Noninfectious Complications of Blood Transfusion

Diagnosis of transfusion-associated graft-vs.-host disease: the importance of short tandem repeat analysis

Transfusion-associated graft-vs.-host disease (TA-GvHD) can occur following transfusion of blood products containing immunocompetent lymphocytes, usually from HLA homozygous donors, into immunocompromised patients sharing one HLA haplotype with the donor. The diagnosis of TA-GvHD may be delayed due to the initial nonspecific clinical features involved. Investigations to detect the presence of donor-derived cells in the blood and/or affected tissues of the recipient are essential to confirm the diagnosis. We report the investigation of suspected TA-GvHD using short tandem repeat (STR) analysis, to detect the presence of donor cells (chimerism), in an immunocompetent patient admitted for coronary artery bypass surgery. Peripheral blood and skin biopsies (from affected and nonaffected sites) from the patient and peripheral blood samples from the implicated donors were taken for HLA typing and STR analysis. STR analysis revealed the presence of donor material in the patient's peripheral blood sample and in DNA extracted from the affected skin biopsy but not the unaffected biopsy, suggesting lymphocytes from this donor were responsible for the development of TA-GvHD. Furthermore, HLA typing results supported the diagnosis of TA-GvHD. These data demonstrate the use of STR and HLA analysis as effective tools in the diagnosis of TA-GvHD.

Evaluation of a visual risk communication tool: effects on knowledge and perception of blood transfusion risk

BACKGROUND

Effective risk communication in transfusion medicine is important for health-care consumers, but understanding the numerical magnitude of risks can be difficult. The objective of this study was to determine the effect of a visual risk communication tool on the knowledge and perception of transfusion risk.

STUDY DESIGN AND METHODS

Laypeople were randomly assigned to receive transfusion risk information with either a written or a visual presentation format for communicating and comparing the probabilities of transfusion risks relative to other hazards. Knowledge of transfusion risk was ascertained with a multiple-choice quiz and risk perception was ascertained by psychometric scaling and principal components analysis.

RESULTS

Two-hundred subjects were recruited and randomly assigned. Risk communication with both written and visual presentation formats increased knowledge of transfusion risk and decreased the perceived dread and severity of transfusion risk. Neither format changed the perceived knowledge and control of transfusion risk, nor the perceived benefit of transfusion. No differences in knowledge or risk perception outcomes were detected between the groups randomly assigned to written or visual presentation formats.

CONCLUSION

Risk communication that incorporates risk comparisons in either written or visual presentation formats can improve knowledge and reduce the perception of transfusion risk in laypeople.

The risks associated with blood and blood product transfusion

Although transfusion of blood and blood products is often of life-saving benefit for the many patients who receive transfusions every year, it is not without considerable risk. Nurses need to be aware of these risks so that they can respond to patient anxiety about transfusion. This article outlines risks associated with transfusion and the measures taken to minimize them. Attention will be focused principally on the two most significant risks: transmission of serious blood-borne infection and the potentially fatal acute immune haemolytic reaction that can occur if patients receive incompatible red cells. Other significant adverse effects will be discussed briefly. Recent initiative aimed at monitoring the incidence of these adverse effects and increasing the safety of blood transfusion will be discussed, with special emphasis on the nurse's role in the transfusion process.

[Evaluation of the immediate transfusion reaction incident reporting system at the Brest University Hospital Center]

The Haemovigilance Unit of Brest University Hospital has had a reporting system of transfusion reactions since october 1994. Reporting "any unexpected or undesirable effect due or likely to be due to the administering of blood cell components" must be done on an answering machine immediately or in the next eight hours. The main goal of the evaluation of this epidemiological surveillance system was to assess its sensitivity, its positive predictive value, its acceptability, its timeliness and its simplicity, according to the Centers for Disease Control criteria. An exhaustive monitoring of the immediate transfusion reactions (ITR) occurring within the 24 hours following the procedure was conducted from April 1, to June 30, 1998. Two sources of information were used, the spontaneous notification to the Haemovigilance Unit using the answering machine, and a telephone survey of the nurse responsible for the transfusion or post-transfusion follow-up. During the survey, 19 ITR, among which 12 were reported to the Haemovigilance Unit on the answering machine, were recorded. The incidence rate of the I.T.R. was estimated at 5@1000 transfused blood cell components. The sensitivity of the notification system was estimated at 63% (95% confidence interval: 41-85) and the positive predictive value at 70% (95% confidence interval: 48-92). This notification system is operational. The function of sanitary alert is ensured at the primary level of the system surveillance. The undernotification of the ITR (37% of false negative) must be corrected by specific recommendations.

Acute gastrointestinal bleeding in the intensive care unit. The intensivist's perspective

Gastrointestinal (GI) hemorrhage is a common and potentially lethal medical emergency that is a common cause for intensive care unit admission. The intensivist plays an important role as a member of the medical team managing the patient with GI bleeding who is at high risk because of severe bleeding, comorbidity, or the presence of endoscopic stigmata of recent hemorrhage. This article presents the intensivist's approach to GI hemorrhage in initial patient assessment, triage, resuscitation, specialist consultation, diagnostic evaluation, and medical therapy. This article focuses on types of GI bleeding of particular concern to the intensivist, including esophageal variceal bleeding, stress-related GI bleeding, and GI bleeding associated with myocardial infarcation.

Reduction of bioactive substances in stored donor blood: prestorage versus bedside leucofiltration

Leucocyte filtration has been suggested to improve transfusion products. We studied the effect of prestorage versus bedside leucofiltration on reduction of bioactive substances and leucocyte content in donor blood. Forty-five units of whole blood from healthy blood donors were studied. Of these units, 9 were stored under standard conditions for 35 d, 9 were leucofiltered after donation and then stored for 35 d, and 3x9 units were stored for 7, 21 and 35 d, respectively, before leucofiltration. Samples were collected from blood units immediately after donation, and before and after leucofiltration, and analysed by ELISA and RIA methods for extracellular content of myeloperoxidase (MPO), eosinophil cationic protein (ECP), histamine (HIS) and plasminogen activator inhibitor-1 (PAI-1). Leucocyte content was counted in all samples. In non-filtered blood extracellular MPO, ECP, HIS and PAI-1 were accumulated in a storage time-dependent manner, while prestorage leucofiltration prevented this accumulation. Leucofiltration after storage for 7, 21 or 35 d did not significantly reduce the accumulated bioactive substances, which were similar to levels in non-filtered blood stored for the same period of time. Prestorage and bedside leucofiltration on day 7 reduced the leucocyte content to less than 0.5x10(6)/L, whereas the median content in blood stored for 21 or 35 d was only reduced to 32.0 and 52.2x10(6)/L, respectively. Prestorage leucofiltration may thus be advantageous to bedside leucofiltration.

Quality of reinfused drainage blood after total knee arthroplasty

Reinfusion of postoperative wound drainage blood has become an attractive alternative in primary total knee and hip arthroplasty. Quality of the drainage blood was studied with respect to content of extracellular bioactive substances and coagulation split products. Using the HandyVac ATS autotransfusion system, drainage blood was collected and reinfused within 6 hours postoperatively from 10 patients undergoing primary total knee arthroplasty. Blood samples were collected from the patients immediately after and 1 hour after opening of the tourniquet and after reinfusion of drainage blood. Samples were also collected from the drainage blood immediately before and at the end of reinfusion. The leukocyte-derived and platelet-derived bioactive substances histamine, eosinophil cationic protein (ECP), eosinophil protein X (EPX), myeloperoxidase (MPO), plasminogen activator inhibitor type 1 (PAI-1), and activated complement factor C3(C3a) and various coagulation factors and split products were analyzed in patient and drainage blood samples. None of the patients received additional predonated autologous blood or allogeneic blood components during the study period. Within 6 hours postoperatively, 250 to 1,000 mL drainage blood was collected and reinfused. Histamine, ECP, EPX, MPO, PAI-1, and C3a content was significantly increased in drainage blood immediately before and at the end of reinfusion. Reinfusion did not change the concentration of these substances in samples from the patients. Coagulation factors and various split products showed that drainage blood was defibrinated. Reinfusion of drainage blood did not change the coagulative capacity of the patients. Drainage blood appears to be defibrinated and contains various extracellular leukocyte-derived and platelet-derived bioactive substances. Reinfusion does not change the coagulative capacity or the concentration of bioactive substances of patients.

Prestorage leukocyte filtration may reduce leukocyte-derived bioactive substance accumulation in patients operated for burn trauma

Adverse effects of perioperative blood transfusion appear to be storage-time-dependent and may be related to extracellular accumulation of bioactive substances in blood products. In this study the clinical effects of leukofiltered and non-filtered blood products in patients undergoing surgery for burn trauma are investigated. 24 consecutive patients were randomly selected to receive transfusion with non-filtered blood components (group A, n = 12) or similar products, which were prestorage leukofiltered (group B, n = 12). The burn injury was scored using the Bull and Fischer index of age and burn surface area. Histamine, interleukin-6 (IL-6), plasminogen activator inhibitor-1 (PAI-1), eosinophil cationic protein (ECP) and myeloperoxidase (MPO) were analysed in plasma or serum collected from all patients 30 min before skin incision, at skin incision and 5, 10 and 30 min and thereafter every 30 min after skin incision until the grafts were secured by wrapping. Samples were also taken 8 h after skin incision and in the morning of postoperative days 1-5. The amount of blood products transfused from admission until day 5 postoperatively was recorded. All patients were followed until discharge or death. The Bull and Fischer index was comparable in the two groups. Prestorage leukofiltration reduced the amount of blood products required for transfusion significantly (p < 0.05) compared with non-filtered products. The levels of the various bioactive substances changed during and after the operation. In particular, ECP and MPO levels increased significantly (p < 0.05) in group A patients compared with unchanged (ECP) or decreased (MPO) levels in group B patients. IL-6 analyses showed, that the trauma had more severe impact on group B patients than on group A patients. Nevertheless, 4 patients died in group A and 2 in group B; all with a Bull and Fischer index between 1.0 and 2.0. Prestorage leukocyte filtration may reduce transfusion related accumulation of various bioactive substances and the requirement for blood in burn trauma patients.

Blood and blood product use in perioperative patient care

A variety of health care personnel are involved in the collection, storage, and administration of the 20 million units of blood products that are transfused into millions of patients each year. This article reviews blood transfusion practices, nursing care guidelines, and new developments to help perioperative nurses prevent or ameliorate adverse transfusion outcomes in surgical patients.

Effect of heating on extracellular bioactive substances in stored human blood: in vitro study

BACKGROUND

We have previously shown extracellular accumulation of various leukocyte and platelet-derived bioactive substances in human blood during storage. Release of bioactive substances may be temperature-dependent, and we studied the effect of heating during in vitro transfusion on bioactive substance accumulation in stored human blood.

METHODS

Eight units of whole blood and eight units of prestorage leukofiltered whole blood were stored at 4 degrees C for 7 days. Subsequently, the blood from all 16 units was transfused via a blood-heating device, which increased the blood temperature to 37 degrees C at outlet. Samples for enzyme-linked immunosorbent assay or radioimmunoassay analyses of histamine, myeloperoxidase (MPO), eosinophil cationic protein (ECP), and plasminogen activator inhibitor-1 (PAI-1) were drawn from the units at donation, after 7 days of storage just before transfusion, and during the in vitro transfusion.

RESULTS

Extracellular concentrations of histamine, MPO, ECP, and PAI-1 were significantly (p < 0.05) increased in nonfiltered whole blood stored for 7 days compared with concentrations in fresh donated blood and in prestorage leukofiltered whole blood stored for 7 days. Heating reduced histamine, MPO, and ECP concentrations significantly (p < 0.05) in nonfiltered whole blood, whereas PAI-1 concentrations increased significantly (p < 0.05). Finally, there was no difference in concentrations of histamine, MPO, ECP, and PAI-1 in samples collected before and after heating of leukofiltered whole blood.

CONCLUSIONS

Heating reduces accumulation of extracellular leukocyte-derived bioactive substances in whole blood, whereas it increases platelet-derived substances. Prestorage leukofiltration, however, reduces the obligatory extracellular accumulation of leukocyte and platelet-derived bioactive substances, which in addition is unchanged by heating.

Effect of transfusion on physiologic changes after resuscitated trauma

BACKGROUND

The purpose of this experimental study was to test whether transfusion potentiated physiologic changes associated with fluid resuscitated trauma in controlled conditions.

METHODS

Anesthetized and ventilated mongrel pigs were subjected to soft-tissue injury plus 35% hemorrhage and 1 hour shock and then were resuscitated with either autologous (shed) or heterologous (cross-transfused) fresh whole blood. Leukocyte differential counts, T-lymphocyte subsets, neutrophil adherence molecule (CD18) expression, granulocyte oxidative burst, plasma cortisol, and serum chemistries were monitored in awake animals with indwelling catheters on 3 consecutive days. Changes were referenced to preinjury baseline values and to a control group that received heterologous transfusion but no shock. To determine whether these changes might have influenced host defense, a low-dose challenge with Escherichia coli endotoxin (lipopolysaccharide [LPS]; 1 to 2 micrograms/kg for 30 minutes) was administered on day 4.

RESULTS

During recovery, neutrophil counts, neutrophil CD18 expression, and granulocyte oxidative burst were generally increased, but the changes were not potentiated by transfusion. Lymphocyte subpopulations remained relatively constant. Serum enzyme markers were elevated with trauma plus shed blood or trauma plus cross-transfusion, but they remained essentially unchanged after heterologous transfusion only. Plasma cortisol, a nonspecific index of stress, peaked at 3 to 6 times higher than baseline. The increases tended to be higher and later with heterologous transfusion only, relative to trauma plus shed blood or trauma plus cross-transfusion. The delayed LPS challenge evoked profound but transient pulmonary hypertension and leukopenia, followed by subsequent hypoxemia; the time courses and magnitude of these changes were similar in all groups.

CONCLUSIONS

If these measured variables before and after LPS challenge are a valid index of host defense in this species, then a 35% transfusion does not potentiate the risk for posttrauma immune dysfunction when the magnitude of injury is constant. Thus the predisposition to infection after human trauma might be due to cold storage of blood; separation of blood into components, or other transfusion-related practices rather than to transfusion per se.

Leucocyte and platelet-derived bioactive substances in stored blood: effect of prestorage leucocyte filtration

Adverse reactions to transfusion of allogeneic blood may depend on content of leucocytes and platelets and on storage-time of the erythrocyte suspensions. Therefore, we studied the efficacy of prestorage leucocyte reduction by filtration on total content and extracellular accumulation of histamine, eosinophil cationic protein (ECP), eosinophil protein X (EPX), myeloperoxidase (MPO), plasminogen activator inhibitor type-1 (PAI-1) and interleukin-6 (IL-6) in samples obtained from 5 units of SAGM blood, 7 units of plasma-reduced whole-blood and 6 units of whole-blood before and after filtration, respectively. In addition, we analysed supernatants from the same units after storage at +4 degrees C for 0, 21 and 35 d, respectively. The filtration was performed at room temperature within 2-4 h after donation. The substances were analysed by ELISA and RIA methods and we also analysed the donor plasma levels of the same bioactive substances. The total content of histamine, ECP, EPX, and MPO were 10-70-fold higher in all unfiltered erythrocyte products compared to donor plasma concentrations, while PAI-1 content was 15-20-fold higher only in plasma-reduced whole-blood and whole-blood. Prestorage leucocyte filtration significantly reduced the total histamine, ECP, EPX, MPO and PAI-1 content to levels similar to donor plasma levels in plasma-reduced whole-blood and whole-blood, while PAI-1 was still low in filtered SAGM blood. In addition, the levels of extracellular bioactive substances at d 0 after donation and filtration were within the range of concentrations in donor plasma, and there was no time-dependent accumulation during storage for 35 d at +4 degrees C. IL-6 was not detected in either plasma or samples obtained from the blood bags. These results suggest prestorage leucocyte filtration to deplete leucocyte contents to levels, which prevent the previously shown time-dependent accumulation of leucocyte derived bioactive substances in various erythrocyte suspensions. In addition, the PAI-1 results suggest leucocyte filters to reduce the obligatory platelet content in whole-blood products.

Bioactive substance accumulation and septic complications in a burn trauma patient: effect of perioperative blood transfusion?

Evidence has emerged that suggests adverse effects to perioperative homologous blood transfusion are related to the age of the blood products. Recently, time-dependent accumulation of bioactive substances in red cell suspensions, standard platelet concentrates and fresh frozen plasma during storage have been shown. The potential adverse effects of these bioactive substances were analysed in a burn trauma patient. A patient with 40 per cent second and third degree burn trauma without other injuries underwent a two-step transplantation operation. Samples for analyses of histamine, eosinophil cationic protein (ECP), eosinophil protein X (EPX), neutrophil myeloperoxidase (MPO) and interleukin 6 (IL-6) were drawn frequently from the patient before, during and after the operations, and from all transfused red cell, platelet and fresh frozen plasma units. Urine was sampled every hour during the first operation for analyses of ECP and EPX excretion. All analyses were performed by ELISA and RIA methods, and results compared to patient outcome. The patient received a total of 48 and 8 SAGM blood, 6 and 0 platelet and 12 and 4 fresh frozen plasma units at the two operations, respectively. Transfused products contained a total of 64.54 nmol and 17.50 nmol histamine, 115518 ng and 25764 ng ECP, 174457 ng and 38770 ng EPX, 6950915 ng and 1505125 ng MPO, and 14740 pg and 5600 pg IL-6 at the two operations, respectively. The accumulation of the substances in patient plasma correlated to postoperative septic reactions, without any disclosure of bacteraemia after the first operation, while the accumulation at the second operation correlated to the septic reaction and Pseudomonas aeruginosa infection. Time-dependent accumulation of bioactive substances in blood products during storage may be related to the development of post-transfusion adverse effects.

Time-dependent, spontaneous release of white cell- and platelet-derived bioactive substances from stored human blood

BACKGROUND

The mechanisms of the detrimental effects of perioperative allogeneic blood transfusion are still unclear. Previous studies have suggested a higher incidence of adverse effects after the use of blood stored for prolonged time. Therefore, a possible time-dependent release of various white cell- and platelet-derived bioactive substances in stored human red cell suspensions was studied.

STUDY DESIGN AND METHODS

Whole blood (6 units), plasma-reduced whole blood (6 units), and saline-adenine-glucose-mannitol blood (6 units) from 18 unpaid, normal blood donors were stored under standard blood bank conditions at 4 degrees C for 35 days. After refrigeration, samples were collected from all blood bags on Days 0, 2, 5, 9, 14, 21, 28, and 35 of storage. Extracellular concentrations of eosinophil cationic protein, eosinophil protein X, plasminogen activator inhibitor 1, myeloperoxidase, and interleukin 6 were analyzed by enzyme-linked immunosorbent assay and radioimmunoassay. The total intracellular and donor plasma levels of these substances also were analyzed at the time of blood donation.

RESULTS

Eosinophil cationic protein, eosinophil protein X, and myeloperoxidase increased 10- to 25-fold (p < 0.05) in a time-dependent manner in whole blood, plasma-reduced whole blood, and saline-adenine-glucose-mannitol blood during storage for 35 days. Plasminogen activator inhibitor 1 increased threefold to sixfold (p < 0.05) in whole blood and plasma-reduced whole blood, but not in saline-adenine-glucose-mannitol blood. Interleukin 6 was not detected in either plasma or samples obtained from the blood bags.

CONCLUSION

Stored whole blood, plasma-reduced whole blood, and saline-adenine-glucose-mannitol blood may release white cell- and platelet-derived bioactive substances in a time-dependent manner, which may be related to the detrimental effects of perioperative blood transfusions. Therefore, prestorage white cell reduction should be considered for further improvement of red cell suspensions.

Perioperative morbidity in maxillofacial orthopaedic surgery: a retrospective study

The data of 2049 patients, who underwent maxillofacial orthopaedic surgery, were retrospectively analysed for major intra- and immediate postoperative complications. Immediate life-threatening complications were very rare. They can in most cases be avoided by good anaesthetic and surgical techniques and adequate postoperative care. The most frequently encountered problem in maxillary surgery is excessive blood loss, whilst a compromised airway due to swelling is the most frequent complication in mandibular surgery. Good co-operation between anaesthetist and surgeon is essential to prevent major intraoperative and immediate postoperative problems.

Granulocyte transfusions. Time for a second look

Among the available therapies to support neutropenic patients with infection, granulocyte transfusions have generated considerable controversy. Plagued by the inconvenience of harvesting cells, infusion-associated toxicity, and marginal efficacy, granulocyte transfusions, once in vogue in the 1980s, had been relegated to a secondary role. Several recent developments, however, have given new impetus to re-evaluating the role of granulocyte transfusions. The two most notable reasons include the ability to increase the number of circulating granulocytes in the donor by treatment with one or two doses of recombinant hematopoietic growth factors, such as granulocyte- and granulocyte-macrophage colony stimulating factor, and improvements in the efficiency of the collection process. Armed with these advances, it is an appropriate time to review the existing data and consider studies designed to determine the appropriate role of granulocyte transfusions in neutropenic hosts.