Leukodepletion of autologous whole blood has no impact on perioperative infection rate and length of hospital stay

Association of Veterinary Hematology and Transfusion Medicine (AVHTM) Transfusion Reaction Small Animal Consensus Statement (TRACS) Part 2: Prevention and monitoring

OBJECTIVE

To systematically review available evidence to develop guidelines for the prevention of transfusion reactions and monitoring of transfusion administration in dogs and cats.

DESIGN

Evidence evaluation of the literature (identified through Medline searches through Pubmed and Google Scholar searches) was carried out for identified transfusion reaction types in dogs and cats. Evidence was evaluated using PICO (Population, Intervention, Comparison, Outcome) questions generated for each reaction type. Evidence was categorized by level of evidence (LOE) and quality (Good, Fair, or Poor). Guidelines for prevention and monitoring were generated based on the synthesis of the evidence. Consensus on the final recommendations and a proposed transfusion administration monitoring form was achieved through Delphi-style surveys. Draft recommendations and the monitoring form were made available through veterinary specialty listservs and comments were incorporated.

RESULTS

Twenty-nine guidelines and a transfusion administration monitoring form were formulated from the evidence review with a high degree of consensus CONCLUSIONS: This systematic evidence evaluation process yielded recommended prevention and monitoring guidelines and a proposed transfusion administration form. However, significant knowledge gaps were identified, demonstrating the need for additional research in veterinary transfusion medicine.

Thromboelastometric evaluation of coagulation profiles of cold-stored autologous whole blood: A prospective observational study

Preoperative autologous blood donation is a well-established procedure to reduce the need for allogeneic blood transfusion. We hypothesized that coagulation activity is maintained in cold-stored whole blood, because the fundamental polymerization properties of fibrin are preserved.Fifty adult patients who underwent elective cardiothoracic surgery were enrolled.Autologous whole blood collected 2 to 4 times at almost 1-week intervals before surgery was stored at approximately 4°C until reinfusion at the time of surgery. Blood samples were drawn just before reinfusion, and rotational thromboelastometry variables and fibrinogen levels were measured.A total of 158 samples were analyzed. The mean duration of cold storage was 16.7 ± 7.4 days (range: 6-33 days). Platelet counts were very low due to collection through a leukoreduction filter. The mean fibrinogen level was 2.3 ± 0.6 g/L. Amplitude at 10 minutes after CT (A10), amplitude at 20 minutes after CT (A20), and maximum clot firmness (MCF) values as determined by FIBTEM analysis were 10.8 ± 3.8, 12.2 ± 4.2, and 13.1 ± 4.7 mm, respectively. Fibrinogen levels were strongly correlated with A10, A20, and FIBTEM-MCF values (ρ = 0.83, P < .0001, ρ = 0.84, P < .0001, ρ = 0.85, P < .0001, respectively). Fibrinogen levels were not correlated with the duration of cold storage (ρ = 0.06, P = .43).The results of the present study demonstrate that fibrin polymerization occurs in cold-stored autologous whole blood, and that such activity is strongly correlated with fibrinogen levels. Furthermore, our data suggest that cold-stored leukoreduced autologous whole blood retains fibrin polymerization properties throughout 33 days.

Centers for Disease Control and Prevention 2017 Guidelines for Prevention of Surgical Site Infections: Review and Relevant Recommendations

PURPOSE OF REVIEW

The associated patient morbidity and resource-intensive nature of managing surgical site infections (SSI) has focused attention toward not only improving treatment protocols but also enhancing preventative measures. The purpose of this review was to summarize the relevant updated CDC guidelines for the prevention of SSI that were released in 2017. The CDC recommends the integration of the guidelines for improvement in quality metrics, reportable outcomes, and patient safety.

RECENT FINDINGS

The updated guidelines include generalized recommendations for parenteral antimicrobial prophylaxis, non-parenteral antimicrobial prophylaxis, glycemic control, normothermia, oxygenation, and antiseptic prophylaxis. The arthroplasty section includes recommendations for blood transfusion, systemic immunosuppressive therapy, and antibiotics during drain use. There was low-quality evidence precluding recommendations for preoperative intra-articular corticosteroid injections, orthopedic surgical space suits, and biofilm management. The recommendations provided throughout this review, including more recent guidelines from other organizations such as the AAOS and ACR, should assist clinicians in developing and/or refining surgical site prevention protocols for their patients undergoing total joint arthroplasty procedures.

Impact of prestorage leucoreduction of autologous whole blood on length of hospital stay with a subgroup analysis in bilateral hip arthroplasty

BACKGROUND

Although prestorage leucoreduction (LR) of blood components for transfusion has gained favour around the world, evidence of its beneficial clinical effects is ambiguous.

STUDY DESIGN AND METHODS

To reveal whether leucocytes and/or platelets in transfused blood are related to transfusion-related adverse effects, a prospective randomized crossover study was performed on patients who donated autologous blood prior to elective surgery. Among 1487 primary enrolees, a total of 192 patients undergoing two-stage, bilateral total hip arthroplasty were randomized to receive autologous blood that was either prestorage leucoreduced, or not, for the first procedure. For the second procedure, each patient was crossed over to receive alternatively processed autologous blood. Length of hospital stay served as a primary end-point, with perioperative infectious/thrombotic complications, pre- and postoperative laboratory values, and body temperature serving as secondary endpoints.

RESULTS

No significant differences emerged between prestorage LR and non-LR cohorts in length of hospital stay, as well as perioperative infectious/thrombotic complications, postoperative body temperature and duration of fever. Postoperative laboratory values including white blood cell counts and C-reactive protein levels had no significant differences.

CONCLUSION

This study could not prove any superiority of prestorage LR over non-LR for autologous whole blood among patients who underwent total hip arthroplasty.

Transfusion-related immunomodulation and cancer

Blood and blood-component therapy triggers immunological reactions in recipients. Transfusion-related immunomodulation [TRIM] is an important complex biological immune reaction to transfusion culminating in immunosuppression. The mechanisms underlying TRIM include the presence of residual leukocytes and apoptotic cells, the transfusion of immunosuppressive cytokines either present in donor components or generated during blood processing, the transfer of metabolically active growth factor-loaded microparticles and extracellular vesicles and the presence of free hemoglobin or extracellular vesicle-bound hemoglobin. TRIM variables include donor-specific factors as well as processing variables. TRIM may explain, at least in part, the controversial negative clinical outcomes observed in cancer patients receiving transfusion in the context of curative-intent surgeries. The use of novel technologies including metabolomics and proteomics on stored blood may pave the way for a deeper understanding of TRIM in general and its impact on cancer progression.

Role of Leukoreduction of Packed Red Blood Cell Units in Trauma Patients: A Review

Hemorrhagic shock is a leading cause of mortality within the trauma population, and blood transfusion is the standard of care. Leukoreduction filters remove donor leukocytes prior to transfusion of blood products. While the benefits of leukocyte depletion are well documented in scientific literature, these benefits do not translate directly to the clinical setting. This review summarizes current research regarding leukoreduction in the clinical arena, as well as studies performed exclusively in the trauma population.

Molecular mechanisms of erythrocyte aging

Anemia and hemorrhagic shock are leading causes of morbidity and mortality worldwide, and transfusion of human blood products is the ideal treatment for these conditions. As human erythrocytes age during storage in blood banks they undergo many biochemical and structural changes, termed the red blood cell 'storage lesion'. Specifically, ATP and pH levels decrease as metabolic end products, oxidative stress, cytokines, and cell-free hemoglobin increase. Also, membrane proteins and lipids undergo conformational and organizational changes that result in membrane loss, viscoelastic changes and microparticle formation. As a result, transfusion of aged blood is associated with a host of adverse consequences such as decreased tissue perfusion, increased risk of infection, and increased mortality. This review summarizes current research detailing the known parts of the erythrocyte storage lesion and their physiologic consequences.

The effect of pre-storage whole-blood leukocyte reduction on cytokines/chemokines levels in autologous CPDA-1 whole blood

BACKGROUND

In this study, we aimed to investigate the effectiveness of pre-storage leukocyte filtration of autologous blood (AB), especially focusing on the cytokines/chemokines accumulation on blood products.

MATERIALS AND METHODS

After approval of the ethics committee of the University of Tokyo, a total of 26 orthopedic patients, who donated AB prior to surgery after informed consent, were enrolled. The effects of filtration on blood cell counts were analyzed, and the accumulation of cytokines and chemokines were measured on pre- and post-leukoreduced (LR) samples, using the Luminex system. The time-dependent changes of the cytokines/chemokines and the effect of the filtration on their concentration were analyzed, and compared with the normal plasma levels reported in the literature.

RESULTS

LR effectively reduced the number of leukocytes and platelets, without affecting that of red cells. The concentration of most of the cytokines/chemokines analyzed, except the EGF, sCD40-L and sFas-L, decreased time-dependently of storage or did not change in pre-LR samples. However, EGF, sCD40L and sFas-L were significantly reduced by LR. Some, such as IL-8 and RANTES, were also importantly decreased by LR, and others, such as IL-1β and TNF-α, were not significantly affected by LR.

CONCLUSIONS

Leukocyte filtration effectively removes platelets and leukocytes from AB, thus preventing the accumulation of cytokines/chemokines. Since adverse effects due to AB transfusion, although rare, are observed, there is need to consider the implementation of pre-storage leukocyte reduction (PSLR) for AB.

Innate immune activation after transfusion of stored red blood cells

The transfusion of red blood cells (RBCs), although necessary for treatment of anemia and blood loss, has also been linked to increased morbidity and mortality. RBCs stored for longer durations and transfused in larger volumes are often cited as contributory to adverse outcomes. The potential mechanisms underlying deleterious effects of RBC transfusion are just beginning to be elucidated. In this narrative review, we explore the hypothesis that prolonged RBC storage results in elaboration of substances which may function as danger associated molecular pattern molecules that activate the innate immune system with consequences unfavorable to healthy homeostasis. The nature of these chemical mediators and the biological responses to them offers insight into the mechanisms of these pathological responses. Three major areas of activation of the innate immune apparatus by stored RBCs have been tentatively identified: RBC hemolysis, recipient neutrophil priming, and reactive oxygen species production. The possible mechanisms by which each might perturb the innate immune response are reviewed in a search for potential novel pathways through which transfusion can lead to an altered inflammatory response.

Limited utility of algorithms predicting blood transfusions

BACKGROUND

Prediction of transfusion is presumed to reduce wastage rates in pre-operative autologus blood donation (PABD) and unnecessary providing and cross-matching in allogeneic transfusion. The clinical utility of published algorithms in predicting transfusions was analysed.

MATERIALS AND METHODS

In a cohort of 195 patients undergoing total hip arthroplasty, after PABD, expected transfusion needs were predicted with two published algorithms (A and B). The algorithms were then compared to actual transfusions. Assumptions and formulae of these algorithms were varied in an attempt to improve their prognostic utility.

RESULTS

The optimal variation of A resulted in allogeneic transfusions (PABD setting) or uncross-matched transfusions (allogeneic setting) of 27.3%, and a wastage rate of autologous units or unnecessary cross-matching of 73.8%, compared to 33.3% and 76.6%, respectively, for the original algorithm. The original version of algorithm B resulted in (allogeneic) transfusions of 78.8%, and a wastage rate or unnecessary cross-matching of 46.2%. The former could be improved by a variation of the algorithm to 69.7%. Comparing the optimal variations of both algorithms, the more elaborate algorithm A reduced overall transfusion risk significantly better (P =0.001). The two algorithms were not statistically different in reducing resource consumption (P =0.09).

DISCUSSION

Although the prognostic utility of algorithm A was significantly better for reducing overall transfusion risk, both algorithms were unable to meaningfully identify patients who would benefit from PABD or cross-matching. The algorithms could not increase the percentage of PABD patients transfused, or the percentage of cross-matched patients transfused in the allogeneic setting. Furthermore, they could neither reduce transfusion risk nor resource consumption.

2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines

BACKGROUND

Practice guidelines reflect published literature. Because of the ever changing literature base, it is necessary to update and revise guideline recommendations from time to time. The Society of Thoracic Surgeons recommends review and possible update of previously published guidelines at least every three years. This summary is an update of the blood conservation guideline published in 2007.

METHODS

The search methods used in the current version differ compared to the previously published guideline. Literature searches were conducted using standardized MeSH terms from the National Library of Medicine PUBMED database list of search terms. The following terms comprised the standard baseline search terms for all topics and were connected with the logical 'OR' connector--Extracorporeal circulation (MeSH number E04.292), cardiovascular surgical procedures (MeSH number E04.100), and vascular diseases (MeSH number C14.907). Use of these broad search terms allowed specific topics to be added to the search with the logical 'AND' connector.

RESULTS

In this 2011 guideline update, areas of major revision include: 1) management of dual anti-platelet therapy before operation, 2) use of drugs that augment red blood cell volume or limit blood loss, 3) use of blood derivatives including fresh frozen plasma, Factor XIII, leukoreduced red blood cells, platelet plasmapheresis, recombinant Factor VII, antithrombin III, and Factor IX concentrates, 4) changes in management of blood salvage, 5) use of minimally invasive procedures to limit perioperative bleeding and blood transfusion, 6) recommendations for blood conservation related to extracorporeal membrane oxygenation and cardiopulmonary perfusion, 7) use of topical hemostatic agents, and 8) new insights into the value of team interventions in blood management.

CONCLUSIONS

Much has changed since the previously published 2007 STS blood management guidelines and this document contains new and revised recommendations.

The influence of maintaining the correct whole blood-to-anticoagulant ratio during donation on the quality of leukoreduced whole blood

BACKGROUND

It is unclear whether maintaining the correct whole blood-to-anticoagulant (WB : AC) ratio during collection can improve the quality of red blood cell (RBC)-containing blood products to a clinically relevant degree.

STUDY DESIGN AND METHODS

A total of 2 × 20 CPDA-1 leukoreduced whole blood (WB) units suspended in CPDA-1 were investigated. In one group, AC was continuously added to the donated blood, maintaining the correct WB : AC ratio during collection, using a new drawing device (MacoPharma ABC). In the other group, WB units were produced conventionally. Adenosine triphosphate (ATP), 2,3-diphosphoglycerate, free hemoglobin (Hb), potassium, glucose, lactate, pH, and variables of coagulation were determined on Days 1, 7, 21, 35, 42, and 49 of storage. Variables of RBC deformability and aggregability were determined using a laser-assisted optical rotational cell analyzer.

RESULTS

The ABC and conventional group showed comparable unit volumes of 525 (SD, 5.3) mL versus 524 (SD, 10.2) mL and Hb content of 65.9 (SD, 5.1) g/unit versus 67.5 (SD, 7.8) g/unit, but higher variation after conventional blood drawing (p = 0.006 and p = 0.07, respectively) was observed. During storage, none of the measured quality variables were significantly different between the groups. Mean (SD) ATP was 2.33 (0.41) µmol/g Hb versus 2.24 (0.39) µmol/g Hb after 42-day storage. Deformability was not different (p = 0.44), whereas the extent of the aggregability was higher in the conventional group (p = 0.04).

CONCLUSION

The ABC device provided a better standardized blood product but did not improve RBC storage variables or plasma quality. It slightly reduced RBC aggregability during storage. Excess AC at the beginning of a donation appears not to significantly affect RBC storage in conventional blood drawing.

The optimal hematocrit

Nearly 15 million units of packed red blood cells and whole blood are transfused annually in the United States alone. Until recently, the major risks from blood transfusion were thought to be transmission of viral infections, and overall, blood transfusion was believed by most providers to be safe. A safe hemoglobin threshold above which red cell transfusion is clearly unnecessary has not been established. This article addresses the numerous problems that surround the use and consequences of blood transfusion, such as hemoglobin and hematocrit levels, oxygenation, storage time, immunomodulation, infection, and anemia. The relevant literature is comprehensively reviewed.

Preventing platelet-derived microparticle formation--and possible side effects-with prestorage leukofiltration of whole blood

CONTEXT

Platelet-derived microparticles (PDMPs) probably function in hemostasis, thrombosis, inflammation, and transfusion-related immunomodulation.

OBJECTIVE

To compare PDMP levels of leukocyte-filtered and unfiltered whole blood during storage.

DESIGN

Ten whole blood donations were collected and processed. Half of each collection was filtered, half remained unfiltered, and both halves were measured for red cell, white cell, and platelet (PLT) content before storage. Samples were drawn on days 0, 1, 2, 3, 5, 7, 14, 21, 28, and 35 and analyzed by flow cytometry.

RESULTS

Leukocyte filtration lowered prestorage PDMP and PLT counts by an average of 72% and 99%, respectively. Prestorage PDMP counts were 123 +/- 51/microL in unfiltered whole blood supernatant versus 34 +/- 18/microL after filtration. Prestorage PLT counts were 190 +/- 49/microL in unfiltered whole blood supernatant versus 2 +/- 4/microL after filtration. Moreover, PDMP and PLT counts in filtered whole blood remained low throughout storage, typically below 100/microL. In contrast, unfiltered whole blood PDMP- and PLT-gated events increased approximately 2 log during storage, with the peak number of PLT-gated events tending to coincide with the peak number of PDMP-gated events (4 donors) or to come after the peak number of PDMP-gated events (6 donors).

CONCLUSIONS

Leukocyte filtration of whole blood lowers prestorage PDMP and PLT counts. Platelet-derived microparticle and PLT counts remain low throughout 35 days of storage. In contrast, PDMP- and PLT-gated events increase significantly in unfiltered whole blood. The nature of PLT-gated events in stored blood warrants further investigation.

Risk factors for endometritis after low transverse cesarean delivery

OBJECTIVE

To determine independent risk factors for endometritis after low transverse cesarean delivery.

STUDY DESIGN

We performed a retrospective case-control study during the period from July 1999 through June 2001 in a large tertiary care academic hospital. Endometritis was defined as fever beginning more than 24 hours or continuing for at least 24 hours after delivery plus fundal tenderness in the absence of other causes for fever. Independent risk factors for endometritis were determined by means of multivariable logistic regression. A fractional polynomial method was used to examine risk of endometritis associated with the continuous variable, duration of rupture of membranes.

RESULTS

Endometritis was identified in 124 (7.7%) of 1,605 women within 30 days after low transverse cesarean delivery. Independent risk factors for endometritis included age (odds ratio [OR] for each additional year, 0.93 [corrected] [95% confidence interval {CI}, 0.90-0.97]) and anemia or perioperative blood transfusion (OR, 2.18 [CI, 1.30-3.68]). Risk of endometritis was marginally associated with a proxy for low socioeconomic status, lack of private health insurance (OR, 1.72 [CI, 0.99-3.00]); with amniotomy (OR, 1.69 [CI, 0.97-2.95]); and with longer duration of rupture of membranes.

CONCLUSION

Risk of endometritis was independently associated with younger age and anemia and was marginally associated with lack of private health insurance and amniotomy. The odds of endometritis increased approximately 1.7-fold within 1 hour after rupture of membranes, but increased duration of rupture was only marginally associated with increased risk. Knowledge of these risk factors can guide selective use of prophylactic antibiotics during labor and heighten awareness of the risk in subgroups at highest risk of infection.