC) plasma, and platelets (PLT) units, was the mainstay of transfusion for many years until it was discovered that the component parts of a blood donation could be stored under different conditions thereby optimizing the storage length of each product. The use of low anti-A and -B titer group O whole blood (LTOWB) has recently been rediscovered for use in massively bleeding trauma patients. Whole blood has several advantages over conventional component therapy for these patients, including simplifying the logistics of the resuscitation, being more concentrated than whole blood that is reconstituted from conventional components, and providing cold-stored PLTs, amongst other benefits. While randomized controlled trials to determine the efficacy of using LTOWB in the resuscitation of massively bleeding trauma patients are currently underway, retrospective data has shown that massively bleeding recipients of LTOWB with traumatic injury do not have worse outcomes compared to patients who received conventional components and, in some cases, recipients of LTOWB have more favourable outcomes. This paper will describe some of the advantages of using LTOWB and will discuss the emerging evidence for its use in massively bleeding patients.
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Affiliation(s)
- J N Seheult
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA.
| | - M P Bahr
- Vitalant, 3636 Boulevard of the Allies, Pittsburgh, PA 15213, USA.
| | - P C Spinella
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St Louis, 660 S Euclid Avenue # 8124, Saint Louis, MO 63110, USA.
| | - D J Triulzi
- Vitalant, 3636 Boulevard of the Allies, Pittsburgh, PA 15213, USA; Department of Pathology, University of Pittsburgh, Pittsburgh, PA 15269, USA.
| | - M H Yazer
- Vitalant, 3636 Boulevard of the Allies, Pittsburgh, PA 15213, USA; Department of Pathology, University of Pittsburgh, Pittsburgh, PA 15269, USA.
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33
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Blumberg N, Henrichs K, Cholette J, Pietropaoli A, Spinelli S, Noronha S, Phipps R, Refaai MA. Sickle red blood cells are more susceptible to in vitro haemolysis when exposed to normal saline versus Plasma-Lyte A. Vox Sang 2019; 114:325-329. [PMID: 30937917 DOI: 10.1111/vox.12777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/07/2019] [Accepted: 03/11/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Normal saline has been the fluid of choice for resuscitation, rehydration and fluid replacement during plasma or red cell exchange/cytapheresis. There are increased concerns about its clinical effects and data showing it causes more haemolysis in vitro than buffered solutions such as Plasma-Lyte A. METHODS We investigated whether normal saline or Plasma-Lyte A was associated with greater haemolysis during hours of in vitro incubation with both normal red cells and samples from patients with sickle cell anaemia. RESULTS Sickle red cells haemolysed more than normal red cells did in both crystalloid solutions. The results of 24-hour exposure to saline were particularly striking (median of 163 mg/dl (IQ range 105-247) for sickle red cells vs. 53 (48-92) for normal red cells (P < 0·0001). In patient samples containing variable quantities of haemoglobin S red cells, increased haemoglobin S was associated with increased haemolysis. This effect was greater for normal saline than Plasma-Lyte A (P = 0·12). CONCLUSIONS These in vitro models demonstrate that short-term ex vivo exposure of sickle red cells to normal saline leads to greater haemolysis than short-term exposure of normal red cells, and this effect is exacerbated by normal saline. Whether use of normal saline causes increased haemolysis in vivo is unknown. Given recent evidence that normal saline increases renal failure and mortality in critically ill patients, further studies are urgently needed.
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Affiliation(s)
- Neil Blumberg
- Department of Pathology and Laboratory Medicine (Transfusion Medicine), University of Rochester Medical Center, Rochester, NY, USA
| | - Kelly Henrichs
- Department of Pathology and Laboratory Medicine (Transfusion Medicine), University of Rochester Medical Center, Rochester, NY, USA
| | - Jill Cholette
- Department of Pediatrics, Critical Care and Cardiology, University of Rochester Medical Center, Rochester, NY, USA
| | - Anthony Pietropaoli
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Sherry Spinelli
- Department of Pathology and Laboratory Medicine (Transfusion Medicine), University of Rochester Medical Center, Rochester, NY, USA
| | - Suzie Noronha
- Department of Pediatrics, Hematology-Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Richard Phipps
- Department of Pathology and Laboratory Medicine (Transfusion Medicine), University of Rochester Medical Center, Rochester, NY, USA.,Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA.,Departments of Microbiology and Immunology and Environmental Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Majed A Refaai
- Department of Pathology and Laboratory Medicine (Transfusion Medicine), University of Rochester Medical Center, Rochester, NY, USA.,Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
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34
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Zenor L, Anderson CJ. Bridge over Troubled Water. PHYSICIAN ASSISTANT CLINICS 2019. [DOI: 10.1016/j.cpha.2018.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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35
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Lukose J, N M, Mohan G, Shastry S, Chidangil S. Normal saline-induced deoxygenation of red blood cells probed by optical tweezers combined with the micro-Raman technique. RSC Adv 2019; 9:7878-7884. [PMID: 35521160 PMCID: PMC9061285 DOI: 10.1039/c8ra10061f] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 02/18/2019] [Indexed: 11/21/2022] Open
Abstract
The use of normal saline for washing red blood cells and treating critically ill patients is a regular medical practice in hospital settings. An optical tweezer in combination with Raman spectroscopy is an analytical tool employed for the investigation of single cell dynamics, thus providing molecular fingerprint of the cell by optically trapping the cell at a laser focus. In this study, the impact of normal saline on individual human red blood cell was compared with that of blood plasma using Raman tweezers spectroscopy. Major spectral variations in the marker frequencies at 1209 cm-1, 1222 cm-1, 1544 cm-1, and 1561 cm-1 of the Raman spectrum of the treated cells imply that the transition of hemoglobin to the deoxygenated state occurs when 0.9% normal saline is used. This may result in serious implications in blood transfusion. The results obtained from the principal component analysis also displayed clear differentiation among the red blood cells diluted in normal saline and those diluted in plasma. In future studies, efforts will be made to correlate the deoxygenation status of red blood cells with various human disorders.
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Affiliation(s)
- Jijo Lukose
- Centre of Excellence for Biophotonics, Department of Atomic and Molecular Physics, Manipal Academy of Higher Education Manipal Karnataka India-576104
| | - Mithun N
- Centre of Excellence for Biophotonics, Department of Atomic and Molecular Physics, Manipal Academy of Higher Education Manipal Karnataka India-576104
| | - Ganesh Mohan
- Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal Academy of Higher Education Manipal Karnataka India-576104
| | - Shamee Shastry
- Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal Academy of Higher Education Manipal Karnataka India-576104
| | - Santhosh Chidangil
- Centre of Excellence for Biophotonics, Department of Atomic and Molecular Physics, Manipal Academy of Higher Education Manipal Karnataka India-576104
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36
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Seheult JN, Stram MN, Sperry J, Spinella PC, Triulzi DJ, Yazer MH. In silico model of the dilutional effects of conventional component therapy versus whole blood in the management of massively bleeding adult trauma patients. Transfusion 2018; 59:146-158. [PMID: 30414181 DOI: 10.1111/trf.14983] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/24/2018] [Accepted: 09/01/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND There are multiple approaches to the blood product and fluid resuscitation of a bleeding trauma patient. An in silico model of different trauma resuscitation strategies was constructed to predict their effects on the volumes of the different body fluid compartments and on several important hemostatic factors. STUDY DESIGN AND METHODS This multicompartment dynamic deterministic model comprised four interconnected modules (hemostatic, resuscitation, body fluid compartment, and dilutional coagulopathy). The model was divided into five resuscitation phases with simulations using six different resuscitation strategies: whole blood (WB) only, conventional component therapy (CCT) only or 10 units of WB followed by CCT, with either 1 L of crystalloid or 1.5 units of WB or red blood cells in the prehospital phase. RESULTS At the end of the simulations using 1 L of crystalloid fluids in the prehospital resuscitation phase, the use of WB led to a 1.4 g/dL higher hemoglobin concentration, 32 mg/dL higher fibrinogen concentration, and 0.9 L lower total extracellular fluid volume compared to CCT. Prehospital blood product transfusion in place of crystalloid resulted in higher hemoglobin and fibrinogen concentrations and a lower international normalized ratio throughout the resuscitation regardless of the resuscitation strategy used. Throughout both the prehospital crystalloid and prehospital blood product transfusion simulations, the hemoglobin and fibrinogen concentrations and platelet counts were higher, and the international normalized ratio was lower, when WB was used compared to CCT. CONCLUSIONS This model predicted improved hemostatic factor levels and a smaller total extracellular fluid volume volume when WB was transfused instead of CCT to bleeding trauma patients.
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Affiliation(s)
- Jansen N Seheult
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania.,The Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
| | - Michelle N Stram
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Philip C Spinella
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St. Louis, St Louis, Missouri
| | - Darrell J Triulzi
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania.,The Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania.,The Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
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37
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Connolly K. Intravenous Fluid Administration: Improving Patient Outcomes With Evidence-based Care. J Nurse Pract 2018. [DOI: 10.1016/j.nurpra.2018.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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38
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Heshmati F. Low-volume standardized ECP for children and adults. Transfus Apher Sci 2018; 57:337-338. [PMID: 29921548 DOI: 10.1016/j.transci.2018.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This manuscript highlights a new ANSM (French security agency for food & drug) approved method of ECP in order to render ECP easier and more secure for children and adults, with shorter time of procedure and lower final volume of cells (100 ml) and lower injected 8-MOP. This modified procedure is appropriately called "a Low Volume ECP (LV-ECP)".
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Affiliation(s)
- Farhad Heshmati
- Cochin Hospital, 27, rue du Fg St Jacques, 75014 Paris France.
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