Identification of the blood component responsible for increased susceptibility to gut-derived infection

Intra-Operative Abdominal Drain Placement for Gallbladder Cancer Surgery and Risk of Infectious Complications

Background: Routine intra-operative abdominal drain placement (IADP) is not beneficial for uncomplicated cholecystectomies though outcomes in gallbladder cancer surgery is unclear. This retrospective study hypothesized that patients with IADP (+IADP) for gallbladder cancer surgery have a higher risk of post-operative infectious complications (PIC) compared with patients without IADP (-IADP). Patients and Methods: The 2014-2017 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for +IADP and -IADP patients who had gallbladder cancer surgery. Post-operative infectious complications were defined as septic shock, organ/space infection (OSI), or percutaneous drainage. Multivariable analyses were performed to analyze the associated risk of PIC. Results: Of 385 patients, 237 (61.6%) were +IADP. The +IADP patients had higher rates of post-operative bile leak, OSI, re-admission, and increased length of stay (p < 0.05). The +IADP patients were not associated with increased risk of PIC (p > 0.05). Bile leak (odds ratio [OR], 10.61; p < 0.001), peri-operative blood transfusion (OR, 3.77; p = 0.003), biliary reconstruction (OR, 2.88; p = 0.018), and pre-operative biliary stent placement (OR, 3.02; p = 0.018) were the strongest associated risk factors of PIC. Patients with drains in place at or longer than 30 days post-operatively had an increased associated risk compared with patients who did not (OR, 6.88; 95% confidence interval [CI], 2.16-21.86; p < 0.001). Conclusions: More than 60% of gallbladder cancer surgeries included IADP and was not associated with an increased risk of PIC. Intra-operative abdominal drain placement was not associated with an increased risk of PIC, unless drains were left in place for 30 days or longer. Increased risk of PIC was associated with bile leak, peri-operative blood transfusion, pre-operative biliary stent placement, and biliary reconstruction.

Perioperative blood transfusion is associated with an increased risk for post-surgical infection following pancreaticoduodenectomy

BACKGROUND/PURPOSE

Perioperative blood transfusion is common after pancreaticoduodenectomy (PD) and may predispose patients to infectious complications. The purpose of this study is to examine the association between perioperative blood transfusion and the development of post-surgical infection after PD.

METHODS

Patients who underwent PD from 2014 to 2015 were identified in the NSQIP pancreas-specific database. Logistic regression analysis was used to compute adjusted odds ratios (aOR) to identify an independent association between perioperative red blood cell transfusion (within 72 h of surgery) and the development of post-operative infection after 72 h.

RESULTS

A total of 6869 patients underwent PD during this time period. Of these, 1372 (20.0%) patients received a perioperative blood transfusion. Patients receiving transfusion had a higher rate of post-operative infection (34.7% vs 26.5%, p < 0.001). After adjusting for significant covariates, perioperative transfusion was independently associated the subsequent development of any post-operative infection (aOR 1.41 [1.23-1.62], p < 0.001), including pneumonia (aOR 2.01 [1.48-2.74], p < 0.001), sepsis (aOR 1.62 [1.29-2.04], p < 0.001), and septic shock (aOR 1.92 [1.38-2.68], p < 0.001).

CONCLUSION

There is a strong independent association between perioperative blood transfusion and the development of subsequent post-operative infection following PD.

Balance Between the Proinflammatory and Anti-Inflammatory Immune Responses with Blood Transfusion in Sepsis

Blood product transfusion may exacerbate the initial immunosuppressive response of sepsis. Nurses and other patient care providers must be diligent in recognizing and managing a worsening immune status, using flow cytometry to monitor patients' immune status. This type of monitoring may be instrumental in reducing morbidity and mortality in persons with sepsis. This article discusses the recent literature on the associated inflammatory responses that occur with blood transfusion and provides an analysis of alterations in key inflammatory pathways in response to transfusion in a sepsis population.

Transfusion-related immunomodulation due to peripheral blood dendritic cells expressing the CD200 tolerance signaling molecule and alloantigen

BACKGROUND

The transfusion of allogeneic blood products containing white cells (WBCs) has been reported to reduce resistance to infection, stimulate the growth of some types of tumors in animal models, and prevent abortion of allogeneic embryos in the CBAxDBA/2 murine model.

STUDY DESIGN AND METHODS

In this study, the issue explored was whether allogeneic BALB/c whole blood given to C57Bl/6 mice by tail vein after injection of syngeneic FSL-10 fibrosarcoma cells increased the number of lung nodules enumerated on Day 21. The effect on the tumor growth-promoting effect produced by allogeneic BALB/c whole blood was then examined by exposure of the allogeneic BALB/c blood to various monoclonal antibodies (MoAbs). The antibodies added to the BALB/c blood included anti-murine CD200 antibodies, anti-lymphoid dendritic cell (DC) antibodies (DEC205), or anti-myeloid DC (anti-CD11c) antibodies.

RESULTS

The tumor growth-promoting effect of the allogeneic BALB/c blood was abrogated by the addition to the BALB/c blood of MoAb either to myeloid DCs (anti-CD11c) or to the CD200 tolerance signaling molecule, but not by adding MoAb to lymphoid DCs (DEC205). BALB/c blood also was shown to increase the percentage of transforming growth factor (TGF)-beta+ splenocytes detected in recipient mice, on Day 12 after transfusion. This effect was abrogated by adding anti-CD200 antibody to the BALB/c donor blood. Moreover, physiologic concentrations of TGF-beta, but not interleukin-10, were shown to stimulate, in cell culture experiments, the proliferation of syngeneic FSL-10 sarcoma cells.

CONCLUSIONS

These data support the hypothesis that the mechanism of the tumor growth-promoting effect of allogeneic blood is mediated by a highly potent population of peripheral blood DCs expressing the CD200 tolerance signaling molecule. These data also indicate that tumor cell growth can be mediated by the stimulation of TGF-beta-producing cells and that TGF-beta may act by tumor cell growth stimulation, rather than by host immunosuppression.

Transfusion-related immunomodulation (TRIM): an update

Allogeneic blood transfusion (ABT)-related immunomodulation (TRIM) encompasses the laboratory immune aberrations that occur after ABT and their established or purported clinical effects. TRIM is a real biologic phenomenon resulting in at least one established beneficial clinical effect in humans, but the existence of deleterious clinical TRIM effects has not yet been confirmed. Initially, TRIM encompassed effects attributable to ABT by immunomodulatory mechanisms (e.g., cancer recurrence, postoperative infection, or virus activation). More recently, TRIM has also included effects attributable to ABT by pro-inflammatory mechanisms (e.g., multiple-organ failure or mortality). TRIM effects may be mediated by: (1) allogeneic mononuclear cells; (2) white-blood-cell (WBC)-derived soluble mediators; and/or (3) soluble HLA peptides circulating in allogeneic plasma. This review categorizes the available randomized controlled trials based on the inference(s) that they permit about possible mediator(s) of TRIM, and examines the strength of the evidence available for relying on WBC reduction or autologous transfusion to prevent TRIM effects.

Is increased mortality associated with post-operative infections after leukocytes containing red blood cell transfusions in cardiac surgery? An extended analysis

In two randomized trials in cardiac surgery we observed that leukoreduced allogeneic red blood cell (RBC) transfusions (LR) compared with standard buffy-coat-depleted RBC transfusions (BCD) resulted in lower rates of post-operative infections and mortality. To unravel whether this comprises two independent side effects or could be related complications of allogeneic leukocytes, we performed a re-analysis on the patients of these two trials. For all analyses, homogeneity tests were shown not to be significant. Data on characteristics of post-operative infections, nature of microorganisms, number of transfusions and causes of death in both studies were subjected to an integrated analysis. In both studies combined, 1085 patients had been assigned to prestorage leukoreduced RBCs (LR, n= 542) or standard buffy-coat-depleted RBCs (BCD, n= 543). Post-operative infections were significantly higher in the BCD group [BCD: 34.2% vs. LR: 24.0%, common odds ratios (COR): 1.65, 95% confidence interval (CI): 1.27-2.15], whereas the species of cultured microorganisms and the type of the infections were similar in both randomization arms. Mortality with infections was significantly higher in patients receiving BCD compared with LR (BCD: 5.5% vs. LR: 2.2%, COR: 2.59, 95% CI: 1.31-5.14), whereas mortality without infections was similar in both arms (BCD: 3.9% vs. LR: 3.1%, COR: 1.24, 95% CI: 0.65-2.38). The only cause of death that differed significantly between BCD and LR was the combination of multiple organ dysfunction syndrome with infections. This re-analysis shows that transfusion of leukocytes containing RBCs during cardiac surgery may be associated with more infections with fatal outcome. This should be confirmed in a larger extended analysis or a prospective study.

Evaluation of nonleukoreduced red blood cell transfusion units collected at delivery from the placenta

BACKGROUND

The objective of this study was to evaluate the suitability of cord blood (CB) as a source of red blood cells (RBCs) for autologous transfusion.

STUDY DESIGN AND METHODS

CB was collected in 150-mL storage containers with citrate phosphate dextrose (CPD) as anticoagulant and stored in either saline, adenine, glucose, and mannitol (SAG-M; n = 18) or phosphate, adenine, glucose, guanosine, saline, and mannitol (PAGGS-M; n = 18) for 35 days at 4 degrees C. Hematologic status and hemolysis were studied. The lipopolysaccharide (LPS)-induced production of tumor necrosis factor (TNF)-alpha and transforming growth factor (TGF)-beta1 from CB monocytes was analyzed after incubation with addition of weekly sampled supernatants from the CB RBC units. Five additional units (PAGGS-M) were leukoreduced and thereafter analyzed as indicated above.

RESULTS

Hemolysis increased significantly over time, in SAG-M more than in PAGGS-M. During storage in both media, the number of white blood cells (WBCs) decreased, and the LPS-induced production of TNF-alpha and TGF-beta1 decreased and increased, respectively. There were no significant changes in the LPS-induced production of TNF-alpha and TGF-beta1 in the leukoreduced CB RBC units.

CONCLUSION

Hemolysis in CB RBC units increased significantly over time, and PAGGS-M appears to be superior to SAG-M as a preservation solution for CB RBC. The changes in LPS-induced TNF-alpha and TGF-beta1 production over time were probably caused by substances released from apoptotic and/or necrotic WBCs. Further studies are needed to identify both which substances are responsible for the changes in LPS-induced cytokine release and the clinical significance hereof.

Universal Leukocyte Reduction

This article discusses the evidence for the generally accepted uses of leukocyte-reduced blood and the controversy over leukocyte reduction and transfusion-related immunomodulation. A perspective is provided on the continued need for leukocyte reduction on the part of all patients in the United States.

Allogeneic blood transfusion increases the risk of postoperative bacterial infection: a meta-analysis

BACKGROUND

Immunosuppression is a consequence of allogeneic (homologous) blood transfusion (ABT) in humans and is associated with an increased risk in cancer recurrence rates after potentially curative surgery as well as an increase in the frequency of postoperative bacterial infections. Although a meta-analysis has been reported demonstrating the relationship between ABT and colon cancer recurrence, no meta-analysis has been reported demonstrating the relationship of ABT to postoperative bacterial infection.

METHODS

Twenty peer-reviewed articles published from 1986 to 2000 were included in a meta-analysis. Criteria for inclusion included a clearly defined control group (nontransfused) compared with a treated (transfused) group and statistical analysis of accumulated data that included stepwise multivariate logistic regression analysis. In addition, a subgroup of publications that included only the traumatically injured patient was included in a separate meta-analysis. A fixed effects analysis was conducted with odds ratios obtained by using the conditional maximum likelihood method and 95% confidence intervals on the obtained odds ratios were determined using the mid-p technique.

RESULTS

The total number of subjects included in this meta-analysis was 13,152 (5,215 in the transfused group and 7,937 in the nontransfused group). The common odds ratio for all articles included in this meta-analysis evaluating the association of ABT to the incidence of postoperative bacterial infection was 3.45 (range, 1.43-15.15), with 17 of the 20 studies demonstrating a value of p < or = 0.05. These results provide overwhelming evidence that ABT is associated with a significantly increased risk of postoperative bacterial infection in the surgical patient. The common odds ratio of the subgroup of trauma patients was 5.263 (range, 5.03-5.43), with all studies showing a value of p < 0.05 (0.005-0.0001). These results demonstrate that ABT is associated with a greater risk of postoperative bacterial infection in the trauma patient when compared with those patients receiving ABT during or after elective surgery.

CONCLUSION

These results demonstrate that ABT is an associated and apparently significant and frequently overlooked risk factor for the development of postoperative bacterial infection in the surgical patient. Allogeneic blood transfusion is a greater risk factor in the traumatically injured patient when compared with the elective surgical patient for the development of postoperative bacterial infection.

The HLA system in blood transfusion

The human leukocyte antigen (HLA) system, originally discovered as the result of a transfusion reaction, is now known to play a crucial role in many areas of clinical medicine. The main function of the HLA molecules is to present antigenic peptides to the immune system and in this way regulate the induction of immune responses. This is a highly regulated process which requires a close interaction between the HLA molecules, the antigenic peptide and the T cell receptor.HLA molecules are also known to be associated with a variety of autoimmune, non-autoimmune and infectious diseases and to restrict the antibody response to certain antigens and to vaccines. It is likely that the mechanism responsible for this restriction is the preferential presentation of antigen-derived peptides to T cells. Furthermore, HLA antigens, in contrast to most polymorphic molecules, have the ability to activate the immune system using two different pathways of T cell activation, the direct and indirect pathways. As a result of these features, HLA antigens and antibodies are responsible for some of the serious clinical complications of blood transfusion, and have an important influence on the outcome of solid organ and haemopoietic stem cell transplantation.

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.

Transfusion and postoperative pneumonia in coronary artery bypass graft surgery: effect of the length of storage of transfused red cells

BACKGROUND

Various bioactive substances are released from white cell (WBC) granules into red cell (RBC) components in a time-dependent manner during blood storage. Some of these substances may have immunosuppressive effects and may contribute to transfusion-induced immunomodulation. RBCs transfused after prolonged storage may be associated with a higher incidence of postoperative infections than fresh RBCs. This hypothesis does not seem to have been investigated in a clinical study.

STUDY DESIGN AND METHODS

The records of 416 consecutive patients undergoing coronary artery bypass graft operations at the Massachusetts General Hospital were reviewed. The association between the length of storage of the transfused RBCs, as well as the number of units of non-WBC-reduced allogeneic RBCs and/or platelets transfused, and the occurrence of postoperative pneumonia was calculated by logistic regression analyses adjusting for the effects of confounding factors. Among these were the numbers of days of intubation, days of impaired consciousness, and units of RBCs transfused.

RESULTS

By Centers for Disease Control and Prevention criteria, pneumonia developed in 54 patients (13.0%). Among 269 patients given RBCs, the risk of pneumonia increased by 1 percent per day of increase in the mean storage time of the transfused RBCs (p<0.005). In an analysis of all patients, the risk of pneumonia increased by 5 percent per unit of non-WBC-reduced allogeneic RBCs and/or platelets received (p = 0.0584).

CONCLUSION

After adjustment for the effects of the risk factors for pneumonia and the number of transfused RBCs, an association was observed between the length of storage of transfused RBCs and the development of postoperative pneumonia. This association should be investigated further in future studies of the outcomes of blood transfusion.

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.

Randomized trial comparing packed red cell blood transfusion with and without leukocyte depletion for gastrointestinal surgery

BACKGROUND

Allogeneic transfusion is associated with postoperative infections that significantly prolong hospital stays and increase costs. Recent studies suggest that filtering leukocytes from blood prior to transfusion reduces the risk of postoperative infection associated with blood transfusion. We compared the incidence of postoperative infections, hospital stays, and hospital charges of gastrointestinal surgery patients transfused with packed red cells or leukocyte-depleted cells.

METHODS

Consecutive patients admitted for elective gastrointestinal surgery without previous blood transfusion were randomized to receive routine packed red cells or packed red cells filtered to remove leukocytes if transfusion was required. Multivariate analysis was used to assess the significance of the relationship between leukocyte-depleted blood and postoperative infectious complications, postoperative stay, and hospital charges.

RESULTS

Fifty-nine (27%) of the 221 patients were transfused. The most significant variable related to transfusion was intraoperative blood loss (P <0.0001), followed by admission hematocrit (P <0.0001) and age (P = 0.0022). Infections were noted in 16% of the patients: 11% of untransfused patients, 16% of leukocyte-depleted blood recipients, and 44% of patients transfused with packed red cells. Both operative site and nosocomial infections were significantly (P <0.001) more frequent in patients transfused with packed red cells compared with patients transfused with leukocyte-depleted red cells. Postoperative stays averaged 9 days for untransfused patients, 12 days for leukocyte-depleted recipients, and 18 days for recipients of packed red cells. Hospital charges were $19,132, $33,954, and $41,002, respectively. Both transfusion and infection were significantly (P <0.001) related to postoperative stay in multivariate analysis. Hospital charges were significantly related to postoperative stay (P <0.001), blood loss (P <0.001), age (P <0.001), infection (P = 0.007), and randomization to packed red cells (P = 0.032).

CONCLUSIONS

Filtering blood of leukocytes prior to transfusion for elective gastrointestinal surgery is associated with lower risk of postoperative infection, shorter postoperative stays, and lower hospital charges.

Blood transfusion and total joint replacement surgery: T helper 2 (TH2) cytokine secretion and clinical outcome

Surgery and blood transfusions have both been reported to cause decreases in various measures of cell-mediated immunity. A study of in vitro T helper lymphocyte type 2 (Th2) cytokine secretion after major joint replacement surgery was performed because these cytokines (IL4 and IL10) generally down-regulate cellular immune function. Th1 cytokines such as IL2 tend to up-regulate cellular immunity. Forty-three patients undergoing elective joint replacement surgery had pre- and multiple post-operative levels of IL2, IL4 and IL10 secretion measured and analysed with regard to demographic and clinical outcome data. Total joint replacement alone without allogeneic transfusions led to substantial increases in peak mean IL4 (2.1 times the pre-operative level) and IL10 secretion in vitro (4.3-fold) compared with much more modest increases in IL2 (1.36-fold) (P < 0.0001 for changes from baseline for each cytokine). In 14 patients who received allogeneic transfusions, these changes were greater than those in recipients of only autologous blood for IL4 (5.0-fold; P = 0.0036 vs. no allogeneic transfusion) and IL10 (15.7-fold; P = 0.079) but not for IL2 (1.38-fold; P = 0.38). The dramatic increase in Th2 cytokine secretion and minimal change in Th1 cytokine secretion after total joint replacement, with or without allogeneic transfusions, was seen regardless of type of anaesthetic, duration of surgery or whether knee or hip replacement occurred. These changes in cytokine patterns may contribute to the decreases in cellular immune function seen after surgery. Allogeneic transfusions but not autologous transfusions appear to exacerbate this immune deviation toward a T helper 2 (Th2) type response, and thus probably contribute to down-regulation of cellular immunity in the setting of joint replacement surgery.

Artificial nutrition after major abdominal surgery: impact of route of administration and composition of the diet

OBJECTIVE

To evaluate the impact of the route of administration of artificial nutrition and the composition of the diet on outcome.

DESIGN

Prospective, randomized, clinical trial.

SETTING

Department of surgery, university hospital.

PATIENTS

One hundred sixty-six consecutive patients undergoing curative surgery for gastric or pancreatic cancer.

INTERVENTIONS

At operation, the patients were randomized into three groups to receive: a) a standard enteral formula (control group; n = 55); b) the same enteral formula enriched with arginine, RNA, and omega-3 fatty acids (enriched group; n = 55); and c) total parenteral nutrition (TPN group; n = 56). The three regimens were isocaloric and isonitrogenous. Enteral nutrition was started within 12 hrs following surgery. The infusion rate was progressively increased to reach the nutritional goal (25 kcal/kg/day) on postoperative day 4.

MEASUREMENTS AND MAIN RESULTS

Tolerance of enteral feeding, rate and severity of postoperative complications, and length of hospital stay were recorded. Early enteral infusion was well tolerated. Side effects were recorded in 22.7% of the patients, but only 6.3% did not reach the nutritional goal. The enriched group had a lower severity of infection than the parenteral group (4.0 vs. 8.6; p < .05). In subgroups of malnourished (n = 78) and homologous transfused patients (n = 42), the administration of the enriched formula significantly reduced both severity of infection and length of stay compared with the parenteral group (p < .05). Moreover, in transfused patients, the rate of septic complications was 20.0% in the enriched group, 38.4% in the control group, and 42.8% in the TPN group.

CONCLUSIONS

Early enteral feeding is a suitable alternative to TPN after major abdominal surgery. The use of the enriched diet appears to be more beneficial in malnourished and transfused patients.

Influence of blood transfusion on bactericidal activity of human leukocytes and sera against Yersinia enterocolitica and Salmonella typhimurium

Patients undergoing joint surgery and blood transfusion were studied. Serum and leukocyte bactericidal tests in vitro against Salmonella typhimurium and Yersinia enterocolitica were carried out preoperatively as well as on the 1st, 3rd and 7th days after the operation. The serum complement (C3 and C4) concentrations were determined at the same intervals. It was found that after blood transfusion the bactericidic activity of sera and the serum C3 complement concentrations were increased. In contrast the killing ability of leukocytes was suppressed.

The effect of blood transfusion on susceptibility to bacterial infection in genetically defined mouse models

BACKGROUND

Blood transfusions suppress immune function and increase susceptibility to infection, but the effects are not consistent.

STUDY DESIGN AND METHODS

Genetically defined mouse strains with the same or different haplotypes were used as blood transfusion recipients and donors. Transfused animals were subjected to cecal ligation and puncture (CLP) and followed for survival or were injected intravenously with Candida albicans to follow clearance of the Candida from the kidneys.

RESULTS

BALB/c (H-2d) mice transfused with C3H/HeJ (H-2k) or DBA/2 (H-2d) blood followed by CLP showed significantly lower survival (7 and 10%) than mice transfused with syngeneic blood (61%) or saline controls (56%). Lower survival was also observed in C3H/HeJ (H-2k) mice transfused with BALB/c (H-2d) blood and subjected to CLP (25%) compared with syngeneic transfusion (80%) or saline controls (70%). C57BL/6J (H-2b) mice showed minimal increases in mortality after CLP after transfusion with blood from C3H/HeJ (H-2k) (60% survival), DBA/2 (H-2d) (70% survival), or BALB/c (H-2d) mice (90% survival). When C. albicans was infused intravenously into transfused mice, a similar pattern of altered resistance to infection was found.

CONCLUSION

The ability of blood transfusions to increase susceptibility to bacterial infection appears to be dependent on genetic factors unrelated to the major haplotype.

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.

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.

Dietary fatty acids modulate host bacteriocidal response,microbial translocation and survival following blood transfusion and thermal injury

The effect of dietary lipids on bacterial translocation, killing of translocated organisms and host survival was studied in a burned animal model. Balb/c mice were fed with one of the three experimental AIN-76A diets (containing 15% of energy from fish oil, safflower oil or a 50:50 mixture), AIN-76A without added lipids or a nonpurified stock diet. All animals were transfused on day 10. On day 15, the animals were gavaged with 10(10) 14C radiolabelled Escherichia coli and given a 20% burn injury. Survival was 84% in the fish oil group versus 36% in the safflower oil and 50:50 diet groups, and 25% and 20% in the two control groups (P < 0.0001). The numbers of viable translocating bacteria were reduced in all tested organs in the fish oil groups compared to the other groups. It is concluded that a diet enriched in fish oil has beneficial effects during gut-derived sepsis.

Randomised comparison of leucocyte-depleted versus buffy-coat-poor blood transfusion and complications after colorectal surgery

BACKGROUND

Allogeneic blood transfusion is associated with an increased frequency of postoperative infection. We studied whether such events can be avoided by the intraoperative and postoperative use of leucocyte-depleted blood.

METHODS

589 consecutive patients scheduled for elective colorectal surgery were randomised to receive buffy-coat poor (n = 299) or filtered leucocyte-depleted red-cells (n = 290) when transfusion was indicated. 260 patients actually received blood transfusion. Three patients were excluded from analysis.

FINDINGS

The 142 patients randomised to and transfused with buffy-coat-poor blood had a significantly higher frequency of wound infections and intra-abdominal abscesses than the 155 patients who were allocated to this group but who were not transfused. (12 vs 1%, p < 0.0001) and (5 vs 0%, p = 0.005), respectively. Those receiving buffy-coat-poor blood also had a significantly higher frequency of wound infections and intra-abdominal abscesses than the 118 randomised to and receiving leucocyte-depleted blood (12 vs 0%, p < 0.0001) and (5 vs 0%, p = 0.017), respectively. Postoperative pneumonia occurred at a significantly higher rate in patients receiving buffy-coat-poor blood: 23 versus 3% in non-transfused patients (p < 0.0001), and 23 versus 3% in patients transfused with leucocyte-depleted blood (p < 0.001). The mortality rate between the groups was not statistically different.

INTERPRETATION

Our data suggests that the association between allogeneic blood transfusion and postoperative infection is limited to allogeneic blood products that are not adequately depleted of immunosuppressive leucocytes. This undesirable effect can be reduced by leucocyte depletion with high-efficiency filters.

A single unit of transfused allogeneic blood increases postoperative infections

The aim of this prospective study was to evaluate if there was a statistical correlation between allogeneic blood transfusion and postoperative infections, and if this could have a dose-dependent pattern. The evaluation was based on multiple logistic and receiver operating characteristics (ROC) curve analyses. On hospital admission the following parameters were determined in 267 consecutive patients with colorectal cancer: hemoglobin, serum albumin, serum cholinesterase activity, total iron binding capacity and weight loss. Duration of operation, operative blood loss, amount of transfused blood, Dukes' cancer stage and occurrence of postoperative infections were also recorded. One hundred and thirty-two patients (49.4%) were given perioperatively allogeneic blood. Postoperative infections developed in 47 (17.6%) patients. Multivariate analysis identified allogeneic blood transfusion as the only variable related to the occurrence of postoperative infections (p < 0.05). ROC curve analysis showed that the risk for the occurrence of infection was significantly higher in patients transfused one unit of blood (p < 0.01). Moreover, a significant trend between increasing number of transfused blood units and susceptibility to infection was found (p < 0.00019).

A cost analysis of autologous and allogeneic transfusions in hip-replacement surgery

PURPOSE

To analyze the cost consequences of autologous versus allogeneic transfusions.

METHODS

Costs were determined when allogeneic transfusions were given in addition to, or instead of, autologous transfusions. Hospital charges were used to estimate costs for hip-replacement surgery. The main outcome measure was estimated incremental hospital costs per unit transfused.

RESULTS

Among donors of autologous blood, mean total charges were $7,200 greater for recipients of both autologous and allogeneic transfusions than for recipients of autologous transfusion only (P=0.0001). Each allogeneic transfusion was associated with additional costs of $1,480. In a second cohort of patients receiving identical amounts of either allogeneic or autologous blood (mean=2.3 units), total hospital charges were a mean of $4,800 greater (P=0.0001) for allogeneic recipients. The per unit excess costs associated with each unit of allogeneic blood cohort were $1,043.

CONCLUSIONS

Allogeneic transfusions are associated with incremental hospital costs of about $1,000 to $1,500 per unit transfused when compared with costs for similar patients receiving no transfusions or 1 to 5 units of autologous blood.

Potential for reduction in morbidity and cost with total leucocyte control for cardiac surgery

The economics of health care in the USA and abroad has caused a shift in the focus on therapeutic interventions that transcend issues of safety and clinical efficacy. Now, cost justification is emerging as a major consideration to influence clinical practice. This brief review of the medical literature attempts to identify leucocyte-mediated adverse reactions that develop in open-hear surgery, quantify the costs incurred to manage such reactions and infer the savings that may accrue by controlling the burden of leucocytes presented to the open-heart surgical patient using commercially available leucocyte reducing filtration technology.

Transfusion medicine in obstetrics and gynecology

Obstetricians and Gynecologists care for many patients with conditions potentially requiring blood transfusions. Cesarean section and hysterectomy are the two surgeries performed most frequently and both have the potential for blood loss requiring transfusion. Other examples include postpartum hemorrhage, placenta previa, and ruptured ectopic pregnancy. Obstetricians and gynecologists need to become knowledgeable about the ever-changing aspects of blood transfusion and apply it in their clinical practice. This review intends to update obstetricians and gynecologists and other health care professionals about the basic as well as the latest technologies of blood transfusion. The different types of blood components are discussed including their preparation, indications, risks, and benefits. The complications of blood transfusion and their management are reviewed, including infections, noninfectious, and immunological etiologies. HIV and hepatitis are explored, these being the most serious infectious risks of transfusion. Autologous blood transfusion, an underutilized option, is examined. Hemodilution and intraoperative blood salvage, other techniques for using the patient's own blood, are discussed. Finally, synthetic agents such as erythropoietin, granulocyte colony-stimulating factors, factors, desmopressin acetate, gonadotropin-releasing hormone agonists, and new products are introduced as potential replacements to blood transfusion in the future.

Leukodepleted-ABO-identical blood components in the treatment of hematologic malignancies: a cost analysis

To assess the effect of ABO-identical, filtration leukodepleted transfusions on resource consumption and costs of care we performed a cohort study in consecutive adult patients admitted for induction therapy of acute myeloid or lymphoid leukemia during 1985-92 (n = 120) and consecutive adult patients admitted for autologous bone marrow transplantation for Hodgkin's or non-Hodgkin's lymphoma during 1989-1991 in our university hospital. Patients with acute leukemia received either ABO unmatched, unfiltered transfusions (1985-89), ABO identical, unfiltered transfusions (1987-90), or ABO identical, filtered transfusions (1990-92). Patients with lymphoma received either ABO unmatched, unfiltered transfusions (1989-90) or ABO identical, filtered transfusions (1990-91). Mean platelet transfusion requirements per patient decreased with ABO identical platelets and filtered transfusions: from 143 to 71 units in the transplant setting; from 146 to 83 in acute leukemia (P < 0.05). Mean hospital ancillary service charges in 1992 dollars decreased with ABO identical platelets and filtered transfusions approximately $14,000 per patient for acute leukemia and $26,000 for for lymphoma. Per patient actual costs for filters ($643 in transplantation for lymphoma and $875 in leukemia) were offset by savings in actual blood component purchase costs alone ($4,127 in lymphoma and $3,283 in leukemia). In our setting, introduction of ABO identical platelets and filtration leukodepletion were implemented with substantial decreases in costs.