Donor Exposure Research Articles

The effect of prenatal and postnatal dietary exposures on childhood development of atopic disease

Prenatal and early life dietary factors may influence asthma and allergic disease development. We review recent studies and consensus statements regarding the effects of prenatal/early life dietary exposures on atopic disease. The American Academy of Pediatrics consensus statement highlighted the inadequacy of evidence for pregnancy antigen avoidance diets or delay of infant complementary foods beyond 4-6 months. Recent studies raise the question of whether early food introduction may promote tolerance, though controlled trials are pending. A recent meta-analysis suggested that antioxidants may protect against the development of atopy. Furthermore, some of the conflicting results on the effects of vitamin E may be related to variability in the isoforms prevalent in local diet. Recent studies of vitamin D similarly suggest that it may be protective, though this remains controversial. Finally, prenatal methyl donor exposure promoted the development of allergy in an animal model. There are conflicting data on the effects of most prenatal and early childhood dietary exposures on childhood atopic disease. Longitudinal prenatal/birth cohort studies with prospective measurements and clinical supplementation trials of promising dietary factors will be needed to make reliable recommendations in this vulnerable population of pregnant women and their infants.

Cochrane review: Early erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants

AbstractBackgroundLow plasma levels of erythropoietin (EPO) in preterm infants provide a rationale for the use of EPO to prevent or treat anaemia.ObjectivesTo assess the effectiveness and safety of early initiation of EPO in reducing red blood cell (RBC) transfusions in preterm and/or low birth weight infants.Search strategyThe Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, CINAHL, abstracts from scientific meetings published in Pediatric Research and reference lists of identified trials and reviews were searched through July 2009.Selection criteriaRandomised or quasi‐randomised controlled trials of early (< 8 days of age) initiation of EPO treatment vs. placebo or no intervention in preterm and/or low birth weight neonates.Data collection and analysisData collection and analysis were accomplished using the methods of the Neonatal Cochrane Review Group.Main resultsUpdate includes 27 studies that enrolled 2219 preterm infants. Early EPO reduced the risk of the "use of one or more RBC transfusions" [typical RR; 0.80 (95% CI 0.75, 0.86); 16 studies, 1825 infants].Early EPO led to a significant reduction in the total volume (ml/kg) of blood transfused per infant and in the number of transfusions per infant. Two studies (n = 188) reported a significant reduction in the number of donors to whom the infant was exposed.There was a significant increase in the risk of stage ≥ 3 retinopathy of prematurity (ROP) in the early EPO group [typical RR; 1.65 (95% CI 1.12, 2.43); 8 studies, 984 infants]. The rates for mortality and other neonatal morbidities were not significantly changed by early EPO treatment nor were neurodevelopmental outcomes at 18 to 22 months in the small number of infants tested to‐date.Authors' conclusionsEarly administration of EPO reduces the use of RBC transfusions and the volume of RBCs transfused. These small reductions are of limited clinical importance. Donor exposure is probably not avoided since most studies included infants who had received RBC transfusions prior to trial entry. There was a significant increase in the rate of ROP (stage ≥ 3). Early EPO does not significantly decrease or increase any of the other important adverse outcomes. Ongoing research should deal with the issue of ROP and evaluate the current clinical practice that will limit donor exposure. Due to the limited benefits and the increased risk of ROP, early administration of EPO is not recommended. Evidence is lacking for the possible neuroprotective role of EPO in preterm infants.Plain Language SummaryEarly erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infantsIn newborn infants, the number of red blood cells in the circulation decreases after birth. In infants born before term, this decrease is exaggerated by frequent withdrawal of blood, which may be necessary to monitor the infant's clinical condition. Therefore, infants born before term are likely to require transfusions of red blood cells. Low levels of erythropoietin (EPO), a substance in the blood that stimulates red blood cell production, in preterm infants provide a rationale for the use of EPO to prevent or treat anemia. EPO can be given "early" (before the infant reaches eight days of age) in order to prevent or decrease the use of red blood cell transfusions. More than 2200 infants born before term have been enrolled in 27 studies that used this approach. Early EPO treatment reduces the number of red blood cell transfusions and donor exposures following its use. However, the overall benefit of EPO may not be clinically important, as many of these infants had been exposed to red blood cell transfusions prior to entry into the trials. Treatment with early EPO did not have any important effects on mortality or common complications of preterm birth with the exception that EPO increased the risk for retinopathy of prematurity, a serious complication that may cause blindness in babies born before term. The addition of four new studies enrolling 145 infants did not change the conclusions. Based on our findings, EPO is not recommended for routine use in preterm infants.

Blood Transfusion and Survival in Cardiac Surgery

Blood Transfusion and Survival in Cardiac Surgery

Donor statin treatment protects against severe acute graft-versus-host disease after related allogeneic hematopoietic cell transplantation

AbstractWe retrospectively analyzed outcomes among 567 patients with hematologic malignancies who had hematopoietic cell transplantation from human leukocyte antigen-identical sibling donors between 2001 and 2007 for a correlation between statin use and risk of graft-versus-host disease (GVHD). Compared with allografts where neither the donor nor recipient was treated with a statin at the time of transplantation (n = 464), statin use by the donor and not the recipient (n = 75) was associated with a decreased risk of grade 3-4 acute GVHD (multivariate hazard ratio, 0.28; 95% confidence interval, 0.1-0.9). Statin use by both donor and recipient (n = 12) was suggestively associated with a decreased risk of grade 3 or 4 acute GVHD (multivariate hazard ratio, 0.00; 95% confidence interval, undefined), whereas statin use by the recipient and not the donor (n = 16) did not confer GVHD protection. Risks of chronic GVHD, recurrent malignancy, nonrelapse mortality, and overall mortality were not significantly affected by donor or recipient statin exposure. Statin-associated GVHD protection was restricted to recipients with cyclosporine-based postgrafting immunosuppression and was not observed among those given tacrolimus (P = .009). These results suggest that donor statin treatment may be a promising strategy to prevent severe acute GVHD without compromising immunologic control of the underlying malignancy.

A prospective study of multiple donor exposure blood recipients: surveillance value and limitations for hemovigilance

There have been few recent systematic studies of blood recipients for direct evidence of blood safety, especially for emerging pathogens that may pose a threat to the blood supply. Recipients who would likely require transfusion from multiple donors were recruited and a blood specimen was collected before their first study transfusion and at intervals after their study transfusion(s). Blood samples associated with the units that were transfused to enrolled recipients were also collected. Part of each recipient specimen and selected donor specimens was tested for the targeted blood-borne agents, parvovirus B19 (B19) and Chlamydia pneumoniae (Cp), that were piloted in this study, and the remaining material was kept in a repository. Between April 2004 and December 2006, a total of 120 recipients were recruited with 4047 subsequent donor exposures. On average, each recipient was followed up seven times. Of recipients who were adequately followed up and were initially immunoglobulin G antibody negative, one in 31 and one to two in 49 seroconverted to B19 and Cp after a total of 922 and 1413 evaluable transfusions, respectively. The detection of seroconversion was complicated by passively acquired donor antibodies for these two seroprevalent agents. Negative results for nucleic acids of the agents limited our ability to further clarify the relationship of these seroconversions to transfusion-transmitted infection. The risk of transfusion-associated B19 infection appears to be low but no conclusion of transfusion transmission can be made for Cp. The approach piloted through this study offers added value beyond the current hemovigilance strategy in the United States.

Reexposure of cord blood to noninherited maternal HLA antigens improves transplant outcome in hematological malignancies

Cord blood (CB) hematopoietic stem cell transplantation can be successful even if donor and recipient are not fully matched for human leukocyte antigens (HLA). This may result from tolerance-inducing events during pregnancy but to date this concept has not been tested in CB transplantation. Hence we analyzed the impact of fetal exposure to noninherited maternal antigens (NIMA) of the HLA-A, -B antigens, or -DRB1 alleles on the outcome of CB transplants. The 1,121 patients studied were transplanted for hematological malignancy with a single CB unit: 1,059 received grafts mismatched for one or two HLA antigens. Of these patients, 79 patients had a mismatched antigen that was identical to a donor NIMA, 25 with one HLA mismatch (MM), and 54 with two. If there was a NIMA match, transplant-related mortality (TRM) was improved, especially in patients >or=10 years (P = 0.012) as were overall mortality and treatment failure (P = 0.022 and 0.020, respectively, in the older subset), perhaps related to improved neutrophil recovery, especially in patients who received a low total nucleated cell (TNC) dose (P = 0.031). Posttransplant relapse rate also tended to be reduced, especially in patients with myelogenous malignancies given units with a single HLA mismatch (P = 0.074). These findings represent unique evidence that donor exposure to NIMA can improve survival in unrelated CB transplantation and might reduce relapse, indicating that cord blood cells can mount an antileukemic effect. By matching for donor NIMAs in search algorithms of CB inventories, the probability of selecting a graft with an optimal outcome will increase significantly.

Donor Statin Treatment Protects against Severe Acute Graft-Versus-Host Disease After Related Allogeneic Hematopoietic Cell Transplantation.

Abstract 2227Poster Board II-204Acute graft-versus-host disease (GVHD) contributes to morbidity and mortality after allogeneic hematopoietic cell transplantation (HCT) and more effective prevention and treatment strategies are needed. The 3-hydroxy-3-methylglutaryl coenzyme A-reductase inhibitors (statins) have been shown to possess immunomodulatory properties in vitro and in vivo. To determine whether donor or recipient statin use may affect the risk of GVHD, we retrospectively analyzed outcomes among 567 patients with hematologic malignancies who had hematopoietic cell transplantation from HLA-matched related donors at a single institution between 2001 and 2007. Compared to allografts where neither the donor nor recipient was treated with a statin at the time of transplant (n=464), statin use by the donor and not the recipient (n=75) was associated with a profoundly decreased risk of grade 3-4 acute GVHD (multivariate hazard ratio [HR], 0.28; 95= confidence interval [CI], 0.1-0.9; p=0.03) (Table). Statin use by both donor and recipient (n=12) was suggestively associated with a decreased risk of grade 3-4 acute GVHD (HR, 0.00; 95= CI, undefined; p=0.06), while statin use by the recipient and not the donor (n=16) did not confer GVHD-protection. Risks of chronic GVHD, recurrent malignancy, non-relapse mortality and overall mortality were not significantly affected by donor or recipient statin exposure. Statin-associated GVHD-protection was restricted to recipients with cyclosporine-based postgrafting immunosuppression (n=417; 74=) and was not observed among those given tacrolimus (significance of effect modification: cyclosporine vs. tacrolimus, p=0.009). These results suggest that donor statin treatment may be a promising strategy for preventing severe acute GVHD without compromising immunologic control of the underlying malignancy.TableMultivariate analysis for association of recipient and/or donor statin use with various outcomes compared to control group (R-/D-, n=464).Recipient on statin only (R+/D-, n=16)Donor on statin only (R-/D+, n=75)Both recipient and donor on statin (R+/D+, n=12)EndpointHR* (95= CI)p*HR* (95= CI)p*HR* (95= CI)p*Grade 2-4 GVHD1.01 (0.5-2.0)0.980.89 (0.6-1.2)0.470.33 (0.1-1.0)0.06Grade 3-4 GVHD1.78 (0.6-5.0)0.280.28 (0.1-0.9)0.030.00 (undef.)0.06Chronic GVHD0.93 (0.5-1.8)0.830.82 (0.6-1.2)0.260.58 (0.3-1.3)0.19Relapse/progression0.97 (0.4-2.7)0.960.63 (0.4-1.1)0.110.74 (0.2-3.0)0.67NRM0.45 (0.2-1.2)0.120.72 (0.4-1.2)0.170.66 (0.2-2.0)0.49Overall mortality0.58 (0.3-1.2)0.160.73 (0.5-1.1)0.100.77 (0.3-1.9)0.56Abbreviations: GVHD, graft-versus-host disease; NRM, not-relapse-mortality.*Adjusted for female?male sex-mismatch, conditioning-intensity, donor age >50 years, patient age >50 years, tacrolimus treatment after transplant, and disease risk. Disclosures:No relevant conflicts of interest to declare.

Re-Exposure of Cord Blood (CB) to Non-Inherited Maternal HLA Antigens (NIMA) Improves Transplant Outcome in Patients (pts) with Hematologic Malignancies and May Reduce Relapse.

Abstract 661CB hematopoietic stem cell transplantation (CBT) can be successful even if donor and recipient are not fully matched for human leukocyte antigens (HLA). This may result, at least in part, from tolerance-inducing events during pregnancy, but this concept has not been tested to date. Hence we analyzed the impact of fetal exposure to NIMA of the HLA-A, -B antigens or -DRB1 alleles on the outcome of 1121 pts with hematologic malignancies. All pts received single CB units provided by the NYBC, for treatment of ALL (N=451), AML (N=376), CML (N=116), MDS (N=79), other (N=99); 22% were transplanted in advanced stage. Median age was 9.7 years (range: 0.1-67); 29% of recipients were >16 years. Most pts (96%) received myeloablative cytoreduction. Sixty-two pts received fully matched grafts while 1059 received units mismatched (MM) for one or two HLA antigens. Of these, 79 (7%) had a MM antigen which was identical to a donor NIMA (Example: Pt: A1, A3; CBU: A1, A2; mother-CBU: A1, A3; A3 is NIMA). NIMA match was found in 25 recipients with one HLA MM and 54 of those with two MM. The NIMA match was identified after the transplant and was not used in unit selection. In multivariate analyses, NIMA matched transplants (NMTs), showed faster neutrophil recovery (RR=1.3, p=0.043), even for grafts with cell dose <3×107 (RR=1.6, p=0.053). There was no difference in the incidence of acute (grade II-IV) or chronic GvHD. 3-year relapse risk (cumulative incidence 22%) was reduced compared to 1 or 2 HLA MM no NIMA matched transplants, especially in pts with myelogenous malignancies given units with 1 HLA MM (RR=0.2, p=0.074). Further, 3-year transplant-related mortality was reduced (RR=0.7, p=0.034), particularly in pts ≥5 years old (RR=0.5, p=0.006), as was the 3-year overall mortality (RR= 0.7, p=0.029 and RR=0.6, p=0.015, respectively). As a result, in the NMTs, treatment failure (relapse or death) was significantly lower, particularly in pts ≥5 years (RR=0.7, p=0.019) and DFS was significantly improved (figure) and was similar to that of the 0 HLA MM group. These findings are the first indication that donor exposure to NIMA can improve post-transplant survival in unrelated CBT and might reduce relapse. We propose to include the NIMA of CB units in search algorithms. Thus, for pts lacking fully HLA matched grafts, HLA MM but NIMA matched CB units could be selected preferentially, since no adverse effects were seen. This strategy of selecting HLA MM grafts with optimal outcome effectively “expands” the current CB Inventory several-fold. [Display omitted] Patient GroupNRR(95% Cl)p value0 MM360.5(0.3–0.8)0.0051 MM / NIMA Match180.4(0.2–0.9)0.0262 MM / NIMA Match400.8(0.5–1.2)0.3091 MM / No NIMA Match229reference group2 MM / No NIMA Match4871.1(0.9–1.3)0.365 Disclosures:No relevant conflicts of interest to declare.

Tobacco Smoke Exposure in Either the Donor or Recipient Before Transplantation Accelerates Cardiac Allograft Rejection, Vascular Inflammation, and Graft Loss

Tobacco exposure in cardiac transplant recipients, before and after transplantation, may increase the risk of cardiac allograft vasculopathy and allograft loss, but no direct evidence for this phenomenon is forthcoming. In this experimental study, we investigated early consequences of tobacco smoke exposure in cardiac transplant donors and recipients with an emphasis on alloinflammatory mediators of graft outcome. Using heterotopic rat cardiac transplantation, we tested the effects of donor or recipient tobacco smoke exposure in 6 groups of animals (rat heterotopic cardiac transplantation) as follows: tobacco-naïve allogeneic rejecting controls (n=6), tobacco-naïve nonrejecting controls (n=3; killed on day 5 to simulate survival times of tobacco-treated animals), isografts (n=3), both donor and recipient rats exposed to tobacco smoke (n=4), only donor rats exposed to tobacco smoke (n=7), and only recipient rats exposed to tobacco smoke (n=6). Polymerase chain reaction studies of tissue and peripheral (systemic) protein expression were performed to evaluate inflammatory (tumor necrosis factor-alpha, interferon-gamma, interleukin-6) and alloimmune (interleukin-1 receptor 2, programmed cell death-1, and stromal cell-derived factor-1) pathways, as was histological analysis of the cardiac allografts. Our experiments reveal that pretransplantation tobacco exposure in donors and/or recipients results in heightened systemic inflammation and increased oxidative stress, reduces posttransplantation cardiac allograft survival by 33% to 57%, and increases intragraft inflammation (tumor necrosis factor-alpha, interferon-gamma, interleukin-6) and alloimmune activation (CD3, interleukin-1 receptor 2, programmed cell death-1, and stromal cell-derived factor-1) with consequent myocardial and vascular destruction. These sentinel findings confirm that tobacco smoke exposure in either donors or recipients leads to accelerated allograft rejection, vascular inflammation, and graft loss. Molecular pathways that intersect as arbiters in this phenomenon include instigation of alloimmune activation associated with tobacco smoke-induced inflammation.

2008 Emily Cooley Memorial Lecture: lessons learned from pediatric transfusion medicine clinical trials . . . a little child shall lead them

Many clinical practices in transfusion medicine are controversial and/or lack definitive guidelines established by sound clinical trials. Although recommendations based on results of clinical trials performed using infants and children may not always be applied directly to adults--and vice versa--lessons learned from pediatric trials can be useful when critically assessing the design/results/conclusions of adult trials. Four randomized clinical trials (RCTs) studying pediatric patients were critically reviewed. They addressed two red blood cell (RBC) transfusion issues: 1) transfusion guidelines by which RBC transfusions are "triggered" by liberal (LIB; high pretransfusion patient hematocrit [Hct] levels) versus being "triggered" by restricted (RES; low pretransfusion Hct levels) and 2) transfusion of fresh RBCs (<or=7 days' storage) versus RBCs (up to 42 days' storage). Findings established by primary outcomes generally were firm (e.g., fewer RBC transfusions were given to infants/children managed by RES guidelines; transfusing small volumes of RBCs stored up to 42 days to preterm infants diminished allogeneic donor exposures and were equally efficacious and safe as fresh RBCs stored <or=7 days). Findings based on secondary outcomes, subset, and post hoc analyses were inconsistent (e.g., clinical outcomes were equivalent after LIB or RES transfusions in only two of three RCTs; in the third, more neurologic problems were found in neonates given RES transfusions). Clinical practices should be based on data pertaining to the primary outcomes of RCTs, because trials are designed and statistically powered to address these issues. Clinical practices suggested by analysis of secondary outcomes, subsets of patients, and post hoc analyses should be applied cautiously until studied further-ideally, as primary outcomes in subsequent RCTs.

Automated platelet collection using the latest apheresis devices in an Indian setting

In a developing nation like India where there is a scarcity of resources and voluntary donors, provision of safe and good quality blood and its components is a huge challenge. The demand for platelets is increasing constantly due to better management of various patient categories, specifically hemato-oncological cases, where there is an increased demand of platelet transfusion. The use of apheresis single donor platelets (SDPs) has been attributed to increased gap between demand and supply of whole blood derived random donor platelets (RDPs). Moreover, the other benefits of SDPs such as decreased donor exposure and simplification of inventory management cannot be overlooked. However, the increased costs and logistic problems, compounded by the lack of awareness, limit the donor recruitment and procedures for SDPs. In Indian scenario, there are no specific guidelines or standards available which can be followed, while simultaneously addressing the associated problems. In this review, we have tried to analyze the various problems of donor selection, donor safety and the quality issues regarding plateletpheresis. Based on this we have tried to give certain recommendations which might help the centers in resolving the problems related to plateletpheresis.

Prevalence and specificities of red blood cell alloantibodies in transfused Ugandans with different diseases

Alloantibody formation against red blood cell (RBC) antigens is a common complication of transfusion therapy. However, the prevalence of RBC alloimmunization is hardly known in Black Africans. In Uganda, the practice is to transfuse ABO/D compatible blood without screening for immune antibodies. The aim of this study was to determine the prevalence and specificities of RBC alloantibodies in transfused Ugandans. Using a cross-sectional design, transfused patients at Mulago Hospital in Kampala, Uganda were investigated. Demographic characteristics and transfusion histories were recorded. EDTA blood samples were obtained from consenting patients and RBC alloimmunization was demonstrated using immunohaematological tests. A total of 214 transfused patients (mean age, 30.3 years; F/M ratio, 1.0) were investigated. Thirteen patients (6.1%) possessed RBC alloantibodies whose specificities were six anti-E; three anti-S; one each of anti-D, -K and -Le(a); and two samples were pan-reactive. Eleven (84.6%) of the alloimmunized patients had experienced up to 10 transfusion episodes. The number of units of blood transfused and the transfusion episodes were significantly associated with the RBC alloimmunization rate (P = 0.01). The prevalence of RBC alloimmunization in transfused Ugandans was 6.1% and was associated with the number of donor exposures. This immunization rate is similar to that observed in transfused Caucasians despite differences in RBC antigen distributions. Patients with malaria were less likely to develop RBC alloantibodies. Alloantibodies were mainly against E and S antigens. We recommend the introduction of pretransfusion antibody tests in Uganda depending on the recipient's diagnosis.

A comparative cohort study on transfusion practice and outcome in two Dutch tertiary neonatal centres

The objective of this study was to investigate how a red blood cell transfusion volume of 15 or 20 mL kg(-1) body weight affects the total number of administered transfusions and neonatal complications in premature infants born before 32 gestational weeks. In this observational study, we analysed clinical data from two cohorts of 218 and 241 premature infants admitted to two neonatal centres which used the same transfusion guideline and product, but different transfusion volumes. Outcome parameters were the number of administered transfusions and the composite outcome of bronchopulmonary dysplasia, retinopathy of prematurity, intraventricular haemorrhage and mortality. The proportion of transfused infants was significantly lower (59 vs. 77%) in the centre using a lower transfusion volume of 15 mL kg(-1). In infants born between a gestational age of 24 0/7 weeks and 27 6/7 weeks. a similar proportion received transfusions in both centres, with an equal number of transfusions per infant. In infants born between a gestational age of 28 0/7 weeks and 31 6/7 weeks, the proportion of transfused infants (49 vs. 74%) was significantly higher in the centre using a larger transfusion volume. In these infants, transfusion with 20 mL kg(-1) resulted, however, in a mean reduction of one transfusion episode per infant. The higher proportion of transfused infants was associated with a higher pre-transfusion haematocrit in less ill infants, suggesting the use of different triggers based on clinical grounds. Composite clinical complications were similar in both cohorts. Clinical neonatal outcome was similar disregard of a higher proportion of transfused patients and a higher total amount of RBC transfused in one of the centres. A larger transfusion volume of 20 mL kg(-1) prolonged the interval until next transfusion and can reduce donor exposure in infants born between a gestational age of 28 0/7 weeks and 31 6/7 weeks.

Clinical Evaluation of the Terumo Capiox ® FX05 Hollow Fiber Oxygenator with Integrated Arterial Line Filter

Perfusion techniques and equipment in pediatric open heart surgery have continued to focus on decreasing prime volumes and lowering surface areas of the cardiopulmonary bypass circuit. While this has improved drastically over the last 20 years, greater demand is being placed on the perfusionist to reduce the deleterious effects of bypass without compromising safety or efficiency. Specifically, manufacturers of disposable perfusion equipment have focused on providing pediatric perfusionists with oxygenators that provide the smallest prime and surface area possible while attempting to maximize performance. Recently,Terumo Cardiovascular has introduced the Capiox® FX05, a neonatal hollow fiber oxygenator that includes an integrated arterial line filter. The FX05 provides a blood flow range of 0.1–1.5 L/min and a low priming volume of 43 mL. Additionally, it is coated with X Coating”, a biocompatible, hydrophilic polymer surface coating that reduces platelet adhesion and protein denaturation. The purpose of this study was to test the FX05 for gas transfer, blood path resistance, and blood handling characteristics in a standardized clinical setting. Heat exchange coefficients were also calculated during the cooling and warming period. Other data analyzed includes bypass circuit prime volumes and initial patient hematocrit along with the total operative homologous blood donor exposures. In summary, the FX05 offers good gas exchange capabilities and a low pressure drop during normal cardiopulmonary bypass parameters along with the safety of an integrated arterial line filter. Furthermore, the FX05 with integrated filter allows a reduction in overall bypass prime volume and surface area while promoting the reduction of homologous blood transfusions, optimizing hemostasis.

Transfusion for trauma: civilian lessons from the battlefield?

Transfusion for trauma: civilian lessons from the battlefield?

Predictors of Blood Loss in Fronto-Orbital Advancement and Remodeling

Fronto-orbital advancement and remodeling for craniosynostosis is extensive surgery and is associated with potential risks; the most significant of these is blood loss. We prospectively studied 116 consecutive patients undergoing fronto-orbital advancement by the same surgical team for a 5-year 6-month period to determine what factors are associated with blood loss and transfusion of blood products. The data collected on the calvarial sutures involved were whether the patient had a diagnosed syndrome, the age at operation, the length of the operation, the estimated blood volume lost during the perioperative course, the number of units of packed cells transfused (donor exposures), and the use of other blood products. The mean (SD) total blood volume lost was 116% (5.4) of the estimated preoperative volume. The median number of whole units of packed cells transfused was 2 units. Other blood products were given in 28% of the cases. There was significantly greater blood loss in those patients with recognized craniofacial syndromes, pansynostosis, an operating time longer than 5 hours, and an age of 18 months or younger at operation. The use of other blood products was associated with those patients losing a blood volume higher than the mean.

351: Immune Activation and Cardiac Allograft Survival: Effects of Donor and Recipient Tobacco Smoke Exposure

351: Immune Activation and Cardiac Allograft Survival: Effects of Donor and Recipient Tobacco Smoke Exposure

Exposure to nitric oxide protects against oxidative damage but increases the labile iron pool in sorghum embryonic axes.

Sodium nitroprusside (SNP) and diethylenetriamine NONOate (DETA NONOate), were used as the source of exogenous NO to study the effect of NO upon germination of sorghum (Sorghum bicolor (L.) Moench) seeds through its possible interaction with iron. Modulation of cellular Fe status could be an important factor for the establishment of oxidative stress and the regulation of plant physiology. Fresh and dry weights of the embryonic axes were significantly increased in the presence of 0.1 mM SNP, as compared to control. Spin trapping EPR was used to assess the NO content in axes from control seeds after 24 h of imbibition (2.4±0.2 nmol NO g−1 FW) and seeds exposed to 0.01, 0.1, and 1 mM SNP (3.1±0.3, 4.6±0.2, and 6.0±0.9 nmol NO g−1 FW, respectively) and 1 mM DETA NONOate (6.2±0.6 nmol NO g−1 FW). Incubation of seeds with 1 mM SNP protected against oxidative damage to lipids and maintained membrane integrity. The content of the deferoxamine–Fe (III) complex significantly increased in homogenates of axes excised from seeds incubated in the presence of 1 mM SNP or 1 mM DETA NONOate as compared to the control (19±2 nmol Fe g−1 FW, 15.2±0.5 nmol Fe g−1 FW, and 8±1 nmol Fe g−1 FW, respectively), whereas total Fe content in the axes was not affected by the NO donor exposure. Data presented here provide experimental evidence to support the hypothesis that increased availability of NO drives not only protective effects to biomacromolecules, but to increasing the Fe availability for promoting cellular development as well.

The Efficacy of Aprotinin in Arterial Switch Operations in Infants

In the present study we assessed whether aprotinin at a total dose (40,000 kallikrein inhibitor units (KIU)/kg) is effective in reducing postoperative blood loss and blood product requirement after arterial switch operations in infants. A prospective, double-blind, randomized study, evaluated 50 infants who underwent arterial switch operations for transposition of great arteries. Patients were randomized into a placebo group, 25 patients who received normal saline and a treatment group, 25 patients who received 20,000 KIU/kg of aprotinin after induction of anesthesia, followed by 20,000 KIU/kg of aprotinin added to pump prime. Postoperative blood loss through the thoracic chest tubes and blood product requirements (mL/kg/24 h) were measured for the first 24 h in the intensive care unit. Postoperative blood loss in the first 24 h was significantly (P < 0.0001) higher in the placebo group (49.7 +/- 11.9 mL/kg/24 h) as compared to the aprotinin group (37.1 +/- 3.5 mL/kg/24 h). Requirements for fresh frozen plasma (mL/kg/24 h) and use of platelet concentrate transfusion (mL/kg/24 h) were significantly less in patients who received aprotinin (P < 0.0001), but did not reduce the proportion of patients transfused with blood products. The number of total donor exposures to all allogenic blood products was less in the aprotinin group [range (median) = 2-4 (3)] than the placebo group [range (median) = 7-14 (10)]. The re-exploration for excessive bleeding was significantly less with aprotinin group (16% vs 32%) (P = 0.01). Our study concludes that aprotinin decreased the postoperative blood loss and requirement of transfusion of fresh frozen plasma and platelets (mL/kg/24 h) during the early postoperative period. Further, it reduced the number of donor exposures and re-exploration for excessive bleeding in the treatment population.

When to transfuse preterm babies

The physiological anaemia experienced by preterm babies is exacerbated by common care practices such as early clamping of the umbilical cord at birth and gradual exsanguination by phlebotomy for laboratory...