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Miguel CF, Pereira CC. Evaluation of the feasibility for replacing sheep blood with human blood in culture media used in microbiological diagnostics. AN ACAD BRAS CIENC 2024; 96:e20231168. [PMID: 38808880 DOI: 10.1590/0001-3765202420231168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/04/2024] [Indexed: 05/30/2024] Open
Abstract
The present study aimed to suggest the replacement of animal blood with human blood in culture media, involving alternative methods and ethical considerations, such as animal welfare, in addition to potential laboratory cost reduction. Characteristics of growth and hemolysis development were compared in different culture media, using both sheep blood and human blood. Blood types from the ABO blood group system were tested, and commercially acquired sheep blood agar was used for comparison. Bacteria of the genus Streptococcus spp., Staphylococcus aureus, Enterococcus faecalis, and Escherichia coli were tested. It was observed that growth in media with type A and O positive blood showed closer similarities to those performed in agar with sheep blood. Depending on the bacterial species, the results were either more positive or not, with faster-growing and less demanding bacteria showing better results than, for example, S. pneumoniae, which demonstrated difficulty in the growth process and hemolysis generation in human blood agar. The research suggests that in some situations, sheep blood could be replaced, especially when the goal is growth and isolation, but may not be as suitable when the objective is to analyze hemolysis or when the studied species is demanding.
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Affiliation(s)
- Carla F Miguel
- Centro Universitário Salesiano, UniSales, Avenida Vitória, 950, Forte São João, 29017-950 Vitoria, ES, Brazil
| | - Christiane C Pereira
- Coordenadora da Pós-Graduação e Coordenadora do Curso de Farmácia, Centro Universitário Salesiano, UniSales, Avenida Vitoria, 950, Forte São João, 29017-950 Vitória, ES, Brazil
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2
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Ha M, Stewart KE, Butt AL, Vandyck KB, Tran S, Jain A, Edil B, Tanaka KA. Trends and predictions of perioperative transfusion and venous thromboembolism in hepatectomy using a North American Registry. Transfusion 2023; 63:2061-2071. [PMID: 37656947 DOI: 10.1111/trf.17528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Studies indicate a link between allogeneic blood transfusion and venous thromboembolism (VTE) post-major surgery. Analyzing trends and predictors of these outcomes after hepatectomy can inform risk management. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was used for a retrospective analysis. Primary outcomes were perioperative red blood cell (RBC) transfusion and VTE events within 30 days of hepatectomy. Seven-year trends and predictors were evaluated. RESULTS Among 29,131 hepatectomy patients, transfusion rates showed no statistically significant decreasing trends (p = .122) from 2014 to 2020 (18.13%-16.71%), while VTE rates showed a downward trend over the 7 years (p = .021); 17.2% received RBC transfusion, with higher rates in surgeries lasting ≥282 min (median: 220 min). Calculated RBC mass [hematocrit (%) × body weight (kg) × 10-5 × 70/ √ (body mass index/22)] at or below 1.5 L substantially increased transfusion odds. VTE was reported postoperatively in 2.6% of cases more frequently in longer cases involving transfusions. The adjusted odds ratio (aOR) of VTE escalated from the shortest operative time to the longest (3.17; 95% confidence interval [CI], 2.37-4.22). The adjusted odds of VTE doubled for transfused patients compared to non-transfused patients (aOR, 2.19; 95% CI, 1.86-2.57). CONCLUSIONS Rates of RBC transfusion and VTE rates hepatectomy have minimally changed in the recent years. VTE prevention is challenging in extended surgeries at increased risk of bleeding and RBC transfusions. Patient-level data on coagulation and thromboprophylaxis can potentially refine risk assessment for postoperative VTE.
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Affiliation(s)
- Monica Ha
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kenneth E Stewart
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Amir L Butt
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kofi B Vandyck
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Sydany Tran
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Ajay Jain
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Barish Edil
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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3
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Raphael J, Feng X, Shotwell MS, Mazzeffi MA, Bollen BA, Shah AS, Kertai MD. Association of Intraoperative Red Blood Cell Transfusions With Venous Thromboembolism and Adverse Outcomes After Cardiac Surgery. Ann Surg 2023; 278:e650-e660. [PMID: 36538645 DOI: 10.1097/sla.0000000000005733] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We determined whether intraoperative packed red blood cell (PRBC) transfusion was associated with a higher incidence of hospital-acquired venous thromboembolic (HA-VTE) complications and adverse outcomes after isolated coronary artery bypass grafting (CABG) surgery. BACKGROUND Intraoperative PRBC has been associated with increased risk for postoperative deep venous thrombosis after cardiac surgery, but validation of these findings in a large, multi-institutional, national cohort of cardiac surgery patients has been lacking. METHODS A registry-based cohort study of 751,893 patients with isolated CABG between January 1, 2015, to December 31, 2019. Using propensity score-weighted regression analysis, we analyzed the effect of intraoperative PRBC on the incidence of HA-VTE and adverse outcomes. RESULTS Administration of 1, 2, 3, and ≥4 units of PRBC transfusion was associated with increased odds for HA-VTE [odds ratios (ORs): 1.27 (1.22-1.32), 1.21 (1.16-1.26), 1.93 (1.85-2.00), 1.82 (1.75-1.89)], deep venous thrombosis [ORs: 1.39 (1.33-1.46), 1.38 (1.32-1.44), 2.18 (2.09-2.28), 1.82 (1.74-1.91], operative mortality [ORs: 1.11 (1.08-1.14), 1.16 (1.13-1.19), 1.29 (1.26-1.32), 1.47 (1.43-1.50)], readmission within 30 days [ORs: 1.05 (1.04-1.06), 1.16 (1.13-1.19), 1.29 (1.26-1.32), 1.47 (1.43-1.50)], and a prolonged postoperative length of stay [mean difference in days, 0.23 (0.19-0.27), 0.34 (0.30-0.39), 0.69 (0.64-0.74), 0.77 (0.72-0.820]. The odds of pulmonary venous thromboembolism were lower for patients transfused with 1 or 2 units [ORs: 0.98 (0.91-1.06), 0.75 (0.68-0.81)] of PRBC but remained significantly elevated for those receiving 3 and ≥4 units [ORs: 1.19 (1.09-1.29), 1.35 (1.25-1.48)]. CONCLUSIONS Intraoperative PRBC transfusion was associated with HA-VTE and adverse outcomes after isolated CABG surgery.
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Affiliation(s)
- Jacob Raphael
- Department of Anesthesiology, Thomas Jefferson University Hospitals, Philadelphia, PA
| | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Michael A Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
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4
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Kosenko E, Tikhonova L, Alilova G, Montoliu C. Erythrocytes Functionality in SARS-CoV-2 Infection: Potential Link with Alzheimer's Disease. Int J Mol Sci 2023; 24:5739. [PMID: 36982809 PMCID: PMC10051442 DOI: 10.3390/ijms24065739] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a rapidly spreading acute respiratory infection caused by SARS-CoV-2. The pathogenesis of the disease remains unclear. Recently, several hypotheses have emerged to explain the mechanism of interaction between SARS-CoV-2 and erythrocytes, and its negative effect on the oxygen-transport function that depends on erythrocyte metabolism, which is responsible for hemoglobin-oxygen affinity (Hb-O2 affinity). In clinical settings, the modulators of the Hb-O2 affinity are not currently measured to assess tissue oxygenation, thereby providing inadequate evaluation of erythrocyte dysfunction in the integrated oxygen-transport system. To discover more about hypoxemia/hypoxia in COVID-19 patients, this review highlights the need for further investigation of the relationship between biochemical aberrations in erythrocytes and oxygen-transport efficiency. Furthermore, patients with severe COVID-19 experience symptoms similar to Alzheimer's, suggesting that their brains have been altered in ways that increase the likelihood of Alzheimer's. Mindful of the partly assessed role of structural, metabolic abnormalities that underlie erythrocyte dysfunction in the pathophysiology of Alzheimer's disease (AD), we further summarize the available data showing that COVID-19 neurocognitive impairments most probably share similar patterns with known mechanisms of brain dysfunctions in AD. Identification of parameters responsible for erythrocyte function that vary under SARS-CoV-2 may contribute to the search for additional components of progressive and irreversible failure in the integrated oxygen-transport system leading to tissue hypoperfusion. This is particularly relevant for the older generation who experience age-related disorders of erythrocyte metabolism and are prone to AD, and provide an opportunity for new personalized therapies to control this deadly infection.
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Affiliation(s)
- Elena Kosenko
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, 142290 Pushchino, Russia
| | - Lyudmila Tikhonova
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, 142290 Pushchino, Russia
| | - Gubidat Alilova
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, 142290 Pushchino, Russia
| | - Carmina Montoliu
- Hospital Clinico Research Foundation, INCLIVA Health Research Institute, 46010 Valencia, Spain
- Pathology Department, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain
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5
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Antonelou MH. Tools and metrics for the assessment of post-storage performance of red blood cells: no one is left over. Transfusion 2023; 63:1-6. [PMID: 36537147 DOI: 10.1111/trf.17228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Marianna H Antonelou
- Department of Biology, School of Science, National and Kapodistrian University of Athens (NKUA), Panepistimiopolis, Athens, Greece
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6
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Gyi R, Cho BC, Hensley NB. Patient Blood Management in Vascular Surgery. Anesthesiol Clin 2022; 40:605-625. [PMID: 36328618 DOI: 10.1016/j.anclin.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Patient blood management (PBM) is an evidence-based, multidisciplinary approach aimed at appropriately allocating blood products to patients requiring transfusion while simultaneously minimizing inappropriate transfusions. The 3 pillars of patient blood management are optimizing erythropoiesis, minimizing blood loss, and optimizing physiological reserve of anemia. Benefits seen from PBM include limiting hospital costs and mitigating harm from numerous risks of transfusion.
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Affiliation(s)
- Richard Gyi
- Department of Anesthesiology, Johns Hopkins Hospital, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA
| | - Brian C Cho
- Department of Anesthesiology, Johns Hopkins Hospital, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA; Division of Cardiothoracic Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA
| | - Nadia B Hensley
- Division of Cardiothoracic Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA.
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7
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Feng H, Patel D, Magda JJ, Geher S, Sigala PA, Gale BK. Multiple-Streams Focusing-Based Cell Separation in High Viscoelasticity Flow. ACS OMEGA 2022; 7:41759-41767. [PMID: 36406492 PMCID: PMC9670260 DOI: 10.1021/acsomega.2c06021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 10/25/2022] [Indexed: 06/16/2023]
Abstract
Viscoelastic flow has been widely used in microfluidic particle separation processes, in which particles get focused on the channel center in diluted viscoelastic flow. In this paper, the transition from single-stream focusing to multiple-streams focusing (MSF) in high viscoelastic flow is observed, which is applied for cell separation processes. Particle focusing stream bifurcation is caused by the balance between elastic force and viscoelastic secondary flow drag force. The influence of cell physical properties, such as cell dimension, shape, and deformability, on the formation of multiple-streams focusing is studied in detail. Particle separation is realized utilizing different separation criteria. The size-based separation of red (RBC) and white (WBC) blood cells is demonstrated in which cells get focused in different streams based on their dimension difference. Cells with different deformabilities get stretched in the viscoelastic flow, leading to the change of focusing streams, and this property is harnessed to separate red blood cells infected with the malaria parasite, Plasmodium falciparum. The achieved results promote our understanding of particle movement in the high viscoelastic flow and enable new particle manipulation and separation processes for sample treatment in biofluids.
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Affiliation(s)
- Haidong Feng
- Department
of Mechanical Engineering, University of
Utah, Salt Lake
City, Utah84112, United States
- Department
of Biological Engineering, Massachusetts
Institute of Technology, Cambridge, Massachusetts02139, United States
| | - Dhruv Patel
- Department
of Mechanical Engineering, University of
Utah, Salt Lake
City, Utah84112, United States
| | - Jules J. Magda
- Department
of Chemical Engineering, University of Utah, Salt Lake City, Utah84112, United States
| | - Sage Geher
- Department
of Biochemistry, University of Utah School
of Medicine, Salt Lake City, Utah84112, United States
| | - Paul A. Sigala
- Department
of Biochemistry, University of Utah School
of Medicine, Salt Lake City, Utah84112, United States
| | - Bruce K. Gale
- Department
of Mechanical Engineering, University of
Utah, Salt Lake
City, Utah84112, United States
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8
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Bellach L, Eigenschink M, Hassanein A, Savran D, Salzer U, Müllner EW, Repa A, Klebermass-Schrehof K, Wisgrill L, Giordano V, Berger A. Packed red blood cell transfusion in preterm infants. Lancet Haematol 2022; 9:e615-e626. [PMID: 35901846 DOI: 10.1016/s2352-3026(22)00207-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 06/15/2023]
Abstract
Premature infants commonly receive adult packed red blood cells (pRBCs) during their hospital stay. As adult erythrocytes differ substantially from those of preterm infants, transfusion of adult pRBCs into preterm infants can be considered inappropriate for the physiology of a preterm infant. An absence of standardisation of transfusion protocols makes it difficult to compare and interpret pertinent clinical data, as reflected by unclear associations between pRBC transfusion and complications related to prematurity, such as bronchopulmonary dysplasia, neurodevelopmental impairment, retinopathy of prematurity, or necrotising enterocolitis. The difficulty in interpreting clinical data is further increased by differences in study designs that either overestimate pRBC-associated complications of prematurity or have not yet been designed to directly link pRBC transfusions to their respective complications. Thus, neonatal transfusion practice has become an ongoing difficulty, in which differences in transfusion guidelines hinder the ability to generate comparable clinical data, and heterogeneity in clinical data prevents the implementation of standardised transfusion protocols. To overcome these issues, novel approaches with biochemical-clinical translational designs could enable clinicians to gather causal evidence instead of circumstantial correlation.
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Affiliation(s)
- Luise Bellach
- Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Michael Eigenschink
- Center for Medical Biochemistry, Max Perutz Labs, Medical University of Vienna, Vienna, Austria
| | - Abtin Hassanein
- Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Danylo Savran
- Center for Medical Biochemistry, Max Perutz Labs, Medical University of Vienna, Vienna, Austria
| | - Ulrich Salzer
- Center for Medical Biochemistry, Max Perutz Labs, Medical University of Vienna, Vienna, Austria
| | - Ernst W Müllner
- Center for Medical Biochemistry, Max Perutz Labs, Medical University of Vienna, Vienna, Austria
| | - Andreas Repa
- Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Katrin Klebermass-Schrehof
- Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Lukas Wisgrill
- Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Vito Giordano
- Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Angelika Berger
- Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria.
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9
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Boecker C, Sitzmann N, Halblaub Miranda JL, Suhr H, Wiedemann P, Bieback K, Rudolph M, Klüter H. Noninferior Red Cell Concentrate Quality after Repeated Air Rescue Mission Transport for Prehospital Transfusion. Transfus Med Hemother 2022; 49:172-179. [PMID: 35813604 PMCID: PMC9209961 DOI: 10.1159/000520650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/29/2021] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Transfusion of red cell concentrates (RCCs) is an integral therapy after severe hemorrhage or trauma. Prehospital transfusion offers an immediate intervention in emergency cases. Air ambulance-based prehospital transfusion, already used in different countries, is currently established in Germany. Limited information is available for regulatory-compliant transport logistics of RCCs and their quality after repeated air rescue missions. Thus, the aim of this study was (i) to validate regulatory-compliant logistics and (ii) to assess product quality, analyzing biochemical parameters and RBC morphology. STUDY DESIGN AND METHODS Due to regulatory requirements, we adapted a rotation system of 1 day transport, 1 day quarantine storage and 1 day storage over the entire RCC shelf life. RCCs transported on air rescue missions (flight group) were compared against a control group, treated identically except for helicopter transport. RCCs were visually inspected, and their temperature was documented throughout the entire rotation cycles. RCCs at the end of shelf life (end point samples) were assessed for levels of hemoglobin, hematocrit, free hemoglobin, hemolysis, mean corpuscular volume, potassium and pH. In addition, morphological changes were assessed using flow morphometry. RESULTS In total 81 RCCs were assessed in the flight group and 50 in the control group. Within the flight group, 30 RCCs were transfused. RCCs were dispatched on average 11 times (7-13 times). The average flight time was 18.3 h (6.6-28.8 h). The rotation system ensured adherence to regulatory guidelines, especially compliance to storage conditions of +2 to +6°C of intermediate storage. Biochemical and morphological quality parameters did not exhibit any changes upon repeated air rescue missions. A correlation with respect to the flight time was not observed either. DISCUSSION The quality of RCCs after repeated air rescue missions is noninferior to control samples regarding biochemical and morphological parameters. The product quality is within German regulations for up to 42 days of storage. The logistics and maintenance of the thermal conditions are safe and feasible. Thus, a rotation system of RCCs offers a regulatory-compliant option to supply air rescue missions with RCCs to allow life-saving prehospital transfusions at the incident scene.
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Affiliation(s)
- Clemens Boecker
- Department of Biotechnology, Mannheim University of Applied Sciences, Mannheim, Germany
- Institute of Transfusion Medicine and Immunology, German Red Cross Blood Service, Baden-Württemberg − Hessen, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nicole Sitzmann
- Institute of Transfusion Medicine and Immunology, German Red Cross Blood Service, Baden-Württemberg − Hessen, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Hajo Suhr
- Department of Information Technology, Mannheim University of Applied Sciences, Mannheim, Germany
| | - Philipp Wiedemann
- Department of Biotechnology, Mannheim University of Applied Sciences, Mannheim, Germany
| | - Karen Bieback
- Institute of Transfusion Medicine and Immunology, German Red Cross Blood Service, Baden-Württemberg − Hessen, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marcus Rudolph
- Scientific working group, DRF Stiftung Luftrettung gAG, Filderstadt, Germany
| | - Harald Klüter
- Institute of Transfusion Medicine and Immunology, German Red Cross Blood Service, Baden-Württemberg − Hessen, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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10
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Storage of red blood cells in alkaline PAGGGM improves metabolism but has no effect on posttransfusion recovery. Blood Adv 2022; 6:3899-3910. [PMID: 35477178 PMCID: PMC9278290 DOI: 10.1182/bloodadvances.2022006987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/08/2022] [Indexed: 11/20/2022] Open
Abstract
Storage of red blood cells in the alkaline storage solution PAGGGM improves metabolism but has no effect on posttransfusion recovery. Transfused red blood cells can recover from the metabolic storage lesion within a day after transfusion.
Additive solutions are used to limit changes that red blood cells (RBCs) undergo during storage. Several studies have shown better preservation of glucose and redox metabolism using the alkaline additive solution PAGGGM (phosphate-adenine-glucose-guanosine-gluconate-mannitol). In this randomized open-label intervention trial in 20 healthy volunteers, the effect of storage, PAGGGM vs SAGM (saline-adenine-glucose-mannitol), on posttransfusion recovery (PTR) and metabolic restoration after transfusion was assessed. Subjects received an autologous biotinylated RBC concentrate stored for 35 days in SAGM or PAGGGM. As a reference for the PTR, a 2-day stored autologous biotinylated RBC concentrate stored in SAGM was simultaneously transfused. RBC phenotype and PTR were assessed after transfusion. Biotinylated RBCs were isolated from the circulation for metabolomics analysis up to 24 hours after transfusion. The PTR was significantly higher in the 2-day stored RBCs than in 35-day stored RBCs 2 and 7 days after transfusion: 96% (90 to 99) vs 72% (66 to 89) and 96% (90 to 99) vs 72% (66 to 89), respectively. PTR of SAGM- and PAGGGM-stored RBCs did not differ significantly. Glucose and redox metabolism were better preserved in PAGGGM-stored RBCs. The differences measured in the blood bag remained present only until 1 day after transfusion. No differences in RBC phenotype were found besides an increased complement C3 deposition on 35-day RBCs stored in PAGGGM. Our data indicate that despite better metabolic preservation, PAGGGM is not a suitable alternative for SAGM because storage in PAGGGM did not result in an increased PTR. Finally, RBCs recovered from circulation after transfusion showed reversal of the metabolic storage lesion in vivo within a day. This study is registered in the Dutch trial register (NTR6492).
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11
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Barshtein G, Pajic-Lijakovic I, Gural A. Deformability of Stored Red Blood Cells. Front Physiol 2021; 12:722896. [PMID: 34690797 PMCID: PMC8530101 DOI: 10.3389/fphys.2021.722896] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/18/2021] [Indexed: 12/24/2022] Open
Abstract
Red blood cells (RBCs) deformability refers to the cells’ ability to adapt their shape to the dynamically changing flow conditions so as to minimize their resistance to flow. The high red cell deformability enables it to pass through small blood vessels and significantly determines erythrocyte survival. Under normal physiological states, the RBCs are attuned to allow for adequate blood flow. However, rigid erythrocytes can disrupt the perfusion of peripheral tissues and directly block microvessels. Therefore, RBC deformability has been recognized as a sensitive indicator of RBC functionality. The loss of deformability, which a change in the cell shape can cause, modification of cell membrane or a shift in cytosol composition, can occur due to various pathological conditions or as a part of normal RBC aging (in vitro or in vivo). However, despite extensive research, we still do not fully understand the processes leading to increased cell rigidity under cold storage conditions in a blood bank (in vitro aging), In the present review, we discuss publications that examined the effect of RBCs’ cold storage on their deformability and the biological mechanisms governing this change. We first discuss the change in the deformability of cells during their cold storage. After that, we consider storage-related alterations in RBCs features, which can lead to impaired cell deformation. Finally, we attempt to trace a causal relationship between the observed phenomena and offer recommendations for improving the functionality of stored cells.
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Affiliation(s)
- Gregory Barshtein
- Biochemistry Department, The Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Alexander Gural
- Department of Hematology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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12
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Flatman LK, Fergusson DA, Lacroix J, Ducruet T, Papenburg J, Fontela PS. Association between the length of storage of transfused leukoreduced red blood cell units and hospital-acquired infections in critically ill children: A secondary analysis of the TRIPICU study. Transfus Med 2021; 31:467-473. [PMID: 34585466 DOI: 10.1111/tme.12824] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 09/08/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Evaluate the association between leukoreduced red blood cell (RBC) storage length and hospital-acquired infection (HAI) incidence rate in critically ill children. BACKGROUND RBC transfusions are common in critically ill children. Despite their benefits, observational studies suggest an association between them and HAIs. One possible mechanism for increased HAI is transfusion-related immunomodulation due to bioactive substances' release as transfused blood ages. METHODS In this secondary analysis of the 'Transfusion Requirement in Paediatric Intensive Care Units' (TRIPICU) study, we analysed a subset of 257 participants that received only one pre-storage leukoreduced RBC transfusion. RBC storage length was classified as 1) transfusion of 'fresh' RBCs (≤10 days), 2) transfusion of 'stored' RBCs (21-34 days), and 3) transfusion of 'long-stored' RBCs (≥35 days). All were compared to a 'golden' period (11-20 days), representing the time between 'fresh' and 'stored'. We used quasi-Poisson multivariable regression models to estimate the HAI incidence rate ratio (IRR) and corresponding 95% confidence interval (CI). RESULTS We found that the association between the length of storage time of leukoreduced RBCs and HAIs was not significant in the 'fresh' group (IRR 1.23; 95% CI 0.55, 2.78) and the 'stored' group (IRR 1.61; 95% CI 0.63, 4.13) when compared to the 'golden' period. However, we observed a statistically significant association between the 'long-stored' group and an increase in the HAI incidence rate (IRR 3.66; 95% CI 1.22, 10.98). CONCLUSION Transfusion of leukoreduced RBC units stored for ≥35 days is associated with increased HAI incidence rate in haemodynamically stable, critically ill children.
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Affiliation(s)
- Leah K Flatman
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Thierry Ducruet
- Unité de recherche clinique appliquée (URCA), Université de Montréal, Centre de Recherche, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Jesse Papenburg
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Division of Pediatric Infectious Diseases, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Patricia S Fontela
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
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Mansour A, Decouture B, Roussel M, Lefevre C, Skreko L, Picard V, Ouattara A, Bachelot-Loza C, Gaussem P, Nesseler N, Gouin-Thibault I. Combined Platelet and Erythrocyte Salvage: Evaluation of a New Filtration-based Autotransfusion Device. Anesthesiology 2021; 135:246-257. [PMID: 33984126 DOI: 10.1097/aln.0000000000003820] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The SAME device (i-SEP, France) is an innovative filtration-based autotransfusion device able to salvage and wash both red blood cells and platelets. This study evaluated the device performances using human whole blood with the hypothesis that the device will be able to salvage platelets while achieving a erythrocyte yield of 80% and removal ratios of 90% for heparin and 80% for major plasma proteins without inducing signification activation of salvaged cells. METHODS Thirty healthy human whole blood units (median volume, 478 ml) were diluted, heparinized, and processed by the device in two consecutive treatment cycles. Samples from the collection reservoir and the concentrated blood were analyzed. Complete blood count was performed to measure blood cell recovery rates. Flow cytometry evaluated the activation state and function of platelets and leukocytes. Heparin and plasma proteins were measured to assess washing performance. RESULTS The global erythrocyte yield was 88.1% (84.1 to 91.1%; median [25th to 75th]) with posttreatment hematocrits of 48.9% (44.8 to 51.4%) and 51.4% (48.4 to 53.2%) for the first and second cycles, respectively. Ektacytometry did not show evidence of erythrocyte alteration. Platelet recovery was 36.8% (26.3 to 43.4%), with posttreatment counts of 88 × 109/l (73 to 101 × 109/l) and 115 × 109/l (95 to 135 × 109/l) for the first and second cycles, respectively. Recovered platelets showed a low basal P-selectin expression at 10.8% (8.1 to 15.2%) and a strong response to thrombin-activating peptide. Leukocyte yield was 93.0% (90.1 to 95.7%) with no activation or cell death. Global removal ratios were 98.3% (97.8 to 98.9%), 98.2% (96.9 to 98.8%), and 88.3% (86.6 to 90.7%) for heparin, albumin, and fibrinogen, respectively. The processing times were 4.4 min (4.2 to 4.6 min) and 4.4 min (4.2 to 4.7 min) for the first and second cycles, respectively. CONCLUSIONS This study demonstrated the performance of the SAME device. Platelets and red blood cells were salvaged without significant impact on cell integrity and function. In the meantime, leukocytes were not activated, and the washing quality of the device prevented reinfusion of high concentrations of heparin and plasma proteins. EDITOR’S PERSPECTIVE
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Livshits L, Barshtein G, Arbell D, Gural A, Levin C, Guizouarn H. Do We Store Packed Red Blood Cells under "Quasi-Diabetic" Conditions? Biomolecules 2021; 11:biom11070992. [PMID: 34356616 PMCID: PMC8301930 DOI: 10.3390/biom11070992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/21/2021] [Accepted: 07/01/2021] [Indexed: 01/28/2023] Open
Abstract
Red blood cell (RBC) transfusion is one of the most common therapeutic procedures in modern medicine. Although frequently lifesaving, it often has deleterious side effects. RBC quality is one of the critical factors for transfusion efficacy and safety. The role of various factors in the cells’ ability to maintain their functionality during storage is widely discussed in professional literature. Thus, the extra- and intracellular factors inducing an accelerated RBC aging need to be identified and therapeutically modified. Despite the extensively studied in vivo effect of chronic hyperglycemia on RBC hemodynamic and metabolic properties, as well as on their lifespan, only limited attention has been directed at the high sugar concentration in RBCs storage media, a possible cause of damage to red blood cells. This mini-review aims to compare the biophysical and biochemical changes observed in the red blood cells during cold storage and in patients with non-insulin-dependent diabetes mellitus (NIDDM). Given the well-described corresponding RBC alterations in NIDDM and during cold storage, we may regard the stored (especially long-stored) RBCs as “quasi-diabetic”. Keeping in mind that these RBC modifications may be crucial for the initial steps of microvascular pathogenesis, suitable preventive care for the transfused patients should be considered. We hope that our hypothesis will stimulate targeted experimental research to establish a relationship between a high sugar concentration in a storage medium and a deterioration in cells’ functional properties during storage.
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Affiliation(s)
- Leonid Livshits
- Red Blood Cell Research Group, Institute of Veterinary Physiology, Vetsuisse Faculty, University of Zürich, CH-8057 Zurich, Switzerland;
| | - Gregory Barshtein
- Biochemistry Department, The Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 91905, Israel
- Correspondence: ; Tel.: +972-2-6758309
| | - Dan Arbell
- Pediatric Surgery Department, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel;
| | - Alexander Gural
- Department of Hematology, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel;
| | - Carina Levin
- Pediatric Hematology Unit, Emek Medical Center, Afula 1834111, Israel;
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 32000, Israel
| | - Hélène Guizouarn
- Institut de Biologie Valrose, Université Côte d’Azur, CNRS, Inserm, 28 Av. Valrose, 06100 Nice, France;
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15
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Colares PGB, Carlos LMDB, Ramos MCDMF, Campos CPS, Nascimento VDD, Cassiano JGM, Valente TM. Intraoperative blood salvage in proximal femur epiphysiolysis surgical treatment with hip controlled dislocation technique: a case series study. Braz J Anesthesiol 2021; 71:545-549. [PMID: 34097945 PMCID: PMC9373080 DOI: 10.1016/j.bjane.2021.02.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 01/24/2021] [Accepted: 02/06/2021] [Indexed: 11/06/2022] Open
Abstract
Objectives To report a case series of Intraoperative Blood Salvage (IOS) in surgeries during the treatment for Slipped Capital Femoral Epiphysis (SCFE) with controlled dislocation of the hip, identifying its efficacy, complications, and the profile of patients with SCFE. Methods Descriptive study reporting a case series, comprising patients seen between January 2016 and March 2018, diagnosed with SCFE, and treated with controlled surgical dislocation of the hip using IOS. Results Sample comprised of 15 patients, with a mean age of 13.1 years. The most affected side was the left with 8 cases. None of the patients required allogeneic blood in the postoperative period. Mean pre- and postoperative hemoglobin were 13.2 and 11.2 g.dL-1, respectively, and mean hemoglobin difference was 1.8 g.dL-1. Mean pre- and postoperative hematocrit were 39.13% and 33.20%, respectively, and mean hematocrit difference was 5.52%. No intraoperative complications were observed. One patient presented vomiting and another one, wound infection in the postoperative period. Conclusion IOS was an alternative blood salvage approach and prevented allogeneic blood transfusion, enabling reduction of potential complications.
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Affiliation(s)
- Paulo Giordano Baima Colares
- Universidade de Fortaleza, Fortaleza, CE, Brazil; Hospital Instituto Doutor José Frota, Departamento de Ortopedia, Fortaleza, CE, Brazil
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16
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Padiyath A, Lo BD, Ong CS, Goswami D, Steppan DA, Frank SM, Steppan J. Red blood cell storage duration and peri-operative outcomes in paediatric cardiac surgery. Vox Sang 2021; 116:965-975. [PMID: 33761164 DOI: 10.1111/vox.13098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Prior research on red blood cell (RBC) storage duration and clinical outcomes in paediatric cardiac surgery has shown conflicting results. The purpose of this study was to evaluate whether blood stored for a longer duration is harmful in these patients. METHODS We performed a retrospective cohort study of paediatric patients undergoing cardiac surgery at our institution between January 2011 and June 2015. Patients were stratified based on whether they were transfused RBCs stored for ≤15 days (fresher blood) or >15 days (older blood). The primary outcome was composite morbidity, with prolonged length of stay (LOS) as a secondary outcome. Subgroup analyses were performed after stratification by RBC transfusion volume (≤2 vs. >2 RBC units). Multivariable logistic regression models were used to assess the impact of RBC storage duration on composite morbidity and prolonged LOS. RESULTS Of 461 patients, 122 (26·5%) received fresher blood and 339 (73·5%) received older blood. The overall rate of composite morbidity was 18·0% (n = 22) for patients receiving fresher blood and 13·6% (n = 46) for patients receiving older blood (P = 0·24). In the risk-adjusted model, patients receiving older blood did not exhibit an increased risk of composite morbidity (OR: 0·74, 95% CI: 0·37-1·47, P = 0·40) or prolonged LOS (OR: 0·72, 95% CI: 0·38-1·35, P = 0·30) compared to patients receiving fresher blood. Similar results were seen after stratification by RBC transfusion volume. CONCLUSIONS Transfusing RBCs stored for a longer duration was not associated with an increased risk of morbidity or prolonged LOS in paediatric cardiac surgery patients.
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Affiliation(s)
- Asif Padiyath
- Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brian D Lo
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chin Siang Ong
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Dheeraj Goswami
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Diana A Steppan
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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17
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Bizjak DA, Grolle A, Urena JAN, Bloch W, Deitenbeck R, Grau M. Monitoring of RBC rheology after cryopreservation to detect autologous blood doping in vivo? A pilot study. Clin Hemorheol Microcirc 2020; 76:367-379. [PMID: 32675400 DOI: 10.3233/ch-200887] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND: Autologous blood doping (ABD) is applied to improve performance capacity. ABD includes blood donation, red blood cell (RBC) storage at –80°C and re-infusion prior to or during competition. ABD is not directly detectable with current detection techniques. OBJECTIVE: Since cryopreservation is known to affect RBC physiology in vitro, the aim of the study was to examine whether these alterations are detectable in vivo. METHODS: Blood from six healthy male donors was transferred into conventional blood bags, cryopreserved, stored for 18 weeks at –80°C and re-infused with a RBC volume corresponding to ∼4% of total blood volume into respective donor. RBC physiology parameters were measured before blood donation/re-infusion, and 0/1/2/6/24/48/72 h and 1 w post re-infusion. RESULTS: RBC parameters and age markers were unaffected during intervention. RBC deformability increased from pre-blood-sampling to pre-re-infusion while deformability and viscosity values remained unaltered post re-infusion. RBC nitric oxide associated analytes, metabolic parameters and electrolyte concentrations remained unaffected. CONCLUSIONS: The data of this pilot study indicate that the increase in RBC deformability might be related to neoformation of RBC after blood donation. The lack of changes in tested parameters might be related to the low re-infused RBC volume which might explain differences to in vitro results.
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Affiliation(s)
- Daniel A. Bizjak
- German Sport University Cologne, Department of Molecular and Cellular Sports Medicine, Cologne, Germany
| | - Andreas Grolle
- German Red Cross Blood Donation Service West, Hagen, Germany
| | | | - Wilhelm Bloch
- German Sport University Cologne, Department of Molecular and Cellular Sports Medicine, Cologne, Germany
| | | | - Marijke Grau
- German Sport University Cologne, Department of Molecular and Cellular Sports Medicine, Cologne, Germany
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Fourtounas M. Cell saver physics – a review. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s3.2537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cell salvage, cell saver, cell processor or autologous blood transfusion is the process of collecting a patient’s blood from the surgical field, washing, filtering and transfusing it back to the same patient. There are six basic steps involved in cell salvage. Step one involves the collection of shed blood into a reservoir with an anticoagulant-saline mixture. Step two is the filtration of debris and clots. In step three, the red blood cells (RBCs) are separated from the nonerythrocyte components. This process may be likened to clothes in the washing machine. Washing with saline removes contaminants in step four and the RBCs are resuspended in saline and transferred to the reinfusion bag. Waste products are transferred into the waste bag in step five. In step six, the resuspended, washed RBCs are collected in a bag at room temperature which can be reinfused.
The functioning of the cell saver is based on Newton’s First and Second Laws of Motion, where centripetal forces are generated to separate the blood components depending on their density. The denser RBCs are driven to the outer wall of the centrifuge bowl with the plasma collecting on the inside. A typical yield will retrieve 50–95.8% RBCs with a final haematocrit of 50–70%.
Cell savers are used in procedures with a large volume of anticipated blood loss, high risk of bleeding, low preoperative haemoglobin, in patients with rare blood groups or multiple antibodies and in some Jehovah’s Witness patients.
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Qin CX, Yesantharao LV, Merkel KR, Goswami DK, Garcia AV, Whitman GJR, Frank SM, Bembea MM. Blood Utilization and Clinical Outcomes in Extracorporeal Membrane Oxygenation Patients. Anesth Analg 2020; 131:901-908. [PMID: 32304461 DOI: 10.1213/ane.0000000000004807] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Patients requiring extracorporeal membrane oxygenation (ECMO) support are critically ill and have substantial transfusion requirements, which convey both risks and benefits. A retrospective analysis was conducted to assess the association between blood component administration and adverse outcomes in adult, pediatric, and neonatal ECMO patients. METHODS We evaluated 217 ECMO patients at a single center hospitalized between January 2009 and June 2016. Three cohorts (88 adult, 57 pediatric, and 72 neonatal patients) were included for assessment of patient characteristics, blood utilization, and clinical outcomes. Univariable and multivariable analyses were used to assess the association between transfusions and clinical outcomes (primary outcome: mortality and secondary outcomes: morbid events). The analysis included the main exposure of interest (total number of blood component units transfused) and potential confounding variables (age group cohort, case mix index, sex, ECMO mode and duration, and primary ECMO indication). RESULTS After adjustment for confounders, with each additional blood component unit transfused, there was an estimated increase in odds for mortality by 1% (odds ratio [OR] = 1.01; 95% confidence interval [CI], 1.00-1.02; P = .013) and an increase in odds for thrombotic events by 1% (OR = 1.01; 95% CI, 1.00-1.02; P = .007). Mortality was higher in the adult (57 of 88; 64.8%) and pediatric (37 of 57; 64.9%) than in the neonatal cohort (19 of 72; 26.4%) (P < .0001). Median total blood components transfused per day followed a similar pattern for the adult (2.3 units; interquartile range [IQR] = 0.8-7.0), pediatric (2.9 units; IQR = 1.1-10), and neonatal (1.0 units; IQR = 0.7-1.6) cohorts (P < .0001). Over the entire hospitalization, the total median blood components transfused was highest in the neonatal (41 units; IQR = 24-94) and pediatric (41 units; IQR = 17-113) compared to the adult (30 units; IQR = 9-58) cohort (P = .007). There was no significant interaction between total units transfused over the hospital stay and age cohort for mortality (P = .35). CONCLUSIONS Given the association between transfusion and adverse outcomes, effective blood management strategies may be beneficial in ECMO patients.
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Affiliation(s)
- Caroline X Qin
- From the Departments of Anesthesiology/Critical Care Medicine
| | | | - Kevin R Merkel
- From the Departments of Anesthesiology/Critical Care Medicine
| | | | | | - Glenn J R Whitman
- Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Steven M Frank
- From the Departments of Anesthesiology/Critical Care Medicine.,The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland
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20
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Sherstyukova E, Chernysh A, Moroz V, Kozlova E, Sergunova V, Gudkova O. The relationship of membrane stiffness, cytoskeleton structure and storage time of pRBCs. Vox Sang 2020; 116:405-415. [PMID: 33103792 DOI: 10.1111/vox.13017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/10/2020] [Accepted: 09/22/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES In clinical practice, it has been shown that transfusion of packed red blood cells (pRBCs) with late shelf life increases the risk of post-transfusion complications. OBJECTIVE To study relationship of membrane stiffness, cytoskeleton structure and storage time of pRBCs. MATERIALS AND METHODS pRBCs were processed and stored according to blood bank procedure, for 42 days, at +4°C; pRBC samples were taken on days 3, 12, 19, 21, 24, 28, 35 and 42. Cytoskeleton images and membrane stiffness were studied using atomic force microscope. RESULTS In the course of the pRBC storage, the cytoskeleton network configuration underwent structural changes. Simultaneously, pRBC membrane stiffness was increasing, with the correlation coefficient 0·88. Until 19 days, the stiffness grew slowly, in 19-24 days there occurred a transition period, after which its growth rate was three times higher than the initial. A chain of pathological processes developed in pRBC during long storage: pH reduction (linked to increased oxidative stress), then cytoskeletal destruction and an associated increase in pRBC membrane stiffness. CONCLUSION During prolonged storage of pRBCs and their acidification, there is a progression of pRBC cytoskeletal changes and associated increase of membrane stiffness, observed to increase in rate after days 19-24. Mutual measurements of cytoskeletal integrity and membrane stiffness may be useful quality assessment tool to study the molecular mechanisms of RBC structural degradation during storage.
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Affiliation(s)
- Ekaterina Sherstyukova
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia.,Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Aleksandr Chernysh
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia.,Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Viktor Moroz
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia
| | - Elena Kozlova
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia.,Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Viktoria Sergunova
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia
| | - Olga Gudkova
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, V.A. Negovsky Research Institute of General Reanimatology, Moscow, Russia
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21
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Man Y, Kucukal E, An R, Watson QD, Bosch J, Zimmerman PA, Little JA, Gurkan UA. Microfluidic assessment of red blood cell mediated microvascular occlusion. LAB ON A CHIP 2020; 20:2086-2099. [PMID: 32427268 PMCID: PMC7473457 DOI: 10.1039/d0lc00112k] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Abnormal red blood cell (RBC) deformability contributes to hemolysis, thrombophilia, inflammation, and microvascular occlusion in various circulatory diseases. A quantitative and objective assessment of microvascular occlusion mediated by RBCs with abnormal deformability would provide valuable insights into disease pathogenesis and therapeutic strategies. To that end, we present a new functional microfluidic assay, OcclusionChip, which mimics two key architectural features of the capillary bed in the circulatory system. First, the embedded micropillar arrays within the microchannel form gradient microcapillaries, from 20 μm down to 4 μm, which mimic microcapillary networks. These precisely engineered microcapillaries retain RBCs with impaired deformability, such that stiffer RBCs occlude the wider upstream microcapillaries, while less stiff RBCs occlude the finer downstream microcapillaries. Second, the micropillar arrays are coupled with two side passageways, which mimic the arteriovenous anastomoses that act as shunts in the capillary bed. These side microfluidic anastomoses prevent microchannel blockage, and enable versatility and testing of clinical blood samples at near-physiologic hematocrit levels. Further, we define a new generalizable parameter, Occlusion Index (OI), which is an indicative index of RBC deformability and the associated microcapillary occlusion. We demonstrate the promise of OcclusionChip in diverse pathophysiological scenarios that result in impaired RBC deformability, including mercury toxin, storage lesion, end-stage renal disease, malaria, and sickle cell disease (SCD). Hydroxyurea therapy improves RBC deformability and increases fetal hemoglobin (HbF%) in some, but not all, treated patients with SCD. HbF% greater than 8.6% has been shown to improve clinical outcomes in SCD. We show that OI associates with HbF% in 16 subjects with SCD. Subjects with higher HbF levels (HbF > 8.6%) displayed significantly lower OI (0.88% ± 0.10%, N = 6) compared with those with lower HbF levels (HbF ≤ 8.6%) who displayed greater OI (3.18% ± 0.34%, N = 10, p < 0.001). Moreover, hypoxic OcclusionChip assay revealed a significant correlation between hypoxic OI and subject-specific sickle hemoglobin (HbS) level in SCD. OcclusionChip enables versatile in vitro assessment of microvascular occlusion mediated by RBCs in a wide range of clinical conditions. OI may serve as a new parameter to evaluate the efficacy of treatments improving RBC deformability, including hemoglobin modifying drugs, anti-sickling agents, and genetic therapies.
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Affiliation(s)
- Yuncheng Man
- Department of Mechanical and Aerospace Engineering, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106, USA.
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22
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Modelling of Red Blood Cell Morphological and Deformability Changes during In-Vitro Storage. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10093209] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Storage lesion is a critical issue facing transfusion treatments, and it adversely affects the quality and viability of stored red blood cells (RBCs). RBC deformability is a key indicator of cell health. Deformability measurements of each RBC unit are a key challenge in transfusion medicine research and clinical haematology. In this paper, a numerical study, inspired from the previous research for RBC deformability and morphology predictions, is conducted for the first time, to investigate the deformability and morphology characteristics of RBCs undergoing storage lesion. This study investigates the evolution of the cell shape factor, elongation index and membrane spicule details, where applicable, of discocyte, echinocyte I, echinocyte II, echinocyte III and sphero-echinocyte morphologies during 42 days of in-vitro storage at 4 °C in saline-adenine-glucose-mannitol (SAGM). Computer simulations were performed to investigate the influence of storage lesion-induced membrane structural defects on cell deformability and its recoverability during optical tweezers stretching deformations. The predicted morphology and deformability indicate decreasing quality and viability of stored RBCs undergoing storage lesion. The loss of membrane structural integrity due to the storage lesion further degrades the cell deformability and recoverability during mechanical deformations. This numerical approach provides a potential framework to study the RBC deformation characteristics under varying pathophysiological conditions for better diagnostics and treatments.
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23
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Robidoux J, Laforce-Lavoie A, Charette SJ, Shevkoplyas SS, Yoshida T, Lewin A, Brouard D. Development of a flow standard to enable highly reproducible measurements of deformability of stored red blood cells in a microfluidic device. Transfusion 2020; 60:1032-1041. [PMID: 32237236 PMCID: PMC9701565 DOI: 10.1111/trf.15770] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Great deformability allows red blood cells (RBCs) to flow through narrow capillaries in tissues. A number of microfluidic devices with capillary-like microchannels have been developed to monitor storage-related impairment of RBC deformability during blood banking operations. This proof-of-concept study describes a new method to standardize and improve reproducibility of the RBC deformability measurements using one of these devices. STUDY DESIGN AND METHODS The rate of RBC flow through the microfluidic capillary network of the microvascular analyzer (MVA) device made of polydimethylsiloxane was measured to assess RBC deformability. A suspension of microbeads in a solution of glycerol in phosphate-buffered saline was developed to be used as an internal flow rate reference alongside RBC samples in the same device. RBC deformability and other in vitro quality markers were assessed weekly in six leukoreduced RBC concentrates (RCCs) dispersed in saline-adenine-glucose-mannitol additive solution and stored over 42 days at 4°C. RESULTS The use of flow reference reduced device-to-device measurement variability from 10% to 2%. Repeated-measure analysis using the generalized estimating equation (GEE) method showed a significant monotonic decrease in relative RBC flow rate with storage from Week 0. By the end of storage, relative RBC flow rate decreased by 22 ± 6% on average. CONCLUSIONS The suspension of microbeads was successfully used as a flow reference to increase reproducibility of RBC deformability measurements using the MVA. Deformability results suggest an early and late aging phase for stored RCCs, with significant decreases between successive weeks suggesting a highly sensitive measurement method.
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Affiliation(s)
| | | | - Steve J. Charette
- Biochemistry, Microbiology and Bioinformatics Department, Université Laval, Montreal, Quebec, Canada
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24
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Goel R, Josephson CD, Patel EU, Petersen MR, Makhani S, Frank SM, Ness PM, Bloch EM, Gehrie EA, Lokhandwala PM, Nellis MM, Karam O, Shaz BH, Patel RM, Tobian AA. Perioperative Transfusions and Venous Thromboembolism. Pediatrics 2020; 145:peds.2019-2351. [PMID: 32198293 PMCID: PMC7111487 DOI: 10.1542/peds.2019-2351] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Annual incidence of venous thromboembolism (VTE) including postoperative VTE in hospitalized children is rising significantly. A growing body of evidence supports the role of red blood cells (RBCs) in pathologic thrombosis. In this study, we examined the association of perioperative RBC transfusion with postoperative VTE in pediatric patients. METHODS The pediatric databases of the American College of Surgeons' National Surgical Quality Improvement Project from 2012 to 2017 were used. Multivariable logistic regression was used to examine the association between perioperative RBC transfusion status and the development of new or progressive VTE within 30 days of surgery. The analyses were age stratified, as follows: neonates (≤28 days), infants (>28 days and <1 year), and children (≥1 year). RESULTS In this study, we included 20 492 neonates, 79 744 infants, and 382 862 children. Postoperative development of VTE was reported in 99 (0.48%) neonates, 147 (0.2%) infants, and 374 (0.1%) children. In all age groups, development of VTE was significantly more common among patients with a perioperative RBC transfusion than patients without a perioperative RBC transfusion (neonates: adjusted odds ratio [aOR] = 4.1, 95% confidence interval [CI] = 2.5-6.7; infants: aOR = 2.4, 95% CI = 1.7-3.6; children: aOR = 2.2, 95% CI = 1.7-2.9). Among children who received an intra- or postoperative transfusion, the weight-based volume of RBCs (mL/kg) transfused was associated with postoperative VTE in a dose-dependent manner: second tertile (odds ratio = 2.3, 95% CI = 1.3-4.1) and third tertile (odds ratio = 4.1, 95% CI = 2.3-7.4) versus first tertile. CONCLUSIONS Perioperative RBC transfusions are independently associated with development of new or progressive postoperative VTE in children, infants, and neonates. These findings need further validation in prospective studies and emphasize the need for evidence-based perioperative pediatric blood transfusion decisions.
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Affiliation(s)
- Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland;,Departments of Internal Medicine and Pediatrics, School of Medicine, Southern Illinois University and Mississippi Valley Regional Blood Center, Springfield, Illinois
| | - Cassandra D. Josephson
- Department of Pathology, School of Medicine, Emory University and,Department of Pediatrics, Children’s Healthcare of Atlanta and School of Medicine, Emory University, Atlanta, Georgia
| | - Eshan U. Patel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Molly R. Petersen
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Sarah Makhani
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Steven M. Frank
- Department of Anesthesiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Paul M. Ness
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Evan M. Bloch
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Eric A. Gehrie
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Parvez M. Lokhandwala
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | | | - Oliver Karam
- Department of Pediatrics, Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia; and
| | | | - Ravi M. Patel
- Department of Pediatrics, Children’s Healthcare of Atlanta and School of Medicine, Emory University, Atlanta, Georgia
| | - Aaron A.R. Tobian
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, Maryland
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Freitas Leal JK, Lasonder E, Sharma V, Schiller J, Fanelli G, Rinalducci S, Brock R, Bosman G. Vesiculation of Red Blood Cells in the Blood Bank: A Multi-Omics Approach towards Identification of Causes and Consequences. Proteomes 2020; 8:proteomes8020006. [PMID: 32244435 PMCID: PMC7356037 DOI: 10.3390/proteomes8020006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/26/2020] [Accepted: 03/28/2020] [Indexed: 12/17/2022] Open
Abstract
Microvesicle generation is an integral part of the aging process of red blood cells in vivo and in vitro. Extensive vesiculation impairs function and survival of red blood cells after transfusion, and microvesicles contribute to transfusion reactions. The triggers and mechanisms of microvesicle generation are largely unknown. In this study, we combined morphological, immunochemical, proteomic, lipidomic, and metabolomic analyses to obtain an integrated understanding of the mechanisms underlying microvesicle generation during the storage of red blood cell concentrates. Our data indicate that changes in membrane organization, triggered by altered protein conformation, constitute the main mechanism of vesiculation, and precede changes in lipid organization. The resulting selective accumulation of membrane components in microvesicles is accompanied by the recruitment of plasma proteins involved in inflammation and coagulation. Our data may serve as a basis for further dissection of the fundamental mechanisms of red blood cell aging and vesiculation, for identifying the cause-effect relationship between blood bank storage and transfusion complications, and for assessing the role of microvesicles in pathologies affecting red blood cells.
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Affiliation(s)
- Joames K. Freitas Leal
- Department of Biochemistry (286), Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (J.K.F.L.); (R.B.)
| | - Edwin Lasonder
- Department of Applied Sciences, Faculty of Life and Health Sciences, Northumbria University, Newcastle-Upon-Tyne NE1 8ST, UK;
| | - Vikram Sharma
- School of Biomedical Sciences, University of Plymouth, Plymouth PL4 8AA, UK;
| | - Jürgen Schiller
- Institute for Medical Physics and Biophysics, Medical Faculty, University of Leipzig, 4107 Leipzig, Germany;
| | - Giuseppina Fanelli
- Department of Ecological and Biological Sciences (DEB), University of Tuscia, 01100 Viterbo, Italy; (G.F.); (S.R.)
| | - Sara Rinalducci
- Department of Ecological and Biological Sciences (DEB), University of Tuscia, 01100 Viterbo, Italy; (G.F.); (S.R.)
| | - Roland Brock
- Department of Biochemistry (286), Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (J.K.F.L.); (R.B.)
| | - Giel Bosman
- Department of Biochemistry (286), Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (J.K.F.L.); (R.B.)
- Correspondence:
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Abstract
INTRODUCTION Autologous salvaged blood, commonly referred to as "cell saver" or "cell salvage" blood, is an important method of blood conservation. Understanding the mechanism of action and summarizing the existing evidence regarding the safety, efficiency, and the relative costs of cell salvage may help educate clinicians on how and when to best utilize autotransfusion. METHODS This review focuses on issues concerning the quality of red blood cells (RBC), efficiency, and the cost effectiveness relative to autotransfusion. The key considerations of safe use and clinical applicability are described along with the challenges for wider dissemination. RESULTS Cell salvage can reduce requirements for allogeneic transfusions, along with the associated risks and costs. Autologous salvaged RBCs provide high-quality transfusion, since the cells have not been subjected to the adverse effects of storage as occurs with banked blood. The risks for RBC alloimmunization and transfusion-related infectious diseases are also avoided. With a careful selection of cases, salvaged blood can be more cost effective than donor blood. Cell salvage may have a role in cardiac, major vascular, orthopedic, transplant, and trauma surgeries. However, there remain theoretical safety concerns in cases with bacterial contamination or in cancer surgery. CONCLUSION In addition to other methods of blood conservation used in patient blood management programs, autologous salvaged blood adds value and is cost effective for appropriate surgical cases. Evidence suggests that autologous salvaged blood may be of higher quality and confer a cost reduction compared with the allogeneic banked blood, when used appropriately.
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27
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Mikhail C, Pennington Z, Arnold PM, Brodke DS, Chapman JR, Chutkan N, Daubs MD, DeVine JG, Fehlings MG, Gelb DE, Ghobrial GM, Harrop JS, Hoelscher C, Jiang F, Knightly JJ, Kwon BK, Mroz TE, Nassr A, Riew KD, Sekhon LH, Smith JS, Traynelis VC, Wang JC, Weber MH, Wilson JR, Witiw CD, Sciubba DM, Cho SK. Minimizing Blood Loss in Spine Surgery. Global Spine J 2020; 10:71S-83S. [PMID: 31934525 PMCID: PMC6947684 DOI: 10.1177/2192568219868475] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
STUDY DESIGN Broad narrative review. OBJECTIVE To review and summarize the current literature on guidelines, outcomes, techniques and indications surrounding multiple modalities of minimizing blood loss in spine surgery. METHODS A thorough review of peer-reviewed literature was performed on the guidelines, outcomes, techniques, and indications for multiple modalities of minimizing blood loss in spine surgery. RESULTS There is a large body of literature that provides a consensus on guidelines regarding the appropriate timing of discontinuation of anticoagulation, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements prior to surgery. Additionally, there is a more heterogenous discussion the utility of preoperative autologous blood donation facilitated by erythropoietin and iron supplementation for healthy patients slated for procedures with high anticipated blood loss and for whom allogeneic transfusion is likely. Intraoperative maneuvers available to minimize blood loss include positioning and maintaining normothermia. Tranexamic acid (TXA), bipolar sealer electrocautery, and topical hemostatic agents, and hypotensive anesthesia (mean arterial pressure (MAP) <65 mm Hg) should be strongly considered in cases with larger exposures and higher anticipated blood loss. There is strong level 1 evidence for the use of TXA in spine surgery as it reduces the overall blood loss and transfusion requirements. CONCLUSION As the volume and complexity of spinal procedures rise, intraoperative blood loss management has become a pivotal topic of research within the field. There are many tools for minimizing blood loss in patients undergoing spine surgery. The current literature supports combining techniques to use a cost- effective multimodal approach to minimize blood loss in the perioperative period.
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Affiliation(s)
| | | | - Paul M. Arnold
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Norman Chutkan
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - John G. DeVine
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Daniel E. Gelb
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Fan Jiang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Brian K. Kwon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas E. Mroz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmad Nassr
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - K. Daniel Riew
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lali H. Sekhon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | | | | | | | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, USA.
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Ichikawa J, Koshino I, Arashiki N, Nakamura F, Komori M. Changes in Erythrocyte Morphology at Initiation of Cardiopulmonary Bypass Without Blood Transfusion Were Not Associated With Less Deformability During Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:2960-2967. [DOI: 10.1053/j.jvca.2019.03.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 03/12/2019] [Accepted: 03/14/2019] [Indexed: 11/11/2022]
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29
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Visagie M, Qin CX, Cho BC, Merkel KR, Kajstura TJ, Amin RM, Purvis TE, Kebaish KM, Frank SM. The impact of patient blood management on blood utilization and clinical outcomes in complex spine surgery. Transfusion 2019; 59:3639-3645. [PMID: 31625178 DOI: 10.1111/trf.15544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 09/11/2019] [Accepted: 09/11/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patient blood management (PBM) is especially applicable in major spine surgery, during which bleeding and transfusion are common. What remains unclear in this setting is the overall impact of bundled PBM measures on transfusion requirements and clinical outcomes. We compared these outcomes before and after implementing a PBM program. STUDY DESIGN AND METHODS We conducted a retrospective review of 928 adult complex spine surgery patients performed by a single surgeon between January 2009 and June 2016. Although PBM measures were phased in over time, tranexamic acid (TXA) administration became standard protocol in July 2013, which defined our pre- and post-PBM periods. Transfusion rates for all blood components before and after PBM implementation were compared, as were morbid event rates and mortality. RESULTS Baseline characteristics were similar before and after PBM. Before PBM, the mean number of units/patient decreased for red blood cells (RBCs; by 19.5%; p = 0.0057) and plasma (by 33%; p = 0.0008), but not for platelets (p = 0.15). After risk adjustment by multivariable analyses, the composite outcome of morbidity or mortality showed a nonsignificant trend toward improvement after PBM (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.39-1.01; p = 0.055), and the risk of thrombotic events was unchanged (OR, 1.12; 95% CI, 0.42-2.58; p = 0.80). CONCLUSION In complex spine surgery, a multifaceted PBM program that includes TXA can be advantageous by reducing transfusion requirements without changing clinical outcomes.
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Affiliation(s)
- Mereze Visagie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Caroline X Qin
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian C Cho
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kevin R Merkel
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tymoteusz J Kajstura
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Raj M Amin
- Department of Orthopaedic Surgery, Baltimore, Maryland
| | - Taylor E Purvis
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Johns Hopkins Health System Blood Management Program, Department of Anesthesiology/Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland
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30
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Pinto RN, Sebastian JA, Parsons MJ, Chang TC, Turner TR, Acker JP, Kolios MC. Label‐Free Analysis of Red Blood Cell Storage Lesions Using Imaging Flow Cytometry. Cytometry A 2019; 95:976-984. [DOI: 10.1002/cyto.a.23846] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 06/12/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Ruben N. Pinto
- Institute of Biomedical Engineering Science and Technology (iBEST) Toronto Ontario M5B 1T8 Canada
- Department of PhysicsRyerson University Toronto Ontario M5B 2K3 Canada
| | - Joseph A. Sebastian
- Institute of Biomedical Engineering Science and Technology (iBEST) Toronto Ontario M5B 1T8 Canada
- Department of Electrical, Computer, and Biomedical EngineeringRyerson University Toronto Ontario M5B 2K3 Canada
| | - Michael J. Parsons
- Lunenfeld‐Tanenbaum Research Institute (LTRI)Sinai Health System Toronto Ontario M5G 1X5 Canada
| | - Tim C. Chang
- MilliporeSigma, a business of Merck KGaA Seattle Washington 98119
| | - Tracey R. Turner
- Centre for InnovationCanadian Blood Services Edmonton Alberta T6G 2R8 Canada
| | - Jason P. Acker
- Centre for InnovationCanadian Blood Services Edmonton Alberta T6G 2R8 Canada
- Department of Laboratory Medicine and PathologyUniversity of Alberta Edmonton Alberta T6G 2R8 Canada
| | - Michael C. Kolios
- Institute of Biomedical Engineering Science and Technology (iBEST) Toronto Ontario M5B 1T8 Canada
- Department of PhysicsRyerson University Toronto Ontario M5B 2K3 Canada
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31
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Geekiyanage NM, Balanant MA, Sauret E, Saha S, Flower R, Lim CT, Gu Y. A coarse-grained red blood cell membrane model to study stomatocyte-discocyte-echinocyte morphologies. PLoS One 2019; 14:e0215447. [PMID: 31002688 PMCID: PMC6474605 DOI: 10.1371/journal.pone.0215447] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/02/2019] [Indexed: 02/02/2023] Open
Abstract
An improved red blood cell (RBC) membrane model is developed based on the bilayer coupling model (BCM) to accurately predict the complete sequence of stomatocyte-discocyte-echinocyte (SDE) transformation of a RBC. The coarse-grained (CG)-RBC membrane model is proposed to predict the minimum energy configuration of the RBC from the competition between lipid-bilayer bending resistance and cytoskeletal shear resistance under given reference constraints. In addition to the conventional membrane surface area, cell volume and bilayer-leaflet-area-difference constraints, a new constraint: total-membrane-curvature is proposed in the model to better predict RBC shapes in agreement with experimental observations. A quantitative evaluation of several cellular measurements including length, thickness and shape factor, is performed for the first time, between CG-RBC model predicted and three-dimensional (3D) confocal microscopy imaging generated RBC shapes at equivalent reference constraints. The validated CG-RBC membrane model is then employed to investigate the effect of reduced cell volume and elastic length scale on SDE transformation, to evaluate the RBC deformability during SDE transformation, and to identify the most probable RBC cytoskeletal reference state. The CG-RBC membrane model can predict the SDE shape behaviour under diverse shape-transforming scenarios, in-vitro RBC storage, microvascular circulation and flow through microfluidic devices.
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Affiliation(s)
- Nadeeshani Maheshika Geekiyanage
- School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Marie Anne Balanant
- School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- Research & Development, Australian Red Cross Blood Service, Brisbane, Queensland, Australia
| | - Emilie Sauret
- School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Suvash Saha
- University of Technology Sydney (UTS), Ultimo, New South Wales, Australia
| | - Robert Flower
- Research & Development, Australian Red Cross Blood Service, Brisbane, Queensland, Australia
| | - Chwee Teck Lim
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore
- Biomedical Institute for Global Health Research and Technology, National University of Singapore, Singapore
- Mechanobiology Institute, National University of Singapore, Singapore
| | - YuanTong Gu
- School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
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32
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Balasubramanian V, Li JKJ, O'Hara D, Kaya M. Myocardial oxygen balance during acute normovolemic hemodilution: A novel compartmental modeling approach. Comput Biol Med 2018; 105:16-26. [PMID: 30572164 DOI: 10.1016/j.compbiomed.2018.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 12/11/2018] [Accepted: 12/11/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Hemodilution was introduced initially as a blood conservation technique to reduce allogeneic blood transfusion in patients undergoing surgical procedures. Although the technique has been approved by the National Institute of Health consensus panel, limits of hemodilution under anesthetic conditions have not been established as they have in animal models. METHODS A novel multi-compartmental modeling approach has been proposed that includes the effect of anesthesia to quantify the effect of hemodilution on myocardial oxygen balance during myocardial ischemia. RESULTS The results showed that isovolemic hemodilution would cause detrimental effects around a hematocrit of 15%. Even though the fall in oxygen content caused by the decrease in hemoglobin concentration was compensated by an increase in coronary blood flow induced by hypoxic vasodilation and decreased viscosity, the endocardial tissue received less oxygen compared to the epicardial regions, and this sub-endocardial ischemia eventually led to cardiac failure. Statistical analysis also showed that the type of acellular replacement fluid failed to affect the heart rate, the stroke index or the cardiac index during hemodilution, and supplemental oxygen improved the endocardial oxygen supply. CONCLUSION The model validates the clinical conclusions that sub-endocardial ischemia causes cardiac failure under extreme hemodilution conditions and the model can also be easily integrated into other human simulators.
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Affiliation(s)
- Vignesh Balasubramanian
- Department of Biomedical and Chemical Engineering and Sciences, Florida Institute of Technology, Melbourne, FL, USA
| | - John K-J Li
- Department of Biomedical Engineering and Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ, USA; College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Dorene O'Hara
- Department of Orthopedic, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Mehmet Kaya
- Department of Biomedical and Chemical Engineering and Sciences, Florida Institute of Technology, Melbourne, FL, USA.
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33
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Kristof K, Büttner B, Grimm A, Mewes C, Schmack B, Popov AF, Ghadimi M, Beissbarth T, Hinz J, Bergmann I, Mansur A. Anaemia requiring red blood cell transfusion is associated with unfavourable 90-day survival in surgical patients with sepsis. BMC Res Notes 2018; 11:879. [PMID: 30537993 PMCID: PMC6290543 DOI: 10.1186/s13104-018-3988-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 12/05/2018] [Indexed: 12/26/2022] Open
Abstract
Objective The mortality associated with sepsis remains unacceptably high, despite modern high-quality intensive care. Based on the results from previous studies, anaemia and its management in patients with sepsis appear to impact outcomes; however, the transfusion policy is still being debated, and the ideal approach may be extremely specific to the individual. This study aimed to investigate the long-term impact of anaemia requiring red blood cell (RBC) transfusion on mortality and disease severity in patients with sepsis. We studied a general surgical intensive care unit (ICU) population, excluding cardiac surgery patients. 435 patients were enrolled in this observational study between 2012 and 2016. Results Patients who received RBC transfusion between 28 days before and 28 days after the development of sepsis (n = 302) exhibited a significantly higher 90-day mortality rate (34.1% vs 19.6%; P = 0.004, Kaplan–Meier analysis). This association remained significant after adjusting for confounders in the multivariate Cox regression analysis (hazard ratio 1.68; 95% confidence interval 1.03–2.73; P = 0.035). Patients who received transfusions also showed significantly higher morbidity scores, such as SOFA scores, and ICU lengths of stay compared to patients without transfusions (n = 133). Our results indicate that anaemia and RBC transfusion are associated with unfavourable outcomes in patients with sepsis. Electronic supplementary material The online version of this article (10.1186/s13104-018-3988-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katalin Kristof
- Department of Anesthesiology, University Medical Center, Georg August University, Goettingen, Germany
| | - Benedikt Büttner
- Department of Anesthesiology, University Medical Center, Georg August University, Goettingen, Germany
| | - Anna Grimm
- Department of Anesthesiology, University Medical Center, Georg August University, Goettingen, Germany
| | - Caspar Mewes
- Department of Anesthesiology, University Medical Center, Georg August University, Goettingen, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, University Hospital, Ruprecht Karls University, Heidelberg, Germany
| | - Aron Frederik Popov
- Department of Thoracic and Cardiovascular Surgery, University Medical Center, Goethe University, Frankfurt, Germany
| | - Michael Ghadimi
- Department of General, Visceral and Pediatric Surgery, University Medical Center, Georg August University, Goettingen, Germany
| | - Tim Beissbarth
- Department of Medical Statistics, University Medical Center, Georg August University, Goettingen, Germany
| | - José Hinz
- Department of Anesthesiology, University Medical Center, Georg August University, Goettingen, Germany
| | - Ingo Bergmann
- Department of Anesthesiology, University Medical Center, Georg August University, Goettingen, Germany
| | - Ashham Mansur
- Department of Anesthesiology, University Medical Center, Georg August University, Goettingen, Germany.
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34
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Koch CG, Duncan AI, Figueroa P, Dai L, Sessler DI, Frank SM, Ness PM, Mihaljevic T, Blackstone EH. Real Age: Red Blood Cell Aging During Storage. Ann Thorac Surg 2018; 107:973-980. [PMID: 30342044 DOI: 10.1016/j.athoracsur.2018.08.073] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 07/10/2018] [Accepted: 08/20/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND During cold storage, some red blood cell (RBC) units age more rapidly than others. Yet, the Food and Drug Administration has set a uniform storage limit of 42 days. Objectives of this review are to present evidence for an RBC storage lesion and suggest that functional measures of stored RBC quality-which we call real age-may be more appropriate than calendar age. METHODS During RBC storage, biochemical substances and byproducts accumulate and RBC shape alters. Factors that influence the rate of degradation include donor characteristics, bio-preservation conditions, and vesiculation. Better understanding of markers of RBC quality may lead to standardized, quantifiable, and operationally practical measures to improve donor selection, assess quality of an RBC unit, improve storage conditions, and test efficacy of the transfused product. RESULTS The conundrum is that clinical trials of younger versus older RBC units have not aligned with in vitro aging data; that is, the units transfused were not old enough. In vitro changes are considerable beyond 28 to 35 days, and average storage age for older transfused units was 14 to 21 days. CONCLUSIONS RBC product real age varies by donor characteristics, storage conditions, and biological changes during storage. Metrics to measure temporal changes in quality of the stored RBC product may be more appropriate than the 42-day expiration date. Randomized trials and observational studies are focused on average effect, but, in the evolving age of precision medicine, we must acknowledge that vulnerable populations and individuals may be harmed by aging blood.
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Affiliation(s)
- Colleen G Koch
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland.
| | - Andra I Duncan
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | | | - Lu Dai
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| | - Paul M Ness
- Department of Transfusion Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| | - Tomislav Mihaljevic
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
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35
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Jaferzadeh K, Moon I, Bardyn M, Prudent M, Tissot JD, Rappaz B, Javidi B, Turcatti G, Marquet P. Quantification of stored red blood cell fluctuations by time-lapse holographic cell imaging. BIOMEDICAL OPTICS EXPRESS 2018; 9:4714-4729. [PMID: 30319898 PMCID: PMC6179419 DOI: 10.1364/boe.9.004714] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/05/2018] [Accepted: 09/05/2018] [Indexed: 05/03/2023]
Abstract
We propose methods to quantitatively calculate the fluctuation rate of red blood cells with nanometric axial and millisecond temporal sensitivity at the single-cell level by using time-lapse holographic cell imaging. For this quantitative analysis, cell membrane fluctuations (CMFs) were measured for RBCs stored at different storage times. Measurements were taken over the whole membrane for both the ring and dimple sections separately. The measurements show that healthy RBCs that maintain their discocyte shape become stiffer with storage time. The correlation analysis demonstrates a significant negative correlation between CMFs and the sphericity coefficient, which characterizes the morphological type of erythrocyte. In addition, we show the correlation results between CMFs and other morphological properties such as projected surface area, surface area, mean corpuscular volume, and mean corpuscular hemoglobin.
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Affiliation(s)
- Keyvan Jaferzadeh
- Department of Robotics Engineering, DGIST, 333 Techno Jungang-daero, Hyeonpung-myeon, Dalseong-gun, Daegu 42988, South Korea
| | - Inkyu Moon
- Department of Robotics Engineering, DGIST, 333 Techno Jungang-daero, Hyeonpung-myeon, Dalseong-gun, Daegu 42988, South Korea
| | - Manon Bardyn
- Transfusion Interrégionale CRS, Laboratoire de Recherche sur les Produits Sanguins, Epalinges, Switzerland
| | - Michel Prudent
- Transfusion Interrégionale CRS, Laboratoire de Recherche sur les Produits Sanguins, Epalinges, Switzerland
| | - Jean-Daniel Tissot
- Transfusion Interrégionale CRS, Laboratoire de Recherche sur les Produits Sanguins, Epalinges, Switzerland
| | - Benjamin Rappaz
- Biomolecular Screening Facility, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Bahram Javidi
- Department of Electrical and Computer Engineering, U-2157, University of Connecticut, Storrs, CT 06269, USA
| | - Gerardo Turcatti
- Biomolecular Screening Facility, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Pierre Marquet
- Centre de recherche CERVO, 2601 chemin de la Canardière, Québec, QC G1J 2G3, Canada
- International Joint Research Unit in Child Psychiatry, Département de Psychiatrie CHUV, Prilly Lausanne, Switzerland, University of Lausanne, Switzerland, Université Laval, Québec, QC G1V 0A6, Canada
- Center for Optics, Photonics and Lasers (COPL), Laval University, Quebec City, QC, Canada
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Barshtein G, Arbell D, Livshits L, Gural A. Is It Possible to Reverse the Storage-Induced Lesion of Red Blood Cells? Front Physiol 2018; 9:914. [PMID: 30087617 PMCID: PMC6066962 DOI: 10.3389/fphys.2018.00914] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 06/22/2018] [Indexed: 12/12/2022] Open
Abstract
Cold-storage of packed red blood cells (PRBCs) in the blood bank is reportedly associated with alteration in a wide range of RBC features, which change cell storage each on its own timescale. Thus, some of the changes take place at an early stage of storage (during the first 7 days), while others occur later. We still do not have a clear understanding what happens to the damaged PRBC following their transfusion. We know that some portion (from a few to 10%) of transfused cells with a high degree of damage are removed from the bloodstream immediately or in the first hour(s) after the transfusion. The remaining cells partially restore their functionality and remain in the recipient’s blood for a longer time. Thus, the ability of transfused cells to recover is a significant factor in PRBC transfusion effectiveness. In the present review, we discuss publications that examined RBC lesions induced by the cold storage, aiming to offer a better understanding of the time frame in which these lesions occur, with particular emphasis on the question of their reversibility. We argue that transfused RBCs are capable (in a matter of a few hours) of restoring their pre-storage levels of ATP and 2,3-DPG, with subsequent restoration of cell functionality, especially of those properties having a more pronounced ATP-dependence. The extent of reversal is inversely proportional to the extent of damage, and some of the changes cannot be reversed.
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Affiliation(s)
- Gregory Barshtein
- Faculty of Medicine, Biochemistry Department, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dan Arbell
- Pediatric Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Leonid Livshits
- Faculty of Medicine, Biochemistry Department, Hebrew University of Jerusalem, Jerusalem, Israel.,Institute of Veterinary Physiology, University of Zurich, Zürich, Switzerland
| | - Alexander Gural
- Blood Bank, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Transfusion of Red Blood Cells Stored More Than 28 Days is Associated With Increased Morbidity Following Spine Surgery. Spine (Phila Pa 1976) 2018; 43:947-953. [PMID: 29189567 DOI: 10.1097/brs.0000000000002464] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study. OBJECTIVE The aim of this study was to describe the association between storage duration of packed red blood cells (PRBCs) and perioperative adverse events in patients undergoing spine surgery at a tertiary care center. SUMMARY OF BACKGROUND DATA Despite retrospective studies that have shown that longer PRBC storage duration worsens patient outcomes, randomized clinical trials have found no difference in outcomes. However, no studies have examined the impact of giving the oldest blood (28 days old or more) on morbidity within spine surgery. METHODS The surgical administrative database at our institution was queried for patients transfused with PRBCs who underwent spine surgery between December 4, 2008, and June 26, 2015. Patients undergoing spinal fusion, tumor-related surgeries, and other identified spine surgeries were included. Patients were divided into two groups on the basis of storage duration of blood transfused: exclusively ≤28 days' storage or exclusively >28 days' storage. The primary outcome was composite in-hospital morbidity, which included (1) infection, (2) thrombotic event, (3) renal injury, (4) respiratory event, and/or (5) ischemic event. RESULTS In total, 1141 patients who received a transfusion were included for analysis in this retrospective study; 710 were transfused exclusively with PRBCs ≤28 days' storage and 431 exclusively with PRBCs >28 days' storage. Perioperative complications occurred in 119 patients (10.4%). Patients who received blood stored for >28 days had higher odds of developing any one complication [odds ratio (OR) = 1.82; 95% confidence interval (95% CI), 1.20-2.74; P = 0.005] even after adjusting for competing perioperative risk factors. CONCLUSION Blood stored for >28 days is independently associated with higher odds of developing perioperative complications in patients transfused during spinal surgery. Our results suggest that blood storage duration may be an appropriate parameter to consider when developing institutional transfusion guidelines that seek to optimize patient outcomes. LEVEL OF EVIDENCE 3.
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Roussel C, Buffet PA, Amireault P. Measuring Post-transfusion Recovery and Survival of Red Blood Cells: Strengths and Weaknesses of Chromium-51 Labeling and Alternative Methods. Front Med (Lausanne) 2018; 5:130. [PMID: 29868587 PMCID: PMC5962717 DOI: 10.3389/fmed.2018.00130] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/19/2018] [Indexed: 12/17/2022] Open
Abstract
The proportion of transfused red blood cells (RBCs) that remain in circulation is an important surrogate marker of transfusion efficacy and contributes to predict the potential benefit of a transfusion process. Over the last 50 years, most of the transfusion recovery data were generated by chromium-51 (51Cr)-labeling studies and were predominantly performed to validate new storage systems and new processes to prepare RBC concentrates. As a consequence, our understanding of transfusion efficacy is strongly dependent on the strengths and weaknesses of 51Cr labeling in particular. Other methods such as antigen mismatch or biotin-based labeling can bring relevant information, for example, on the long-term survival of transfused RBC. These radioactivity-free methods can be used in patients including from vulnerable groups. We provide an overview of the methods used to measure transfusion recovery in humans, compare their strengths and weaknesses, and discuss their potential limitations. Also, based on our understanding of the spleen-specific filtration of damaged RBC and historical transfusion recovery data, we propose that RBC deformability and morphology are storage lesion markers that could become useful predictors of transfusion recovery. Transfusion recovery can and should be accurately explored by more than one method. Technical optimization and clarification of concepts is still needed in this important field of transfusion and physiology.
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Affiliation(s)
- Camille Roussel
- Biologie Intégrée du Globule Rouge UMR_S1134, INSERM, Univ. Paris Diderot, Sorbonne Paris Cité, Univ. de la Réunion, Univ. des Antilles, Paris, France.,Institut National de la Transfusion Sanguine, Paris, France.,Laboratoire d'Excellence GR-Ex, Paris, France.,Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutic Implications U1163/CNRS ERL 8254, INSERM, CNRS, Univ Paris Descartes, Sorbonne Paris Cité, Paris, France.,Université Paris Descartes, Paris, France
| | - Pierre A Buffet
- Biologie Intégrée du Globule Rouge UMR_S1134, INSERM, Univ. Paris Diderot, Sorbonne Paris Cité, Univ. de la Réunion, Univ. des Antilles, Paris, France.,Institut National de la Transfusion Sanguine, Paris, France.,Laboratoire d'Excellence GR-Ex, Paris, France.,Université Paris Descartes, Paris, France.,Assistance publique des hôpitaux de Paris, Paris, France
| | - Pascal Amireault
- Biologie Intégrée du Globule Rouge UMR_S1134, INSERM, Univ. Paris Diderot, Sorbonne Paris Cité, Univ. de la Réunion, Univ. des Antilles, Paris, France.,Institut National de la Transfusion Sanguine, Paris, France.,Laboratoire d'Excellence GR-Ex, Paris, France.,Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutic Implications U1163/CNRS ERL 8254, INSERM, CNRS, Univ Paris Descartes, Sorbonne Paris Cité, Paris, France
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Hunsicker O, Hessler K, Krannich A, Boemke W, Braicu I, Sehouli J, Meyer O, Pruß A, Spies C, Feldheiser A. Duration of storage influences the hemoglobin rising effect of red blood cells in patients undergoing major abdominal surgery. Transfusion 2018; 58:1870-1880. [DOI: 10.1111/trf.14627] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/05/2018] [Accepted: 03/05/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Oliver Hunsicker
- Department of Anesthesiology and Operative Intensive Care Medicine; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - Katarina Hessler
- Department of Anesthesiology and Operative Intensive Care Medicine; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - Alexander Krannich
- Experimental and Clinical Research Center; Charité-Universitätsmedizin Berlin and Max Delbrueck Center for Molecular Medicine in the Helmholtz Association; Berlin Germany
- Max Delbrueck Center for Molecular Medicine in the Helmholtz Association; Berlin Germany
| | - Willehad Boemke
- Department of Anesthesiology and Operative Intensive Care Medicine; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - Ioana Braicu
- Department of Gynecology; European Competence Center for Ovarian Cancer, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum; Berlin Germany
| | - Jalid Sehouli
- Department of Gynecology; European Competence Center for Ovarian Cancer, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum; Berlin Germany
| | - Oliver Meyer
- Institute of Transfusion Medicine; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - Axel Pruß
- Institute of Transfusion Medicine; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - Aarne Feldheiser
- Department of Anesthesiology and Operative Intensive Care Medicine; Charité-Universitätsmedizin Berlin; Berlin Germany
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40
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Chen Y, Feng Y, Wan J, Chen H. Enhanced separation of aged RBCs by designing channel cross section. BIOMICROFLUIDICS 2018; 12:024106. [PMID: 29576837 PMCID: PMC5849466 DOI: 10.1063/1.5024598] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 03/02/2018] [Indexed: 05/31/2023]
Abstract
Prolonged storage will alter the biophysical properties of red blood cells (RBCs), and it decreases the quality of stored blood for blood transfusion. It has been known that less deformable aged RBCs can be separated by margination, but the recognition of the storage time from the separation efficiency of the stiff RBCs is still a challenge. In this study, we realized enhanced separation of aged RBCs from normal RBCs by controlling the channel cross section and demonstrated that the storage time can be deduced from the percentage of the separated RBCs in the stored RBCs. This separation technology helps to reveal the regulation of time on the RBC aging mechanism and offer a new method to separate stiffened cells with high efficiency.
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Affiliation(s)
- Yuanyuan Chen
- State Key Laboratory of Tribology, Tsinghua University, Beijing 100084, China
| | - Yuzhen Feng
- School of Mechanical Engineering, University of Science and Technology Beijing, Beijing 100083, China
| | - Jiandi Wan
- Department of Microsystem Engineering, Rochester Institute of Technology, Rochester, New York 14623-5608, USA
| | - Haosheng Chen
- State Key Laboratory of Tribology, Tsinghua University, Beijing 100084, China
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Ugurel E, Kucuksumer Z, Eglenen B, Yalcin O. Blood storage alters mechanical stress responses of erythrocytes. Clin Hemorheol Microcirc 2017; 66:143-155. [PMID: 28282803 PMCID: PMC5523916 DOI: 10.3233/ch-160219] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND: Erythrocytes undergo irreversible morphological and biochemical changes during storage. Reduced levels of deformability have been reported for stored erythrocytes. Erythrocyte deformability is essential for healthy microcirculation. OBJECTIVE: The aim of this study is to evaluate shear stress (SS) induced improvements of erythrocyte deformability in stored blood. METHODS: Deformability changes were evaluated by applying physiological levels of SS (5 and 10 Pa) in metabolically depleted blood for 48 hours and stored blood for 35 days with citrate phosphate dextrose adenine-1 (CPDA-1). Laser diffractometry was used to measure erythrocyte deformability before and after application of SS. RESULTS: Erythrocyte deformability, as a response to continuous SS, was significantly improved in metabolically depleted blood, whereas it was significantly impaired in the blood stored for 35 days with CPDA-1 (p≤0.05). The SS-induced improvements of deformability were deteriorated due to storage and relatively impaired according to the storage time. However, deformability of stored blood after exposure to mechanical stress tends to increase at low levels of shear while decreasing at high SS levels. CONCLUSION: Impairment of erythrocyte deformability after storage may contribute to impairments in the recipient’s microcirculation after blood transfusion. The period of the storage should be considered to prevent microcirculatory problems and insufficient oxygen delivery to the tissues.
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Affiliation(s)
| | | | | | - Ozlem Yalcin
- Corresponding author: Ozlem Yalcin, Department of Physiology, Koc University, School of Medicine Sariyer, Istanbul, Turkey. Tel.: +90 2123381136; Fax: +90 212 338 1168; E-mail:
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Jani VP, Mailo S, Athar A, Lucas A, Williams AT, Cabrales P. Blood Quality Diagnostic Device Detects Storage Differences Between Donors. IEEE TRANSACTIONS ON BIOMEDICAL CIRCUITS AND SYSTEMS 2017; 11:1400-1405. [PMID: 28981425 PMCID: PMC5779850 DOI: 10.1109/tbcas.2017.2749304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
In 2013, nearly 15 million units of banked blood were transfused in the United States of America alone. Blood shortages are expected to increase globally. Donated blood is not equal due to differences in quality and deterioration rate. There are no methods to detect time-dependent biochemical and biophysical changes of red blood cells (RBCs) or the deterioration rate of donated RBCs. Nine randomly selected RBC units collected by the San Diego Blood Bank were examined for interdonor variability over six weeks of storage. In vitro RBC quality was assessed weekly by conventional biochemical tests including free Hb, K+, ATP, P50, 2,3 DPG, lactate, and pH. Deformability was measured via cell filtration. Briefly, the RBC suspension (10% Hct), was forced through a 5.0-μm pore membrane (106 mm2) at various flow rates. No interdonor variability in biochemical or mechanical parameters was observed at baseline. Interdonor variability in biochemical properties (free Hb, K+, ATP, P50, 2,3 DPG, lactate, and pH) was observed after 14 days of storage. However, significant differences from baseline in RBC mechanical properties (i.e., filterability) were observed as early as 7 days into storage at the lowest flow rates and after 28 days of storage at all flow rates. There was a net decrease in filterability over time for all donors, but the rate at which filterability decreased (i.e., deterioration rates) was different when comparing individual donors. Changes in all biochemical parameters were significant different between donors. These data suggest that filterability is more sensitive to changes in blood quality than conventional biochemical parameters.
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Kozlova E, Chernysh A, Moroz V, Sergunova V, Gudkova O, Manchenko E. Morphology, membrane nanostructure and stiffness for quality assessment of packed red blood cells. Sci Rep 2017; 7:7846. [PMID: 28798476 PMCID: PMC5552796 DOI: 10.1038/s41598-017-08255-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 07/07/2017] [Indexed: 02/07/2023] Open
Abstract
Transfusion of packed red blood cells (PRBC) to patients in critical states is often accompanied by post-transfusion complications. This may be related with disturbance of properties of PRBC and their membranes during long-term storage in the hemopreservative solution. The purpose of our work is the study of transformation of morphology, membranes stiffness and nanostructure for assessment of PRBC quality, in vitro. By atomic force microscopy we studied the transformation of cell morphology, the appearance of topological nanodefects of membranes and by atomic force spectroscopy studied the change of membrane stiffness during 40 days of storage of PRBC. It was shown that there is a transition period (20–26 days), in which we observed an increase in the Young’s modulus of the membranes 1.6–2 times and transition of cells into irreversible forms. This process was preceded by the appearance of topological nanodefects of membranes. These parameters can be used for quality assessment of PRBC and for improvement of transfusion rules.
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Affiliation(s)
- E Kozlova
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, V.A. Negovsky Scientific Research Institute of General Reanimatology, Moscow, Russian Federation. .,Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow StateMedical University of the Ministry of Health of the Russian Federation, Moscow, Russian Federation.
| | - A Chernysh
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, V.A. Negovsky Scientific Research Institute of General Reanimatology, Moscow, Russian Federation.,Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow StateMedical University of the Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - V Moroz
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, V.A. Negovsky Scientific Research Institute of General Reanimatology, Moscow, Russian Federation
| | - V Sergunova
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, V.A. Negovsky Scientific Research Institute of General Reanimatology, Moscow, Russian Federation
| | - O Gudkova
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, V.A. Negovsky Scientific Research Institute of General Reanimatology, Moscow, Russian Federation
| | - E Manchenko
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, V.A. Negovsky Scientific Research Institute of General Reanimatology, Moscow, Russian Federation
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Nagababu E, Scott AV, Johnson DJ, Goyal A, Lipsitz JA, Barodka VM, Berkowitz DE, Frank SM. The Impact of Surgery and Stored Red Blood Cell Transfusions on Nitric Oxide Homeostasis. Anesth Analg 2017; 123:274-82. [PMID: 27308950 DOI: 10.1213/ane.0000000000001392] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cell-free hemoglobin (Hb) forms in stored red blood cells (RBCs) as a result of hemolysis. Studies suggest that this cell-free Hb may decrease nitric oxide (NO) bioavailability, potentially leading to endothelial dysfunction, vascular injury, and multiorgan dysfunction after transfusion. We tested the hypothesis that moderate doses of stored RBC transfusions increase cell-free Hb and decrease NO availability in postoperative surgical patients. METHODS Twenty-six patients undergoing multilevel spine fusion surgery were studied. We compared those who received no stored RBCs (n = 9) with those who received moderate amounts (6.1 ± 3.0 units) of stored RBCs over 3 perioperative days (n = 17). Percent hemolysis (cell-free Hb), RBC-NO (heme-NO), and plasma nitrite and nitrate were measured in samples from the stored RBC bags and from patients' blood, before and after surgery. RESULTS Posttransfusion hemolysis was increased approximately 3.5-fold over preoperative levels (P = 0.0002) in blood samples collected immediately after surgery but not on postoperative days 1 to 3. Decreases in both heme-NO (by approximately 50%) and plasma nitrite (by approximately 40%) occurred postoperatively, both in nontransfused patients (P = 0.036 and P = 0.026, respectively) and transfused patients (P = 0.0068 and P = 0.003, respectively) and returned to preoperative baseline levels by postoperative day 2 or 3. Postoperative plasma nitrite and nitrate were decreased significantly in both groups, and this change was slower to return to baseline in the transfused patients, suggesting that blood loss and hemodilution from crystalloid administration contribute to this finding. CONCLUSIONS The decrease in NO metabolites occurred irrespective of stored RBC transfusions, suggesting this decrease may be related to blood loss during surgery and hemodilution rather than to scavenging of NO or inhibition of NO synthesis by stored RBC transfusions.
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Affiliation(s)
- Enika Nagababu
- From the Departments of *Anesthesiology/Critical Care Medicine and ‡Biomedical Engineering, The Johns Hopkins Medical Institutions, Baltimore, Maryland; and †Department of Radiology, Era Medical College, Lucknow, India
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Sikorski RA, Rizkalla NA, Yang WW, Frank SM. Autologous blood salvage in the era of patient blood management. Vox Sang 2017; 112:499-510. [DOI: 10.1111/vox.12527] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 04/01/2017] [Accepted: 04/06/2017] [Indexed: 12/11/2022]
Affiliation(s)
- R. A. Sikorski
- Department of Anesthesiology/Critical Care Medicine; The Johns Hopkins Medical Institutions; Baltimore MA USA
| | - N. A. Rizkalla
- Department of Anesthesiology/Critical Care Medicine; The Johns Hopkins Medical Institutions; Baltimore MA USA
| | - W. W. Yang
- Department of Anesthesiology/Critical Care Medicine; The Johns Hopkins Medical Institutions; Baltimore MA USA
| | - S. M. Frank
- Department of Anesthesiology/Critical Care Medicine; Johns Hopkins Health System Blood Management Program; The Johns Hopkins Medical Institutions; MA USA
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Effect of RBC Transfusion on Sublingual Microcirculation in Hemorrhagic Shock Patients: A Pilot Study. Crit Care Med 2017; 45:e154-e160. [PMID: 27635767 DOI: 10.1097/ccm.0000000000002064] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The effects of RBC transfusion on microvascular perfusion are not well documented. We investigated the effect of RBC transfusion on sublingual microcirculation in hemorrhagic shock patients. DESIGN Prospective, preliminary observational study. SETTINGS A 28-bed, surgical ICU in a university hospital. PATIENTS Fifteen hemorrhagic shock patients requiring RBC transfusion. INTERVENTION Transfusion of one unit of RBCs. MEASUREMENTS AND MAIN RESULTS The sublingual microcirculation was assessed with a Sidestream Dark Field imaging device before and after RBC transfusion. After transfusion of one unit of RBC, hemoglobin concentration increased from 8.5 g/dL (7.6-9.5 g/dL) to 9.6 g/dL (9.1-10.3 g/dL) g/dL (p = 0.02) but no effect on macrocirculatory parameters (arterial pressure, cardiac index, heart rate, and pulse pressure variations) was observed. Transfusion of RBC significantly increased microcirculatory flow index (from 2.3 [1.6-2.5] to 2.7 [2.6-2.9]; p < 0.003), the proportion of perfused vessels (from 79% [57-88%] to 92% [88-97%]; p < 0.004), and the functional capillary density (from 21 [19-22] to 24 [22-26] mm/mm; p = 0.003). Transfusion of RBC significantly decreased the flow heterogeneity index (from 0.51 [0.34-0.62] to 0.16 [0.04-0.29]; p < 0.001). No correlations were observed between other macrovascular parameters and microvascular changes after transfusion. The change in microvascular perfusion after transfusion correlated negatively with baseline microvascular perfusion. CONCLUSIONS RBC transfusion improves sublingual microcirculation independently of macrocirculation and the hemoglobin level in hemorrhagic shock patients. The change in microvascular perfusion after transfusion correlated negatively with baseline microvascular perfusion. Evaluation of microcirculation perfusion is critical for optimization of microvascular perfusion and to define which patients can benefit from RBC transfusion during cardiovascular resuscitation.
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Red Cell Storage Duration Does Not Affect Outcome after Massive Blood Transfusion in Trauma and Nontrauma Patients: A Retrospective Analysis of 305 Patients. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3718615. [PMID: 28589139 PMCID: PMC5446873 DOI: 10.1155/2017/3718615] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 03/23/2017] [Accepted: 04/05/2017] [Indexed: 02/05/2023]
Abstract
Background Prolonged storage of packed red blood cells (PRBCs) may increase morbidity and mortality, and patients having massive transfusion might be especially susceptible. We therefore tested the hypothesis that prolonged storage increases mortality in patients receiving massive transfusion after trauma or nontrauma surgery. Secondarily, we considered the extent to which storage effects differ for trauma and nontrauma surgery. Methods We considered surgical patients given more than 10 units of PRBC within 24 hours and evaluated the relationship between mean PRBC storage duration and in-hospital mortality using multivariable logistic regression. Potential nonlinearities in the relationship were assessed via restricted cubic splines. The secondary hypothesis was evaluated by considering whether there was an interaction between the type of surgery (trauma versus nontrauma) and the effect of storage duration on outcomes. Results 305 patients were given a total of 8,046 units of PRBCs, with duration ranging from 8 to 36 days (mean ± SD: 22 ± 6 days). The odds ratio [95% confidence interval (CI)] for in-hospital mortality corresponding to a one-day in mean PRBC storage duration was 0.99 (0.95, 1.03, P = 0.77). The relationship did not differ for trauma and nontrauma patients (P = 0.75). Results were similar after adjusting for multiple potential confounders. Conclusions Mortality after massive blood transfusion was no worse in patients transfused with PRBC stored for long periods. Trauma and nontrauma patients did not differ in their susceptibility to prolonged PRBC storage.
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Health Policy, Ethical, Business, and Financial Issues Related to Blood Management in Orthopedics. Tech Orthop 2017. [DOI: 10.1097/bto.0000000000000210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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49
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Atkins CG, Schulze HG, Chen D, Devine DV, Blades MW, Turner RFB. Using Raman spectroscopy to assess hemoglobin oxygenation in red blood cell concentrate: an objective proxy for morphological index to gauge the quality of stored blood? Analyst 2017; 142:2199-2210. [DOI: 10.1039/c7an00349h] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A relationship has been found between hemoglobin oxygenation of stored red blood cells (measured using Raman spectroscopy) and a morphological index.
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Affiliation(s)
- Chad G. Atkins
- Michael Smith Laboratories
- The University of British Columbia
- Vancouver
- Canada
- Department of Chemistry
| | - H. Georg Schulze
- Michael Smith Laboratories
- The University of British Columbia
- Vancouver
- Canada
| | - Deborah Chen
- Department of Pathology and Laboratory Medicine
- The University of British Columbia
- Vancouver
- Canada
- Centre for Blood Research
| | - Dana V. Devine
- Department of Pathology and Laboratory Medicine
- The University of British Columbia
- Vancouver
- Canada
- Centre for Blood Research
| | - Michael W. Blades
- Department of Chemistry
- The University of British Columbia
- Vancouver
- Canada
| | - Robin F. B. Turner
- Michael Smith Laboratories
- The University of British Columbia
- Vancouver
- Canada
- Department of Chemistry
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Age of Transfused Blood Impacts Perioperative Outcomes Among Patients Who Undergo Major Gastrointestinal Surgery. Ann Surg 2017; 265:103-110. [DOI: 10.1097/sla.0000000000001647] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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