Association between duration of storage of transfused red blood cells and morbidity and mortality in adult patients: myth or reality?

Premature Macrophage Activation by Stored Red Blood Cell Transfusion Halts Liver Regeneration Post-Partial Hepatectomy in Rats

Liver resection is a common treatment for various conditions and often requires blood transfusions to compensate for operative blood loss. As partial hepatectomy (PHx) is frequently performed in patients with a pre-damaged liver, avoiding further injury is of paramount clinical importance. Our aim was to study the impact of red blood cell (RBC) resuscitation on liver regeneration. We assessed the impact of RBC storage time on liver regeneration following 50% PHx in rats and explored possible contributing molecular mechanisms using immunohistochemistry, RNA-Seq, and macrophage depletion. The liver was successfully regenerated after PHx when rats were transfused with fresh RBCs (F-RBCs). However, in rats resuscitated with stored RBCs (S-RBCs), the regeneration process was disrupted, as detected by delayed hepatocyte proliferation and lack of hypertrophy. The delayed regeneration was associated with elevated numbers of hemorrhage-activated liver macrophages (Mhem) secreting HO-1. Depletion of macrophages prior to PHx and transfusion improved the regeneration process. Gene expression profiling revealed alterations in numerous genes belonging to critical pathways, including cell cycle and DNA replication, and genes associated with immune cell activation, such as chemokine signaling and platelet activation and adhesion. Our results implicate activated macrophages in delayed liver regeneration following S-RBC transfusion via HO-1 and PAI-1 overexpression.

A deep 96-well plate RBC storage platform for high-throughput screening of novel storage solutions

Background: Red blood cell (RBC) storage solutions, also known as additive solutions (ASs), first developed in the 1970s, enable extended storage of RBCs. Unfortunately, the advancements in this field have been limited, due to labor intensive and time-consuming serial in vitro and in vivo testing, coupled with very high commercialization hurdles. This study examines the utility of deep 96-well plates for preliminary screenings of novel ASs through comparison of RBC storage with the standard PVC bags in terms of hemolysis and ATP levels, under both normoxic (N) and hypoxic/hypocapnic (H) storage conditions. The necessity for the presence of DEHP, normally provided by PVC bags, is also examined. Materials and methods: A pool of 2 ABO compatible RBC units was split between a bag and a plate. Each plate well contained either 1, 2 or 0 PVC strips cut from standard storage bags to supply DEHP. The H bags and plates were processed in an anaerobic glovebox and stored in O2 barrier bags. Hemolysis and ATP were measured bi-weekly using standard methods. Results: Final ATP and hemolysis values for the plate-stored RBCs were comparable to the typical values observed for 6-week storage of leukoreduced AS-3 RBCs in PVC bags under both N and H conditions. Hemolysis was below FDA and EU benchmarks of 1% and 0.8%, respectively, and excluding DEHP from plates during storage, resulted in an inconsequential increase when compared to bag samples. Discussion: In combination with high-throughput metabolomics workflow, this platform provides a highly efficient preliminary screening platform to accelerate the initial testing and consequent development of novel RBC ASs.

Tranexamic Acid in Patients With Cancer Undergoing Endoprosthetic Reconstruction: A Cost Analysis

INTRODUCTION

Tranexamic acid (TXA) decreases blood loss, perioperative transfusion rates, and cost in total hip and total knee arthroplasty. In a previous study, topical TXA decreased both perioperative blood loss and transfusions in patients undergoing resection of aggressive bone tumors and endoprosthetic reconstruction. The purpose of this study was to explore the cost effectiveness of TXA in patients undergoing resection of an aggressive bone tumor and endoprosthetic reconstruction, assessing transfusion cost, TXA administration cost, postoperative hospitalization cost, posthospital disposition, and 30-day readmissions.

METHODS

This study included 126 patients who underwent resection of an aggressive bone tumor and endoprosthetic resection at a single academic medical center; 61 patients in the TXA cohort and 65 patients in the non-TXA cohort. The cost of 1 unit of packed red blood cells, not including administration or complications, was estimated at our institution. The cost of hospitalization was estimated for lodging and basic care. The cost of TXA was $55 per patient. Patients were followed up for 30 days to identify hospital readmissions.

RESULTS

Patients in the TXA cohort experienced a TXA and blood transfusion cost reduction of $155.88 per patient (P = 0.007). Proximal femur replacement patients experienced a $282.05 transfusion cost reduction (P = 0.008), whereas distal femur replacement patients only experienced a transfusion cost reduction of $32.64 (P = 0.43). An average hospital admission cost reduction of $5,072.23 per patient (P < 0.001) was associated with TXA use. Proximal femur replacement patients who received TXA experienced a hospital cost reduction of $5,728.38 (P < 0.001), whereas distal femur replacement patients experienced a reduction of $3,724.90 (P = 0.01). No differences between the cohorts were identified in discharge to home (P = 0.37) or readmissions (P = 0.77).

DISCUSSION

TXA administration is cost effective in patients undergoing resection of an aggressive bone tumor and endoprosthetic reconstruction through reducing both perioperative transfusion rates and postoperative hospitalization.

LEVEL OF EVIDENCE

III-Retrospective Cohort Study.

Perioperative Transfusion is Related to the Length of Hospital Stays in Primary Liver Cancer Patients

Purpose

Blood loss may be corrected with red blood cell transfusion, but may ultimately contribute to negative impacts. This study was a retrospective analysis to assess the impact of perioperative blood transfusion on hospital stay days in liver cancer patients.

Methods

We retrospectively examined data from patients with primary liver cancer who underwent curative resection. Patients were divided into perioperative blood transfusion (PBT) and non-PBT groups. Data were given as means and SDs for continuous variables and as counts and percentage for categorical variables. The correlation between blood transfusion and hospital stay days was analyzed by Fisher's exact test. Multivariable logistic regression analyses were used to identify independent predictors of length of hospital stays.

Results

Totally 206/1031 patients (20.3%) were given perioperative transfusion. The mean length of hospital stay was 17.8 days in PBT and 13.9 days in non-PBT groups. Our multivariable logistic regression showed transfusion, total bilirubin, indirect bilirubin, and the ratio of albumin to bilirubin were all indicators of the length of hospital stay days. Perioperative transfusion was also associated with prolonged length of hospital stays (95% CI: 0.395-0.811, p = 0.002). Transfusion also affected intrinsic coagulation factors (activated partial thromboplastin time, fibrinogen, platelet), inflammatory index (neutrocyte to lymphocyte ratio, monocyte), albumin and bilirubin levels.

Conclusion

Perioperative transfusion of blood was associated with a significantly increased length of hospital stays probably via changing intrinsic coagulation and inflammatory factors and bilirubin levels in plasma.

Current Understanding of the Relationship between Blood Donor Variability and Blood Component Quality

While differences among donors has long challenged meeting quality standards for the production of blood components for transfusion, only recently has the molecular basis for many of these differences become understood. This review article will examine our current understanding of the molecular differences that impact the quality of red blood cells (RBC), platelets, and plasma components. Factors affecting RBC quality include cytoskeletal elements and membrane proteins associated with the oxidative response as well as known enzyme polymorphisms and hemoglobin variants. Donor age and health status may also be important. Platelet quality is impacted by variables that are less well understood, but that include platelet storage sensitive metabolic parameters, responsiveness to agonists accumulating in storage containers and factors affecting the maintenance of pH. An increased understanding of these variables can be used to improve the quality of blood components for transfusion by using donor management algorithms based on a donors individual molecular and genetic profile.

Transfusion of Older Red Blood Cells Increases the Risk of Acute Kidney Injury After Orthotopic Liver Transplantation: A Propensity Score Analysis

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.

Impact of stored red cells on clinical outcome in critically ill

BACKGROUND

The use and benefit of fresh blood and leuco-reduced blood for critically ill patients has been inconclusive. In this study we have tried to observe the same, in patients admitted to intensive care unit.

STUDY DESIGN AND METHODS

Prospective study was done to observe the effect of transfusion in critically ill patients in a tertiary care hospital. Clinical condition in cases and controls was assessed with the help of Simplified Acute Physiology Score II scoring tool. Clinical outcome among patients who received blood was compared using two cutoffs, 14 and 21 days of shelf life to delineate fresh from old blood. Length of hospital stay, length of stay in ICU, number of days on ventilator and number of hospital acquired infections were used as the surrogate markers for morbidity.

RESULTS

Of the 558 critically ill patients admitted during the study period, 427 received (cases) while 131 did not receive the transfusion (controls). Mean SAPS II scores of cases and controls were comparable. We observed a significantly higher rate of mortality among patients who received RBC units over 21 days. However morbidity parameters were affected even when the cutoff of 14 days is considered. Buffy-coat reduced blood did not influence the outcome in the study group.

CONCLUSION

Critically ill patients may be prioritized for receiving fresher units of packed red cells preferably less than 21 days old. Transfusion is an independent risk factor for morbidity. Hence the risk to benefit ratio should be carefully assessed for every red cell transfusion in critically ill patients.

Pre-clinical study protocol: Blood transfusion in endotoxaemic shock

The Surviving Sepsis Campaign (SCC) and the American College of Critical Care Medicine (ACCM) guidelines recommend blood transfusion in sepsis when the haemoglobin concentration drops below 7.0 g/dL and 10.0 g/dL respectively, while the World Health Organisation (WHO) guideline recommends transfusion in septic shock 'if intravenous (IV) fluids do not maintain adequate circulation', as a supportive measure of last resort. Volume expansion using crystalloid and colloid fluid boluses for haemodynamic resuscitation in severe illness/sepsis, has been associated with adverse outcomes in recent literature. However, the volume expansion effect(s) following blood transfusion for haemodynamic circulatory support, in severe illness remain unclear with most previous studies having focused on evaluating effects of either different RBC storage durations (short versus long duration) or haemoglobin thresholds (low versus high threshold) pre-transfusion. •We describe the protocol for a pre-clinical randomised controlled trial designed to examine haemodynamic effect(s) of early volume expansion using packed RBCs (PRBCs) transfusion (before any crystalloids or colloids) in a validated ovine-model of hyperdynamic endotoxaemic shock.•Additional exploration of mechanisms underlying any physiological, haemodynamic, haematological, immunologic and tissue specific-effects of blood transfusion will be undertaken including comparison of effects of short (≤5 days) versus long (≥30 days) storage duration of PRBCs prior to transfusion.

Extracellular Vesicles in Red Blood Cell Concentrates: An Overview

Red blood cell (RBC) concentrates may be stored for up to 42 days before transfusion to a patient. During storage extracellular vesicles (EVs) develop and can be detected in significant amounts in RBC concentrates. The concentration of EVs is affected by component preparation methods, storage solutions, and inter-donor variation. Laboratory investigations have focused on the effect of EVs on in vitro assays of thrombin generation and immune responses. Assays for EVs in RBC concentrates are not standardized. The aims of this review are to describe the factors that determine the presence of erythrocyte-EVs in RBC concentrates, the current techniques used to characterize them, and the potential role of EV analysis as a quality control maker for RBC storage.

Cancer relapse in surgical patients who received perioperative transfusion of blood and blood products: A case-control study

Background and Aims:

Immunomodulatory consequences of allogeneic blood transfusion may outweigh the advantages of improved oxygen delivery and tissue perfusion, especially in patients with cancer. In colorectal cancer, there is evidence of cancer relapse in patients who received transfusion. This retrospective analysis was undertaken to evaluate the relationship between perioperative blood transfusion and cancer recurrence in patients undergoing oncosurgery.

Methods:

In this case-control study, we retrospectively analysed the case sheets of 194 patients who had perioperative transfusion and underwent cancer surgery from March to December 2013(Study group, Cases). They were compared with controls matched for cancer site and TNM staging who did not receive perioperative transfusions (Control Group, Controls). We intended to find out if the Study group had any increased risk of cancer relapse compared with the controls. Records from the institute cancer registry were analysed in 2018 to give a follow-up period of 5 years. Continuous variables were analysed using Student's T test and Mann Whitney U test for normally distributed and skewed data respectively. For Categorical data Fisher's exact test and Chi square test were applied. The risk for recurrence was estimated using odds ratio.

Results:

The recurrence rate in cases and controls was 53.09% and 19.59% respectively and the odds ratio, 4.647 (CI: 2.954, 7.309). In Cases, significant relapse was noted for carcinomas of ovary, colorectal, bladder, larynx, head of pancreas and liver.

Conclusion:

In surgical oncology patients, ABT is associated with greater rate of recurrence.

Transfusion of red blood cells stored for shorter versus longer duration for all conditions

BACKGROUND

Red blood cell (RBC) transfusion is a common treatment for anaemia in many conditions. The safety and efficacy of transfusing RBC units that have been stored for different durations before a transfusion is a current concern. The duration of storage for a RBC unit can be up to 42 days. If evidence from randomised controlled trials (RCT) were to indicate that clinical outcomes are affected by storage duration, the implications for inventory management and clinical practice would be significant.

OBJECTIVES

To assess the effects of using red blood cells (RBCs) stored for a shorter versus a longer duration, or versus RBCs stored for standard practice duration, in people requiring a RBC transfusion.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, PubMed (for epublications), LILACS, Transfusion Evidence Library, Web of Science CPCI-S and four international clinical trial registries on 20 November 2017.

SELECTION CRITERIA

We included RCTs that compared transfusion of RBCs of shorter versus longer storage duration, or versus standard practice storage duration.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods.

MAIN RESULTS

We included 22 trials (42,835 participants) in this review.The GRADE quality of evidence ranged from very low to moderate for our primary outcome of in-hospital and short-term mortality reported at different time points.Transfusion of RBCs of shorter versus longer storage duration Eleven trials (2249 participants) compared transfusion of RBCs of shorter versus longer storage duration. Two trials enrolled low birth weight neonates, two enrolled children with severe anaemia secondary to malaria or sickle cell disease, and eight enrolled adults across a range of clinical settings (intensive care, cardiac surgery, major elective surgery, hospitalised in-patients, haematology outpatients). We judged only two trials to be at low risk of bias across all domains; most trials had an unclear risk for multiple domains.Transfusion of RBCs of shorter versus longer storage duration probably leads to little or no difference in mortality at seven-day follow-up (risk ratio (RR) 1.42, 95% confidence interval (CI) 0.66 to 3.06; 1 trial, 3098 participants; moderate quality evidence) or 30-day follow-up (RR 0.85, 95%CI 0.50 to 1.45; 2 trials, 1121 participants; moderate quality evidence) in adults undergoing major elective cardiac or non-cardiac surgery.For neonates, no studies reported on the primary outcome of in-hospital or short-term mortality. At 40 weeks gestational age, the effect of RBCs of shorter versus longer storage duration on the risk of death was uncertain, as the quality of evidence is very low (RR 0.90, 95% CI 0.41 to 1.85; 1 trial, 52 participants).The effect of RBCs of shorter versus longer storage duration on the risk of death in children with severe anaemia was also uncertain within 24 hours of transfusion (RR 1.50, 95% CI 0.43 to 5.25; 2 trials, 364 participants; very low quality evidence), or at 30-day follow-up (RR 1.40, 95% CI 0.45 to 4.31; 1 trial, 290 participants; low quality evidence).Only one trial, in children with severe anaemia (290 participants), reported adverse transfusion reactions. Only one child in each arm experienced an adverse reaction within 24 hours of transfusion.Transfusion of RBCs of shorter versus standard practice storage duration Eleven trials (40,588 participants) compared transfusion of RBCs of shorter versus standard practice storage duration. Three trials enrolled critically ill term neonates; two of these enrolled very low birth weight neonates. There were no trials in children. Eight trials enrolled critically ill and non-critically ill adults, with most being hospitalised. We judged four trials to be at low risk of bias across all domains with the others having an unclear risk of bias across multiple domains.Transfusion of RBCs of shorter versus standard practice storage duration probably leads to little or no difference in adult in-hospital mortality (RR 1.05, 95% CI 0.97 to 1.14; 4 trials, 25,704 participants; moderate quality evidence), ICU mortality (RR 1.06, 95% CI 0.98 to 1.15; 3 trials, 13,066 participants; moderate quality evidence), or 30-day mortality (RR 1.04, 95% CI 0.96 to 1.13; 4 trials, 7510 participants;moderate quality evidence).Two of the three trials that enrolled neonates reported that there were no adverse transfusion reactions. One trial reported an isolated case of cytomegalovirus infection in participants assigned to the standard practice storage duration group. Two trials in critically ill adults reported data on transfusion reactions: one observed no difference in acute transfusion reactions between arms (RR 0.67, 95% CI 0.19 to 2.36, 2413 participants), but the other observed more febrile nonhaemolytic reactions in the shorter storage duration arm (RR 1.48, 95% CI 1.13 to 1.95, 4919 participants).Trial sequential analysis showed that we may now have sufficient evidence to reject a 5% relative risk increase or decrease of death within 30 days when transfusing RBCs of shorter versus longer storage duration across all patient groups.

AUTHORS' CONCLUSIONS

The effect of storage duration on clinically important outcomes has now been investigated in large, high quality RCTs, predominantly in adults. There appears to be no evidence of an effect on mortality that is related to length of storage of transfused RBCs. However, the quality of evidence in neonates and children is low. The current practice in blood banks of using the oldest available RBCs can be continued safely. Additional RCTs are not required, but research using alternative study designs, should focus on particular subgroups (e.g. those requiring multiple RBC units) and on factors affecting RBC quality.

Longer storage of red blood cells does not affect mortality in transfused liver transplant recipients

BACKGROUND

The characteristics of red blood cell (RBC) products change after 2 weeks of cold storage. It is unclear whether older RBCs affect mortality after liver transplantation. This retrospective cohort study aimed to evaluate the association between the age of transfused RBCs and death after living donor liver transplantation (LDLT).

STUDY DESIGN AND METHODS

Of 200 recipients who underwent LDLT, 118 who received RBCs with a mean storage duration of less than 10 days (shorter storage group) were compared with 82 with an RBC mean storage duration of more than 14 days (longer storage group). Key exclusion criteria were transfusion of very fresh RBCs stored for less than 4 days and transfusion of old RBCs in recipients of the shorter storage group. The primary outcome was posttransplant overall death. Survival analysis was performed using the Cox model.

RESULTS

Mean RBC storage duration was 7 days in the shorter storage group and 17 days in the longer storage group. Death probability at 1, 2, and 5 years posttransplant was 5.1%, 7.6%, and 13.6% in the shorter storage group, respectively, and 6.1%, 8.5%, and 13.5% in the longer storage group. Death risk was comparable between the two groups in univariable (hazard ratio [HR] 1.00, 95% confidence interval [CI], 0.47-2.16, p = 0.991) and multivariable (HR 1.07, 95% CI, 0.46-2.50, p = 0.882) analyses. Graft failure risk was also comparable (HR 1.04, 95% CI, 0.50-2.18, p = 0.916). Hepatocellular carcinoma recurrence probability at 1, 2, and 5 years was 10.8%, 15.4%, and 23.1%, respectively, in the shorter storage group and 11.4%, 15.9%, and 20.7% in the longer storage group (HR 0.84, 95% CI, 0.37-1.89, p = 0.670). No significant differences were observed regarding graft regeneration/function, vascular/biliary complications, acute kidney injury, surgical site infection, or rejection (p > 0.05).

CONCLUSIONS

No evidence was found that transfusion of old RBCs contributes to death after LDLT.

The age of blood in pediatric intensive care units (ABC PICU): study protocol for a randomized controlled trial

Background

The “Age of Blood in Children in Pediatric Intensive Care Unit” (ABC PICU) study is a randomized controlled trial (RCT) that aims to determine if red blood cell (RBC) unit storage age affects outcomes in critically ill children. While RBCs can be stored for up to 42 days in additive solutions, their efficacy and safety after long-term storage have been challenged. Preclinical and clinical observational evidence suggests loss of efficacy and lack of safety of older RBC units, especially in more vulnerable populations such as critically ill children. Because there is a belief that shorter storage will improve outcomes, some physicians and institutions systematically transfuse fresh RBCs to children. Conversely, the standard practice of blood banks is to deliver the oldest available RBC unit (first-in, first-out policy) in order to decrease wastage.

Methods/design

The ABC PICU study, is a double-blind superiority trial comparing the development of “New or Progressive Multiple Organ Dysfunction Syndrome” (NPMODS) in 1538 critically ill children randomized to either transfusion with RBCs stored for ≤ 7 days or to standard-issue RBCs (oldest in inventory). Patients are being recruited from 52 centers in the US, Canada, France, Italy, and Israel.

Discussion

The ABC PICU study should have significant implications for blood procurement services. A relative risk reduction of 33% is postulated in the short-storage arm. If a difference is found, this will indicate that fresher RBCs do improve outcomes in the pediatric intensive care unit population and would justify that use in critically ill children.

If no difference is found, this will reassure clinicians and transfusion medicine specialists regarding the safety of the current system of allocating the oldest RBC unit in inventory and will discourage clinicians from preferentially requesting fresher blood for critically ill children.

Trial registration

ClinicalTrials.gov, ID: NCT01977547. Registered on 6 November 2013.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2809-y) contains supplementary material, which is available to authorized users.

Age of transfused blood in critically ill adult trauma patients: a prespecified nested analysis of the Age of Blood Evaluation randomized trial

BACKGROUND

Blood transfusion is common in the resuscitation of patients with traumatic injury. However, the clinical impact of the length of storage of transfused blood is unclear in this population.

STUDY DESIGN AND METHODS

We undertook a prespecified nested analysis of 372 trauma victims of the 2510 critically ill patients from 64 centers treated as part of the Age of Blood Evaluation (ABLE) randomized controlled trial. Patients were randomized according to their trauma status to receive either a transfusion of fresh blood stored not more than 7 days or standard-issue blood. Our primary outcome was 90-day all-cause mortality.

RESULTS

Overall, 186 trauma patients received fresh blood and 186 received standard-issue blood. Adherence to transfusion protocol was 94% (915/971) for all fresh blood transfused and 100% (753/753) for all standard-issue blood transfused. Mean ± SD blood storage duration was 5.6 ± 3.8 days in the fresh group and 22.7 ± 8.4 days in the standard-issue group (p < 0.001). Ninety-day mortality in the fresh group was 21% (38/185), compared to 16% (29/184) in the standard-issue group, with an unadjusted absolute risk difference of 5% (95% confidence interval [CI], -3.1 to 12.6) and an adjusted absolute risk difference of 2% (95% CI, -3.5 to 6.8).

CONCLUSION

In critically ill trauma patients, transfusion of fresh blood did not decrease 90-day mortality or secondary outcomes, a finding similar to the overall population of the ABLE trial.

The "Aging Factor" Eotaxin-1 (CCL11) Is Detectable in Transfusion Blood Products and Increases with the Donor's Age

Background: High blood levels of the chemokine eotaxin-1 (CCL11) have recently been associated with aging and dementia, as well as impaired memory and learning in humans. Importantly, eotaxin-1 was shown to pass the blood-brain-barrier (BBB) and has been identified as crucial mediator of decreased neurogenesis and cognitive impairment in young mice after being surgically connected to the vessel system of old animals in a parabiosis model. It thus has to be assumed that differences in eotaxin-1 levels between blood donors and recipients might influence cognitive functions also in humans. However, it is unknown if eotaxin-1 is stable during processing and storage of transfusion blood components. This study assesses eotaxin-1 concentrations in fresh-frozen plasma (FFP), erythrocyte concentrate (EC), and platelet concentrate (PC) in dependence of storage time as well as the donor’s age and gender.

Methods: Eotaxin-1 was measured in FFP (n = 168), EC (n = 160) and PC (n = 8) ready-to-use for transfusion employing a Q-Plex immunoassay for eotaxin-1. Absolute quantification of eotaxin-1 was performed with Q-view software.

Results: Eotaxin-1 was consistently detected at a physiological level in FFP and EC but not PC. Eotaxin-1 levels were comparable in male and female donors but increased significantly with rising age of donors in both, FFP and EC. Furthermore, eotaxin-1 was not influenced by storage time of either blood component. Finally, eotaxin-1 is subject to only minor fluctuations within one donor over a longer period of time.

Conclusion: Eotaxin-1 is detectable and stable in FFP and EC and increases with donor’s age. Considering the presumed involvement in aging and cognitive malfunction, differences in donor- and recipient eotaxin-1 levels might affect mental factors after blood transfusion.

Supernatants and lipids from stored red blood cells activate pulmonary microvascular endothelium through the BLT2 receptor and protein kinase C activation

BACKGROUND

Although transfusion is a lifesaving intervention, it may be associated with significant morbidity in injured patients. We hypothesize that stored red blood cells (RBCs) induce proinflammatory activation of human pulmonary microvascular endothelial cells (HMVECs) resulting in neutrophil (PMN) adhesion and predisposition to acute lung injury (ALI).

STUDY DESIGN AND METHODS

Ten units of RBCs were collected; 50% (by weight) were leukoreduced (LR-RBCs) and the remainder was unmodified and stored in additive solution-5 (AS-5). An additional 10 units of RBCs were collected, leukoreduced, and stored in AS-3. HMVECs were incubated with [10%-40%]_FINAL of the supernatants on Day (D)1 to D42 of storage, lipid extracts, and purified lipids. Endothelial surface expression of intercellular adhesion molecule-1 (ICAM-1), interleukin (IL)-8 release, and PMN adhesion to HMVECs were measured. HMVEC signaling via the BLT2 receptor was evaluated. Supernatants and lipids were also employed as the first event in a two-event model of ALI.

RESULTS

The supernatants [10%-40%]_FINAL from D21 LR-RBCs and D42 RBCs and LR-RBCs and the lipids from D42 stored in AS-5 induced increased ICAM-1 surface expression on endothelium, IL-8 release, and PMN adhesion. In addition, the supernatants [20%-40%]_FINAL from D21 and D42 RBCs in AS-5 also increased endothelial surface expression of ICAM-1. D42 supernatants and lipids also caused coprecipitation of β-arrestin-1 with BLT2, protein kinase C (PKC)β_I , and PKCδ and served as the first event in a two-event rodent model of ALI.

CONCLUSION

Lipids that accumulate during RBC storage activate endothelium and predispose to ALI, which may explain some of the adverse events associated with the transfusion of critically injured patients.

The effects of storage of red blood cells on the development of postoperative infections after noncardiac surgery

BACKGROUND

Prolonged storage of red blood cells (RBCs) is a potential risk factor for postoperative infections. The objective of this study was to examine the effect of age of RBCs transfused on development of postoperative infection.

STUDY DESIGN AND METHODS

In this prospective, double-blind randomized trial, 199 patients undergoing elective noncardiac surgery and requiring RBC transfusion were assigned to receive nonleukoreduced RBCs stored for not more than 14 days ("fresh blood" group, n = 101) or for more than 14 days ("old blood" group, n = 98). The primary outcome was occurrence of infection within 28 days after surgery; secondary outcomes were postoperative acute kidney injury (AKI), in-hospital and 90-day mortality, admission to intensive care unit, and hospital length of stay (LOS). As older blood was not always available, an "as-treated" (AT) analysis was also performed according to actual age of the RBCs transfused.

RESULTS

The median [interquartile range] storage time of RBCs was 6 [5-10] and 15 [11-20] days in fresh blood and in old blood groups, respectively. The occurrence of postoperative infection did not differ between groups (fresh blood 22% vs. old blood 25%; relative risk [RR], 1.17; confidence interval [CI], 0.71-1.93), although wound infections occurred more frequently in old blood (15% vs. 5%; RR, 3.09; CI, 1.17- 8.18). Patients receiving older units had a higher rate of AKI (24% vs. 6%; p < 0.001) and, according to AT analysis, longer LOS (mean difference, 3.6 days; CI, 0.6-7.5).

CONCLUSION

Prolonged RBC storage time did not increase the risk of postoperative infection. However, old blood transfusion increased wound infections rate and incidence of AKI.

Heme as a Target for Therapeutic Interventions

Heme is a complex of iron and the tetrapyrrole protoporphyrin IX with essential functions in aerobic organisms. Heme is the prosthetic group of hemoproteins such as hemoglobin and myoglobin, which are crucial for reversible oxygen binding and transport. By contrast, high levels of free heme, which may occur in various pathophysiological conditions, are toxic via pro-oxidant, pro-inflammatory and cytotoxic effects. The toxicity of heme plays a major role for the pathogenesis of prototypical hemolytic disorders including sickle cell disease and malaria. Moreover, there is increasing appreciation that detrimental effects of heme may also be critically involved in diseases, which usually are not associated with hemolysis such as severe sepsis and atherosclerosis. In mammalians homeostasis of heme and its potential toxicity are primarily controlled by two physiological systems. First, the scavenger protein hemopexin (Hx) non-covalently binds extracellular free heme with high affinity and attenuates toxicity of heme in plasma. Second, heme oxygenases (HOs), in particular the inducible HO isozyme, HO-1, can provide antioxidant cytoprotection via enzymatic degradation of intracellular heme. This review summarizes current knowledge on the pathophysiological role of heme for various diseases as demonstrated in experimental animal models and in humans. The functional significance of Hx and HOs for the regulation of heme homeostasis is highlighted. Finally, the therapeutic potential of pharmacological strategies that apply Hx and HO-1 in various clinical settings is discussed.

Effect of Tranexamic Acid on Transfusion Rates Following Total Joint Arthroplasty: A Cost and Comparative Effectiveness Analysis

Tranexamic acid (TXA) is used to reduce blood loss in orthopedic total joint arthroplasty (TJA). This study evaluates the effectiveness of TXA in reducing transfusions and hospital cost in TJA. Participants undergoing elective TJA were stratified into 2 cohorts: those not receiving and those receiving intravenous TXA. TXA decreased total hip arthroplasty (THA) transfusions from 22.7% to 11.9%, and total knee arthroplasty (TKA) from 19.4% to 7.0%. The average direct hospital cost reduction for THA and TKA was $3083 and $2582, respectively. Implementation of a TJA TXA protocol significantly reduced transfusions in a safe and cost-effective manner.

Effects of Leukoreduction and Storage on Erythrocyte Phosphatidylserine Expression and Eicosanoid Concentrations in Units of Canine Packed Red Blood Cells

Background

Storage of canine packed red blood cells (pRBCs) can increase erythrocyte phosphatidylserine (PS) expression and eicosanoid concentrations.

Hypothesis/Objectives

To determine the effects of leukoreduction on erythrocyte PS expression and eicosanoid concentrations in stored units of canine pRBCs. Our hypothesis was that leukoreduction would decrease PS expression and eicosanoid concentrations.

Animals

Eight healthy dogs.

Methods

In a cross‐over study, units of whole blood were leukoreduced (LR) or non‐LR and stored (10 and 21 days) as pRBCs. Samples were collected at donation, and before and after a simulated transfusion. PS expression was measured by flow cytometry, and concentrations of arachidonic acid (AA), prostaglandin F_2α (PGF_2α), prostaglandin E₂ (PGE₂), prostaglandin D₂ (PGD₂), thromboxane B₂ (TXB₂), 6‐keto‐prostaglandin F_1α (6‐keto‐PGF_1α), and leukotriene B₄ (LTB₄) were quantified by liquid chromatography–mass spectrometry.

Results

There was no change in PS expression during leukoreduction, storage, and simulated transfusion for non‐LR and LR units. Immediately after leukoreduction, there was a significant increase in TXB₂ and PGF_2α concentrations, but during storage, these eicosanoids decreased to non‐LR concentrations. In both LR and non‐LR units, 6‐keto‐PGF_1α concentrations increased during storage and simulated transfusion, but there was no difference between unit type. There was no difference in AA, LTB₄, PGE₂, and PGD₂ concentrations between unit types.

Conclusions and Clinical Importance

Leukoreduction, storage, and simulated transfusion do not alter erythrocyte PS expression. Leukoreduction causes an immediate increase in concentrations of TXB₂ and PGF_2α, but concentrations decrease to non‐LR concentrations with storage. Leukoreduction does not decrease the accumulation of 6‐keto‐PGF_1α during storage.

Effectiveness of Provider Education Followed by Computerized Provider Order Entry Alerts in Reducing Inappropriate Red Blood Cell Transfusion

To reduce the rate of inappropriate red blood cell transfusion, a provider education program, followed by alerts in the computerized provider order entry system (CPOE), was established to encourage AABB transfusion guidelines. Metrics were established for nonemergent inpatient transfusions. Service lines with high order volume were targeted with formal education regarding AABB 2012 transfusion guidelines. Transfusion orders were reviewed in real time with email communications sent to ordering providers falling outside of AABB recommendations. After 12 months of provider education, alerts were activated in CPOE. With provider education alone, the incidence of pretransfusion hemoglobin levels greater than 8 g/dL decreased from 16.64% to 6.36%, posttransfusion hemoglobin levels greater than 10 g/dL from 14.03% to 3.78%, and number of nonemergent two-unit red blood cell orders from 45.26% to 22.66%. Red blood cell utilization decreased by 13%. No additional significant reduction in nonemergent two-unit orders was observed with CPOE alerts. Provider education, an effective and low-cost method, should be considered as a first-line method for reducing inappropriate red blood cell transfusion rates in stable adult inpatients. Alerts in the computerized order entry system did not significantly lower the percentage of two-unit red blood cells orders but may help to maintain educational efforts.

Inventory management strategies that reduce the age of red blood cell components at the time of transfusion

BACKGROUND

There has been interest concerning patient outcomes when older red blood cell (RBC) components are utilized. Inventory management is key to maintaining a stock of fresher RBCs for general transfusion needs. We have altered our practice for RBC management to reduce RBC age at the time of transfusion.

STUDY DESIGN AND METHODS

Retrospective review of RBC age at time of transfusion at a tertiary care hospital with active trauma service was performed. The baseline nonirradiated RBC inventory was decreased from 12 to 15 days of stock to 7 to 10 days of stock, with request made to the blood supplier for fresher RBCs, specified at 75% of RBCs less than 14 days old. The age of RBCs at time of receipt and at time of transfusion was tracked on a monthly basis for the next 12 months.

RESULTS

The mean age of RBCs at transfusion was decreased by 9 days on average for the year. Significant decreases in the mean age of RBCs at transfusion were seen in the second half of the year, with 4 of 6 months seeing a mean age of less than 20 days. There were no documented incidences of hospital blood shortages after the reduction in inventory; no surgery was canceled or delayed because of inventory.

CONCLUSION

Inventory age depends on active management, combined with vendor cooperation to receive fresher components. Reducing the age of RBC components transfused is possible without experiencing blood component shortages. Longer periods of observation may allow for further adjustment of stocking levels on a seasonal basis.

Impact of the age of stored blood on trauma patient mortality: a systematic review

BACKGROUND

The impact of the age of stored red blood cells on mortality in patients sustaining traumatic injuries requiring transfusion of blood products is unknown. The objective of this systematic review was to identify and describe the available literature on the use of older versus newer blood in trauma patient populations.

METHODS

We searched PubMed, Embase, Lilac and the Cochrane Database for published studies comparing the transfusion of newer versus older red blood cells in adult patients sustaining traumatic injuries. Studies included for review reported on trauma patients receiving transfusions of packed red blood cells, identified the age of stored blood that was transfused and reported patient mortality as an end point. We extracted data using a standardized form and assessed study quality using the Newcastle-Ottawa Scale.

RESULTS

Seven studies were identified (6780 patients) from 3936 initial search results. Four studies reported that transfusion of older blood was independently associated with increased mortality in trauma patients, while 3 studies did not observe any increase in patient mortality with the use of older versus newer blood. Three studies associated the transfusion of older blood with adverse patient outcomes, including longer stay in the intensive care unit, complicated sepsis, pneumonia and renal dysfunction. Studies varied considerably in design, volumes of blood transfused and definitions applied for old and new blood..

CONCLUSION

The impact of the age of stored packed red blood cells on mortality in trauma patients is inconclusive. Future investigations are warranted.

Squeezing red blood cells on an optical waveguide to monitor cell deformability during blood storage

Red blood cells squeeze through micro-capillaries as part of blood circulation in the body. The deformability of red blood cells is thus critical for blood circulation. In this work, we report a method to optically squeeze red blood cells using the evanescent field present on top of a planar waveguide chip. The optical forces from a narrow waveguide are used to squeeze red blood cells to a size comparable to the waveguide width. Optical forces and pressure distributions on the cells are numerically computed to explain the squeezing process. The proposed technique is used to quantify the loss of blood deformability that occurs during blood storage lesion. Squeezing red blood cells using waveguides is a sensitive technique and works simultaneously on several cells, making the method suitable for monitoring stored blood.

Transfusion indications for patients with cancer

BACKGROUND

During the last few years, considerable focus has been given to the management of anemia and coagulopathies. This article provides current concepts of red blood cell (RBC) and plasma coagulation factor replacements.

METHODS

The literature was reviewed for clinical studies relevant to RBC transfusion indications and outcomes as well as for the uses of coagulation factor replacement products for coagulopathies most likely encountered in patients with cancer.

RESULTS

Most patients without complications can be treated with a hemoglobin level of 7 g/dL as an indication for RBC transfusion. However, the effects of disease among patients with cancer may cause fatigue, so transfusions at higher hemoglobin levels may be clinically helpful. Leukoreduced RBCs are recommended as standard therapy for all patients with cancer, most of whom do not develop coagulopathy. Transfusions to correct mild abnormalities are not indicated in this patient population. Data are inconclusive regarding the value of coagulation factor replacement for invasive procedures when the international normalized ratio is below 2.

CONCLUSIONS

Indications for RBC transfusion have become more conservative as data and experience have shown that patients can be safely and effectively maintained at lower hemoglobin levels. Coagulation factor replacement is unnecessary for most modest coagulopathies.

Prolonged storage of packed red blood cells for blood transfusion

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.

[The ABLE study: A randomized controlled trial on the efficacy of fresh red cell units to improve the outcome of transfused critically ill adults]

Red blood cell units are stored up to 42 days post-collection. The standard policy of blood banks is to deliver the oldest units in order to limit blood wastage. Many caregivers believe that giving fresh rather than old units can improve the outcome of their transfused patients. The ABLE study aims to check if the transfusion of red blood cell units stored seven days or less (fresh arm) improve the outcome of transfused critically ill adults compared to patients who received units delivered according to the standard delivery policy (control arm). From March 2009 to May 2014, 1211 patients were allocated to the fresh arm, 1219 to the control arm (length of storage: 6.1 ± 4.9 and 22.0 ± 8.4 days respectively, P<0.001). The primary outcome measure was 90-day all-cause mortality post-randomisation: there were 448 deaths (37.0%) in the fresh arm and 430 (35.3%) in the control arm (absolute risk difference: 1.7%; 95% confidence interval: -2.1% to 5.5%). In a survival analysis, the risk of death was higher in the fresh arm (hazard ratio: 1.1; 95%CI: 0.9 to 1.2), but the difference was not statistically significant (P=0.38). The same trend against the fresh arm was observed with all but one secondary outcome measures. The conclusion is that the transfusion of red blood cell units stored seven days or less does not improve the outcome of critically ill adults compared to the transfusion of units stored about three weeks (22.0 ± 8.4 days).

Transfusion of fresher versus older red blood cells for all conditions

BACKGROUND

Red blood cell transfusion is a common treatment for anaemia in many clinical conditions. One current concern is uncertainty as to the clinical consequences (notably efficacy and safety) of transfusing red blood cell units that have been stored for different durations of time before a transfusion. If evidence from randomised controlled trials were to indicate that clinical outcomes are affected by storage age, the implications for inventory management and clinical practice would be significant.

OBJECTIVES

To assess the effects of using fresher versus older red blood cells in people requiring a red blood cell transfusion.

SEARCH METHODS

We ran the search on 29th September 2014. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OvidSP), Embase (OvidSP), CINAHL (EBSCO), PubMed (for e-publications), three other databases and trial registers.

SELECTION CRITERIA

We included randomised controlled trials comparing fresher red blood cell transfusion versus active transfusion of older red blood cells, and comparing fresher red blood cell transfusion versus current standard practice. All definitions of 'fresher' and 'older'/'standard practice' red blood cells were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted from the trial report data on adverse red blood cell transfusion reactions, when reported.

MAIN RESULTS

We included 16 trials (1864 participants) in the review. Eight trials (279 participants) compared transfusion of fresher red blood cells versus transfusion of older stored red blood cells ('fresher' vs 'older'). Eight trials (1585 participants) compared the transfusion of fresher red blood cells versus current standard practice ('fresher' vs 'standard practice'). Five trials enrolled neonates, one trial enrolled children and 12 trials enrolled adults. Overall sample sizes were small: only two trials randomly assigned more than 100 participants.We performed no meta-analyses for a variety of reasons: no uniform definition of 'fresher' or 'older' red blood cell storage; overlap in the distribution of the age of red blood cells; and heterogeneity in measurements and reporting of outcomes of interest to this review. We tabulated and reported results by individual trial. Overall risk of bias was low or unclear, with four incidences of high risk of bias: in allocation concealment (three trials) and in incomplete outcome data (one trial).No trial measured all of the outcomes of interest in this review. Four trials comparing 'fresher' with 'older' red blood cells reported the primary outcome: mortality within seven days (one study; 74 participants) and at 30 days (three trials; 62 participants). Six trials comparing 'fresher' with 'standard practice' red blood cells reported the primary outcome: mortality within seven days (three studies; 159 participants) and at 30 days (three trials; 1018 participants). All 10 trials reported no clear differences in mortality at either time point between intervention arms.Three trials comparing 'fresher' with 'standard practice' red blood cells reported red blood cell transfusion-associated adverse events. No adverse reactions were reported in two trials, and one incidence of cytomegalovirus (CMV) infection was described in the 'standard practice' arm in one trial.Overall the trials reported no clear difference between either of the intervention comparisons in long-term mortality (three trials; 478 participants); clinically accepted measures of multiple organ dysfunction (two trials: 399 participants); incidence of in-hospital infection (two trials; 429 participants); duration of mechanical ventilation (three trials: 95 participants); and number of participants requiring respiratory organ support (five trials; 528 participants) or renal support (one trial; 57 participants). The outcome 'physiological markers of oxygen consumption or alterations in microcirculation' was reported by 11 studies, but the measures used were highly varied, and no formal statistical analysis was undertaken.

AUTHORS' CONCLUSIONS

Several factors precluded firm conclusions about the clinical outcomes of transfusing red blood cell units that have been stored for different periods of time before transfusion, including differences in clinical population and setting, diversity in the interventions used, methodological limitations and differences in how outcomes were measured and reported.No clear differences in the primary outcome - death - were noted between 'fresher' and 'older' or 'standard practice' red blood cells in trials that reported this outcome. Findings of a large number of ongoing trials will be incorporated into this review when they are published.Updates of this review will explore the degree of overlap in trials between 'fresher', 'older' and 'standard practice' storage ages of red blood cells and will consider whether the size of any observed effects is dependent on recipient factors such as clinical background, patient age or clinical presentation.

Effects of red-cell storage duration on patients undergoing cardiac surgery

BACKGROUND

Some observational studies have reported that transfusion of red-cell units that have been stored for more than 2 to 3 weeks is associated with serious, even fatal, adverse events. Patients undergoing cardiac surgery may be especially vulnerable to the adverse effects of transfusion.

METHODS

We conducted a randomized trial at multiple sites from 2010 to 2014. Participants 12 years of age or older who were undergoing complex cardiac surgery and were likely to undergo transfusion of red cells were randomly assigned to receive leukocyte-reduced red cells stored for 10 days or less (shorter-term storage group) or for 21 days or more (longer-term storage group) for all intraoperative and postoperative transfusions. The primary outcome was the change in Multiple Organ Dysfunction Score (MODS; range, 0 to 24, with higher scores indicating more severe organ dysfunction) from the preoperative score to the highest composite score through day 7 or the time of death or discharge.

RESULTS

The median storage time of red-cell units provided to the 1098 participants who received red-cell transfusion was 7 days in the shorter-term storage group and 28 days in the longer-term storage group. The mean change in MODS was an increase of 8.5 and 8.7 points, respectively (95% confidence interval for the difference, -0.6 to 0.3; P=0.44). The 7-day mortality was 2.8% in the shorter-term storage group and 2.0% in the longer-term storage group (P=0.43); 28-day mortality was 4.4% and 5.3%, respectively (P=0.57). Adverse events did not differ significantly between groups except that hyperbilirubinemia was more common in the longer-term storage group.

CONCLUSIONS

The duration of red-cell storage was not associated with significant differences in the change in MODS. We did not find that the transfusion of red cells stored for 10 days or less was superior to the transfusion of red cells stored for 21 days or more among patients 12 years of age or older who were undergoing complex cardiac surgery. (Funded by the National Heart, Lung, and Blood Institute; RECESS ClinicalTrials.gov number, NCT00991341.).

Blood transfusions in septic shock: is 7.0 g/dL really the appropriate threshold?

OBJECTIVE

To evaluate the immediate effects of red blood cell transfusion on central venous oxygen saturation and lactate levels in septic shock patients with different transfusion triggers.

METHODS

We included patients with a diagnosis of septic shock within the last 48 hours and hemoglobin levels below 9.0 g/dL Patients were randomized for immediate transfusion with hemoglobin concentrations maintained above 9.0 g/dL (Group Hb9) or to withhold transfusion unless hemoglobin felt bellow 7.0 g/dL (Group Hb7). Hemoglobin, lactate, central venous oxygen saturation levels were determined before and one hour after each transfusion.

RESULTS

We included 46 patients and 74 transfusions. Patients in Group Hb7 had a significant reduction in median lactate from 2.44 (2.00 - 3.22) mMol/L to 2.21 (1.80 - 2.79) mMol/L, p = 0.005, which was not observed in Group Hb9 [1.90 (1.80 - 2.65) mMol/L to 2.00 (1.70 - 2.41) mMol/L, p = 0.23]. Central venous oxygen saturation levels increased in Group Hb7 [68.0 (64.0 - 72.0)% to 72.0 (69.0 - 75.0)%, p < 0.0001] but not in Group Hb9 [72.0 (69.0 - 74.0)% to 72.0 (71.0 - 73.0)%, p = 0.98]. Patients with elevated lactate or central venous oxygen saturation < 70% at baseline had a significant increase in these variables, regardless of baseline hemoglobin levels. Patients with normal values did not show a decrease in either group.

CONCLUSION

Red blood cell transfusion increased central venous oxygen saturation and decreased lactate levels in patients with hypoperfusion regardless of their baseline hemoglobin levels. Transfusion did not appear to impair these variables in patients without hypoperfusion. ClinicalTrials.gov NCT01611753.

Anemia and Transfusion in Critical Care

Objective:

The objective of this report is to review the physiology and management of anemia in critical care. Selected publications on physiology and transfusion related to anemia and critical care, including the modern randomized trials of conservative versus liberal transfusion policy, were used. Anemia is compensated and tolerated in most critically ill patients as long as oxygen delivery is at least twice oxygen consumption. There are risks to blood transfusion which can be minimized by blood banking practice. The availability of cultured red cells may allow correction of anemia without significant risk. The benefit of transfusion in anemia must be weighted against the risk in any specific patient.

Conclusion and Recommendation:

In a criticially ill patient, anemia should be managed to avoid oxygen supply dependency (oxygen delivery less than twice comsumption) and to maintain moderate oxygen delivery reserve (DO2/VO2 > 3).

The pathophysiology and consequences of red blood cell storage

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.

Clinical effects of blood donor characteristics in transfusion recipients: protocol of a framework to study the blood donor-recipient continuum

INTRODUCTION

When used appropriately, transfusion of red blood cells (RBCs) is a necessary life-saving therapy. However, RBC transfusions have been associated with negative outcomes such as infection and organ damage. Seeking explanations for the beneficial and deleterious effects of RBC transfusions is necessary to ensure the safe and optimal use of this precious resource. This study will create a framework to analyse the influence of blood donor characteristics on recipient outcomes.

METHODS AND ANALYSIS

We will conduct a multisite, longitudinal cohort study using blood donor data routinely collected by Canadian Blood Services, and recipient data from health administrative databases. Our project will include a thorough validation of primary data, the linkage of various databases into one large longitudinal database, an in-depth epidemiological analysis and a careful interpretation and dissemination of the results to assist the decision-making process of clinicians, researchers and policymakers in transfusion medicine. Our primary donor characteristic will be age of blood donors and our secondary donor characteristics will be donor-recipient blood group compatibility and blood donor sex. Our primary recipient outcome will be a statistically appropriate survival analysis post-RBC transfusion up to a maximum of 8 years. Our secondary recipient outcomes will include 1-year, 2-year and 5-year mortality; hospital and intensive care unit length of stay; rehospitalisation; new cancer and cancer recurrence rate; infection rate; new occurrence of myocardial infarctions and need for haemodialysis.

ETHICS AND DISSEMINATION

Our results will help determine whether we need to tailor transfusion based on donor characteristics, and perhaps this will improve patient outcome. Our results will be customised to target the different stakeholders involved with blood transfusions and will include presentations, peer-reviewed publications and the use of the dissemination network of blood supply organisations. We obtained approval from the Research Ethics boards and privacy offices of all involved institutions.

Damage control resuscitation

The early recognition and management of hemorrhage shock are among the most difficult tasks challenging the clinician during primary assessment of the acutely bleeding patient. Often with little time, within a chaotic setting, and without sufficient clinical data, a decision must be reached to begin transfusion of blood components in massive amounts. The practice of massive transfusion has advanced considerably and is now a more complete and, arguably, more effective process. This new therapeutic paradigm, referred to as damage control resuscitation (DCR), differs considerably in many important respects from previous management strategies for catastrophic blood loss. We review several important elements of DCR including immediate correction of specific coagulopathies induced by hemorrhage and management of several extreme homeostatic imbalances that may appear in the aftermath of resuscitation. We also emphasize that the foremost objective in managing exsanguinating hemorrhage is always expedient and definitive control of the source of bleeding.

Routine storage of red blood cell (RBC) units in additive solution-3: a comprehensive investigation of the RBC metabolome

BACKGROUND

In most countries, red blood cells (RBCs) can be stored up to 42 days before transfusion. However, observational studies have suggested that storage duration might be associated with increased morbidity and mortality. While clinical trials are under way, impaired metabolism has been documented in RBCs stored in several additive solutions (ASs). Here we hypothesize that, despite reported beneficial effects, storage in AS-3 results in metabolic impairment weeks before the end of the unit shelf life.

STUDY DESIGN AND METHODS

Five leukofiltered AS-3 RBC units were sampled before, during, and after leukoreduction Day 0 and then assayed on a weekly basis from storage Day 1 through Day 42. RBC extracts and supernatants were assayed using a ultra-high-performance liquid chromatography separations coupled online with mass spectrometry detection metabolomics workflow.

RESULTS

Blood bank storage significantly affects metabolic profiles of RBC extracts and supernatants by Day 14. In addition to energy and redox metabolism impairment, intra- and extracellular accumulation of amino acids was observed proportionally to storage duration, suggesting a role for glutamine and serine metabolism in aging RBCs.

CONCLUSION

Metabolomics of stored RBCs could drive the introduction of alternative ASs to address some of the storage-dependent metabolic lesions herein reported, thereby increasing the quality of transfused RBCs and minimizing potential links to patient morbidity.

Biochemical and cellular changes in leukocyte-depleted red blood cells stored for transfusion

BACKGROUND

To evaluate biochemical and cellular changes associated with the storage of leukocyte-depleted red blood cells (RBCs).

METHODS

We investigated 10 leukocyte-depleted RBC units, randomly chosen from volunteer donors. Every week an aliquot was collected for laboratorial evaluation, which included complete cell blood count, glucose-6-phosphate dehydrogenase (G6PD) activity, extracellular sodium, potassium and pH, membrane-bound hemoglobin (MBH), band 3 profile, and quantification of RBC membrane proteins composition.

RESULTS

We observed an increase in mean cell volume (from 91.86 ± 4.65 fl to 98.10 ± 5.80 fl, day 0 vs. day 21; p < 0.05), red cell distribution width, percentage of macrocytic RBCs, reticulocyte hemoglobin content and a decreased percentage of microcytic RBCs, mean cell volume concentration and G6PD activity. The extracellular concentration of sodium decreased, and that of potassium increased significantly over time. RBC membrane composition revealed an increase in spectrin/ankyrin ratio after 21 days (from 4.84 ± 0.99 to 5.27 ± 0.94, day 0 vs. day 21; p < 0.05). At day 35, a decrease in ankyrin (from 6.44 ± 1.70% to 5.49 ± 1.96%, day 0 vs. day 35; p < 0.05), in protein 4.1/band 3, protein 4.2/band 3, and ankyrin/band 3 ratios and in band 5 was observed.

CONCLUSIONS

Our data show that leukocyte-depleted RBCs present changes in the RBC morphology, membrane protein composition, enzymatic activity, and extracellular electrolyte concentration and pH.

Quality control of buffy coat removed red cell concentrates--a Croatian experience

OBJECTIVES

Results are presented of the statistical quality control of red cell concentrate buffy coat removed in additive solution (RCC/BC/AS) and red cell concentrate buffy coat removed and leucoreduced in additive solution (RCC/BC/LR/AS) produced at the Croatian Institute of Transfusion Medicine during an 8-year period (2005-2012). The aim was to assess quality conformity of these products with specified requirements, as well as the suitability and justification of current regulations on the minimal quality requirements.

METHODS

The measurements of all the study parameters of the products analysed are expressed using descriptive statistics and graphs showing the distributions of observed parameters.

RESULTS

In RCC/BC/AS, the mean (± SD) volume was 279 ± 17 mL; haematocrit, 0.60 ± 0.03 L L(-1); haemoglobin content, 55 ± 5 g; leucocyte count, 0.65 ± 0.41 × 10(9); and haemolysis at expiry date, 0.16 ± 0.13%. In RCC/BC/LR/AS (post-production filtration), the mean (± SD) volume was 255 ± 14 mL; haematocrit, 0.60 ± 0.02 L L(-1); haemoglobin content, 51 ± 4 g; leucocyte count, 0.11 ± 0.16 × 10(6); and haemolysis at expiry date, 0.11 ± 0.07%. In RCC/BC/LR/AS (inline filtration), the mean (± SD) volume was 254 ± 15 mL; haematocrit, 0.61 ± 0.02 L L(-1); haemoglobin content, 51 ± 5 g; leucocyte count, 0.04 ± 0.06 × 10(6); and haemolysis at expiry date, 0.16 ± 0.10%. The standards were just met for leucocyte count in RCC/BC/AS (90%), whereas for all other parameters satisfactory results were obtained in at least 99% of products analysed. Total incidence of bacterial contamination was 0.23% for all products.

CONCLUSION

Results of the RCC/BC/AS and RCC/BC/LR/AS quality control showed very high conformity with the specified requirements in the majority of study parameters, suggesting that the current requirements could be redefined and improved at the institutional level.

Risk factors for transfusion-associated complications and nonsurvival in dogs receiving packed red blood cell transfusions: 211 cases (2008-2011)

OBJECTIVE

To determine whether the number, volume, or age of transfused packed RBC units; volume of other blood products; or pretransfusion PCV was a risk factor for transfusion-associated complications or nonsurvival in dogs.

DESIGN

Retrospective case series.

ANIMALS

211 client-owned dogs receiving stored packed RBC transfusions.

PROCEDURES

Information collected or calculated from the medical record of each dog included the total number, volume, and dose of packed RBC units; mean age of packed RBC units; number of packed RBC units > 14 days old; age of oldest packed RBC unit; volume and dose of other blood products used; pretransfusion PCV; acute patient physiologic and laboratory evaluation score; transfusion-associated complications; and outcome.

RESULTS

The dose (mL/kg) of other blood products transfused was a risk factor for transfusion-associated complications (OR, 1.03; 95% confidence interval [CI], 1.01 to 1.05). The pretransfusion PCV (OR, 1.13; 95% CI, 1.06 to 1.21) and dose of packed RBCs administered (OR, 1.04; 95% CI, 1.02 to 1.07) were risk factors for nonsurvival. Age of transfused packed RBC units was not identified as a risk factor for transfusion-associated complications or nonsurvival, but the study was statistically underpowered to detect this finding.

CONCLUSIONS AND CLINICAL RELEVANCE

Administration of larger doses of other non-packed RBC blood products was a risk factor for transfusion-associated complications, and a higher pretransfusion PCV and larger dose of packed RBCs administered were risk factors for nonsurvival. Prospective randomized studies are needed to determine whether conservative transfusion strategies will reduce transfusion-associated complications and improve outcome in dogs.

Metabolomics of AS-5 RBC supernatants following routine storage

BACKGROUND AND OBJECTIVES

The safety and efficacy of stored red blood cells (RBCs) transfusion has been long debated due to retrospective clinical evidence and laboratory results, indicating a potential correlation between increased morbidity and mortality following transfusion of RBC units stored longer than 14 days. We hypothesize that storage in Optisol additive solution-5 leads to a unique metabolomics profile in the supernatant of stored RBCs.

MATERIALS AND METHODS

Whole blood was drawn from five healthy donors, RBC units were manufactured, and prestorage leucoreduced by filtration. Samples were taken on days 1 and 42, the cells removed, and mass spectrometry-based metabolomics was performed.

RESULTS

The results confirmed the progressive impairment of RBC energy metabolism by day 42 with indirect markers of a parallel alteration of glutathione and NADPH homeostasis. Moreover, oxidized pro-inflammatory lipids accumulated by the end of storage.

CONCLUSION

The supernatants from stored RBCs may represent a burden to the transfused recipients from a metabolomics standpoint.

Transfusion related morbidity in premature babies: Possible mechanisms and implications for practice

Many premature babies, especially those with a low birth weight are given multiple transfusions during their first few weeks of life. The major serious complications of prematurity include bronchopulmonary dysplasia, with lesser incidences of retinopathy of prematurity, intraventricular haemorrhage, and necrotising enterocolitis. Many studies have shown correlations between the receipt of blood transfusions and the development of these conditions, but little is known of the underlying pathophysiology of this relationship. Recent studies are beginning to provide some answers. This review examines recent findings with regard to the influence of preparation and storage of paediatric packed red blood cell units on heme, iron, and oxidative status of the units and relates these to the ability of the premature baby to deal with these changes following the receipt of blood transfusions. Paediatric packed red blood cell units are a potential source of heme, redox active iron and free radicals, and this increases with storage age. Haemolysis of transfused red blood cells may add further iron and cell free haemoglobin to the recipient baby. Premature babies, particularly those with low birth weight and gestational age appear to have little reserve to cope with any additional iron, heme and/or oxidative load. The consequences of these events are discussed with regard to their contribution to the major complications of prematurity and a novel hypothesis regarding transfusion-related morbidity in premature babies is presented. The review concludes with a discussion of potential means of limiting transfusion related iron/heme and oxidative load through the preparation and storage of packed red blood cell units and through modifications in clinical practice.