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Lee JH, Ward KR. Blood failure: traumatic hemorrhage and the interconnections between oxygen debt, endotheliopathy, and coagulopathy. Clin Exp Emerg Med 2024; 11:9-21. [PMID: 38018069 PMCID: PMC11009713 DOI: 10.15441/ceem.23.127] [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: 09/10/2023] [Accepted: 09/28/2023] [Indexed: 11/30/2023] Open
Abstract
This review explores the concept of "blood failure" in traumatic injury, which arises from the interplay of oxygen debt, the endotheliopathy of trauma (EoT), and acute traumatic coagulopathy (ATC). Traumatic hemorrhage leads to the accumulation of oxygen debt, which can further exacerbate hemorrhage by triggering a cascade of events when severe. Such events include EoT, characterized by endothelial glycocalyx damage, and ATC, involving platelet dysfunction, fibrinogen depletion, and dysregulated fibrinolysis. To manage blood failure effectively, a multifaceted approach is crucial. Damage control resuscitation strategies such as use of permissive hypotension, early hemorrhage control, and aggressive transfusion of blood products including whole blood aim to minimize oxygen debt and promote its repayment while addressing endothelial damage and coagulation. Transfusions of red blood cells, plasma, and platelets, as well as the use of tranexamic acid, play key roles in hemostasis and countering ATC. Whole blood, whether fresh or cold-stored, is emerging as a promising option to address multiple needs in traumatic hemorrhage. This review underscores the intricate relationships between oxygen debt, EoT, and ATC and highlights the importance of comprehensive, integrated strategies in the management of traumatic hemorrhage to prevent blood failure. A multidisciplinary approach is essential to address these interconnected factors effectively and to improve patient outcomes.
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Affiliation(s)
- Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kevin R. Ward
- Department of Emergency Medicine, Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
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Avoiding brain hypoxia in severe traumatic brain injury in settings with limited resources - A pathophysiological guide. J Crit Care 2023; 75:154260. [PMID: 36773368 DOI: 10.1016/j.jcrc.2023.154260] [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: 07/15/2022] [Revised: 12/17/2022] [Accepted: 01/22/2023] [Indexed: 02/11/2023]
Abstract
Cerebral oxygenation represents the balance between oxygen delivery, consumption and utilization by the brain, and therefore reflects the adequacy of cerebral perfusion. Different factors can influence the amount of oxygen to the brain including arterial blood pressure, hemoglobin levels, systemic oxygenation, and transfer of oxygen from blood to the cerebral microcirculation. A mismatch between cerebral oxygen supply and demand results in cerebral hypoxia/ischemia, and is associated with secondary brain damage and worsened outcome after acute brain injury. Therefore, monitoring and prompt treatment of cerebral oxygenation compromise is warranted in both neuro and general intensive care unit populations. Several tools have been proposed for the assessment of cerebral oxygenation, including non-invasive/invasive or indirect/direct methods, including Jugular Venous Oxygen Saturation (SjO2), Partial Brain Tissue Oxygen Tension (PtiO2), Near infrared spectroscopy (NIRS), Transcranial Doppler, electroencephalography and Computed Tomography. In this manuscript, we aim to review the pathophysiology of cerebral oxygenation, describe monitoring technics, and generate recommendations for avoiding brain hypoxia in settings with low availability of resources for direct brain oxygen monitoring.
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Factors Associated With Brain Tissue Oxygenation Changes After RBC Transfusion in Acute Brain Injury Patients. Crit Care Med 2022; 50:e539-e547. [PMID: 35132018 DOI: 10.1097/ccm.0000000000005460] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Anemia is common after acute brain injury and can be associated with brain tissue hypoxia. RBC transfusion (RBCT) can improve brain oxygenation; however, predictors of such improvement remain unknown. We aimed to identify the factors associated with PbtO2 increase (greater than 20% from baseline value) after RBCT, using a generalized mixed model. DESIGN This is a multicentric retrospective cohort study (2012-2020). SETTING This study was conducted in three European ICUs of University Hospitals located in Belgium, Switzerland, and Austria. PATIENTS All patients with acute brain injury who were monitored with brain tissue oxygenation (PbtO2) catheters and received at least one RBCT. INTERVENTION Patients received at least one RBCT. PbtO2 was recorded before, 1 hour, and 2 hours after RBCT. MEASUREMENTS AND MAIN RESULTS We included 69 patients receiving a total of 109 RBCTs after a median of 9 days (5-13 d) after injury. Baseline hemoglobin (Hb) and PbtO2 were 7.9 g/dL [7.3-8.7 g/dL] and 21 mm Hg (16-26 mm Hg), respectively; 2 hours after RBCT, the median absolute Hb and PbtO2 increases from baseline were 1.2 g/dL [0.8-1.8 g/dL] (p = 0.001) and 3 mm Hg (0-6 mm Hg) (p = 0.001). A 20% increase in PbtO2 after RBCT was observed in 45 transfusions (41%). High heart rate (HR) and low PbtO2 at baseline were independently associated with a 20% increase in PbtO2 after RBCT. Baseline PbtO2 had an area under receiver operator characteristic of 0.73 (95% CI, 0.64-0.83) to predict PbtO2 increase; a PbtO2 of 20 mm Hg had a sensitivity of 58% and a specificity of 73% to predict PbtO2 increase after RBCT. CONCLUSIONS Lower PbtO2 values and high HR at baseline could predict a significant increase in brain oxygenation after RBCT.
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Yoshida T, McMahon E, Croxon H, Dunham A, Gaccione P, Abbasi B, Beckman N, Omert L, Field S, Waters A. The oxygen saturation of red blood cell concentrates: The basis for a novel index of red cell oxidative stress. Transfusion 2021; 62:183-193. [PMID: 34761414 DOI: 10.1111/trf.16715] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/10/2021] [Accepted: 10/14/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Oxidative stress is a major driving force in the development of storage lesions in red cell concentrates (RCCs). Unlike manufactured pharmaceuticals, differences in component preparation methods and genetic/physiological status of donors result in nonuniform biochemical characteristics of RCCs. Various characteristics of donated blood on oxygen saturation (SO2 ) distribution were investigated, and a model to estimate potential oxidative stress burden of stored RCC at transfusion is proposed. STUDY DESIGN AND METHODS The oxygen content of freshly prepared RCCs (770) was quantified noninvasively as fractional hemoglobin saturation (SO2 ) with visible reflectance spectrometry. Using separate RCCs and mimicking typical handling of RCCs during routine storage, evolution of SO2 was followed for construction of an empirical model. Based on this model, the oxygen exposure index (OEI) was formulated to estimate the accumulated oxygen exposure burden of RCC at the time of transfusion. RESULTS The SO2 of RCCs varied widely at donation (mean 43% ± 1.3%; range 20%-93%). Multivariate regression model showed that sex and processing method had small effects on SO2 (R2 = 0.12), indicating that variability was mainly attributed to other individual donor characteristics. Storage simulation model indicated that median SO2 increased gradually over 6 weeks (approx. 1.3 fold), while OEI increased at a faster rate (approx. eight-fold). CONCLUSION In addition to storage age, the OEI provides a potential new metric to assess the quality of RCCs at the time of transfusion in terms of their oxidative stress. In future studies, a single noninvasive measurement during storage could link OEI to clinical outcomes in transfusion recipients.
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Affiliation(s)
| | - Emma McMahon
- Irish Blood Transfusion Service, Dublin, Ireland
| | - Harry Croxon
- Irish Blood Transfusion Service, Dublin, Ireland
| | | | | | - Babak Abbasi
- Information Systems and Supply Chain, RMIT University, Melbourne, Victoria, Australia
| | | | | | - Stephen Field
- Irish Blood Transfusion Service, Dublin, Ireland.,School of Medicine, Trinity College Dublin, Dublin, Ireland
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Liu W, He H, Ince C, Long Y. The effect of blood transfusion on sublingual microcirculation in critically ill patients: A scoping review. Microcirculation 2020; 28:e12666. [PMID: 33091957 DOI: 10.1111/micc.12666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 10/10/2020] [Accepted: 10/14/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate the effects of red blood cell (RBC) transfusion on sublingual microcirculation in critically ill patients. METHODS Systematic strategy was conducted to search studies that measured sublingual microcirculation before and after transfusion in critically ill patients. This review was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses Scoping Review Extension. RESULTS The literature search yielded 114 articles. A total of 11 studies met the inclusion criteria. Observational evidence showed diffusive capacity of the microcirculation significantly improved in intraoperative and anemic hematologic patients after transfusion, while the convective parameters significantly improved in traumatic patients. RBC transfusion improved both diffusive and convective microcirculatory parameters in hypovolemic hemorrhagic shock patients. Most of the studies enrolled septic patients showed no microcirculatory improvements after transfusion. The positive effects of the leukoreduction were insufficiently supported. The effects of the storage time of the RBCs were not conclusive. The majority of the evidence supported a negative correlation between baseline proportion of perfused vessels (PPV) and changes in PPV. CONCLUSIONS This scoping review has catalogued evidence that RBC transfusion differently improves sublingual microcirculation in different populations. The existing evidence is not sufficient to conclude the effects of the leukoreduction and storage time of RBCs.
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Affiliation(s)
- Wanglin Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Can Ince
- Department of Intensive Care, Laboratory of Translational Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
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David M, Levy E, Barshtein G, Livshits L, Arbell D, Ben Ishai P, Feldman Y. The dielectric spectroscopy of human red blood cells during 37-day storage: β-dispersion parameterization. BIOCHIMICA ET BIOPHYSICA ACTA-BIOMEMBRANES 2020; 1862:183410. [PMID: 32687816 DOI: 10.1016/j.bbamem.2020.183410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/10/2020] [Accepted: 07/12/2020] [Indexed: 11/17/2022]
Abstract
This study exploits dielectric spectroscopy to monitor the kinetics of red blood cells (RBC) storage lesions, focusing on those processes linked to cellular membrane interface known as β-dispersion. The dielectric response of RBC suspensions, exposed to blood-bank cold storage for 37 days, was studied using time-domain dielectric spectroscopy in the frequency range 500 kHz to 200 MHz. The measured dielectric processes are characterized by their dielectric strength (Δε) and their relaxation times (τ). Changes in the dielectric properties of the RBC suspensions, due to storage-related biophysical changes, were evaluated. For a quantitative characterization of RBC vitality, we characterized the shape of fresh and stored RBC and measured their deformability as expressed by their average elongation ratio, which was achieved under a shear stress of 3.0 Pa. During the second week of storage, an increment in the evolution of the relaxation times and in the dielectric permittivity strength of about 25% was observed. We propose that the characteristic increment of ATP, during the second and third weeks of storage, is responsible for the raise of the specific capacitance of cell membrane, which in turn explains the changes observed in the dielectric response when combined with the influence of the shape changes.
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Affiliation(s)
- Marcelo David
- The Hebrew University of Jerusalem, Applied Physics Department, Jerusalem, Israel.
| | - Evgeniya Levy
- The Hebrew University of Jerusalem, Applied Physics Department, Jerusalem, Israel
| | - Gregory Barshtein
- The Hebrew University of Jerusalem, Faculty of Medicine, Department of Biochemistry & Molecular Biology, Jerusalem, Israel
| | - Leonid Livshits
- The Hebrew University of Jerusalem, Faculty of Medicine, Department of Biochemistry & Molecular Biology, Jerusalem, Israel
| | - Dan Arbell
- Pediatric Surgery, Hadassah Medical Center, Israel
| | - Paul Ben Ishai
- Department of Physics, Ariel University, P.O.B. 3, Ariel 40700, Israel
| | - Yuri Feldman
- The Hebrew University of Jerusalem, Applied Physics Department, Jerusalem, Israel.
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Rodrigues RR, Kayano CY, Dos Santos VP, Moroz LR, Fantoni DT, Ambrósio AM. Evaluation of hematologic, biochemical, and blood gas variables in stored canine packed red blood cells, and the impact of storage time on blood recipients. Vet Clin Pathol 2020; 49:198-206. [PMID: 32542780 DOI: 10.1111/vcp.12865] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 10/13/2019] [Accepted: 10/22/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Canine packed red blood cells (pRBCs) can be stored under refrigeration for several days; however, cellular metabolism remains active inside the units, thus producing substances that affect their quality. OBJECTIVES We aimed to evaluate hematologic, biochemical, and blood gas variable alterations that occur in canine pRBCs during storage, and their effects on recipient clinicopathologic parameters. METHODS The study was conducted in two phases. In phase I, 15 pRBC units containing CPDA-1 were stored for 28 days; samples were collected weekly from the units of days 0 to 28 to measure the packed cell volume (PCV), pH, partial pressure carbon dioxide (PCO2 ), partial pressure oxygen (PO2 ), concentrations of lactate and potassium, and the percent hemolysis. In phase II, another 22 canine pRBC units stored for different time periods (maximum of 21 days) were transfused, and the recipients were evaluated before and after transfusion for changes in clinical parameters (heart rate, respiratory rate, systolic arterial pressure, and rectal temperature) and hematologic variables (PCV, lactate and potassium concentrations, pH, PCO2 , the ratio of arterial oxygen partial pressure to fractional inspired oxygen [PO2 /FiO2 ] ratio, oxygen saturation [SaO2 ], base excess, and bicarbonate [HCO3 ]). RESULTS In the pRBC units, the PCV increased from 70% to 78.33%, the lactate concentration increased 627%, the potassium concentration increased 183%, the percent hemolysis reached 0.69%, and the pH decreased 9% after 28 days. However, the dogs who received transfusions were not negatively affected. There was a significant increase in PCVs, and a significant decrease in heart rates. CONCLUSION Canine pRBCs undergo hematologic, blood gas, and biochemical alterations during storage; however, the transfusion of pRBCs stored for up to 21 days increased PCVs without causing harm to the dogs.
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Affiliation(s)
- Renata R Rodrigues
- Department of Surgery, Faculty of Veterinary Medicine and Animal Science, São Paulo University, São Paulo, Brazil
| | - Caroline Y Kayano
- Department of Surgery, Faculty of Veterinary Medicine and Animal Science, São Paulo University, São Paulo, Brazil
| | - Vinícius P Dos Santos
- Department of Surgery, Faculty of Veterinary Medicine and Animal Science, São Paulo University, São Paulo, Brazil
| | - Ludmila R Moroz
- Laboratory of Clinical Analysis, Bahia Federal University, Salvador, Brazil
| | - Denise T Fantoni
- Department of Surgery, Faculty of Veterinary Medicine and Animal Science, São Paulo University, São Paulo, Brazil
| | - Aline M Ambrósio
- Department of Surgery, Faculty of Veterinary Medicine and Animal Science, São Paulo University, São Paulo, Brazil
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8
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Wang Y, Li Q, Ma T, Liu X, Wang B, Wu Z, Dang S, Lv Y, Wu R. Transfusion of Older Red Blood Cells Increases the Risk of Acute Kidney Injury After Orthotopic Liver Transplantation: A Propensity Score Analysis. Anesth Analg 2019; 127:202-209. [PMID: 28863026 DOI: 10.1213/ane.0000000000002437] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common and serious complication of orthotopic liver transplantation (OLT). Transfusion of older red blood cells (RBCs) has been implicated in poor outcomes in trauma, cardiac surgery, and critically ill patients. However, whether transfusion of older RBCs plays any role in post-OLT AKI remained unknown. The aim of this study was to investigate the effect of the age of transfused RBCs on post-OLT AKI. METHODS The clinical data of consecutive adult patients who received donation after cardiac death and underwent OLT from December 2011 to December 2015 were analyzed. These patients were divided into 2 groups: the newer blood group, who received exclusively RBCs that had been stored for <14 days; and the older blood group, who received RBCs that had been stored for 14 days or more. The incidence of post-OLT AKI, severe AKI, lengths of intensive care unit and hospital stay, and in-hospital mortality after OLT were analyzed. RESULTS Postoperative AKI occurred in 65.1% of patients in the older blood group and 40.5% of patients in the newer blood group (P < .01). The incidence of severe AKI after OLT was significantly higher, and the duration of intensive care unit stay was significantly longer, in the older blood group. After adjustment by the multivariable regression logistic analysis, transfusion of older blood was independently associated with post-OLT AKI (odds ratio [OR] = 2.47 [95% confidence interval {CI}, 1.13-5.41]; P = .024) and severe AKI (OR = 5.88 [95% CI, 2.06-16.80]; P = .001). After adjustment by the inverse probability of treatment weighting analysis, patients in the older blood group still had significantly higher incidences of postoperative AKI (OR = 2.13 [95% CI, 1.07-4.22]; P = .030) and severe AKI (OR = 3.34 [95% CI, 1.47-7.60]; P = .003) than those in the newer blood group. CONCLUSIONS Transfusion of older RBCs significantly increased the risk of postoperative AKI in liver transplant recipients.
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Affiliation(s)
- Yue Wang
- From the Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Xi'an, China.,Institute of Advanced Surgical Technology and Engineering, Xi'an, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Qingshan Li
- From the Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Xi'an, China.,Institute of Advanced Surgical Technology and Engineering, Xi'an, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Tao Ma
- From the Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Xi'an, China.,Institute of Advanced Surgical Technology and Engineering, Xi'an, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xuemin Liu
- Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Bo Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Shaonong Dang
- Department of Epidemiology and Biostatistics, Xi'an Jiaotong University School of Public Health, Xi'an, Shaanxi Province, China
| | - Yi Lv
- From the Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Xi'an, China.,Institute of Advanced Surgical Technology and Engineering, Xi'an, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Rongqian Wu
- From the Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Xi'an, China.,Institute of Advanced Surgical Technology and Engineering, Xi'an, China
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Bishnoi AK, Garg P, Patel K, Ananthanarayanan C, Shah R, Solanki A, Pandya H, Patel S. Effect of Red Blood Cell Storage Duration on Outcome After Paediatric Cardiac Surgery: A Prospective Observational Study. Heart Lung Circ 2019; 28:784-791. [DOI: 10.1016/j.hlc.2018.03.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 12/07/2017] [Accepted: 03/12/2018] [Indexed: 10/17/2022]
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Spinella PC, Sniecinski RM, Trachtenberg F, Inglis HC, Ranganathan G, Heitman JW, Szlam F, Danesh A, Stone M, Keating SM, Levy JH, Assmann SF, Steiner ME, Doctor A, Norris PJ. Effects of blood storage age on immune, coagulation, and nitric oxide parameters in transfused patients undergoing cardiac surgery. Transfusion 2019; 59:1209-1222. [PMID: 30835880 DOI: 10.1111/trf.15228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/13/2018] [Accepted: 12/15/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Retrospective studies suggested that storage age of RBCs is associated with inflammation and thromboembolism. The Red Cell Storage Duration Study (RECESS) trial randomized subjects undergoing complex cardiac surgery to receive RBCs stored for shorter versus longer periods, and no difference was seen in the primary outcome of change in multiple organ dysfunction score. STUDY DESIGN AND METHODS In the current study, 90 subjects from the RECESS trial were studied intensively using a range of hemostasis, immunologic, and nitric oxide parameters. Samples were collected before transfusion and on Days 2, 6, 28, and 180 after transfusion. RESULTS Of 71 parameters tested, only 4 showed a significant difference after transfusion between study arms: CD8+ T-cell interferon-γ secretion and the concentration of extracellular vesicles bearing the B-cell marker CD19 were higher, and plasma endothelial growth factor levels were lower in recipients of fresh versus aged RBCs. Plasma interleukin-6 was higher at Day 2 and lower at Days 6 and 28 in recipients of fresh versus aged RBCs. Multiple parameters showed significant modulation after surgery and transfusion. Most analytes that changed after surgery did not differ based on transfusion status. Several extracellular vesicle markers, including two associated with platelets (CD41a and CD62P), decreased in transfused patients more than in those who underwent surgery without transfusion. CONCLUSIONS Transfusion of fresh versus aged RBCs does not result in substantial changes in hemostasis, immune, or nitric oxide parameters. It is possible that transfusion modulates the level of platelet-derived extracellular vesicles, which will require study of patients randomly assigned to receipt of transfusion to define.
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Affiliation(s)
- Philip C Spinella
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Saint Louis, Missouri
| | - Roman M Sniecinski
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | | | - Fania Szlam
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Ali Danesh
- Vitalant Research Institute, San Francisco, California
| | - Mars Stone
- Vitalant Research Institute, San Francisco, California
| | | | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina
| | | | - Marie E Steiner
- Department of Hematology and Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Allan Doctor
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Saint Louis, Missouri
| | - Philip J Norris
- Vitalant Research Institute, San Francisco, California.,Department of Laboratory Medicine, University of California, San Francisco, California.,Department of Medicine, University of California, San Francisco, California
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Effect of age of transfused red blood cells on neurologic outcome following traumatic brain injury (ABLE-tbi Study): a nested study of the Age of Blood Evaluation (ABLE) trial. Can J Anaesth 2019; 66:696-705. [PMID: 30809776 DOI: 10.1007/s12630-019-01326-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 01/06/2019] [Accepted: 01/10/2019] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Anemia is common in critically ill patients with traumatic brain injury, and often requires red blood cell transfusion. Studies suggest that prolonged storage causes lesions of the red blood cells, including a decreased ability to carry oxygen. Considering the susceptibility of the brain to hypoxemia, victims of traumatic brain injury may thus be more vulnerable to exposure to older red blood cells. METHODS Our study aimed to ascertain whether the administration of fresh red blood cells (seven days or less) results in a better neurologic outcome compared with standard red blood cells in critically ill patients with traumatic brain injury requiring transfusion. The Age of Blood Evaluation in traumatic brain injury (ABLE-tbi) study was a nested study within the ABLE study (ISRCTN44878718). Our primary outcome was the extended Glasgow Outcome Scale (GOSe) at six months. RESULTS In the ABLE study, 217 subjects suffered a traumatic brain injury: 110 in the fresh group, and 107 in the standard group. In the fresh group, 68 (73.1%) of the patients had an unfavourable neurologic outcome (GOSe ≤ 4) compared with 60 (64.5%) in the standard group (P = 0.21). Using a sliding dichotomy approach, we observed no overall effect of fresh red blood cells on neurologic outcome (odds ratio [OR], 1.34; 95% confidence interval [CI], 0.72 to 2.50; P = 0.35) but observed differences across prognostic bands with a decreased odds of unfavourable outcome in patients with the best prognosis at baseline (OR, 0.33; 95% CI, 0.11 to 0.96; P = 0.04) but an increased odds in those with intermediate and worst baseline prognosis (OR, 5.88; 95% CI,1.66 to 20.81; P = 0.006; and OR, 1.67; 95% CI, 0.53 to 5.30; P = 0.38, respectively). CONCLUSION Overall, transfusion of fresh red blood cells was not associated with a better neurologic outcome at six months in critically ill patients with traumatic brain injury. Nevertheless, we cannot exclude a differential effect according to the patient baseline prognosis. TRIAL REGISTRATION ABLE study (ISRCTN44878718); registered 22 August, 2008.
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Zhou X, Xu Z, Wang Y, Sun L, Zhou W, Liu X. Association between storage age of transfused red blood cells and clinical outcomes in critically ill adults: A meta-analysis of randomized controlled trials. Med Intensiva 2018; 43:528-537. [PMID: 30241932 DOI: 10.1016/j.medin.2018.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/02/2018] [Accepted: 07/03/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVES A meta-analysis was performed to assesses the effect of storage age of transfused red blood cells (RBCs) upon clinical outcomes in critically ill adults. METHODS A comprehensive search was conducted in the PubMed, OVID, Web of Science and Cochrane databases for randomized controlled trials (RCTs) comparing the transfusion of fresher versus older RBCs in critically ill adults from database inception to December 2017. The primary endpoint was short-term mortality, and the secondary endpoints were the duration of intensive care unit (ICU) and hospital stay. The pooled odds ratios (OR) and mean differences (MD) were calculated using Stata/SE 11.0. RESULTS A total of six RCTs were identified, of which four were multicenter studies, while two were single-center trials. The pooled results indicated that the transfusion of fresher RBCs was not associated to a decrease in short-term mortality compared with the transfusion of older RBCs (random-effects OR=1.04, 95% confidence interval (CI): 0.96-1.13, P=0.312; I2=0.0%; six trials; 18240 patients), regardless of whether the studies were of a multi-center (random-effects OR=1.04, 95% CI: 0.96-1.13, P=0.292; I2=0.0%) or single-center nature (random-effects OR=1.16, 95% CI: 0.28-4.71, P=0.839; I2=56.7%), or with low risk of bias (random-effects OR=1.04, 95% CI: 0.94-1.16, P=0.445; I2=0.0%). In addition, the transfusion of fresher RBCs did not reduce the geometric mean duration of ICU stay (1.0% increase in geometric mean, 95% CI: -3.0 to 5.1%, P=0.638; I2=81.5%; four trials; 7550 patients) or the geometric mean duration of hospital stay (0.0% increase in geometric mean, 95% CI: -3.9 to 4.1%, P=0.957; I2=7.4%; four trials; 7550 patients) compared with the transfusion of older RBCs. CONCLUSIONS The transfusion of fresher RBCs compared with older RBCs was not associated to better clinical outcomes in critically ill adults.
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Affiliation(s)
- X Zhou
- Department of Intensive Care Medicine, Ningbo No. 2 Hospital, Ningbo, China
| | - Z Xu
- Department of Intensive Care Medicine, Ningbo No. 2 Hospital, Ningbo, China.
| | - Y Wang
- Department of Intensive Care Medicine, Ningbo No. 2 Hospital, Ningbo, China
| | - L Sun
- Department of Geriatrics, Ningbo No. 2 Hospital, Ningbo, China
| | - W Zhou
- Department of Liver Disease, Beilun Hospital of Traditional Chinese Medicine, Ningbo, China
| | - X Liu
- Department of Respiratory Medicine, Ningbo No. 2 Hospital, Ningbo, China
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Saito-Benz M, Murphy WG, Tzeng YC, Atkinson G, Berry MJ. Storage after gamma irradiation affects in vivo oxygen delivery capacity of transfused red blood cells in preterm infants. Transfusion 2018; 58:2108-2112. [DOI: 10.1111/trf.14764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 04/02/2018] [Accepted: 04/04/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Maria Saito-Benz
- Department of Paediatrics and Child Health
- Centre for Translational Physiology; University of Otago
| | - William G. Murphy
- NZ Blood Service, Wellington Regional Hospital; Wellington New Zealand
- School of Medicine and Medical Science; University College; Dublin Ireland
| | - Yu-Chieh Tzeng
- Centre for Translational Physiology; University of Otago
| | - Greg Atkinson
- School of Health and Social Care; Teesside University; Middlesbrough North Yorkshire United Kingdom
| | - Mary J. Berry
- Department of Paediatrics and Child Health
- Centre for Translational Physiology; University of Otago
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Godoy DA, Lubillo S, Rabinstein AA. Pathophysiology and Management of Intracranial Hypertension and Tissular Brain Hypoxia After Severe Traumatic Brain Injury: An Integrative Approach. Neurosurg Clin N Am 2018; 29:195-212. [PMID: 29502711 DOI: 10.1016/j.nec.2017.12.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Monitoring intracranial pressure in comatose patients with severe traumatic brain injury (TBI) is considered necessary by most experts. Acute intracranial hypertension (IHT), when severe and sustained, is a life-threatening complication that demands emergency treatment. Yet, secondary anoxic-ischemic injury after brain trauma can occur in the absence of IHT. In such cases, adding other monitoring modalities can alert clinicians when the patient is in a state of energy failure. This article reviews the mechanisms, diagnosis, and treatment of IHT and brain hypoxia after TBI, emphasizing the need to develop a physiologically integrative approach to the management of these complex situations.
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Affiliation(s)
- Daniel Agustín Godoy
- Intensive Care Unit, San Juan Bautista Hospital, Catamarca, Argentina; Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina.
| | - Santiago Lubillo
- Intensive Care Unit, Hospital Universitario NS de Candelaria, Tenerife, Spain
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15
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Barshtein G, Arbell D, Yedgar S. Hemodynamic Functionality of Transfused Red Blood Cells in the Microcirculation of Blood Recipients. Front Physiol 2018; 9:41. [PMID: 29441026 PMCID: PMC5797635 DOI: 10.3389/fphys.2018.00041] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/11/2018] [Indexed: 01/23/2023] Open
Abstract
The primary goal of red blood cell (RBC) transfusion is to supply oxygen to tissues and organs. However, due to a growing number of studies that have reported negative transfusion outcomes, including reduced blood perfusion, there is rising concern about the risks in blood transfusion. RBC are characterized by unique flow-affecting properties, specifically adherence to blood vessel wall endothelium, cell deformability, and self-aggregability, which define their hemodynamic functionality (HF), namely their potential to affect blood circulation. The role of the HF of RBC in blood circulation, particularly the microcirculation, has been documented in numerous studies with animal models. These studies indicate that the HF of transfused RBC (TRBC) plays an important role in the transfusion outcome. However, studies with animal models must be interpreted with reservations, as animal physiology may not reflect human physiology. To test this concept in humans, we have directly examined the effect of the HF of TRBC, as expressed by their deformability and adherence to vascular endothelium, on the transfusion-induced effect on the skin blood flow and hemoglobin increment in β-thalassemia major patients. The results demonstrated, for the first time in humans, that the TRBC HF is a potent effector of the transfusion outcome, expressed by the transfusion-induced increase in the recipients' hemoglobin level, and the change in the skin blood flow, indicating a link between the microcirculation and the survival of TRBC in the recipients' vascular system. The implication of these findings for blood transfusion practice and to vascular function in blood recipients is discussed.
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Affiliation(s)
- Gregory Barshtein
- Department of Biochemistry, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Dan Arbell
- Department of Pediatric Surgery, Hadassah University Hospital, Jerusalem, Israel
| | - Saul Yedgar
- Department of Biochemistry, Faculty of Medicine, Hebrew University, Jerusalem, Israel
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16
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Jani VP, Yalcin O, Williams AT, Popovsky MA, Cabrales P. Rat red blood cell storage lesions in various additive solutions. Clin Hemorheol Microcirc 2018; 67:45-57. [PMID: 28598831 DOI: 10.3233/ch-170248] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Small rodent models are routinely used to evaluate the safety and efficacy of blood transfusions. Limited comprehensive literature exists about effect of different storage solutions in rat red blood cells (RBCs) characteristics. RBCs undergo time dependent biochemical and biophysical changes during storage known as hypothermic storage lesions (HSLs). OBJECTIVE This study evaluates the effects of RBC additive solutions (AS) during storage of rat RBCs. METHODS Blood was leukoreduced and stored as per manufacturer instructions at 4°C up to 42-days. Three solutions, CPDA-1; AS-1; and AS-7 (SOLX), were evaluated. Biochemical parameters measured included extracellular K+, pH, hemolysis, 2,3-diphosphoglycerate (2,3-DPG), oxygen affinity, ATP, and lactate. Mechanical properties measured included RBC deformability, elongation index (EI), RBC membrane shear elastic modulus (SEM), mean corpuscular volume (MCV), viscosity, and aggregability. RESULTS There were no differences in biochemical or mechanical parameters at baseline or after one week of storage. However, after two weeks, AS-7 preserved biochemical and mechanical properties as compared to CPDA-1 and AS-1. Changes were observed to be significant after 14-days of storage. AS-7 prevented extracellular K+ increase, reduced acidosis, showed lower hemolysis, preserved ATP and 2,3-DPG levels (consequently oxygen affinity), and reduced lactate. AS-7, when compared to CPDA-1 and AS-1, prevented the reduction in RBC deformability and was found to preserve the EI at multiple shear stresses, the membrane SEM, the aggregability and viscosity. DISCUSSION Rat RBCs stored with AS-7 presented reduced changes in biochemical and mechanical parameters, when compared with rat RBCs stored in CPDA-1 and AS-1, after as early as two weeks of storage.
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Affiliation(s)
- Vivek P Jani
- Department of Bioengineering, University of California, San Diego, CA, USA
| | - Ozlem Yalcin
- Department of Bioengineering, University of California, San Diego, CA, USA.,School of Medicine, Koç University, Sariyer, Istanbul, Turkey
| | | | | | - Pedro Cabrales
- Department of Bioengineering, University of California, San Diego, CA, USA
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17
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Kumar MA, Levine J, Faerber J, Elliott JP, Winn HR, Doerfler S, Le Roux P. The Effects of Red Blood Cell Transfusion on Functional Outcome after Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 108:807-816. [PMID: 29038077 DOI: 10.1016/j.wneu.2017.09.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 09/06/2017] [Accepted: 09/07/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND The optimal red blood cell transfusion (RBCT) trigger for patients with aneurysmal subarachnoid hemorrhage (SAH) is unknown. In patients with cerebral vasospasm, anemia may increase susceptibility to ischemic injury; conversely, RBCT may worsen outcome given known deleterious effects. OBJECTIVE To examine the association between RBCT, delayed cerebral ischemia (DCI), vasospasm, and outcome after SAH. METHODS A total of 421 consecutive patients with SAH, admitted to a neurocritical care unit at a university-affiliated hospital and who underwent surgical occlusion of their ruptured aneurysm were retrospectively identified from a prospective observational database. Propensity score methods were used to reduce the bias associated with treatment selection. RESULTS Two hundred and sixty-one patients (62.0%) received an RBCT. Angiographic vasospasm (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.1-2.3; P = 0.025) but not severe angiographic spasm, DCI, or delayed infarction was associated with RBCT. A total of 283 patients (67.2%) experienced a favorable outcome, defined as good or moderately disabled on the Glasgow Outcome Scale; 47 (11.2%) were severely disabled or vegetative and 91 patients (21.6%) were dead at 6-month follow-up. Among patients who survived ≥2 days, RBCT was associated with unfavorable outcome (OR, 2.6; 95% CI, 1.6-4.1). Transfusion of ≥3 units of blood was associated with an increased incidence of unfavorable outcome. Propensity analysis to control for the probability of exposure to RBCT conditional on observed covariates measured before RBCT indicates that RBCT is associated with unfavorable outcome in the absence of DCI (OR, 2.17; 95% CI, 1.56-3.01; P < 0.0001) but not when DCI is present (OR, 0.82; 95% CI, 0.35-1.92; P = 0.65). CONCLUSIONS Blood transfusions are associated with unfavorable outcome after SAH particularly when DCI is absent. Propensity analysis suggests that RBCT may be associated with poor outcome rather than being a marker of disease severity. However, when DCI is present, RBCT may help improve outcome.
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Affiliation(s)
- Monisha A Kumar
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua Levine
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Faerber
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J Paul Elliott
- Colorado Neurological Institute, Englewood, Colorado, USA
| | - H Richard Winn
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Sean Doerfler
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter Le Roux
- Brain and Spine Center and Lankenau Institute of Medical Research Lankenau Medical Center, Wynnewood, Pennsylvania, USA.
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18
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Effects of Red Blood Cell Transfusion on Long-Term Disability of Patients with Traumatic Brain Injury. Neurocrit Care 2017; 24:371-80. [PMID: 26627227 DOI: 10.1007/s12028-015-0220-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND This 3-year prospective study examined the association between red blood cell transfusion (RBCT) and 1-year neurocognitive and disability levels in 309 patients with traumatic brain injury (TBI) admitted to the neurological intensive care unit (NICU). METHODS Using a telephone interview-based survey, functional outcomes were assessed by the Glasgow Outcome Scale (GOS), Rancho Los Amigos Levels of Cognitive Functioning Scale (RLCFS), and Disability Rating Scale (DRS) and dichotomized as favorable and unfavorable (dependent variable). The adjusted influence of RBCT on unfavorable results was assessed by conventional logistic regression, controlling for illness severity and propensity score (introduced as a continuous variable and by propensity score-matched patients). RESULTS Overall, 164 (53 %) patients received ≥1 unit of RBCT during their NICU stay. One year postinjury, transfused patients exhibited significantly higher unfavorable GOS (46.0 vs. 22.0 %), RLCFS (37.4 vs. 15.4 %), and DRS (39.6 vs. 18.7 %) scores than nontransfused patients. Although transfused patients were more severely ill upon admission, their adjusted odds ratios (95 % confidence intervals) for unfavorable GOS, RLCFS, and DRS scores were 2.5 (1.2-5.1), 3.0 (1.4-6.3), and 2.3 (1.1-4.8), respectively. These odds ratios remained largely unmodified when the calculated propensity score was incorporated as an independent continuous variable into the multivariate analysis. Furthermore, in 76 pairs of propensity score-matched patients, the rate of an unfavorable RLCFS score at the 1-year (but not 6-month) follow-up was significantly higher in transfused than nontransfused patients [3.0 (1.1-8.2)]. CONCLUSION Our results strongly suggest an independent association between RBCT and unfavorable long-term functional outcomes of patients with TBI.
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Abstract
Transfusion decision making (TDM) in the critically ill requires consideration of: (1) anemia tolerance, which is linked to active pathology and to physiologic reserve, (2) differences in donor RBC physiology from that of native RBCs, and (3) relative risk from anemia-attributable oxygen delivery failure vs hazards of transfusion, itself. Current approaches to TDM (e.g. hemoglobin thresholds) do not: (1) differentiate between patients with similar anemia, but dissimilar pathology/physiology, and (2) guide transfusion timing and amount to efficacy-based goals (other than resolution of hemoglobin thresholds). Here, we explore approaches to TDM that address the above gaps.
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Affiliation(s)
- Chris Markham
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, McDonnell Pediatric Research Building, Campus Box 8208, 660 South Euclid Avenue, St Louis, MO 63110-1093, USA
| | - Sara Small
- Social Systems Design Laboratory, Brown School of Social Work, Washington University, Campus Box 1196, 1 Brookings Drive, St Louis, MO 63130, USA
| | - Peter Hovmand
- Social Systems Design Laboratory, Brown School of Social Work, Washington University, Campus Box 1196, 1 Brookings Drive, St Louis, MO 63130, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, McDonnell Pediatric Research Building, Campus Box 8208, 660 South Euclid Avenue, St Louis, MO 63110-1093, USA.
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20
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Figaji AA, Graham Fieggen A, Mankahla N, Enslin N, Rohlwink UK. Targeted treatment in severe traumatic brain injury in the age of precision medicine. Childs Nerv Syst 2017; 33:1651-1661. [PMID: 28808845 DOI: 10.1007/s00381-017-3562-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 07/27/2017] [Indexed: 11/28/2022]
Abstract
In recent years, much progress has been made in our understanding of traumatic brain injury (TBI). Clinical outcomes have progressively improved, but evidence-based guidelines for how we manage patients remain surprisingly weak. The problem is that the many interventions and strategies that have been investigated in randomized controlled trials have all disappointed. These include many concepts that had become standard care in TBI. And that is just for adult TBI; in children, the situation is even worse. Not only is pediatric care more difficult than adult care because physiological norms change with age, but also there is less evidence for clinical practice. In this article, we discuss the heterogeneity inherent in TBI and why so many clinical trials have failed. We submit that a key goal for the future is to appreciate important clinical differences between patients in their pathophysiology and their responses to treatment. The challenge that faces us is how to rationally apply therapies based on the specific needs of an individual patient. In doing so, we may be able to apply the principles of precision medicine approaches to the patients we treat.
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Affiliation(s)
- Anthony A Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa.
| | - A Graham Fieggen
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Ncedile Mankahla
- Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
| | - Nico Enslin
- Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
| | - Ursula K Rohlwink
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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21
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Leal-Noval SR, Arellano-Orden V, Muñoz-Gómez M, Cayuela A, Marín-Caballos A, Rincón-Ferrari MD, García-Alfaro C, Amaya-Villar R, Casado-Méndez M, Dusseck R, Murillo-Cabezas F. Red Blood Cell Transfusion Guided by Near Infrared Spectroscopy in Neurocritically Ill Patients with Moderate or Severe Anemia: A Randomized, Controlled Trial. J Neurotrauma 2017; 34:2553-2559. [DOI: 10.1089/neu.2016.4794] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
| | | | - Manuel Muñoz-Gómez
- Perioperative Transfusion Medicine, School of Medicine, University of Málaga, Málaga, Spain
| | - Aurelio Cayuela
- Public Health Department, Statistics and Design Division, University Hospital “Virgen del Valme,” Seville, Spain
| | | | | | | | | | | | - Reginal Dusseck
- Neurocritical Care Unit, University Hospital “Virgen del Rocío,” Seville, Spain
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22
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David M, Levy E, Feldman Y, Ben Ishai P, Zelig O, Yedgar S, Barshtein G. The dielectric spectroscopy of human red blood cells: the differentiation of old from fresh cells. Physiol Meas 2017; 38:1335-1348. [DOI: 10.1088/1361-6579/aa707a] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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23
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Edgren G, Ullum H, Rostgaard K, Erikstrup C, Sartipy U, Holzmann MJ, Nyrén O, Hjalgrim H. Association of Donor Age and Sex With Survival of Patients Receiving Transfusions. JAMA Intern Med 2017; 177:854-860. [PMID: 28437543 PMCID: PMC5540056 DOI: 10.1001/jamainternmed.2017.0890] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Following animal model data indicating the possible rejuvenating effects of blood from young donors, there have been at least 2 observational studies conducted with humans that have investigated whether donor age affects patient outcomes. Results, however, have been conflicting. OBJECTIVE To study the association of donor age and sex with survival of patients receiving transfusions. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study based on the Scandinavian Donations and Transfusions database, with nationwide data, was conducted for all patients from Sweden and Denmark who received at least 1 red blood cell transfusion of autologous blood or blood from unknown donors between January 1, 2003, and December 31, 2012. Patients were followed up from the first transfusion until death, emigration, or end of follow-up. Data analysis was performed from September 15 to November 15, 2016. EXPOSURES The number of transfusions from blood donors of different age and sex. Exposure was treated time dependently throughout follow-up. MAIN OUTCOMES AND MEASURES Hazard ratios (HRs) for death and adjusted cumulative mortality differences, both estimated using Cox proportional hazards regression. RESULTS Results of a crude analysis including 968 264 transfusion recipients (550 257 women and 418 007 men; median age at first transfusion, 73.0 years [interquartile range, 59.8-82.4 years]) showed a U-shaped association between age of the blood donor and recipient mortality, with a nadir in recipients for the most common donor age group (40-49 years) and significant and increasing HRs among recipients of blood from donors of successively more extreme age groups (<20 years: HR, 1.12; 95% CI, 1.10-1.14; ≥70 years: HR, 1.25; 95% CI, 1.08-1.44). Higher mortality was also noted among recipients of blood from female donors (HR, 1.07; 95% CI, 1.07-1.07). Adjustments for number of transfusions with a linear term attenuated the associations, but the increased mortality for recipients of blood from young, old, and female donors was not eliminated. Closer examination of the association between number of transfusions and mortality revealed a nonlinear pattern. After adjustments to accommodate nonlinearity, donor age and sex were no longer associated with patient mortality. CONCLUSIONS AND RELEVANCE Donor age and sex were not associated with patient survival and need not be considered in blood allocation. Any comparison between common and less common categories of transfusions will inevitably be confounded by the number of transfusions, which drives the probability of receiving the less common blood components. Previous positive findings regarding donor age and sex are most likely explained by residual confounding.
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Affiliation(s)
- Gustaf Edgren
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden2Hematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Ullum
- Department of Clinical Immunology, the Blood Bank, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Rostgaard
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Christian Erikstrup
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
| | - Ulrik Sartipy
- Section of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden7Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Martin J Holzmann
- Department of Emergency Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden9Department of Internal Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Olof Nyrén
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Hjalgrim
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark10Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark
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24
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Levy E, David M, Barshtein G, Yedgar S, Livshits L, Ben Ishai P, Feldman Y. Dielectric Response of Cytoplasmic Water and Its Connection to the Vitality of Human Red Blood Cells. II. The Influence of Storage. J Phys Chem B 2017; 121:5273-5278. [PMID: 28453275 DOI: 10.1021/acs.jpcb.7b02662] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Maintaining an appropriate inventory of packaged blood products is a critical part of modern medicine. Consequently, the assessment of red blood cell (RBC) functionality is instrumental for the monitoring of the quality of stored RBC (sRBC) in the blood bank. We present a comprehensive study of sRBC lesion kinetics in SAGM (saline, adenine, glucose, mannitol) solution, using microwave dielectric spectroscopy (0.5-50 GHz) and cell deformability. As part of the research, we have isolated the microwave dielectric response of cytoplasmic water in sRBC. The extracted dielectric parameters are sensitive to the age of the cells and, in particular, to the critical moment of transition from discocyte to echinocyte. From the analysis of the dielectric relaxation as a function of storage-duration, we postulate that the behavior is rooted in the delicate interplay between bound and bulk water in the cellular interior. In particular, the microwave dielectric response reflects the moment when the continuous diffusion of oxygen to the cell and the oxygenation of hemoglobin affects the role played by water in the maintenance of cell integrity. These results open a possible new avenue for the noninvasive inspection of stored red blood cells, permitting a true inventory system for the modern blood bank.
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Affiliation(s)
- Evgeniya Levy
- Department of Applied Physics, The Rachel and Selim Benin School of Engineering and Computer Science, The Hebrew University of Jerusalem , Edmond J. Safra Campus, Jerusalem, 91904, Israel
| | - Marcelo David
- Department of Applied Physics, The Rachel and Selim Benin School of Engineering and Computer Science, The Hebrew University of Jerusalem , Edmond J. Safra Campus, Jerusalem, 91904, Israel
| | - Gregory Barshtein
- Department of Biochemistry & Molecular Biology, IMRIC, Faculty of Medicine, The Hebrew University of Jerusalem , Ein Kerem, Jerusalem, 91120, Israel
| | - Saul Yedgar
- Department of Biochemistry & Molecular Biology, IMRIC, Faculty of Medicine, The Hebrew University of Jerusalem , Ein Kerem, Jerusalem, 91120, Israel
| | - Leonid Livshits
- Department of Biochemistry & Molecular Biology, IMRIC, Faculty of Medicine, The Hebrew University of Jerusalem , Ein Kerem, Jerusalem, 91120, Israel
| | - Paul Ben Ishai
- Department of Physics, Ariel University , P.O.B. 3, Ariel 40700, Israel
| | - Yuri Feldman
- Department of Applied Physics, The Rachel and Selim Benin School of Engineering and Computer Science, The Hebrew University of Jerusalem , Edmond J. Safra Campus, Jerusalem, 91904, Israel
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25
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Laks K, Kirsipuu T, Dmitrijeva T, Salumets A, Palumaa P. Assessment of Blood Contamination in Biological Fluids Using MALDI-TOF MS. Protein J 2017; 35:171-6. [PMID: 27023353 DOI: 10.1007/s10930-016-9657-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Biological fluid sample collection often includes the risk of blood contamination that may alter the proteomic profile of biological fluid. In proteomics studies, exclusion of contaminated samples is usually based on visual inspection and counting of red blood cells in the sample; analysis of specific blood derived proteins is less used. To fill the gap, we developed a fast and sensitive method for ascertainment of blood contamination in crude biological fluids, based on specific blood-derived protein, hemoglobin detection by MALDI-TOF MS. The MALDI-TOF MS based method allows detection of trace hemoglobin with the detection limit of 0.12 nM. UV-spectrometry, which was used as reference method, was found to be less sensitive. The main advantages of the presented method are that it is fast, effective, sensitive, requires very small sample amount and can be applied for detection of blood contamination in various biological fluids collected for proteomics studies. Method applicability was tested on human cerebrospinal and follicular fluid, which proteomes generally do not contain hemoglobin, however, which possess high risk for blood contamination. Present method successfully detected the blood contamination in 12 % of cerebrospinal fluid and 24 % of follicular fluid samples. High percentage of contaminated samples accentuates the need for initial inspection of proteomic samples to avoid incorrect results from blood proteome overlap.
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Affiliation(s)
- Katrina Laks
- Department of Gene Technology, Tallinn University of Technology, Akadeemia st 15, 12618, Tallinn, Estonia. .,Competence Centre on Health Technologies, Tiigi 61b, 50410, Tartu, Estonia.
| | - Tiina Kirsipuu
- Department of Gene Technology, Tallinn University of Technology, Akadeemia st 15, 12618, Tallinn, Estonia.,Competence Centre on Health Technologies, Tiigi 61b, 50410, Tartu, Estonia
| | - Tuuli Dmitrijeva
- Department of Gene Technology, Tallinn University of Technology, Akadeemia st 15, 12618, Tallinn, Estonia
| | - Andres Salumets
- Competence Centre on Health Technologies, Tiigi 61b, 50410, Tartu, Estonia.,Institute of Bio- and Translational Medicine, University of Tartu, Ravila 19, 50411, Tartu, Estonia
| | - Peep Palumaa
- Department of Gene Technology, Tallinn University of Technology, Akadeemia st 15, 12618, Tallinn, Estonia.,Competence Centre on Health Technologies, Tiigi 61b, 50410, Tartu, Estonia
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26
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Podbregar M, Gavric AU, Podbregar E, Mozina H, Stefanovic S. Red blood cell transfusion and skeletal muscle tissue oxygenation in anaemic haematologic outpatients. Radiol Oncol 2016; 50:449-455. [PMID: 27904454 PMCID: PMC5120575 DOI: 10.1515/raon-2015-0046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 08/06/2015] [Indexed: 12/15/2022] Open
Abstract
Background Stored red blood cells (RBCs) accumulate biochemical and biophysical changes, known as storage lesion. The aim of this study was to re-challenge current data that anaemia in chronically anaemic haematology patients is not associated with low skeletal muscle tissue oxygen (StO2), and that RBC storage age does not influence the tissue response after ischaemic provocation, using near-infrared spectroscopy. Patients and methods Twenty-four chronic anaemic haematology patients were included. Thenar skeletal muscle StO2 was measured at rest (basal StO2), with vascular occlusion testing (upslope StO2, maximum StO2) before and after transfusion. Results Basal StO2 was low (53% ± 7%). Average RBC storage time was 10.5 ± 3.9 days. Effects of RBC transfusions were as follows: basal StO2 and upslope StO2 did not change significantly; maximum StO2 increased compared to baseline (64 ± 14% vs. 59 ± 10%, p = 0.049). Change of basal StO2, upslope StO2 and maximum StO2 was negatively related to age of RBCs. The decrease of maximum StO2 was predicted (sensitivity 70%, specificity 100%), after receiving RBCs ≥ 10days old. Discussion Resting skeletal muscle StO2 in chronic anaemic patients is low. RBC storage time affects skeletal muscle StO2 in the resting period and after ischaemic provocation.
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Affiliation(s)
- Matej Podbregar
- Clinical Department for Anaesthesiology and Surgical Intensive Care, University Medical Centre Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Eva Podbregar
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Hugon Mozina
- Emergency Department, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Barshtein G, Pries AR, Goldschmidt N, Zukerman A, Orbach A, Zelig O, Arbell D, Yedgar S. Deformability of transfused red blood cells is a potent determinant of transfusion-induced change in recipient's blood flow. Microcirculation 2016; 23:479-486. [DOI: 10.1111/micc.12296] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 07/06/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Gregory Barshtein
- Department of Biochemistry; Hebrew University Faculty of Medicine; Jerusalem Israel
| | | | - Neta Goldschmidt
- Department of Hematology; Hadassah University Hospital; Jerusalem Israel
| | - Ayelet Zukerman
- Department of Biochemistry; Hebrew University Faculty of Medicine; Jerusalem Israel
| | - Ariel Orbach
- Department of Biochemistry; Hebrew University Faculty of Medicine; Jerusalem Israel
| | - Orly Zelig
- Blood Bank; Hadassah-Hebrew University Hospital; Jerusalem Israel
| | - Dan Arbell
- Department of Pediatric Surgery; Hadassah- Hebrew University Hospital; Jerusalem Israel
| | - Saul Yedgar
- Department of Biochemistry; Hebrew University Faculty of Medicine; Jerusalem Israel
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The Effect of Red Blood Cell Transfusion on Cerebral Autoregulation in Patients with Severe Traumatic Brain Injury. Neurocrit Care 2016; 23:210-6. [PMID: 25894454 DOI: 10.1007/s12028-015-0141-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Red blood cell (RBC) transfusion is associated with inconsistent changes in brain tissue oxygenation (PbO2). Previous studies have failed to consider alterations in cerebral autoregulation. Our objective was to investigate the effect of RBC transfusion on cerebral autoregulation, as measured by pressure reactivity index (PRx). METHODS Retrospective analysis of 28 severe traumatic brain injury (TBI) patients from a prospective registry between 2007 and 2014. We recorded hemoglobin (Hb) concentration, intracranial pressure, PbO2, cerebral perfusion pressure, PRx, and cerebral lactate/pyruvate ratio for 6 h before and after RBC transfusion. We also recorded body temperature, PaO2, PCO2, pH, and fraction of inspired oxygen. Subgroups of normoxia (PbO2 >20 mmHg) and hypoxia (PbO2 <20 mmHg) prior to transfusion were defined a priori. RESULTS The median age was 36 years [interquartile range (IQR) 27-49], 32% were female. The median admission Glasgow Coma score was 5 (IQR 4-9) and injury severity score was 16 (IQR 9-21). Overall, mean Hb concentration [80 g/L (SD 7) to 89 g/L (SD 8), p < 0.001] and PbO2 increased [23.5 mmHg (SD 8) to 25.0 mmHg (SD 9), p = 0.033] following transfusion. PRx increased post-transfusion [0.028 (SD 0.29) to 0.11 (SD 0.24), p = 0.034], indicating worsening cerebrovascular pressure reactivity. In patients with mean PbO2 >20 mmHg pre-transfusion (n = 20), the PRx increased significantly [-0.052 (SD 0.24) to 0.079 (SD 0.22), p = 0.007] but did not change in patients with PbO2 <20 mmHg: PRx [0.22 (SD 0.34) to 0.18 (SD 0.30), p = 0.36]. CONCLUSION RBC transfusion in severe TBI patients results in worsening PRx, indicating impaired cerebral autoregulation.
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Vedantam A, Yamal JM, Rubin ML, Robertson CS, Gopinath SP. Progressive hemorrhagic injury after severe traumatic brain injury: effect of hemoglobin transfusion thresholds. J Neurosurg 2016; 125:1229-1234. [PMID: 26943843 DOI: 10.3171/2015.11.jns151515] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT There is limited literature available to guide transfusion practices for patients with severe traumatic brain injury (TBI). Recent studies have shown that maintaining a higher hemoglobin threshold after severe TBI offers no clinical benefit. The present study aimed to determine if a higher transfusion threshold was independently associated with an increased risk of progressive hemorrhagic injury (PHI), thereby contributing to higher rates of morbidity and mortality. METHODS The authors performed a secondary analysis of data obtained from a recently performed randomized clinical trial studying the effects of erythropoietin and blood transfusions on neurological recovery after severe TBI. Assigned hemoglobin thresholds (10 g/dl vs 7 g/dl) were maintained with packed red blood cell transfusions during the acute phase after injury. PHI was defined as the presence of new or enlarging intracranial hematomas on CT as long as 10 days after injury. A severe PHI was defined as an event that required an escalation of medical management or surgical intervention. Clinical and imaging parameters and transfusion thresholds were used in a multivariate Cox regression analysis to identify independent risk factors for PHI. RESULTS Among 200 patients enrolled in the trial, PHI was detected in 61 patients (30.5%). The majority of patients with PHI had a new, delayed contusion (n = 29) or an increase in contusion size (n = 15). The mean time interval between injury and identification of PHI was 17.2 ± 15.8 hours. The adjusted risk of severe PHI was 2.3 times higher for patients with a transfusion threshold of 10 g/dl (95% confidence interval 1.1-4.7; p = 0.02). Diffuse brain injury was associated with a lower risk of PHI events, whereas higher initial intracranial pressure increased the risk of PHI (p < 0.001). PHI was associated with a longer median length of stay in the intensive care unit (18.3 vs 14.4 days, respectively; p = 0.04) and poorer Glasgow Outcome Scale scores (42.9% vs 25.5%, respectively; p = 0.02) at 6 months. CONCLUSIONS A higher transfusion threshold of 10 g/dl after severe TBI increased the risk of severe PHI events. These results indicate the potential adverse effect of using a higher hemoglobin transfusion threshold after severe TBI.
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Affiliation(s)
| | - Jose-Miguel Yamal
- Department of Biostatistics, University of Texas School of Public Health, Houston, Texas
| | - Maria Laura Rubin
- Department of Biostatistics, University of Texas School of Public Health, Houston, Texas
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Remy KE, Sun J, Wang D, Welsh J, Solomon SB, Klein HG, Natanson C, Cortés-Puch I. Transfusion of recently donated (fresh) red blood cells (RBCs) does not improve survival in comparison with current practice, while safety of the oldest stored units is yet to be established: a meta-analysis. Vox Sang 2016; 111:43-54. [PMID: 26848822 DOI: 10.1111/vox.12380] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 12/16/2015] [Accepted: 12/26/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Preclinical studies generated the hypothesis that older stored red blood cells (RBCs) can increase transfusion risks. To examine the most updated and complete clinical evidence and compare results between two trial designs, we assessed both observational studies and randomized controlled trials (RCTs) studying the effect of RBC storage age on mortality. MATERIALS AND METHODS Five databases were searched through December 2014 for studies comparing mortality using transfused RBCs having longer and shorter storage times. RESULTS Analysis of six RCTs found no significant differences in survival comparing current practice (average storage age of 2 to 3 weeks) to transfusion of 1- to 10-day-old RBCs (OR 0·91, 95% CI 0·77-1·07). RBC storage age was lower in RCTs vs. observational studies (P = 0·01). The 31 observational studies found an increased risk of death (OR 1·13, 95% CI 1·03-1·24) (P = 0·01) with increasing age of RBCs, a different mortality effect than RCTs (P = 0·02). CONCLUSION RCTs established that transfusion of 1- to 10-day-old stored RBCs is not superior to current practice. The apparent discrepancy in mortality between analyses of RCTs and observational studies may in part relate to differences in hypotheses tested and ages of stored RBCs studied. Further trials investigating 1- to 10-day-old stored RBC benefits would seem of lower priority than studies to determine whether 4- to 6-week stored units have safety and efficacy equivalent to the 2- to 3-week-old stored RBCs commonly transfused today.
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Affiliation(s)
- K E Remy
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, MD, USA
| | - J Sun
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, MD, USA
| | - D Wang
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, MD, USA
| | - J Welsh
- NIH Library, NIH, Bethesda, MD, USA
| | - S B Solomon
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, MD, USA
| | - H G Klein
- Department of Transfusion Medicine, Clinical Center, NIH, Bethesda, MD, USA
| | - C Natanson
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, MD, USA
| | - I Cortés-Puch
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, MD, USA
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Anemia and Blood Transfusion in Patients with Isolated Traumatic Brain Injury. Crit Care Res Pract 2015; 2015:672639. [PMID: 26605080 PMCID: PMC4641180 DOI: 10.1155/2015/672639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/02/2015] [Accepted: 10/11/2015] [Indexed: 11/23/2022] Open
Abstract
Rationale. By reducing cerebral oxygen delivery, anemia may aggravate traumatic brain injury (TBI) secondary insult. This study evaluated the impact of anemia and blood transfusion on TBI outcomes. Methods. This was a retrospective cohort study of adult patients with isolated TBI at a tertiary-care intensive care unit from 1/1/2000 to 31/12/2011. Daily hemoglobin level and packed red blood cell (PRBC) transfusion were recorded. Patients with hemoglobin < 10 g/dL during ICU stay (anemic group) were compared with other patients. Results. Anemia was present on admission in two (2%) patients and developed in 48% during the first week with hemoglobin < 7 g/dL occurring in 3.0%. Anemic patients had higher admission Injury Severity Score and underwent more craniotomy (50% versus 13%, p < 0.001). Forty percent of them received PRBC transfusion (2.8 ± 1.5 units per patient, median pretransfusion hemoglobin = 8.8 g/dL). Higher hospital mortality was associated with anemia (25% versus 6% for nonanemic patients, p = 0.01) and PRBC transfusion (38% versus 9% for nontransfused patients, p = 0.003). On multivariate analysis, only PRBC transfusion independently predicted hospital mortality (odds ratio: 6.8; 95% confidence interval: 1.1–42.3). Conclusions. Anemia occurred frequently after isolated TBI, but only PRBC transfusion independently predicted mortality.
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Monitoring of hematological and hemostatic parameters in neurocritical care patients. Neurocrit Care 2015; 21 Suppl 2:S168-76. [PMID: 25208669 DOI: 10.1007/s12028-014-0023-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Anemia and bleeding are paramount concerns in neurocritical care and often relate to the severity of intracranial hemorrhage. Anemia is generally associated with worse outcomes, and efforts to minimize anemia through reduced volume of blood sampled are encouraged. Point-of-care-testing reliably detects the use of non-steroidal anti-inflammatory drugs that may worsen bleeding and reduce platelet activity, particularly in patients with intracerebral hemorrhage. How best to monitor the effect of platelet transfusion or platelet-activating therapy is not well studied. For patients known to take novel oral anticoagulants, drug-specific coagulation tests before neurosurgical intervention are prudent.
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Abstract
Maintenance of adequate oxygenation is a mainstay of intensive care, however, recommendations on the safety, accuracy, and the potential clinical utility of invasive and non-invasive tools to monitor brain and systemic oxygenation in neurocritical care are lacking. A literature search was conducted for English language articles describing bedside brain and systemic oxygen monitoring in neurocritical care patients from 1980 to August 2013. Imaging techniques e.g., PET are not considered. A total of 281 studies were included, the majority described patients with traumatic brain injury (TBI). All tools for oxygen monitoring are safe. Parenchymal brain oxygen (PbtO2) monitoring is accurate to detect brain hypoxia, and it is recommended to titrate individual targets of cerebral perfusion pressure (CPP), ventilator parameters (PaCO2, PaO2), and transfusion, and to manage intracranial hypertension, in combination with ICP monitoring. SjvO2 is less accurate than PbtO2. Given limited data, NIRS is not recommended at present for adult patients who require neurocritical care. Systemic monitoring of oxygen (PaO2, SaO2, SpO2) and CO2 (PaCO2, end-tidal CO2) is recommended in patients who require neurocritical care.
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Yamal JM, Benoit JS, Doshi P, Rubin ML, Tilley BC, Hannay HJ, Robertson CS. Association of transfusion red blood cell storage age and blood oxygenation, long-term neurologic outcome, and mortality in traumatic brain injury. J Trauma Acute Care Surg 2015; 79:843-9. [PMID: 26496111 PMCID: PMC4621763 DOI: 10.1097/ta.0000000000000834] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The effect of red blood cell (RBC) storage on oxygenation in critically ill patients is still unknown. The objective of this study was to determine the association of RBC storage with oxygenation, long-term neurologic recovery, and death after traumatic brain injury. METHODS We used data from a 2 × 2 factorial randomized controlled trial of administration of erythropoietin or placebo and of assignment to transfusion threshold of less than 7g/dL or less than 10 g/dL in neurosurgical intensive care units in two US Level 1 trauma centers. Patients had severe traumatic brain injury with closed head injury, were unable to follow commands, and were enrolled within 6 hours of injury. Blood oxygenation 1 hour after the transfusion as measured by jugular venous oxygen saturation (n = 59) was the primary outcome. Secondary outcomes were brain tissue oxygenation (n = 77), 6-month Glasgow Outcome Scale (GOS) score (n = 122) collected using a structured interview and dichotomized into favorable (good recovery or moderate disability) or unfavorable outcome (severe disability, vegetative state, or dead), and mortality (n = 125). RBC age was defined as the maximum age of RBCs over all units in one transfusion per patient. For long-term outcomes, RBC age was defined as the mean age over all units given. RESULTS We failed to detect an association of RBC age with jugular venous oxygen saturation (linear regression β = 1.59; 95% confidence interval [CI], -2.99 to 6.18; p = 0.49), brain tissue oxygenation (linear regression β = 0.20; 95% CI, -0.23 to 0.63; p = 0.36), GOS score (odds ratio, 1.37; 95% CI, 0.53-3.57; p = 0.52), and mortality (hazard ratio, 1.35; 95% CI, 0.61-2.98; p = 0.46). CONCLUSION Limitations of this study include the fact that the RBC ages were not randomized, although this was a prospective study. We conclude that older blood does not seem to have adverse effects in severe traumatic brain injury. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Jose-Miguel Yamal
- Department of Biostatistics, University of Texas School of Public Health, Houston, TX, USA
| | - Julia S. Benoit
- Department of Basic Vision Sciences, University of Houston, Houston, TX, USA
| | - Pratik Doshi
- Department of Emergency Medicine and Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Maria Laura Rubin
- Department of Biostatistics, University of Texas School of Public Health, Houston, TX, USA
| | - Barbara C. Tilley
- Department of Biostatistics, University of Texas School of Public Health, Houston, TX, USA
| | - H. Julia Hannay
- Department of Psychology, University of Houston, Houston, TX, USA
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Effects of packed red blood cell storage duration on post-transfusion clinical outcomes: a meta-analysis and systematic review. Intensive Care Med 2015; 41:2087-97. [DOI: 10.1007/s00134-015-4078-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 09/22/2015] [Indexed: 12/31/2022]
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Boutin A, Chassé M, Shemilt M, Lauzier F, Moore L, Zarychanski R, Griesdale D, Desjardins P, Lacroix J, Fergusson D, Turgeon AF. Red Blood Cell Transfusion in Patients With Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Transfus Med Rev 2015; 30:15-24. [PMID: 26409622 DOI: 10.1016/j.tmrv.2015.08.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 06/14/2015] [Accepted: 08/15/2015] [Indexed: 01/23/2023]
Abstract
Our objectives were to evaluate the frequency of red blood cell (RBC) transfusion in patients with traumatic brain injury (TBI) as well as potential determinants and outcomes associated with RBC transfusion in this population. We conducted a systematic review of cohort studies and randomized trials of patients with TBI. We searched Medline, Embase, the Cochrane Library, and BIOSIS databases from their inception up to April 2015. We selected studies of adult patients with acute TBI reporting data on RBC transfusions. Cumulative incidences of transfusion were pooled using random-effect models with a DerSimonian approach. To evaluate the association between RBC transfusion and potential determinants or clinical outcomes, we pooled risk ratios or mean differences with random-effect models and the Mantel-Haenszel method. We identified 24 eligible studies (17414 patients). After pooling data from 23 studies (7524 patients), approximately 36% (95% confidence interval [CI], 28-44; I(2) = 98%) of patients received RBC transfusion at some point during their hospital stay. Hemoglobin thresholds for transfusion were rarely available (reported in 9 studies) and varied from 6 to 10 g/dL. Glasgow Coma Scale scores at admission were lower in patients who were transfused than those who were not (3 cohort studies; 1371 patients; mean difference of 1.38 points [95% CI, 0.86-1.89]; I(2) = 12%). Mortality was not significantly different among transfused and nontransfused patients in univariate and multivariate meta-analyses. Hospital length of stay was longer among patients receiving RBC transfusion compared to those who did not (3 studies; n = 455; mean difference, 9.58 days [95% CI, 3.94-15.22]; I(2) = 74%). Results should be considered cautiously due to the high heterogeneity and high risk of confounding from the observational nature of included studies. Red blood cell transfusion is frequent in patients with TBI, and transfusion practices varied widely between studies. Current published data highlight the lack of clinical evidence guiding transfusion strategies in TBI.
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Affiliation(s)
- Amélie Boutin
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada; Department of Social and Preventive Medicine, Université Laval, Quebec City, QC, Canada
| | - Michaël Chassé
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, QC, Canada
| | - Michèle Shemilt
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada
| | - François Lauzier
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, QC, Canada; Department of Medicine, Université Laval, Quebec City, QC, Canada
| | - Lynne Moore
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada; Department of Social and Preventive Medicine, Université Laval, Quebec City, QC, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine and of Haematology & Medical Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Donald Griesdale
- Department of Anesthesia, University of British Columbia, Vancouver, BC, Canada
| | - Philippe Desjardins
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, QC, Canada
| | - Jacques Lacroix
- Department of Pediatrics, Critical Care Medicine, Université de Montréal, Montreal, QC, Canada
| | - Dean Fergusson
- Clinical Epidemiology Unit, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexis F Turgeon
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, QC, Canada.
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Abstract
BACKGROUND Well-characterized biochemical, structural, and physiological changes occur when red blood cells (RBCs) are stored for a period of time and are collectively called the storage lesion. METHODS Key study results are summarized and contrasted and new data from recently completed randomized controlled trials will be discussed. RESULTS It is unclear whether in vitro changes to RBCs that occur during storage are clinically relevant. The clinical effects of RBC storage have been the focus of observational studies in recent years. However, these studies lack any consensus, possibly because of methodological limitations. CONCLUSIONS The clinical significance of storing RBCs is controversial, although new data from randomized controlled trials of neonates and patients undergoing cardiac surgery suggest that the duration of RBC storage is not associated with adverse clinical outcomes in these patient populations.
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Affiliation(s)
- Lirong Qu
- Department of Pathology, Institute for Transfusion Medicine, Pittsburgh, PA 15213, USA.
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Martí‐Carvajal AJ, Simancas‐Racines D, Peña‐González BS. Prolonged storage of packed red blood cells for blood transfusion. Cochrane Database Syst Rev 2015; 2015:CD009330. [PMID: 26171902 PMCID: PMC11055608 DOI: 10.1002/14651858.cd009330.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND A blood transfusion is an acute intervention, used to address life- and health-threatening conditions on a short-term basis. Packed red blood cells are most often used for blood transfusion. Sometimes blood is transfused after prolonged storage but there is continuing debate as to whether transfusion of 'older' blood is as beneficial as transfusion of 'fresher' blood. OBJECTIVES To assess the clinical benefits and harms of prolonged storage of packed red blood cells, in comparison with fresh, on recipients of blood transfusion. SEARCH METHODS We ran the search on 1st May 2014. We searched the Cochrane Injuries Group Specialized Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OvidSP), Embase (OvidSP), CINAHL (EBSCO Host) and two other databases. We also searched clinical trials registers and screened reference lists of the retrieved publications and reviews. We updated this search in June 2015 but these results have not yet been incorporated. SELECTION CRITERIA Randomised clinical trials including participants assessed as requiring red blood cell transfusion were eligible for inclusion. Prolonged storage was defined as red blood cells stored for ≥ 21 days in a blood bank. We did not apply limits regarding the duration of follow-up, or country where the study took place. We excluded trials where patients received a combination of short- and long-stored blood products, and also trials without a clear definition of prolonged storage. DATA COLLECTION AND ANALYSIS We independently performed study selection, risk of bias assessment and data extraction by at least two review authors. The major outcomes were death from any cause, transfusion-related acute lung injury, and adverse events. We estimated relative risk for dichotomous outcomes. We measured statistical heterogeneity using I(2). We used a random-effects model to synthesise the findings. MAIN RESULTS We identified three randomised clinical trials, involving a total of 120 participants, comparing packed red blood cells with ≥ 21 days storage ('prolonged' or 'older') versus packed red blood cells with < 21 days storage ('fresh'). We pooled data to assess the effect of prolonged storage on death from any cause. The confidence in the results from these trials was very low, due to the bias in their design and their limited sample sizes.The estimated effect of packed red blood cells with ≥ 21 days storage versus packed red blood cells with < 21 days storage for the outcome death from any cause was imprecise (5/45 [11.11%] versus 2/46 [4.34%]; RR 2.36; 95% CI 0.65 to 8.52; I(2): 0%, P = 0.26, very low quality of evidence). Trial sequential analysis, with only two trials, shows that we do not yet have convincing evidence that older packed red blood cells induce a 20% relative risk reduction of death from any cause compared with fresher packed red blood cells. No trial included other outcomes of interest specified in this review, namely transfusion-related acute lung injury, postoperative infections, and adverse events. The safety profile is unknown. AUTHORS' CONCLUSIONS Recognising the limitations of the review, relating to the size and nature of the included trials, this Cochrane Review provides no evidence to support or reject the use of packed red blood cells for blood transfusion which have been stored for ≥ 21 days ('prolonged' or 'older') compared with those stored for < 21 days ('fresh'). These results are based on three small single centre trials with high risks of bias. There is insufficient evidence to determine the effects of fresh or older packed red blood cells for blood transfusion. Therefore, we urge readers to interpret the trial results with caution. The results from four large ongoing trials will help to inform future updates of this review.
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Affiliation(s)
| | - Daniel Simancas‐Racines
- Universidad Tecnológica EquinoccialFacultad de Ciencias de la Salud Eugenio EspejoAvenida República de El Salvador 733 y PortugalEdificio Gabriela 3. Of. 403Quito (Pichincha)PichinchaEcuadorCasilla Postal 17‐17‐525
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Changes in gene expression following trauma are related to the age of transfused packed red blood cells. J Trauma Acute Care Surg 2015; 78:535-42. [PMID: 25710424 DOI: 10.1097/ta.0000000000000534] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transfusion of packed red blood cells (PRBCs) is associated with an increased incidence of nosocomial infections and an increased risk of death. The duration of storage before transfusion may influence these outcomes. Here, we explore the association between the age of transfused PRBCs and specific patterns of inflammatory gene expression in severely injured trauma patients. METHODS Severely injured trauma patients requiring intensive care unit treatment and receiving transfusion of PRBCs within 24 hours of the injury were recruited. Blood samples were obtained within 2 hours of the trauma, at 24 hours, and at 72 hours. Messenger RNA was extracted from whole blood, and gene expression was quantified using quantitative polymerase chain reaction. The median age of the units of PRBCs transfused to each patient was recorded. The primary outcome measure was the change in candidate gene expression over the initial 72 hours. RESULTS Sixty-four patients were studied. Fifty-three patients (83%) were male, and the median age was 40.5 years (interquartile range [IQR], 31-59). Median Injury Severity Score (ISS) was 31.5 (IQR, 23-43), and 55 patients (86%) experienced a blunt injury. Forty-one patients (64%) developed a nosocomial infection, and 15 patients (23%) died before hospital discharge. Each patient received a median of 5 U of PRBCs (IQR, 4-9.8 U) during the first 24 hours of hospital admission. The median age of the units of PRBCs transfused in each patient was 20 days (IQR, 17-22 days). Older blood was associated with greater decreases in interleukin 12 (IL-12), IL-23, and RORγt (all p's < 0.05) gene expression over the initial 24 hours, greater decreases in IL-12 gene expression over 72 hours, and a rise in transforming growth factor β gene expression over the first 72 hours. A multivariate analysis confirmed the independence of these associations. CONCLUSION Increasing the duration of storage of PRBCs before transfusion is associated with a pattern of gene expression consistent with more severe immunosuppression. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Orlov D, Karkouti K. The pathophysiology and consequences of red blood cell storage. Anaesthesia 2015; 70 Suppl 1:29-37, e9-12. [PMID: 25440392 DOI: 10.1111/anae.12891] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2014] [Indexed: 12/17/2022]
Abstract
Red cell transfusion therapy is a common treatment modality in contemporary medical practice. Although blood collection and administration is safer and more efficient than ever before, red cells undergo multiple metabolic and structural changes during storage that may compromise their functionality and viability following transfusion. The clinical relevance of these changes is a hotly debated topic that continues to be a matter of intense investigation. In the current review, we begin with an in-depth overview of the pathophysiological mechanisms underlying red cell storage, with a focus on altered metabolism, oxidative stress and red cell membrane damage. We proceed to review the current state of evidence on the clinical relevance and consequences of the red cell storage lesion, while discussing the strengths and limitations of clinical studies.
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Affiliation(s)
- D Orlov
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Driessen A, Schäfer N, Bauerfeind U, Kaske S, Fromm-Dornieden C, Stuermer EK, Maegele M. Functional capacity of reconstituted blood in 1:1:1 versus 3:1:1 ratios: a thrombelastometry study. Scand J Trauma Resusc Emerg Med 2015; 23:2. [PMID: 25571924 PMCID: PMC4296528 DOI: 10.1186/s13049-014-0080-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 12/16/2014] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Different transfusion ratio concepts of packed red blood cells (pRBCs), fresh frozen plasma (FFP) and platelets (PLTs) have been implemented in trauma care, but the optimal ratios are still discussed. In this study the hemostatic potential of two predefined ratios was assessed by using an in vitro thrombelastometric approach. Furthermore, age effects of reconstituted blood were analyzed. METHODS Whole blood (WB) of voluntary donors was separated into pRBCs, FFP and PLTs and reconstituted into the ratios 1:1:1 and 3:1:1 at day 1, 4, 14, and 24. Standard blood count, electrolytes and coagulation proteins were quantified. The functional coagulation in ratio- and age-specific groups was evaluated using rotational thromboelastometry (ROTEM). RESULTS Several coagulation factors reduced significantly in the 3:1:1 ratio and were consistent with increased INR, decelerated clot formation times and A10 (amplitude 10 minutes after clotting time (CT)), flattened α-angle during the EXTEM and diminished MCF for distinct time points during the INTEM, FIBTEM and APTEM assays. With rising age of pRBCs the pH, sodium and potassium reached non-physiological levels. CONCLUSION Under standardized in vitro conditions the higher amount of pRBCs in the 3:1:1 ratio diluted coagulation factors significantly on the expense of its functional coagulation capacity as revealed by ROTEM results. Thus, the coagulation functionality of the 1:1:1 ratio predominated.
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Affiliation(s)
- Arne Driessen
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany. .,Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, D-51109, Cologne, Germany.
| | - Nadine Schäfer
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.
| | - Ursula Bauerfeind
- Institute of Transfusion Medicine Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Cologne (Germany), Ostmerheimer Str. 200, D-51109, Cologne, Germany.
| | - Sigune Kaske
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, D-51109, Cologne, Germany.
| | - Carolin Fromm-Dornieden
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.
| | - Ewa K Stuermer
- Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.
| | - Marc Maegele
- Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, D-51109, Cologne, Germany.
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Red blood cell storage duration and trauma. Transfus Med Rev 2014; 29:120-6. [PMID: 25573415 DOI: 10.1016/j.tmrv.2014.09.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/01/2014] [Accepted: 09/25/2014] [Indexed: 12/28/2022]
Abstract
Numerous retrospective clinical studies suggest that transfusion of longer stored red blood cells (RBCs) is associated with an independent risk of poorer outcomes for certain groups of patients, including trauma, intensive care, and cardiac surgery patients. Large multicenter randomized controlled trials are currently underway to address the concern about RBC storage duration. However, none of these randomized controlled trials focus specifically on trauma patients with hemorrhage. Major trauma, particularly due to road accidents, is the leading cause of critical injury in the younger-than-40-year-old age group. Severe bleeding associated with major trauma induces hemodynamic dysregulation that increases the risk of hypoxia, coagulopathy, and potentially multiorgan failure, which can be fatal. In major trauma, a multitude of stress-associated changes occur to the patient's RBCs, including morphological changes that increase cell rigidity and thereby alter blood flow hemodynamics, particularly in the microvascular vessels, and reduce RBC survival. Initial inflammatory responses induce deleterious cellular interactions, including endothelial activation, RBC adhesion, and erythrophagocytosis that are quickly followed by profound immunosuppressive responses. Stored RBCs exhibit similar biophysical characteristics to those of trauma-stressed RBCs. Whether transfusion of RBCs that exhibit storage lesion changes exacerbates the hemodynamic perturbations already active in the trauma patient is not known. This article reviews findings from several recent nonrandomized studies examining RBC storage duration and clinical outcomes in trauma patients. The rationale for further research on RBC storage duration in the trauma setting is provided.
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Massive transfusion protocol activation does not result in preferential use of older red blood cells. JOURNAL OF BLOOD TRANSFUSION 2014; 2014:328967. [PMID: 25295222 PMCID: PMC4177085 DOI: 10.1155/2014/328967] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 07/26/2014] [Accepted: 08/11/2014] [Indexed: 12/04/2022]
Abstract
Widespread, anecdotal belief exists that patients receiving massive transfusion, particularly those for whom a massive transfusion protocol (MTP) is activated, are more likely to receive older red blood cells (RBCs). Retrospective review of blood bank records from calendar year 2011 identified 131 patients emergently issued ≥10 RBC units (emergency release (ER)) prior to obtaining a type and screen. This cohort was subclassified based on whether there was MTP activation. For comparison, 176 identified patients transfused with ≥10 RBC units in a routine fashion over 24 hours represented the nonemergency release (nER) cohort. Though the median age of ER RBCs was 5 days older than nER RBCs (ER 20, nER 15 days, P < 0.001), both fell within the third week of storage. Regardless of MTP activation, transfused ER RBCs had the same median age (MTP 20, no-MTP 20 days, P = 0.069). In the ER cohort, transition to type-specific blood components increased the median age of transfused RBC units from 17 to 36 days (P < 0.001). These data refute the anecdotal belief that MTP activation results in transfusion of older RBCs. However, upon transition to type-specific blood components, the age of RBCs enters a range in which it is hypothesized that there may be a significant effect of storage age on clinical outcomes.
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Abstract
OBJECTIVE To describe packed RBC utilization patterns in trauma patients admitted to a PICU and study associated outcomes while controlling for severity. DESIGN Retrospective cohort study. SETTING The PICU of a tertiary care children's hospital. PATIENTS All pediatric trauma patients admitted to Helen DeVos Children's Hospital PICU between June 2007 and July 2010, either directly from the emergency department or transferred from another institution. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 389 trauma patients, 107 patients (27.5%) transferred to the PICU were transfused with blood products. Of these transfusions, 81 were packed RBC transfusions and 26 were other blood products. Only 73 of the packed RBC transfusions had a documented time of transfusion: 17 (23.3%) were transfused prior to PICU admission, seven (9.5%) both before and after PICU, and 49 (67.1%) only after PICU admission. After adjusting for injury severity score, transfused patients had higher odds of needing mechanical ventilation (odds ratios, 9.2; 95% CI, 3.6-23.3) and higher risk of mortality (odds ratios, 8.6; 95% CI, 2.6-28.6), when compared with nontransfused patients. Mean age of packed RBC was 19.6 ± 9.3 days (mean ± SD). The impact of age of packed RBCs on mortality was examined as a categorical variable at 14, 21, and 28 days. Packed RBCs more than 28 days old (14/61 patients) were associated with longer lengths of stay (13 ± 12 vs 7 ± 6; p < 0.03), lower discharge Glasgow Coma Scale score (9 ± 6 vs 13 ± 4; p< 0.03), and more mortality (43% vs 13%; p < 0.02) when compared with blood less than 28 days old. CONCLUSIONS In pediatric trauma patients, transfusion of packed RBC and use of older RBC units are associated with higher risk of adverse outcomes independent of injury severity.
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Tuo WW, Wang D, Liang WJ, Huang YX. How cell number and cellular properties of blood-banked red blood cells of different cell ages decline during storage. PLoS One 2014; 9:e105692. [PMID: 25167052 PMCID: PMC4148343 DOI: 10.1371/journal.pone.0105692] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 07/27/2014] [Indexed: 01/17/2023] Open
Abstract
AIMS Numerous studies have suggested that transfusion of red blood cells (RBCs) stored over a long period of time may induce harmful effects due to storage-induced lesions. However, the underlying mechanisms responsible for this damage have not been identified. Furthermore, it is unclear why and how up to 30% of long-stored RBCs disappear from the circulation within 24 hours after transfusion. The aim of this study was to determine how the cell number of RBCs of different ages changes during storage and how these cells undergo cumulative structural and functional changes with storage time. METHODS AND RESULTS We used Percoll centrifugation to fractionate the RBCs in blood bank stored RBC units into different aged sub-populations and then measured the number of intact cells in each sub-population as well the cells' biomechanical and biochemical parameters as functions of the storage period. We found that the RBC units stored for ≤ 14 days could be separated into four fractions: the top or young cell fraction, two middle fractions, and the lower or old fraction. However, after 14 days of storage, the cell number and cellular properties declined rapidly whereby the units stored for 21 days only exhibited the three lower fractions and not the young fraction. The cell number within a unit stored for 21 days decreased by 23% compared to a fresh unit and the cells that were lost had hemolyzed into harmful membrane fragments, microparticles, and free hemoglobin. All remaining cells exhibited cellular properties similar to those of senescent cells. CONCLUSION In RBC units stored for greater than 14 days, there were fewer intact cells with no healthy cells present, as well as harmful membrane fragments, microparticles, and free hemoglobin. Therefore, transfusion of these stored units would not likely help patients and may induce a series of clinical problems.
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Affiliation(s)
- Wei-Wei Tuo
- Department of Biomedical Engineering, Ji Nan University, Guang Zhou, China
| | - Di Wang
- Department of Biomedical Engineering, Ji Nan University, Guang Zhou, China
| | - Wen-Jing Liang
- Department of Biomedical Engineering, Ji Nan University, Guang Zhou, China
| | - Yao-Xiong Huang
- Department of Biomedical Engineering, Ji Nan University, Guang Zhou, China
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Chowdhury T, Kowalski S, Arabi Y, Dash HH. General intensive care for patients with traumatic brain injury: An update. Saudi J Anaesth 2014; 8:256-63. [PMID: 24843343 PMCID: PMC4024687 DOI: 10.4103/1658-354x.130742] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Traumatic brain injury (TBI) is a growing epidemic throughout the world and may present as major global burden in 2020. Some intensive care units throughout the world still have no access to specialized monitoring methods, equipments and other technologies related to intensive care management of these patients; therefore, this review is meant for providing generalized supportive measurement to this subgroup of patients so that evidence based management could minimize or prevent the secondary brain injury. Methods: Therefore, we have included the PubMed search for the relevant clinical trials and reviews (from 1 January 2007 to 31 March 2013), which specifically discussed about the topic. Results: General supportive measures are equally important to prevent and minimize the effects of secondary brain injury and therefore, have a substantial impact on the outcome in patients with TBI. The important considerations for general supportive intensive care unit care remain the prompt reorganization and treatment of hypoxemia, hypotension and hypercarbia. Evidences are found to be either against or weak regarding the use of routine hyperventilation therapy, tight control blood sugar regime, use of colloids and late as well as parenteral nutrition therapy in patients with severe TBI. Conclusion: There is also a need to develop some evidence based protocols for the health-care sectors, in which there is still lack of specific management related to monitoring methods, equipments and other technical resources. Optimization of physiological parameters, understanding of basic neurocritical care knowledge as well as incorporation of newer guidelines would certainly improve the outcome of the TBI patients.
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Affiliation(s)
- Tumul Chowdhury
- Department of Anesthesiology and Perioperative Medicine, Section of Critical Care, University of Manitoba, Winnipeg, Canada
| | - Stephen Kowalski
- Department of Anesthesiology and Perioperative Medicine, Section of Critical Care, University of Manitoba, Winnipeg, Canada
| | - Yaseen Arabi
- Department of Intensive Care, King Abdul-Aziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Hari Hara Dash
- Department of Anesthesia and Perioperative Medicine, Fortis Memorial Research Institute, Gurgaon, Haryana, India
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Domínguez-Berrot AM, González-Vaquero M, Díaz-Domínguez FJ, Robla-Costales J. [Multimodal neuromonitoring in traumatic brain injury: contribution of PTiO2]. Med Intensiva 2014; 38:513-21. [PMID: 24793091 DOI: 10.1016/j.medin.2014.02.005] [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: 11/26/2013] [Revised: 02/01/2014] [Accepted: 02/19/2014] [Indexed: 11/26/2022]
Abstract
The main goal of exhaustively monitoring neurocritical patients is to avoid secondary injury. In the last few years we have witnessed an increase in brain monitoring tools, beyond the checking of intracranial and brain perfusion pressures. These widely used systems offer valuable but possibly insufficient information. Awareness and correction of brain hypoxia is a useful and interesting measure, not only for diagnostic purposes but also when deciding treatment, and to predict an outcome. In this context, it would be of great interest to use all the information gathered from brain oxygenation monitoring systems in conjunction with other available multimodal monitoring devices, in order to offer individualized treatment for each patient.
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Impact of the age of transfused red blood cells in the trauma population: a feasibility study. Injury 2014; 45:605-11. [PMID: 24139171 DOI: 10.1016/j.injury.2013.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 07/12/2013] [Accepted: 07/21/2013] [Indexed: 02/02/2023]
Abstract
UNLABELLED Following injury, transfusion of red blood cells (RBCs) of increased storage duration has been associated with an increased morbidity and mortality. Prospective trials focusing on the impact of the storage age of RBCs in severely bleeding trauma patients have failed to accrue patients. This has been attributed to an inability to maintain a large inventory of fresh RBCs, and the difficulties in obtaining consent in severely bleeding trauma patients. To address these issues, we performed a prospective, observational pilot study to evaluate the feasibility of conducting a trial focusing on RBC age in patients following injury. METHODS Patients with bleeding due to trauma were transfused RBCs ≤10 day old if they were ABO blood Type O (Group O) or were transfused the oldest RBCs in inventory if they were Type A, B or AB (Group A/B/AB). Clinicians were unaware of the specific age of the RBCs. RESULTS 63 patients were analyzed (Group O, n=19; Group A/B/AB, n=44). Half of all patients had severe injuries ISS (median 22). The median admission base deficit was -5 mEq/L, and median total 24h use of RBC and FFP was 1.2 L. The age of RBCs transfused to Group O was significantly lower than for Group A/B/AB [median (IQR) A/B/AB=18.4 (11.4-25.4) days, and Group O=6 (4.2-7.8) days; p<0.001]. CONCLUSIONS It appears feasible to conduct a RBC age trial in trauma patients using ABO blood type to construct comparative groups. Adequate RBC age separation between cohorts and reduced RBC age in the "young" group of patients who received units ≤10 days old was achieved.
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