Rapid Blood Transfusion Research Articles

Reduction in potassium concentration of stored red blood cell units using a resin filter

Hyperkalemia is a serious complication of rapid and massive blood transfusion due to high plasma potassium (K) in stored red blood cell (RBC) units. A potassium adsorption filter (PAF) was developed in Japan to remove K by exchanging with sodium (Na). We performed an in vitro evaluation of its efficacy and feasibility of use. Three AS-3 RBC units were filtered by each PAF using gravity; 10 PAFs were tested. Blood group, age, flow rate, and irradiation status were recorded. Total volume, K, Na, Cl, Mg, total Ca (tCa), RBC count, hemoglobin (Hb), hematocrit (Hct), and plasma Hb were measured before and after filtering each unit. Ionized Ca (iCa), pH, and glucose were measured for some units. After filtration, the mean decrease in K was 97.5% in the first RBC unit, 91.2% in the second unit, and 64.4% in the third unit. The mean increases in Na, Mg, and tCa were 33.0, 151.4, and 116.1%, respectively. iCa and pH remained low; glucose was unchanged. RBC count, Hb, and Hct decreased slightly after filtration of first units; plasma Hb was unchanged. After filtration, there was no visual evidence of increased hemolysis or clot formation. The PAF decreased K concentration in stored AS-3 RBC units to minimal levels in the first and second RBC units. Optimally, one filter could be used for 2 RBC units. Although Na increased, the level may not be clinically significant. PAF may be useful for at-risk patients receiving older units or blood that has been stored after gamma irradiation.

Clinical research of using Sinorgmed for rapid blood transfusion to rescue patient

Objective To explore the Applicable Effect of using Sinorgmed for rapid blood transfusion to rescue patient. Method The 80 patients which need rapid blood transfusion were divided into two team with 40 cases, one was using Sinorgmed for blood transfusion and the other one was using traditional blood transfusion. After the traditional blood transfusion team opens intravenous line, they use forceps hamostatic to press in order to make blood transfusion faster. The sinorgmed team put the sinorgmed between Insyte and the race track, connect the rest portside with injector, turn the valve to pump and bolus the blood to rapid transfusion. Observing the time of blood transfusion and the correct rate of shock between two teams. Result The sinorgmed team uses less time than the traditional blood transusion team, P<0.01, correct rate of shock obviously higer than the tranditional team, P<0.05. Conclusion Using inorgmed for rapid blood transfusion can increase the rescue success rate of Hypovolemic shock. Key words: Rescue; Blood transfusion; Sinorgmed

Fatal Hyperkalemia Due to Rapid Red Cell Transfusion in a Critically Ill Patient

A 60-year-old woman in severe hemorrhagic shock underwent urgent laparotomy to control massive hematemesis. Severe metabolic acidosis due to hemorrhagic shock and hyperkalemia as well as hypocalcemia associated with rapid blood transfusion were aggressively corrected with administration of sodium bicarbonate, insulin, and calcium chloride. Following rapid transfusion of the last 8 units of red cell concentrate (RCC), however, cardiac arrest occurred because of hyperkalemia and did not respond to cardiopulmonary resuscitation. Blood gas analysis revealed that the serum K(+) concentration had increased from 4.05 to 8.24 mEq/L over a 7-minute period, while the Ca(2+) concentration had decreased from 1.43 to 0.53 mmol/L. Rapid transfusion of irradiated RCC containing a high concentration of K(+), an extreme decrease in the circulating blood volume to dilute the exogenously administered K(+) and citrate, and severe metabolic acidosis impeding the intracellular shift of K(+) seemed to have contributed to the extremely rapid development of fetal hyperkalemia accompanied by hypocalcemia. Anesthesiologists must be aware that hyperkalemia due to rapid blood transfusion can develop extremely rapidly in patients in severe hemorrhagic shock.

Transcatheter arterial embolization in a hemodynamically unstable patient with grade IV blunt liver injury: is nonsurgical management an option?

The prevalence of liver injury in patients who have sustained blunt multiple trauma was reported to range from 1 to 8%. Because previous mortality rates were as high as 50-80% for severe hepatic injury, the choice of treatment was under intensive investigation. Whereas nonsurgical management was the standard treatment for the hemodynamically stable patient, there is no consensus on how to treat hemodynamically unstable patients. This report details the case of a patient who sustained blunt multiple trauma, resulting in a grade IV liver injury, graded according to the American Association for the Surgery of Trauma (AAST) Liver Injury Scale. With massive fluid and blood resuscitation, the patient was stable enough to be managed nonsurgically. With transcatheter arterial embolization (TAE), the left and right hepatic arteries were embolized with coils, which allowed for a good recovery. We hypothesize that TAE can be used in the hemodynamically unstable patient who responds to rapid fluid resuscitation and blood transfusion. We caution that there is insufficient evidence until now and would therefore not make any recommendations; however, we would question the need for surgery in unstable patients with this kind of injury in the future.

Sheehan's syndrome.

Sheehan's syndrome occurs as a result of ischemic pituitary necrosis due to severe postpartum hemorrhage. It may be rarely seen without massive bleeding or after normal delivery. Improvement in obstetric care and availability of rapid blood transfusion coincided with a remarkable reduction in the frequency of Sheehan's syndrome particularly in western society. But it has recently been reported more often from well-developed countries. It is one of the most common causes of hypopituitarism in underdeveloped or developing countries. Enlargement of pituitary gland, small sella size, disseminated intravascular coagulation and autoimmunity have been suggested to play a role in the pathogenesis of Sheehan's syndrome in women who suffer from severe postpartum hemorrhage. The patients may seek medical advice because of various presentations ranging from non-specific symptoms to coma and the clinical manifestation may change from one patient to another. Failure of postpartum lactation and failure to resume menses after delivery are the most common presenting symptoms. Although a small percentage of patients with Sheehan's syndrome may cause abrupt onset severe hypopituitarism immediately after delivery, most patients have a mild disease and go undiagnosed and untreated for a long time. It may result in partial or panhypopituitarism and GH is one of the hormones lost earliest. The great majority of the patients has empty sella on CT or MRI. Lymphocytic hypophysitis should be kept in mind in differential diagnosis. In this review, the old and recent data regarding Sheehan's syndrome are presented.

Intraoperative hemorrhage during patent ductus arteriosus ligation in dogs.

To determine the prevalence of intraoperative hemorrhage in a consecutive series of dogs undergoing patent ductus arteriosus (PDA) ligation at a veterinary teaching hospital, and to describe strategies to reduce the risk of ductus perforation and deal with hemorrhage when it occurs. Retrospective clinical study. Sixty-four dogs. The records of all dogs undergoing PDA ligation at the University Veterinary Center, Sydney between May 1989 and February 1998 were reviewed and the prevalence and nature of complications identified. Serious hemorrhage occurred in 4 of 64 dogs (6.25%) that underwent PDA ligation. In all cases, hemorrhage resulted from perforation of the craniomedial aspect of the ductus while attempting to expose the tips of the dissecting forceps. Hemorrhage was controlled in 3 dogs by clamping the main pulmonary artery, digital compression of the descending aorta, and completion of ductus ligation during an approximately 5-minute period of circulatory arrest. The remaining dog exsanguinated during an unsuccessful attempt to locate, clamp, and ligate the bleeding point. The mortality rate for PDA ligation was I of 64 dogs (1.6 %). The technique described in this report permits simple ligation of a range of different ductus morphologies in dogs of varying breeds, weights, and ages. In the event of serious hemorrhage, prompt ventricular outflow occlusion and ductus ligation followed by rapid whole blood transfusion is life saving in most cases.

Mortality after successful transcatheter arterial embolization in patients with unstable pelvic fractures: rate of blood transfusion as a predictive factor.

To determine the factors predictive of mortality in patients with unstable pelvic fractures after successful transcatheter arterial embolization. A retrospective study of pelvic fractures between May of 1995 and April of 1998 was performed. Of 507 patients, 17 who were unstable underwent embolization. The success rate of embolization and the mortality rate after successful embolization were reviewed. Predictive factors (contrast medium extravasation, initial blood pressure, Injury Severity Score, timing of external fixation, time to angiography, volume of blood transfusion, rate of blood transfusion) of the final outcome were statistically analyzed. Embolization was 100% effective in stopping pelvic hemorrhage. The mortality of patients treated successfully with embolization was 17.6%. Among the predictive factors analyzed, only the rate of blood transfusion before embolization, 11.3 +/- 11.0 units/h (death) versus 3.2 +/- 1.9 units/h (survival) showed statistical significance with an odds ratio of 1.62 (95% confidence interval, 1.07-2.46). The success rate of embolization was 100% in stopping arterial hemorrhage of unstable pelvic fractures. The survival rate after successful embolization was 82.4%. Patients who had rapid blood transfusion before embolization had a poor final outcome. The risk of dying increased by 62% for every 1 unit/h increase of transfusion rate.

Anorexia Nervosa with Pancytopenia

Anorexia Nervosa with Pancytopenia

Microangiopathic hemolytic anemia associated with advanced gastric cancer

Progressive, severe anemia developed in a 66-year-old man with advanced gastric cancer. A total gastrectomy was performed, after a rapid blood transfusion, to stop possible bleeding from cancer. There was no blood accumulation in the resected stomach. Laboratory data showed remarkable hemolysis and disseminated intravascular coagulation after the operation. A peripheral blood smear showed leukoerythroblastosis, which is indicative of bone marrow metastasis. Intensive therapy failed to control hemolysis and disseminated intravascular coagulation. On the 17th postoperative day, the patient suffered sudden respiratory arrest and subsequently died, possibly of a cerebrovascular accident. This is a rare case of microangiopathic hemolytic anemia associated with metastasis of gastric cancer to the bone marrow. Operative procedures should not considered for the patient with microangiopathic hemolytic anemia caused by cancer metastasis, because they offer no advantages for the patient's prognosis. Evaluation of causes of anemia can be helpful in managing patients with cancer.

Venous air embolism related to the use of a pressure device for rapid blood transfusion

AbstractA 70 year old woman received a transfusion of packed red blood cells via the distal port of a subclavian central venous catheter. In order to facilitate flow, the blood pack was placed within a manually inflatable pressure bag. When the patient's oxygen saturation and systolic blood pressure fell precipitously, it was noticed that the blood pack was empty and that air was present along the entire length of the intravenous tubing. A provisional diagnosis of venous air embolism was made. Management consisted of positioning the woman head‐down in the left lateral decubitus position and ventilating with 100% oxygen. Air was unable to be aspirated from the affected central venous catheter port. Her condition improved and her subsequent intensive care unit course was uneventful.A pulmonary artery catheter recorded haemodynamic changes at the time of the venous air embolism. There was an initial increase in pulmonary artery pressure and central venous pressure, associated with a decrease in mean arterial pressure and oxygen saturation. Similar observations have been made in animal models of graded (infusion type) venous air embolism.The diagnosis of venous air embolism is generally clinical, aided by echocardiogram, end‐tidal carbon dioxide monitoring, pulse oximetry, chest radiography and haemodynamic monitoring. Current management of venous air embolism includes prevention of further air entry, positioning the patient head‐down in the left lateral decubitus position and administration of 100% oxygen. External cardiac massage, aspiration of air (via central venous catheter, pulmonary artery catheter or transcutaneously) and hyperbaric oxygen may also play a role.

Renovascular Responses to High and Low Perfusate Calcium Steady-State Experiments in the Isolated Perfused Rat Kidney with Baseline Vascular Tone

Acute hypercalcemia is commonly observed in surgical patients after calcium infusion while acute hypocalcemia is common during rapid citrated blood transfusion. Although high and low ionized calcium ([Ca2+]) within the clinical range produce an increase or decrease in cardiac performance and systemic vessel resistance, respectively, their effects on renal vessels have not been quantified. A possible renal vasoconstriction that might occur with high [Ca2+] is of clinical interest because it is a factor which may contribute to impaired renal circulation and decreased function. In this study we examined the renovascular responses to [Ca2+], which was varied within the clinical range under hemodynamically controlled conditions. We instituted high and low [Ca2+] in the per fusate, which consisted of Krebs–Henseleit buffer containing albumin, 60–65 g/liter. Stable high (n= 10) or low (n= 7) [Ca2+] (1.93 ± 0.02 and 0.59 ± 0.01 mM,respectively) was instituted for 10 min and preceded and followed by normal [Ca2+] of the same duration. In a separate protocol (n= 8) verapamil (10−5M) was added to the perfusate 10 min before high [Ca2+] was tested. We measured changes in renal flow at a constant perfusion pressure of 110 mm Hg and also characterized the renal vessels over a range of pressures by pressure vs flow plots. High [Ca2+] was associated with a small decrease in flow (from 28.8 ± 2.4 to 26.9 ± 2.6 ml/min/g,P< 0.02), indicating a small vasopressor effect. This effect was also shown by a leftward shift in the pressure vs flow plots. These changes were prevented by verapamil. GFR decreased (from 0.35 ± 0.04 to 0.28 ± 0.06 ml/min/g,P< 0.01) without a significant change in sodium excretion or fractional sodium excretion. Low [Ca2+] was associated with increased renal flow (from 30.8 ± 2.1 to 35.2 ± 2.7 ml/min/g,P< 0.02), indicating a vasodilator effect. This effect was also shown by a rightward displacement of the pressure vs flow plots. GFR increased from 0.51 ± 0.03 to 0.56 ± 0.04 ml/min/g,P< 0.01, as did sodium excretion (from 2.32 ± 0.22 to 3.87 ± 0.49 μEq/min,P< 0.01) and fractional sodium excretion (from 2.33 ± 0.26 to 3.61 ± 0.49%,P< 0.01). We conclude, first, that in the isolated perfused rat kidney, high [Ca2+] is a weak vasopressor while low [Ca2+] has vasodilator action. Second, high [Ca2+] effects are abolished by verapamil pretreatment. These findings illuminate mechanisms of high [Ca2+] effects on renovascular tone.

Prostaglandin E 1 as a hypotensive drug during general anesthesia for total hip replacement

Study Objective: To determine the effect of intravenous administration of prostaglandin E 1 (PGE 1) in inducing controlled hypotension during general anesthesia. Design: Randomized, prospective study. Setting: Inpatient surgery at a university hospital. Patients: 57 ASA physical status I and II patients scheduled for total hip replacement. Interventions: In 29 patients undergoing total hip replacement, PGE 1 (0.11 ± 0.03 μg/kg/min) was infused to induce hypotension during general anesthesia with enfurane, isofurane, or sevoflurane in nitrous oxide and oxygen. In another 28 patients, the control group, normotensive anesthesia was performed for the same procedure. Measurements and Main Results: Systolic blood pressure decreased significantly ( p < 0.01) from 136 ± 22 mmHg to 93 ± 10 mmHg during PGE 1 infusion, although heart rate did not change significantly. Arterial hemoglobin oxygen saturation showed a mild but significant decrease ( p < 0.05) during PGE 1 infusion. Blood loss (480 ± 132 ml) and blood transfusion (280 ± 260 ml) during surgery were significantly less in patients with hypotensive anesthesia ( p < 0.01 and p < 0.05, respectively) than in patients with normotensive anesthesia (667 ± 326 ml and 468 ± 395 ml, respectively). Blood loss and blood transfusion after surgery were similar in both groups. In the recovery room or surgical ward, 3 of 29 patients with hypotensive anesthesia needed rapid blood transfusion because of moderate hypotension. The volume of urine during surgery was significantly less ( p < 0.05) in the control group. Two patients developed mild phlebitis at the site of the PGE 1 infusion, but there were no serious side effets. Conclusion: These data suggest that PG E 1 can be used safely to induce hypotension, thereby reducing blood loss during total hip replacement with general anesthesia.

Confirmation of high blood flow rates through 150 μ filter/high-flow tubing

Many new products designed to assist in rapid blood infusion are appearing. Some highly touted and routinely used devices for intravenous (IV) infusion have recently been shown to be, at least in part, defective. A tubing with an in-line 150 mu filter (150 mu High-Flow Blood Filter; Saftifilter Blood Administration Sets; Cutter Biological, Berkeley, CA 94710) has recently been introduced to facilitate rapid blood transfusion. It is claimed that at least 8.5 units of blood can be rapidly run through each set before replacement is necessary. To test this under simulated clinical conditions, four sets of ten random units of outdated erythrocytes at 4 to 9 degrees C were each admixed with 250 mL 70 degrees C 0.9 NaCl and infused through the system under a constant 300 mmHg pressure. Two sets infused through unmodified tubing flowed at an average of 25 mL/sec (1500 mL/min) before there was an appreciable slowing of the flow rate. Two sets with 8 Fr catheters attached infused at an average of 22 mL/sec (1320 mL/min) before there was an appreciable slowing of the flow rate. Even after the flow slowed, the 9th and 10th units infused at an average greater than 10 mL/sec (600 mL/min). The tubing/filter exceeded the manufacturer's published claims. This tubing/filter appears to be one element that could be an effective component of a high-flow infusion system.

Hyperkalaemia during rapid blood transfusion and hypovolaemic cardiac arrest in children

A morbidity and mortality review documented a high occurrence of hyperkalaemia in cardiac arrests associated with rapid blood transfusion, which resulted in further study. In order to stimulate events during rapid blood transfusion and cardiac arrest, the central circulation was modeled as a linear one compartment, and used to stimulate a child who suffered a hypovolaemic cardiac arrest and was resuscitated with rapid blood transfusion (RBT). The simulation suggested that the combination of RBT and a low cardiac output state could be associated with hyperkalaemia, if the potassium concentration in the plasma fraction of the transfused blood was greater than or equal to 10 mmol.L-1. In an associated clinical study the plasma potassium concentration during cardiac arrest was documented from a retrospective review of 138 cardiac arrests in a paediatric population. Patients were divided into two groups. The RBT-group received a rapid blood transfusion during resuscitation. The non-RBT group did not receive blood during resuscitation. During cardiac arrest the plasma [K] in the non-RBT group was 5.63 +/- 2.39 mmol.L-1 compared with 8.23 +/- 1.99 mmol.L-1 in the RBT-group (P less than 0.05). The hyperkalaemia during cardiac arrest in the RBT-group could be explained as a consequence of RBT to a hypovolaemic child with a low cardiac output.

Intraoperative rapid autologous blood transfusion

Intraoperative rapid autologous blood transfusion is a resource that is available in many operating suites but is currently underused in gynecologic surgery. A case is presented in which an intraoperative autotransfusion of 1560 ml of free intraperltoneal blood was performed to aid in resuscitation of a 31-year-old woman with a ruptured tubal pregnancy. (Am J Obstet Gynecol 1989;160:1226-7.)

Effects of right ventricular ischemia on left ventricular geometry and the end-diastolic pressure-volume relationship in the dog.

We studied the effects of right ventricular ischemia on left ventricular three-dimensional geometry and the end-diastolic pressure-volume relationship in 16 open-chest dogs before and after pericardiectomy. Left ventricular volume was calculated from three internal dimensions measured with ultrasonic crystals. In one group of eight dogs, right coronary artery (RCA) occlusion for 2 min with the pericardium intact reduced aortic flow by 24 +/- 9% (p less than .001) and septal-lateral dimension by 8 +/- 5% (p less than .01), without changing anterior-posterior and apical-basal dimensions. However, parameters of left ventricular systolic function (aortic flow, left ventricular systolic pressure, peak dP/dt, and mean percent systolic shortening) were similar to those observed at a comparable level of left ventricular end-diastolic volume during inferior vena caval occlusion. In the other group of eight dogs, during RCA occlusion before pericardiectomy the left ventricular end-diastolic pressure-volume relationship determined during rapid blood transfusion shifted leftward and upward significantly from the preocclusion relationship. After pericardiectomy, RCA occlusion caused less significant changes in aortic flow and septal-lateral dimension as well as in the left ventricular end-diastolic pressure-volume relationship. We concluded that right ventricular ischemia causes a leftward shift of the interventricular septum in end-diastole and an alteration of the left ventricular end-diastolic pressure-volume relationship without changing left ventricular myocardial performance. These changes are enhanced by the intact pericardium.

Which patients are likely to die in an accident and emergency department?

Four hundred and eighty-eight deaths occurring in an accident and emergency department over five years were analysed. Their causes were categorised as medical, surgical, or traumatic. Medical causes accounted for 87% of the deaths, of which 60% were from cardiac conditions. Blood loss was an important factor in over half the deaths from surgical and traumatic causes. Lives might have been saved by considering infectious disease in patients with medical conditions and by undertaking more rapid blood transfusion, earlier chest drainage, and lateral cervical spine x rays in appropriate surgical or traumatic cases. The admission to casualty departments of people with terminal neoplasms should be discouraged. The management of medical emergencies should be emphasised when training accident and emergency department staff.

Intravenous Nitroglycerin in Transfusion Therapy for Severe Anemia

The risk of aggravated heart failure due to expanded blood volume and augmented left-ventricular filling pressure poses a challenge when transfusion is indicated by severe anemia complicating congestive heart failure. Intravenous (IV) nitroglycerin therapy produces a favorable redistribution of circulating blood volume and may be used to surmount these hemodynamic constraints during transfusion. In four patients with severe anemia and cardiac failure, IV nitroglycerin permitted rapid and large-volume blood transfusion without compromising cardiac function. In two of the four patients, recalcitrant unstable angina abated after the correction of anemia.

Left ventricular filling pressures after rapid blood transfusion in cases of chronic severe anemia.

Left ventricular filling pressure as reflected by pulmonary artery wedge pressure was measured in 15 adult cases of chronic severe anemia before and after rapid and large blood transfusion, using Swan-Ganz monitoring catheters. Pre-transfusion PAWP was normal in 80% of the cases but increased significantly after blood transfusion (P less than 0.001), reaching more than 18.0 mm Hg in 3 cases. No correlation was found between right atrial pressure and PAWP. In is concluded that administration of 2 units of blood at a rapid speed (8.92 +/ 1.73 ml/minute) in cases of CSA is not always quite safe so far as pulmonary hemodynamics are concerned and should therefore be avoided.

Left ventricular hypertrophy in rats with renovascular hypertension. Alterations in cardiac function and adrenergic responses.

Performance of the hypertrophied left ventricle was studied by determination of the inotropic response to different stimuli in renal hypertensive rats (two-kidney, one clip Goldblatt, RHR, n = 13) and matched sham-operated controls (NR, n = 11). A model was developed to determine maximal pressure development (transient aortic ligation), maximal pumping ability (rapid transfusion, 2 ml/30 sec), and responses to beta stimulation (isoproterenol, 0.01 to 0.10 micron g/kg/min), using dP/dt/P40 as a load-independent index of contractility. With rapid blood transfusion, RHR developed a higher ventricular systolic pressure (211.5 +/- 10.1 mm Hg vs 194.0 +/- 9.3 (SE), p less than 0.001) but at the expense of higher end-diastolic pressure (LVEDP) (12.2 +/- 1.1 mm Hg vs 7.7 +/- 1.0, p less than 0.02). The maximal response of dP/dt/P40 to isoproterenol was diminished in RHR (29.5 +/- 3.2 sec-1 vs 49.6 +/- 5.2, p less than 0.01) whereas the maximal developed pressure (MDP) was greater in RHR than in NR (239.2 +/- 7.5 mm Hg vs 197.0 +/- 3.9, p les than 0.001). A positive correlation was found between MDP and ventricular weight (r = 0.846, p less than 0.001) in contrast with the negative correlation found between ventricular weight and maximal dP/dt/P40 response to isoproterenol (r = 0.677, p less than 0.001). Thus, cardiac hypertrophy in RHR allowed higher developed ventricular pressures but at the expense of higher LVEDP; at the same time, however, the ability to increase contractility in response to beta adrenergic stimulation was decreased. The contrast in results obtained using different tests of cardiac function indicates the need for a multifactorial approach. It also suggests a subtle transformation in this hypertrophy of the pattern of cardiac adaptation to the increased load.