Rapid Transfusion Research Articles

A Surgical Case of Mitral Regurgitation due to Active Infective Endocarditis with Idiopathic Thrombocytopenic Purpura

A 71-year-old woman with idiopathic thrombocytopenic purpura (ITP), who had been treated with steroid and cyclosporine, was admitted in an emergency with fever and dyspnea. The diagnosis was mitral regurgitation due ton infective endocarditis. Although she received treatments for infection and cardiac failure, the cardiac failure could not be controlled. After high-dose γ-globulin therapy, an emergency operation was performed during the active phase of infective endocarditis. Rapid platelet transfusion was administered after weaning from extracorporeal circulation. She recovered and was discharged without postoperative bleeding and re-infection.The treatment course of elective cardiac surgery complicated with ITP has been established, but the course of emergency surgery has not been established because of the small number of cases reported. Since few patients have undergone emergency surgery for active infective endocarditis, we had difficulty in deciding the time of surgery and treatment for increasing the number of platelets before surgery, it was considered that the case provided us with useful suggestion for the future treatment for urgent surgery complicated with ITP.

Transfusion management of patients with alloanti-Gerbich antibodies: Case report

Transfusion management of patients who are alloimmunized against high-prevalence erythrocyte antigens is often problematic. Strategy management depends, not only on the specific clinical circumstances of the patient, but also on the acceptable time frame. In patients without clinically significant antibody incompatible transfusion it may be less harmful than delaying medical intervention. We report a 57-year-old female from Libya, blood group O, RhD-positive, who was treated at the Institute of Cardiovascular Diseases of Vojvodina. At the Blood Transfusion Institute of Vojvodina, during pretransfusion testing an IgG alloantibody of unknown specificity was determined. A total of 200 blood units (O, RhD-positive) were crossmatched, but positive reactions indicating that the donor units were incompatible for that specific patient. By testing the patient's family members in Tripoli, six compatible blood units were found and applied during and after surgery. Due to the deterioration of the patient's condition a rapid transfusion was required; however cross-match compatible blood was not available. After a biological cross-match to predict the clinical significance of this antibody, 12 units of erythrocytes with the lowest positive cross-match reactions, were transfused to the patient without any adverse effects. Good tolerance of the units suggested that the present antibodies were not clinically significant. Later on, a rare alloantibody directed to the high frequency Gerbich blood group antigens was identified by the Foundation Central Laboratory, Blood Transfusion Service in Bern, Switzerland. In cases of emergency patients with alloantibodies against high frequency Gerbich, when autologous or compatible alogenous transfusion is unavailable, blood with the lowest positive cross-match reaction could be transfused if the biological cross-match is negative. Formation of a national register of donors with rare blood groups and their connection with international registers is of crucial significance in the management of patients requiring antigen negative blood otherwise unavailable from routine blood banks.

Guidelines on the use of irradiated blood components prepared by the British Committee for Standards in Haematology blood transfusion task force

Search terms included: Transfusion-associated graft-versus-host disease, Transfusion-associated graft-versus-host, TA-GvHD. The last guideline covering this topic was published in 1996 (British Committee for Standards in Haematology (BCSH) Blood Transfusion Task Force, 1996. The writing group produced the new draft guideline, which was subsequently revised by consensus by members of the Haemato-oncology and Blood Transfusion Task Forces of the BCSH. The guideline was then reviewed by a sounding board of approximately 100 UK haematologists, the BCSH and the committee of the British Society for Haematology and amended, again by consensus. Criteria used to quote levels and grades of evidence are according to the GRADE system (Guyatt et al, 2006). Strong recommendations (grade 1, ‘recommended’) are made when there is confidence that the benefits either do or do not outweigh the harm and burden and costs of treatment. Where the magnitude of benefit or not is less certain a weaker grade 2 recommendation (‘suggested’) is made. Grade 1 recommendations can be applied uniformly to most patients whereas grade 2 recommendations require judicious application. The quality of evidence is graded as A (high quality randomized clinical trials), moderate (B) or low (C). This publication reports the key recommendations of the Writing Group. It is also accessible at http://www.bcshguide lines.com.

Ringer’s lactate is compatible with saline-adenine-glucose-mannitol preserved packed red blood cells for rapid transfusion

Guidelines state that Ringer's lactate (RL) should not be co-administered with packed red blood cells (PRBC) due to a potential risk of clotting. The purpose of this study was to determine whether RL causes clotting in PRBC with the currently used preservative, saline-adenine-glucose-mannitol (SAGM). Phase 1: Samples from 12 units of SAGM-PRBC were diluted from 0-97.5% with RL and normal saline (NS), incubated for 30 min, and passed through 40 μm filters. Additional samples were frozen and batch analyzed using an enzyme-linked immunosorbent assay (ELISA) to measure prothrombin activation fragment 1 + 2 (F1 + 2), indicative of thrombin generation. Packed red blood cells were also diluted, flushed with crystalloid using a rapid transfusion model, and filtered. Phase 2: Eight further units were serially diluted with RL and incubated for 30, 60, 120, 180, and 240 min. Fresh samples were analyzed by filtration and ELISA. Phase 1: No clotting was seen during filtration or using the transfusion model with NS or RL. The F1 + 2 ranged from 2.28 to 154.37 pmol·L⁻¹ in NS dilutions and from 2.80 to 1675.93 pmol·L⁻¹ in RL dilutions, indicating coagulation in some samples. Phase 2: No clotting was observed within 60 min by filtration or ELISA. However, 4 of the 8 units showed clots in the filters of some dilutions between 120 and 240 min. No clotting was detected at any dilution of RL with SAGM- preserved PRBC within 60 min, but clotting was detected with extended incubation. The results indicate RL can be safely co-administered with PRBC during rapid transfusion (< 60 min).

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

Storage of Blood Components Does Not Decrease Haemostatic Potential: In vitro Assessment of Fresh versus Stored Blood Components Using Thromboelastography

Background: Major surgery and severe trauma typically lead to massive blood loss requiring rapid transfusion of large amounts of blood products. It has been suggested that fresh, unrefrigerated whole blood provides a haemostatic advantage in this setting. The aim of the current study was to compare the clot formation parameters of fresh, unrefrigerated whole blood and whole blood reconstituted from components stored for varying periods of time, using rotational thromboelastography (ROTEM®). Methods: Fresh whole blood and reconstituted whole blood using combinations of nonleucoreduced red cell units (stored for 7, 14, 21, 28, or 35 days), platelet concentrates (stored for 1, 3 or 5 days), and fresh frozen plasma (stored for 6 months) were analysed using ROTEM. Measurements of the clotting time (CT), clot formation time (CFT), and maximal clot firmness (MCF) were compared between units of fresh whole blood and reconstituted whole blood samples. Results: There was no difference in the haemostatic parameters measured of fresh whole blood and reconstituted whole blood using red cell units stored for less than 21 days. ROTEM demonstrated that the CT and CFT were significantly shorter for reconstituted whole blood samples using red cells stored for longer than 21 days when compared to fresh whole blood and to reconstituted whole blood samples using red cell units stored for less than 21 days. The CT was inversely correlated to the duration of platelet storage. The MCF was unchanged regardless of duration of blood product storage. Conclusion: Fresh unrefrigerated whole blood and blood products stored for short duration (less than 21 days) were not superior to those stored for longer durations.

Ringer’s lactate is compatible with the rapid infusion of AS-3 preserved packed red blood cells

Ringer's lactate (RL) may be preferable to normal saline (NS) for large volume resuscitation. Authorities recommend against its mixture with packed red blood cells (PRBC) due to a theoretical risk of clotting. The purpose of this study was to test whether RL, as compared with NS, leads to a risk of clotting when used to dilute AS-3 preserved PRBC in a clinically relevant model. Following Ethics Board approval, eight units of unused, unexpired AS-3 preserved PRBC were obtained. Four sets of two parallel studies were performed, comparing RL with NS as the diluent for PRBC. The mixtures were infused using gravity flow through standard blood filter tubing and fluid warmer, to simulate an intraoperative blood transfusion. A series of progressively more dilute samples was collected. These were filtered and analyzed macroscopically, then using enzyme-linked immunosorbent assay to quantify the amount of F1+2 (the breakdown products of thrombin generation). No filters in any of the NS and RL mixtures contained evidence of clot or debris. In the NS group, the F1+2 levels ranged from 2.7 to 38.0 pmol x L(-1). In the RL group, the F1+2 levels ranged from 3.2 to 289.7 pmol x L(-1). All of these values were below the physiologic levels determined in previous studies. In this simulation of intraoperative blood transfusion, RL did not lead to visible or molecular evidence of activation of the clotting cascade. The current study challenges recommendations that AS-3 PRBC should not be mixed with RL for rapid transfusion.

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.

Cardiac asystole at birth: Is hypovolemic shock the cause?

A birth involving shoulder dystocia can rapidly deteriorate-from a fetus with a reassuring tracing in the minutes before birth, to a neonate needing aggressive resuscitation. Infants experiencing a traumatic birth involving shoulder dystocia may be severely compromised, even when the preceding labor was uncomplicated. This paper presents two cases in which infants had normal heart beats recorded 5-10min before birth and were born with cardiac asystole following shoulder dystocia. Often, in cases of shoulder dystocia, infants shift blood to the placenta due to the tight compressive squeeze of the body in the birth canal (along with cord compression) and thereby may be born hypovolemic. Our hypothesis is that the occurrence of sudden cardiac asystole at birth is due to extreme hypovolemic shock secondary to the loss of blood. At birth, the sudden release of pressure on the infant's body results in hypoperfusion resulting in low central circulation and blood pressure. Severe hypovolemic shock from these effects leads to sudden cardiac arrest. Immediate cord clamping maintains the hypovolemic state by preventing the physiologic and readily available placental blood from returning to the infant. Loss of this blood initiates an inflammatory response leading to seizures, hypoxic-ischemic encephalopathy, and brain damage or death. Animal studies have shown that human umbilical stem cells injected into a rat's abdomen after induced brain damage, can protect the rat's brain from developing permanent injury. To prevent damage to newborns, the infant must receive the blood volume and stem cells lost at the time of descent and immediate cord clamping. Recommended countermeasures for research include: (1) resuscitation at the perineum with intact cord; or (2) milking the cord before clamping; or (3) autologous transfusion of placenta blood after the birth; or (4) rapid transfusion of O negative blood after birth and before seizures begin.

Scientific aspects of supplying blood to distant military theaters

Reduction in combat zone morbidity and mortality requires rapid delivery of safe blood products as an integral element of advanced trauma surgical care. This review of the current literature presents scientific aspects of supplying blood for rapid delivery to enhance survival and patient outcome in the combat zone. Most deaths due to hemorrhage can be averted by transfusion during the first hour from injury; therefore, maintaining a dependable inventory of blood products in combat support hospitals is essential. Current casualty care in distant geographic locations involves rapid air evacuation to combat support hospitals or fleet hospitals, where massive transfusions may be required. Resuscitation by forward surgical teams utilizing red blood cells before air evacuation or in-flight has also been reported. To improve survival, these massive transfusions should be composed of not only red blood cells but also other blood components and plasma factors. Rapid on-site combat casualty transfusion support requires specialized blood transport containers and transfusion practices not observed in noncombat settings, such as the mobile walking blood bank and a frozen blood program. Additionally, technology for improved transport containers, cell-free hemoglobin-based oxygen carriers, freeze-dried blood, and recombinant activated coagulation factor has attracted focused interest.

Risk Management in Rapid Transfusion Equipment(Risk Management in Machine of Medical Treatment Related to Anesthetic Equipment)

Risk Management in Rapid Transfusion Equipment(Risk Management in Machine of Medical Treatment Related to Anesthetic Equipment)

照射MAP加赤血球濃厚液急速大量輸血により生じた高カリウム血症に対し, 自己血回収装置による洗浄赤血球で対応した症例

大量出血に対し, 照射MAP加赤血球濃厚液急速投与を行ったところ, 高カリウム血症から心停止に至った症例を経験した. 症例は68歳, 女性. 大量出血による血圧低下のため, 輸血速度を80ml/minに速めたところ, 心電図上QRS幅の延長に引き続き心停止に至った. ただちに胸骨圧迫心マッサージを行い, 塩化カルシウムと炭酸水素ナトリウムの投与で洞調律に復帰した. 心停止直前の血清K値は8. 3mEq/Lであった. 投与したMAP血のK値は45mEq/L (照射後11日) であったため, 以後の赤血球輸血には自己血回収装置 (Cell Saver) を用いて照射血を生理食塩水で洗浄したものを用いた. Cell Saverにより作製した洗浄照射赤血球の輸血は, 高カリウム血症の回避に有効であった.

Alternative Route Transfusion for Transplantation Surgery in Patients Lacking Accessible Veins

Alternative Route Transfusion for Transplantation Surgery in Patients Lacking Accessible Veins

Dilutional Hypokalemia–Induced Arrhythmias Associated With Intraoperative Cell Salvage and Reinfusion

INTRAOPERATIVE ANESTHETIC MANAGEMENT for surgical repair of thoracoabdominal and descending thoracic aortic aneurysms (TAAs) still poses significant challenges to anesthesiologists, despite constant improvements in surgical techniques. 1 Kouchoukos N.T. Dougenis D. Surgery of the thoracic aorta. N Engl J Med. 1997; 336: 1876-1888 Crossref PubMed Scopus (379) Google Scholar Multiple preoperative risk factors have been associated with high morbidity and mortality rates in descending TAA repair. 2 Safi H.J. Miller III, C.C. Huynh T.T. et al. Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic aortic repair. Ann Surg. 2003; 238: 372-381 PubMed Google Scholar , 3 Suzuki S. Davis C.A. Miller III, C.C. et al. Cardiac function mortality following thoracoabdominal and descending thoracic aortic aneurysm repair. Eur J Cardiothorac Surg. 2003; 24: 119-124 Crossref PubMed Scopus (29) Google Scholar In addition, perioperative processes, such as fluid resuscitation, and electrolyte and acid-base imbalances, can contribute to an adverse outcome during descending TAA repair. We report a case in which a potentially life-threatening intraoperative arrhythmia was caused by iatrogenic dilutional hypokalemia resulting from rapid transfusion of normal saline solution–washed autologous blood during the cross-clamp period of repair of a TAA.

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.

A Large-Scale Automated Method for Hepatocyte Isolation: Effects on Proliferation in Culture

Large-scale sterile methods for isolating hepatocytes are desirable for the development of bioartificial liver support systems. In this study the traditional centrifuge method was compared with the use of a Baylor Rapid Autologous Transfusion (BRAT) machine for isolating large quantities of porcine hepatocytes. After isolating hepatocytes, the methods were evaluated in terms of cell viability and yield per liver, proliferation over 7 days, and the effects on the cell cycle using the trypan blue exclusion test, conventional phase-contrast light microscopy, the lactate to pyruvate ratio, the leakage of lactate dehydrogenase (LD) and aspartate aminotransferase (AST), lidocaine clearance, albumin production, and flow cytometry. With the centrifuge method the mean cell viability was 92.5%, while with the BRAT method the viability was 95.9%. The minimal cell yields with the BRAT procedure were 7.3 x 10(9) for 250-ml centrifuge bowls and 2.8 x 10(9) for 165-ml bowls, which compares well with that found by other authors. Because the same initial procedures were employed in both methods the total hepatocyte yield per liver was comparable. Flow cytometry confirmed that the proliferation of hepatocytes was facilitated by oxygenation during the isolation procedure. The recovery of hepatocytes in culture following isolation was similar after either method. Daily microscopic investigation indicated that cytoplasmic vacuolization and granularities were present after either procedure and these disappeared following 3-4 days of culturing. Flow cytometry indicated that the hepatocyte cell cycle was similar after either method; at 7 days the profile indicated that the cells were still proliferating. Trends in the lactate to pyruvate ratio and the leakage of LD and AST indicated that the functional polarity of hepatocytes was regained after approximately 3 days. Lidocaine clearance at 4 days indicated that the cytochrome P450 system was active, while significant albumin production was apparent at day 5. The benefit of using BRAT technology in hepatocyte isolation lies in guaranteed sterility, convenience, speed, and the ability to oxygenate media and cell suspensions during the procedure.

Pulmonary Mucormycosis

A 56-year-old nondiabetic male presented for evaluation of fever and cough shortly after 6 cycles of chemotherapy for treatment of non-Hodgkins lymphoma. Over the subsequent few days, the patient developed hemoptysis, sepsis, hypotension, and severe immunocompromise (total white blood cell count = 100/mm3) and thrombocytopenia (platelet count = 41,000/mm3). Chest x-ray (normal one month prior) demonstrated a prominent cavitary lung lesion involving the left upper lobe (Fig 1 ; sternal wires are from a previous mitral valve repair procedure). Computed tomography of the chest provided additional anatomic detail (Fig 2 ). Because of the patient's rapid clinical deterioration, platelet transfusion and subsequent surgery were performed.Fig 2View Large Image Figure ViewerDownload (PPT) Exploration of the left hemithorax was conducted through a standard posterolateral thoracotomy. A large-diameter (11-cm) necrotic abscess was discovered, requiring anatomic left upper lobectomy. An intercostal muscle flap was used to cover the bronchial stump. After completion of the surgical procedure, the specimen was further examined (Fig 3 ). When the abscess was incised, a prominent rush of air was appreciated as the cavity decompressed and partially collapsed (Fig 4 ). The specimen was sent for histologic and microbiologic evaluation. Postoperatively, aggressive resuscitation was continued in the intensive care unit. Identification of Mucor species (Fig 5 , hematoxylin & eosin, ×400) allowed for treatment with amphotericin B. Unfortunately, the patient died 8 days after surgery following complications of septic shock, renal failure, suspected disseminated intravascular coagulation, and upper extremity ischemia.Fig 4View Large Image Figure ViewerDownload (PPT)Fig 5View Large Image Figure ViewerDownload (PPT)

Massive Gastrointestinal Bleeding Complicating Portal Vein Cross-Clamping During Liver Transplantation

This case report describes the occurrence of massive upper gastrointestinal hemorrhage immediately after cross-clamping of the inferior vena cava and hepatic portal vein. This case suggests that acute intraoperative hemorrhage from a varix should always be a consideration before liver transplantation in patients who have a history of upper gastrointestinal bleeding. A case of severe bleeding during liver transplantation is described in a patient who had a history of bleeding from the stomach before surgery. The importance of understanding surgical options and the ability to provide rapid massive transfusion in the management of this complication are discussed.

Transfusions via hand-held syringes and small-gauge needles as risk factors for hyperkalemia.

Pediatric emergency RBC transfusions are often infused rapidly through 22-gauge (ga) or smaller needles or catheters using hand-held syringes. Data relating needle size, unit age, and infusion rate are needed to assess the risk of hemolysis and hyperkalemia in this setting. Multiple simulated transfusions were performed during storage of RBC units. Aliquots from five units were rapidly passed through needles (18, 20, 22-25 ga) using a hand-held syringe. Resulting plasma Hb and K+ concentrations were measured. Free Hb levels were used as a measure of needle-associated hemolysis (NAH). Passage through 18-ga and 20-ga needles caused no hemolysis, but rapid passage through 23-ga, 24-ga, and 25-ga did. RBCs stored less than 7 days showed significant K+ release with 23- to 25-ga needles. The greatest needle-associated K+ release was 10 mEq per L, on Day 5. Due to high K+ concentrations resulting from spontaneous efflux, K+ release from NAH was not detectable after 2 or more weeks of storage. Rapidly transfusing RBCs using hand-held syringes through 23-ga or smaller needles can cause hemolysis. In RBCs stored 2 weeks or more, NAH does not measurably increase K+ concentrations above that present from storage-related efflux. During rapid transfusions, RBC storage time is the primary risk factor for transfusion-associated hyperkalemia.