Ringer’s lactate and red blood cells: is there sufficient evidence to recommend for routine use?

Abstract

Blood components are biological products that are collected from volunteer blood donors and stored for varying periods of time prior to being reinfused in patients. It is critically important to maintain the viability and functionality of the collected blood when the blood products are being stored and administered to ensure they will function flawlessly when transfused to patients. The process of blood collection has evolved significantly since blood cell preservation was first introduced by Rous and Tourner during World War I. The need for anticoagulation after collection is one unchanging feature that remains, and citrate has been used as the primary anticoagulant since the time of Rous and Turner. Once collected, a unit of whole blood is separated into its various components, i.e., red blood cells, plasma, and platelets, so that each component can be stored under optimal conditions. A glucose source, almost invariably dextrose, must be added to ensure preservation of red cells. Over time, other elements have been added to the preservative solutions to prolong the storage period of the red blood cells. In Canada, whole blood is currently collected into citric acid, sodium citrate, dextrose, sodium biphosphate (CPD or CP2D), or CPD with adenine (CPD-A1 or CPD-A2). After the plasma and platelets are removed from the red blood cells, a nutrient solution is added to the red blood cells. In Quebec, an additive solution 3 (AS-3), which contains additional citrate, is added to the CP2D red blood cells. Since the Canadian Blood Service’s recent change to a buffy coat manufacturing process, the saline adenine glucose mannitol (SAGM) solution, which contains no additional citrate, is added to CPD red blood cells. The final packed red blood cell product (approximately 350 ml) is intended for transfusion at a rate of 2–5 ml min without further manipulation. In Canada, standards regarding the production and storage of blood products are established by Health Canada, and in the USA, they are established by the Food and Drug Administration (FDA). Different national standards for plasma and platelets include minimum levels of coagulation proteins, and platelet function, recovery and survival studies. The standards in Europe and North America regarding red blood cells specify 24-h survival of more than 70% of cells, a minimum level of hemoglobin content, and/or a maximum level of hemolysis. The administration of blood products is within the scope of clinical practice, similar to giving drugs for off-label indications and, as such, is not covered by federal regulations. However, the quality of blood products can be significantly compromised during administration. The potential consequences of administering red blood cells with other solutions or medications are lysis of the red blood cells and the formation of red blood cell clots. Both E. Saidenberg, MD A. Tinmouth, MD (&) Department of Hematology and Transfusion Medicine, The Ottawa Hospital and the University of Ottawa, Ottawa, ON, Canada e-mail: atinmouth@ottawahospital.on.ca