Citrate-phosphate-dextrose Blood Research Articles

Using a Modified CPD Blood Bag to Store Blood from either ECMO or RRT Circuit Blood in Pediatric Patients.

By adapting a citrate phosphate dextrose (CPD) whole blood storage bag, residual blood from a renal replacement therapy (RRT) circuit can be saved in pediatric patients, decreasing in donor exposure later. The techniques used for autologous preoperative blood storage are the basis of storing the RRT circuit blood. The CPD anticoagulant has a benefit of having a commonly used reversal agent for its anticoagulant properties, i.e., calcium. Also, unlike the traditional anticoagulants used in extracorporeal membrane oxygenation (ECMO), i.e., heparin, and direct thrombin inhibitors, i.e., bivalirudin, there is no increase in anticoagulation laboratory parameters after administration. The CPD volume in the bag is reduced but keeps the original ratio the same between CPD and blood. This is accomplished by removing all CPD from the bag, adding back only the exact amount of CPD needed for the smaller amount of blood being transferred from the circuit. The RRT circuit managed at our institution uses 23 mL of CPD for 165 mL of circuit blood when stored with this technique. This calculation assumes a normal patient calcium level. This technique has been used successfully multiple times in more than 30 pediatric patients without incident for 7 years at our center. The CPD bag can also be used to store the residual blood from ECMO circuits after removal of ECMO to allow the blood to be given back to the patient at a later time by keeping the same citrate-to-blood ratio.

Using a Modified CPD Blood Bag to Store Blood from either ECMO or RRT Circuit Blood in Pediatric Patients

By adapting a citrate phosphate dextrose (CPD) whole blood storage bag, residual blood from a renal replacement therapy (RRT) circuit can be saved in pediatric patients, decreasing in donor exposure later. The techniques used for autologous preoperative blood storage are the basis of storing the RRT circuit blood. The CPD anticoagulant has a benefit of having a commonly used reversal agent for its anticoagulant properties, i.e., calcium. Also, unlike the traditional anticoagulants used in extracorporeal membrane oxygenation (ECMO), i.e., heparin, and direct thrombin inhibitors, i.e., bivalirudin, there is no increase in anticoagulation laboratory parameters after administration. The CPD volume in the bag is reduced but keeps the original ratio the same between CPD and blood. This is accomplished by removing all CPD from the bag, adding back only the exact amount of CPD needed for the smaller amount of blood being transferred from the circuit. The RRT circuit managed at our institution uses 23 mL of CPD for 165 mL of circuit blood when stored with this technique. This calculation assumes a normal patient calcium level. This technique has been used successfully multiple times in more than 30 pediatric patients without incident for 7 years at our center. The CPD bag can also be used to store the residual blood from ECMO circuits after removal of ECMO to allow the blood to be given back to the patient at a later time by keeping the same citrate-to-blood ratio.

Upper Extremity Veno-arterial Shunting during Pediatric Orthotopic Liver Transplantation

Upper Extremity Veno-arterial Shunting during Pediatric Orthotopic Liver Transplantation

Antimony electrode for the determination of the intramyocardial pH during open-heart surgery.

The development of an antiomony electrode (Sb) and a pH meter as a substitute for a glass electrode(G) to measure the intramyocardial pH is reported, and the results of their clinical application. The determination of the pH of CPD (citrate-phosphate-dextrose) blood by Sb showed small differences when compared to G (less than 0.1). Sb was also temperature sensitive. The temperature coefficient of Sb was determined in buffers by varying their temperatures, and an antimony-thermocouple electrode and a temperature-compensated pH meter were subsequently constructed. In CPD blood of varying temperatures Sb showed similar tendencies to G. The results of the application of the new apparatus to 28 patients were statistically no different from those obtained previously by G on 22 patients, either in baseline pH or its fall following aortic cross-clamping. It is concluded that although Sb is not as accurate as G, it is a reasonable alternative for the determination of myocardial acidosis during open-heart surgery.

Effect of Blood Transfusion on Acid Base, Glucose and Electrolyte Status in Very Low Birth Weight Infants

The effect of citrate phosphate dextrose (CPD) blood transfusion on the acid base, glucose and electrolyte status of VLBW infants was studied in infants aged 1-7, 8-20 and greater than 20 days; a 4th group composed of infants greater than 20 days subjected to a second transfusion was also studied. All the infants remained clinically well during and after the transfusion. Only the infants in the group 1-7 days experienced a significant fall in ionic Ca and PO2. No significant change in all the other parameters studied was observed. In the other groups of infants studied, the changes observed were not significant, and became less with increasing age and repeat transfusion. VLBW infants apparently tolerate CPD blood transfusion well.

Zinc Ions Inhibit Factor I‐Mediated Release of CR1‐Bound Immune Complexes and Degradation of Cell‐Bound Complement Factors C3b and C4b

ZnCl2 exerted a dose-dependent inhibition of citrate-phosphate-dextrose (CPD) plasma-induced release of 125I-labelled BSA-anti-BSA immune complexes (IC) bound to complement receptor type 1 (CR1, CD35) in human whole blood. Maximal inhibition was observed at 10 mM of ZnCl2. Furthermore, the release of IC bound to erythrocyte (E)-CR1 by purified factor I, factor I-deficient serum plus purified factor I, or normal human serum was reduced by approximately 90%, 64%, and 52%, respectively, in the presence of 10 mM ZnCl2. The effect of ZnCl2 on factor I-mediated degradation of cell-bound C3b/C4b was also investigated employing CPD blood or E from a factor I-deficient donor. These cells expressed covalently bound C3b and C4b as demonstrated by a simple agglutination technique. Upon incubation of CPD whole blood with purified factor I, or of E with purified factor I or normal CPD plasma, the C-fragments were cleaved and the cells were no longer agglutinated by antibodies to C3c and C4c. The presence of ZnCl2 prevented this factor I-mediated degradation of C3b and C4b, as evidenced by the unaffected agglutination of the cells by the antibodies. We conclude that ZnCl2 inhibited factor I activity since: (1) release of complement-preopsonized IC from E-CR1 by purified factor I was markedly inhibited (90%) in the presence of ZnCl2, (2) preincubation of the cells with ZnCl2 caused only a moderate inhibition (32-38%) of the IC release, and (3) degradation by purified factor I of covalently cell-bound C3b and C4b was abrogated in the presence of 10 mM ZnCl2.

Problems related to CPD preserved blood used for NEQAS trials in haematology.

A study of the results of the Belgian National External Quality Assessment Scheme (NEQAS) in haematology, revealed marked differences in MCV values obtained with instruments of different types. For this reason the citrate-phosphate-dextrose (CPD) preserved blood used as NEQAS material was analysed daily with a Coulter S-Plus IV and with a cross-calibrated Ortho ELT-800. The observed differences in MCV are apparently due to differences in measuring apparatus and also to the changing characteristics of the erythrocytes. Ageing of CPD blood during 1 to 4 days (postal delivery) influenced markedly the MCV as measured with the Ortho ELT systems. These time- and instrument-related factors influence the measurements, they interfere with the statistical evaluation of NEQAS results and can lead to errors in the evaluation of individual performers.

High yield of platelet-rich plasma from CPD blood compared to ACD blood.

The yields of platelet-rich plasma (PRP) obtained by centrifugation of CPD (citrate-phosphate-dextrose) blood and ACD (acid-citrate-phosphate) blood were compared. The volumes of PRP from 5 ml blood in test tubes and 200 ml blood in bags were larger by 4% and 4.5%, respectively, when CPD was used as an anticoagulant. In addition, the number of platelets in PRP from CPD blood was higher than that from ACD blood. These data suggest that the optimal centrifugal condition for CPD blood should be different from that for ACD blood.

Preservation of human erythrocytes in the liquid state: biological results with a new medium.

Red blood cells (RBC) were collected with citrate-phosphate-dextrose (CPD) in a blood-pack optimal additive system. After concentration to 90% hematocrit they were diluted with saline-adenine-glucose medium (SAG-RBC), and stored for 35 days. In this work the RBC were stored in the presence of leukocytes. The SAG medium allows RBC conservation during 35 days at +4 degrees C. The adenosine triphosphate (ATP) level of RBC is compatible with their survival. During the first 2 weeks, hemolysis of SAG-RBC was not greater than in CPD blood. Nevertheless, hemolysis reached 1.49% on day 35, and there was a marked increase in RBC osmotic fragility. Scanning electron-microscopic studies of 35-day RBC showed that the majority of them became echinocytes. After incubation in fresh frozen plasma, the RBC recovered satisfactory osmotic resistance and normal disc shape. The post-transfusion viability was normal with greater than 70% recovery after 48 h. The in vivo restoration of 2,3-diphosphoglycerate (2,3-DPG) was rapid in the transfused SAG-RBC, 50% of the initial 2,3-DPG level being restored in 1 h. The in vivo studies proved that the functional quality of these RBC was compatible with their use in transfusion. The most important problem concerns the supernatant hemoglobin level of the SAG-RBC to be used for massive transfusion.

The pH and titratable acidity of stored CPD blood.

Blood stored in citrate-phosphate-dextrose (CPD) solution for periods up to 20 days had a mean pH 6.71. The mean metabolic hydrogen ion excess was 32 mmol/litre and the mean respiratory hydrogen ion excess was 80 mmol/litre. These results for CPD blood are compared with those obtained on acid-citrate-dextrose blood. A prediction is made that clnically, only small variations in metabolic and respiratory acid-base balance would be produced directly due to the acid and base loads in transfused blood.

The contribution of anticoagulants to platelet dysfunction with extracorporeal circulation

This investigations evaluates the effects of anticoagulants on platelet function. Fresh human blood from 40 nonmedicated volunteers was anticoagulated with 4.3 units per milliliter heparin and/or acid-citrate-dextrose (ACD) solution 1:9. Retention of platelets from whole blood on glass beads was performed by the method of Bowie. Platelet retention of heparinized blood averaged 88.1 +/- S.E. 1.5 per cent; ACD platelets averaged 24.6 +/- S.E. 2.8 per cent. Platelet retention with citrate-phosphate-dextrose (CPD) and ethylenediaminetetraacetic acid (EDTA) yielded 26.0 +/- S.E. 3.9 per cent and 19.1 +/- S.E. 7.5 respectively. The addition of ACD to heparinized blood decreased platelet retention (19.7 +/- S.E. 3.1 per cent). The addition of heparin to ACD or CPD blood did not alter the original decreased retention. Calcium added, even in excess, to blood containing heparin and ACD did not reverse the depressed retention (29.3 +/- S.E. 4.6 per cent). The substitution of CPD gave similar results. With mixtures of separately collected ACD and heparininzed blood, depression of platelet retention was directly proportional to the amount of ACD blood present. Altering the pH of the ACD blood did not affect its depressed retention of platelets. Neutralizing heparinized blood 50 per cent with protamine or Polybrene also significantly depressed platelet retention 34.6 +/- S.E. 5.8 per cent and 35.5 +/- S.E. 4.0 per cent, respectively. Neither protamine nor Polybrene had any effect upon ACD blood. These data indicate that anticoagulants may play a significant role in the depressed platelt function observed during and following extracorporeal circulation.

Studies on Citrate‐Phosphate‐Dextrose (CPD) Blood Supplemented with Adenine

The effect of varying adenine concentrations in citrate-phosphate-dextrose (CPD) blood was studied in an attempt to optimize the storage conditions for human erythrocytes with regard to posttransfusion viability and oxygen release function. The maintenance of diphosphoglycerate (DPG) was impaired by adenine supplementation; this effect was closely related to the adenine concentration. A 0.25 mM adenine concentration in CPD blood improved the adenosine triphosphate (ATP) levels and the posttransfusion viability markedly, without appreciably impairing the DPG maintenance. The results suggest that CPD solution supplemented with adenine to give a 0.25 mM concentration in the blood is a better preservative for human erythrocytes than the commonly used acid-citrate-dextrose (ACD), CPD, and ACD-adenine solutions with regard to posttransfusion viability and oxygen release function. Adenine addition to this low concentration is not expected to cause renal damage even after massive transfusion.

Oxygen dissociation after transfusion of blood stored in ACD or CPD solution

In 20 patients undergoing open-heart surgery, 2,3-diphosphoglycerate (2,3-DPG) concentrations, oxygen affinity of hemoglobin (Po2 at half saturation of hemoglobin with oxygen [P50]), hemoglobin concentration, and pH were measured repeatedly. Measurements were made before and at various times after open-heart surgery and replacement of blood loss with blood stored in acid-citrate-dextrose (ACD) or citrate-phosphate-dextrose (CPD) solutions for less than 72 hours (10 cases per group). Infusion of ACD blood caused P50 and 2,3-DPG concentration to decrease significantly after the operation. The infusion of blood stored in CPD did not significantly increase the oxygen affinity. No significant changes in hemoglobin concentration or pH were observed immediately after the operation in either group. To compensate for the increased oxygen affinity, there must be a rise in cardiac output or more likely a decrease in venous Po2. The transfusion of CPD blood, therefore, is more favorable in terms of oxygen supply, particularly in patients who have had cardiac surgery.

Chemical and Hematological Changes in Stored CPD Blood

Blood was drawn from ten healthy volunteer donors into citrate-phosphate-dextrose (CPD) anticoagulant and placed on the quarantine shelf of the blood bank refrigerator. Plasma dextrose, sodium, potassium, chloride, bicarbonate, GOT, LDH, and hemoglobin as well as WBC, hematocrit, MCV, MCHC, whole blood pH, and ammonia were measured on all samples initially and at one, two, seven, 14, 21, and 28 days of storage at 4 C. Whole blood lactate also was analyzed serially on five of the units. An additional 27 units of CPD bank blood (two to 21 days of age), routinely processed, handled, and stored by the blood bank, were submitted to the same analyses on the day of administration to the patient. Five of these processed units, 21 days old, were resampled at 28 days. Results of the analyses are presented and discussed. The most pronounced changes were seen for dextrose, potassium, bicarbonate, lactate, LDH, ammonia, and hemoglobin. Plasma dextrose and bicarbonate declined in concentration while potassium, lactate, LDH, ammonia, and hemoglobin rose with storage. In general, changes in the regularly processed, singly sampled bank units were greater than those observed in the specially processed, quarantined units sampled serially. This study indicates that routine transportation, processing, and handling of bank blood may lead to increased biochemical alteration.

Hemoglobin function of blood stored at 4 C in ACD and CPD with adenine and inosine.

Normal hemoglobin function depends on adequate erythrocyte levels of 2,3‐diphosphoglycerate (2,3‐DPG), a compound that is poorly maintained during blood bank storage in acid‐citrate‐dextrose (ACD). Since 2,3‐DPG is better maintained at the higher pH afforded by citrate‐phosphate‐dextrose (CPD), hemoglobin function was compared during storage in CPD and ACD. Further, hemoglobin function was studied in CPD blood containing adenine and inosine, compounds that provide metabolic energy and thus prolong the shelf‐life of blood, because they also effect the levels of 2,3‐DPG during storage. Hemoglobin function, expressed as the P50 (the P02 at 50 per cent oxygenation, an inverse but direct measure of oxygen affinity) is considerably better maintained during storage in CPD than in ACD. The hemoglobin function or P50 of blood stored in CPD‐adenine is not maintained as well as blood stored in CPD without adenine, but the oxyhemoglobin dissociation curves show only a small difference when compared to the difference between ACD and CPD. Blood stored in CPD‐adenine with inosine, present initially or added at day 25, allows higher P50 values late in storage, thus providing better hemoglobin function for more of the storage period.

The effect of vitamin E on the preservation of blood.

By observing the effects of tocopherylacetate (Toc-ac) and tocopheryl glycolate (Toc-glyc) on the stored citrate-phosphate-dextrose (CPD) blood and the blood added with EDTA-K3, the following results were obtained.1. By adding 10, 20, and 50mg, respectively, of Toc-ac per 100ml or 20 and 50mg Toc-glyc per 100ml, a daily decline of osmotic resistance of erythrocytes in the CPD-stored blood could be suppressed to a certain extent.The range of effects revealed that 50mg per 100ml was the greatest in effectiveness and that Toc-ac and Toc-glyc had almost the same effectiveness.2. It was found that the preservative action of Toc-ac and Toc-glyc for the osmotic resistance of erythrocytes was not due to the action of the solvent in tocopherol.3. With respect to the specimens added with 10 or 20mg per 100ml of Toc-ac, more erythrocytes with normal morphology were observed on the 7th day after the blood sampling, and in the former there was no difference from the one added with the solvent. That is, the residual rate of normal erythrocytes in both cases was somewhat higher, and the solvent itself seemed to have more or less preservative effectiveness in a comparatively short period. In the specimens added with 20 and 50mg of Toc-glyc per 100ml, the residual rate of erythrocytes with normal morphology showed the same high value on the 6th day after the blood sampling, when compared with the group without addition and the group added with the solvent.4. Both in the CPD blood added with 10, 20 and 50mg per 100ml of Toc-ac, 20 and 50mg per 100ml, respectively, of Toc-glyc and in the EDTA blood added with 50mg per 100ml of Toc-ac, the decrease of the number of leucocytes after the blood sampling was suppressed to a certain extent. Moreover in the latter group, there was neither the relative decrease of granulocytes in the differential count of leucocytes nor the increase of lymphocytes observed for 6 hours after the blood sampling.5. Tocopherol added group showed the tendency of a hourly decrease of thrombocytes depressed in the EDTA blood. Furthermore, the preservative effect on the morphology of thrombocytes in the same group was comparatively good.