Manual Red Blood Cell Research Articles

Logistics, risks, and benefits of automated red blood cell exchange for patients with sickle cell disease.

Red blood cell (RBC) transfusions treat and prevent severe complications of sickle cell disease (SCD) and can be delivered as a simple or exchange transfusion. During an exchange, some of the patient's abnormal hemoglobin (Hb) S (HbS) RBCs are removed. An apheresis device can accomplish an automated RBC exchange, simultaneously removing patient's RBCs while returning other blood components along with normal RBCs. Automated RBC exchange is therefore an isovolemic transfusion that can efficiently decrease HbS RBCs while limiting iron loading and hyperviscosity. However, specialized equipment, trained personnel, appropriate vascular access, and increased RBC exposure are required compared to simple or manual RBC exchange. Therefore, risks and benefits must be balanced to make individualized decisions for patients with SCD who require transfusion.

Transfusion support for patients with sickle cell disease

Red blood cell (RBC) transfusion is an essential treatment for many patients with sickle cell disease (SCD), whose RBCs express hemoglobin S (HbS), a mutated form of hemoglobin A (HbA). Transfusion goals include increasing blood oxygen carrying capacity and decreasing the relative amount of HbS to HbA to mitigate vaso-occlusion in small blood vessels. In situations where correction of severe anemia and reduction in HbS may be achieved without removal of RBCs, simple transfusion may be utilized. Partial manual RBC exchange, which removes blood containing HbS by phlebotomy and replaces with donor blood transfusion sequentially allows for larger changes in the ratio of HbS to HbA when compared to simple transfusion. Automated RBC exchange by apheresis is useful in situations where a rapid and drastic HbS reduction is indicated. Vascular access is an important consideration for transfusion. Although peripheral access may be sufficient, central venous catheters and implantable venous access devices may be necessary for adequate access over time. Blood bank considerations include adequate RBC antigen matching to mitigate the risk of RBC alloimmunization, of which patients with SCD are at risk of developing. Transfusion may be utilized in efforts to intervene in the evolution of potentially life-threatening complications of SCD such as acute stroke, severe acute anemia and acute chest syndrome. Transfusion is also useful in several non-acute settings, such as stroke prevention, pregnancy, pre-surgery, and transfusion support for curative therapies. Individualized treatment plans are an essential component of patient care. Continuous evaluation of clinical indications and evolution of guidelines will continue to optimize care for patients with SCD.

Hematology and Plasma Chemistry Reference Values in Nursehound Shark (Scyliorhinus Stellaris) Maintained Under Human Care.

Studies determining baseline hematological reference intervals (RI) in elasmobranchs are very limited. In this study, blood samples were collected from 94 clinically healthy Nursehound Shark (Scyliorhinus stellaris) maintained under human care. Median (RI) in major leukocyte types were similar to other Carcharhinid sharks as lymphocytes were the predominant leukocyte with 38.0 (28.2–53.5)%, followed by coarse eosinophilic granulocytes with 20.0 (12.2–31.7)%, fine eosinophilic granulocytes with 6.0 (1.2–12.8) %, monocytes with 2.0 (0.0–6.0)%, and neutrophils with 2.0 (0.0–6.0)%. Nursehound Shark produced granulated thrombocytes, which were classified as granulocytes and represented 28.5 (12.4–39.7)% of all leukocytes. Median (RI) manual red blood cell and white blood cell counts were 177.50 (132.50–210.00) x 109 cells/l and 8.26 (5.24–14.23) x 109 cells/l, respectively. Median (RI) plasma chemistry values showed alkaline phosphatase 7.7 (4.2–13.0) U/l, aspartate aminotransferase 7.6 (3.3–17.1) U/l, blood urea nitrogen 281.6 (261.2–305.0) mmol/l, calcium 3.97 (3.59–4.47) mmol/l, total cholesterol 2.04 (1.02–3.91) mmol/l, chloride 233.0 (215.2–259.0) mmol/l, iron 3.79 (1.74–6.93) μmol/l, glucose 0.87 (0.47–1.44 mmol/l), potassium 3.8 (2.9–4.6) mmol/l, sodium 243.0 (227.7–271.0) mmol/l, phosphorus 1.58 (1.13–2.10) mmol/l, total protein 24.0 (20.0–35.0) g/l, and triglycerides 0.97 (0.49–3.35) mmol/l. Creatine kinase, gamma glutamyl transferase, and lactate dehydrogenase levels were below the instrument reading range.

Automated RBC Exchange has a greater effect on whole blood viscosity than manual whole blood exchange in adult patients with sickle cell disease.

Blood transfusion is the cornerstone treatment to reduce the clinical severity of sickle cell disease (SCD), but we need to maintain the haematocrit (Hct) within an acceptable range to avoid a deleterious increase in blood viscosity. The aim of this study was to compare the effects of manual versus automated red blood cell (RBC) Exchange on haematological parameters and blood viscosity. This prospective, single-centre, open nonrandomized observational study included forty-three sickle cell patients: 12 had automated RBC Exchange and 31 manual RBC Exchange. Samples were collected in EDTA tubes just before and within one hour after the end of the RBC Exchange to measure the haematological parameters and blood viscosity. Both automated and manual RBC Exchange decreased haemoglobin S levels and leucocyte and platelet counts, but the decrease was greater for automated RBC Exchange. Manual RBC Exchange caused a significant rise in haematocrit and haemoglobin levels and did not change blood viscosity. In contrast, automated RBC Exchange decreased blood viscosity without any significant change in haematocrit and only a very slight increase in haemoglobin levels. The change in blood viscosity correlated with the modifications of haematocrit and haemoglobin levels, irrespective of the RBC Exchange procedure. When adjusted for the volume of RBC Exchange, the magnitude of change in each biological parameter was not different between the two procedures. Our study demonstrates that the automated RBC Exchange provided greater haematological and haemorheological benefits than manual RBC Exchange, mainly because of the higher volume exchanged, suggesting that automated RBC Exchange should be favoured over manual RBC Exchange when possible and indicated.

Expediting red blood cell transfusions by syringing causes significant hemolysis.

Techniques commonly used to expedite blood transfusions include pneumatically pressurizing red blood cell (RBC) bags or manual syringing its contents. We compared these techniques on RBC hemolysis using a simulated transfusion model. Fifteen warmed RBC units that were 12.3 ± 4.3 (95% confidence interval [CI], 10.1-14.5) days old were each subjected to two experimental rapid transfusion techniques. RBCs from each technique were directed through 18- and 22-gauge cannulas attached to blood administration sets. One technique involved RBC bag pressurization to 300 mmHg. The other employed a 20-mL syringe to effect forceful, manual aspiration from the RBC bag followed by forceful, manual RBC injection. The control group was gravity driven without cannulas. Free hemoglobin (Hb) concentrations were measured and percent hemolysis was calculated. Free Hb concentrations and percent hemolysis (median [95% CI]) were similar in the control (0.05 [0.03-0.08] g/dL and 0.13% [0.09%-0.17%], respectively) and pressurized experiments (0.06 [0.05-0.09] g/dL; 0.14% [0.12%-0.22%]), respectively. Syringing resulted in 10-fold higher free Hb concentrations (0.55 [0.38-0.92] g/dL) and percent hemolysis (1.28% [1.03%-2.15%]) than when employing the control (p < 0.0001) or pressurization (p < 0.0001) techniques. Cannula sizes studied did not affect hemolysis. Forceful manual syringing caused significant hemolysis and high free Hb concentrations. Pressurizing RBC bags induced no more hemolysis than after gravity-facilitated transfusions. Syringing to expedite RBC transfusions should be avoided in favor of pneumatic RBC bag pressurization.

Optimal Manual Exchange Transfusion Protocol for Sickle Cell Disease: A Retrospective Comparison of Two Comprehensive Care Centers in the United Kingdom and Canada

Chronic red blood cell (RBC) transfusion is employed for a wide range of sickle cell disease complications, ranging from primary and secondary stroke prophylaxis to prevention of painful vaso-occlusive episodes. Currently different methods are employed by centers for chronic transfusion that include simple, automated and partial manual RBC exchange transfusion. A retrospective cohort study of two different manual RBC exchange transfusion methods was conducted between two comprehensive care centers in Toronto, ON, Canada and London, United Kingdom in 19 and 21 sickle cell disease adults, respectively. London used a weight-based protocol, while Toronto used a unit-based method. Our results indicated that sickle cell disease patients utilizing a weight-based method are more often unable to achieve the prescribed Hb S (HBB: c.20A > T) target compared to the unit-based method (90.0 vs. 53.0% in the weight-based and unit-based methods, respectively, p = 0.0123). On multivariable logistic regression, none of the covariates examined was found to influence the ability to achieve the prescribed Hb S target after accounting for the exchange transfusion method. Mean interval of exchange sessions, session duration, total units of packed RBC, volume of blood used by body weight each year, the mean post exchange hematocrit [or packed cell volume (PCV)] and ferritin change were similar in both cohorts. In conclusion, the unit-based method was more effective at maintaining the prescribed Hb S target.

Computerized Physician Order Entry Improves Compliance With a Manual Exchange Transfusion Protocol in the Pediatric Intensive Care Unit

To evaluate the use of a computerized physician order entry (CPOE) protocol on manual red blood cell (RBC) exchange transfusion in critically ill children with sickle cell disease. We conducted a retrospective study of children with sickle cell disease who received a manual RBC exchange transfusion before (2001 to 2008, n=22) and after (2008 to 2009, n=11) implementation of a CPOE protocol. Outcomes included compliance with protocol, percentage reduction in sickle hemoglobin, and peak hemoglobin during exchange. Compliance with the manual exchange protocol improved after introduction of CPOE (pre-CPOE: 20 protocol violations vs. post-CPOE: 3 violations, P=0.02). Percentage reduction in sickle hemoglobin also improved (pre-CPOE: 55% vs. post-CPOE: 70%, P=0.04), whereas peak hemoglobin during RBC exchange was similar (pre-CPOE: 12.0 g/dL vs. post-CPOE: 11.5 g/dL, P=0.25). However, hemoglobin levels after the mean of 7 hours of exchange were significantly higher pre-CPOE (pre-CPOE: 11.5 g/dL vs. post-CPOE: 10.5 g/dL, P=0.006). Use of CPOE for manual RBC exchange transfusion in children is associated with improved protocol compliance, improved reduction of sickle hemoglobin, and better maintenance of hemoglobin levels in a goal range during prolonged exchanges.

An Evaluation of the Cell-Dyn 3200 for Counting Cells in Cerebrospinal and Other Body Fluids

This study compared the white blood cell (WBC) and red blood cell (RBC) counts obtained with the Cell-Dyn 3200 (CD 3200) with results obtained by hemocytometer, the reference method for counting cerebrospinal fluid (CSF) and other body fluid specimens. Ninety-six CSF and 65 body fluid specimens were evaluated. Background counts were maintained on the CD 3200 at 0.001 x 10(9)/L and 0.00 x 10(12)/L for WBC and RBC counts, respectively. Linearity and precision were acceptable for both the total nucleated cell (TNC) count and the RBC count. The CD 3200 WBC optical count was correlated with the TNC count obtained by the manual reference method for CSF specimens across the range of 0 x 10(9 )/L to 7.863 x 10(9)/L (r2 = 0.9867) and for body fluid specimens across the range of 0 x 10(9)/L to 14.0 x 10(9)/L (r2 = 0.9955). An r2 value of 0.9016 was obtained for the 82 CSF specimens with manual TNC counts of <0.200 x 10(9)/L. Analysis of the CSF and body fluid specimens indicated that automated RBC counts could be reported at > or = 0.003 x 10(12)/L. In this study, 7 CSF and 30 body fluid specimens had RBC counts of >0.003 x 10(12)/L, and there was good agreement with manual RBC counts, with r2 values of 0.9893 and 0.9960 obtained for CSF and other body fluids, respectively. The CD 3200 in our experience has a lower reportable range than the ranges of most automated cell counters reported in the literature. In contrast to the only other instrument with comparable reportable ranges, the CD 3200 requires a smaller sample volume without any special sample preparation, reagents, or software. By using the CD 3200 with our laboratory-specific rules for agreement between duplicate counts, we would be able to reduce our manual CSF specimen counts from 192 TNC and 192 RBC counts to 2 TNC and 178 RBC counts. For body fluid specimens, our manual counts would be reduced from 130 TNC and 130 RBC counts to 10 TNC and 4 RBC counts.