Storage of washed or irradiated red cells in AS-7 improves their in vitro characteristics.

BACKGROUND: AS-7 is a new alkaline hypotonic red cell additive solution (AS) shown to improve red cell quality during storage compared with AS-1. We sought to compare red cells stored in AS-7 with those stored in SAGM using RCC that were either untreated, or washed or irradiated on day 14 of storage. STUDY DESIGN AND METHODS: A pooled and split study design was used to produce seven identical RCC (four in SAGM and three in AS-7). At day 14 following donation, two RCC (one in SAGM and one in AS-7) were gamma irradiated and three RCC (two in SAGM and one in AS-7) were washed and resuspended in either SAGM or AS-7. RCC were sampled for analysis throughout storage and at end of shelf life: day 28 for washed or irradiated and day 35 for untreated RCC. RESULTS: For untreated, washed or irradiated RCC, those stored in AS-7 had lower haemolysis, red cell microvesicles and supernatant potassium content than RCC in SAGM. In addition, ATP levels and pH were better maintained in AS-7 RCC than in SAGM RCC. CONCLUSION: These data suggest that the quality of these components may be improved by storage in AS-7 compared with SAGM.

Decrease in reported posttransfusion hepatitis. Contributions of donor screening for alanine aminotransferase and antibodies to hepatitis B core antigen and changes in the general population.

Blood donor screening for hepatitis B core antibody and elevation of serum alanine aminotransferase level, surrogate markers of hepatitis C/non-A, non-B (NANB) infection, was implemented in 1986. Reported cases of posttransfusion hepatitis (PTH) from 1985 to 1988 were reviewed to ascertain the effect of surrogate testing on the number and character of cases and to compare any changes with those in the incidence of hepatitis in the general population. The reports of all PTH, NANB PTH, and type B PTH decreased 61.5%, 75.4%, and 84.5%, respectively. The rates of reported cases of NANB hepatitis and hepatitis B in the general community also fell during the period of review. The decrease in PTH and background hepatitis was similar between 1985 and 1986. In 1987, the first complete year of surrogate testing, the incidence of PTH decreased at a greater rate, to levels 50% below what would have been projected on the basis of background changes alone for NANB PTH, and to 35% below projected for type B PTH. There appears to have been a substantial decrease in the risk of both type B PTH and NANB PTH in the northeastern United States between 1985 and 1988 due to a combined effect of donor surrogate testing and a decrease in the background rates of hepatitis in the donor population.

Thrombocytosis, coronary thrombosis and acute myocardial infarction.

Clinical and morphologic findings are described in a 22 year old man with prolonged thromboyctosis, and coronary and splenic arterial thrombi causing myocardial and splenic infarcts. The absence of preexistent extensive coronary atherosclerosis, the presence of thrombus in more than one epicardial artery and in multiple intramural coronary arteries, the presence of arterial thrombosis in a noncoronary artery (splenic) and the absence of another apparent cause of the arterial thromboses are evidences that the intraarterial clotting in this patient was related to the severe thrombocytosis. A reveiw of the reported cases of vascular occlusion associated with thrombocytosis indicates that thrombi have infrequently been confirmed as the mechanism of the vascular occlusion. Although the frequency of vascular thrombi in patients with thrombocytosis has not been established, it is clear that vascular thrombosis can be a consequence of thrombocytosis and, as demonstrated by the present patient, that the coronary artery may be the site of the vascular occlusion, a heretofore unconfirmed event.

Intraoperative autologous transfusion.

Intraoperative autologous transfusion is a technique that was first used almost 2 centuries ago but that has realized its potential only in the past 5 years. A growing national awareness of transfusion-related morbidity, of the need for alternative blood sources, and of improved methods for red blood cell recovery has led to an increased frequency of use of autologous transfusion. Most hospital programs use semicontinuous flow centrifugation or canister technology for the intraoperative salvage and reinfusion of shed blood. This technique is particularly valuable for cardiovascular surgical procedures but has been useful in many other types of surgical procedures as well. Deleterious effects formerly attributed to this technique have been eliminated by methodologic improvements. Concerns about use of autologous transfusion in patients who have an infection or a malignant lesion persist. Most hematologic aberrations are related to massive transfusions and should not be considered a contraindication to the general use of autologous blood.

Effect of blood conservation efforts in cardiac operations at the Mayo Clinic.

In a retrospective study of 388 patients who had undergone cardiac operations at our institution during two time periods-before (1982) and after (1984) introduction of autologous transfusion-we analyzed the effect of blood conservation efforts and autologous transfusion on blood usage, postoperative complications, and duration of hospitalization. Cell salvage techniques resulted in a significant reduction (P less than 0.0001) in use of not only homologous blood (from a mean of 9.6 units per patient in 1982 to 3.2 units in 1984) but also fresh-frozen plasma and platelet concentrates. We found no significant difference in morbidity or mortality for the two study periods. Although the mean duration of hospitalization decreased from 11.7 days in 1982 to 9.6 days in 1984, this change was probably related to factors other than the introduction of blood conservation efforts. Thus, techniques used to decrease the amount of blood replacement needed for cardiac surgical procedures are beneficial.

A blood bank consultation service: principles and practice.

In the blood bank setting, a close relationship with both clinicians and patients is essential for good medical practice. In July 1982, the Mayo Clinic Blood Bank and Transfusion Services formally organized a consultation service with daily visits to patients of mutual interest to blood bank consultants and clinicians for practice and education. Detailed diaries of this activity were maintained for 12 months, during which time 802 impatient visits were recorded. The most frequent reasons for consultations were clarification or amplification of the clinical history (34.0%), evaluation of transfusion reactions (27.2%), and assessment of serologic problems (18.2%). These consultations resulted in diagnostic, management, and therapeutic recommendations for a wide variety of medical problems. Of the 802 consultations, 23% were conducted at the direct request of clinicians. We believe that a blood bank consultation service is feasible, is enlightening for the blood bank and clinicians, and contributes to patient care.

The effects of intraoperative blood salvage and induced hypotension on transfusion requirements during spinal surgical procedures.

Spinal surgical procedures, such as placement of Harrington rods for correction of scoliosis, are associated with considerable perioperative blood loss and, hence, with the risks associated with homologous blood transfusions. To test the hypothesis that intraoperative autologous blood transfusions could decrease the amount of homologous blood needed in such operations, we conducted a two-part study: (1) a retrospective review of 142 patients in whom blood salvage was not used and (2) a prospective review of 28 patients who received autologous transfusions. Intraoperative autologous transfusion reduced the amount of homologous blood required by more than 50% (5.1 versus 2.0 units; P less than 0.001). The total amount of homologous blood required during the hospital stay was also significantly reduced by intraoperative autologous transfusion (6.0 versus 3.4 units; P less than 0.001). Induced hypotension in 81 of the 142 patients who did not receive autologous transfusions did not decrease the homologous blood transfusion requirements from those needed by the normotensive patients. We conclude that intraoperative autologous transfusion significantly reduces the need for homologous blood products in patients who undergo spinal surgical procedures. Induced hypotension, which did not affect transfusion requirements in our study, should be further evaluated in a blinded, prospective study.

Meyenburg complexes of the liver and bile cysts as a consequence of hepatic ischemia.

Meyenburg complexes and simple bile cysts are described in a patient having polyarteritis nodosa with involvement of the intrahepatic arterial tree. Similar lesions are found in the liver of monkeys subjected to experimental occlusion of the peripheral hepatic arterial tree. It is proposed that a pathogenetic mechanism conducive to the formation of Meyenburg complexes may be hepatic ischemia.

Parosteal osteogenic sarcoma. Ultrastructural observations in three cases.

Ultrastructural study of three parosteal osteogenic sarcomas showed this type of tumor to contain numerous myofibroblasts. These cells were admixed with occasional cells resembling osteoblasts and fibroblasts. Cartilaginous areas showed the typical arrangement of cartilage cells embedded in a dense collagen matrix. Ultrastructural examination of a recurrent lesion revealed the presence of numerous undifferentiated cells as well as the types of cells just described. In addition, desmosomes were evident between the more undifferentiated cells. The ultrastructural study of these tumors shows that parosteal osteogenic sarcomas are ultrastructurally a distinctive type of osteogenic sarcoma.

Bigger is better: maternal and neonatal predictors of hematopoietic potential of umbilical cord blood units.

Umbilical cord blood (CB) is a useful stem cell source for patients without matched family donors. CB banking is expensive, however, because only a small percentage of the cord units stored are used for transplantation. In this study, we determined whether maternal factors, such as race, age, and smoking status have an effect on laboratory parameters of hematopoietic potential, such as viability, cell counts, CD34+ cell counts, and CFU-GM. We studied the effect of neonatal characteristics such as birth order, birth weight, gestational age, and sex of the baby on the same laboratory parameters. Race and maternal age had no effect on these laboratory parameters. In multivariate analysis, babies of longer gestational age had higher cell counts, but lower CD34+ cell counts and CFU-GM. Bigger babies had higher cell counts, more CD34+ cells, and more CFU-GM. Women with fewer previous live births also produced cord units with higher cell counts, CFU-GM, and CD34+ cell counts. Specifically, each 500 g increase in birth weight contributed to a 28% increase in CD34+ cell counts, each week of gestation contributed to a 9% decrease in CD34+cell counts, and each previous birth contributed to a 17% decrease in CD34+ cell counts (all P < 0.05). These data may be used to select the optimal cord blood donors and allow CB banks efficient resource allocation.

The role of the transfusion medicine consultant.

Over the last 15 years, the field that was once known as blood banking has evolved into the discipline of transfusion medicine. Because of AIDS and a greater appreciation of other transfusion-transmitted diseases, attitudes toward transfusion therapy have changed significantly. Advances in the understanding of the pathophysiology of anemia and thrombocytopenia, as well as new tools for transfusion support have created new roles for the transfusion medicine physician. The transfusion medicine consultant has the opportunity to influence and improve transfusion safety, and contribute positively to cost containment by providing expertise as an educator, auditor of blood component usage, and providing leadership or oversight of therapeutic modalities (such as autologous transfusion, intraoperative red cell salvage, and therapeutic apheresis).

Fellowship training programs in blood banking and transfusion medicine: results of a national survey.

This report details the results of a 1995 survey of the 40 fellowship training programs in blood banking and transfusion medicine in the United States approved by the Accreditation Council for Graduate Medical Education. Fellows primarily enter transfusion medicine training after completing a pathology residency, and are subsequently employed in an academic or university setting, or a blood donor center. Program directors indicated that either the current level, or fewer, transfusion medicine specialists will be needed in the future. The educational content of fellowship training was examined, as well as aspects of proficiency and competency in several areas. Research is an important part of most fellowship programs, and a majority of program directors felt that some formal training in clinical medicine should be a part of fellowship training in transfusion medicine. The information obtained from this survey should be helpful to both fellowship applicants and program directors in delineating important aspects of fellowship training in blood banking and transfusion medicine.

Acute occlusion of the posterior spinal vein. Experimental study in monkeys.

The posterior spinal vein was occluded with silicone in seven rhesus monkeys, and locally resected in one. There were no neurological findings associated with acute venous obstruction of the cord. Follow-up arteriography revealed diversion of venous outflow into the anterior spinal venous system. Histology revealed gliosis associated with demyelinization confined to the posterior columns.

Further characterization of transfusion-related acute lung injury: demographics, clinical and laboratory features, and morbidity.

According to Food and Drug Administration data, transfusion-related acute lung injury (TRALI) is the third most frequent cause of transfusion-associated death in the United States and is characterized by an acute respiratory distress syndrome-like clinical picture following transfusion of plasma-containing blood components. It may be underdiagnosed due to unfamiliarity of clinicians with the syndrome. This report describes the largest series to date, 46 cases, occurring between 1992 and 1998. The male-to-female ratio was approximately 1:1. The mean age at diagnosis was 54 years. The most frequent presenting symptom or signs were acute respiratory distress, hypotension, and hypertension. Antibodies to human leukocyte antigens or granulocytes were identified in 61 percent of cases, with 50 percent associated with antibodies in a donor whose blood had been transfused to a patient developing TRALI. Clinical recovery occurred in 87 percent of patients, but TRALI contributed to deaths in 13 percent. Clinicians need to recognize and diagnose this syndrome in order to respond with appropriate interventions.

Long-term impact of recombinant human erythropoietin on transfusion support in patients with chronic renal failure.

Published reports on the impact of recombinant human erythropoietin (r-HuEpo) on transfusion requirements of patients with chronic renal failure have been limited to small populations and relatively brief follow-up. In this study we reviewed the effects of this drug on 86 patients with well-characterized transfusion requirements, followed for 18 months at seven dialysis centers. The median red blood cell transfusion requirements per patient per year decreased from 14 in 1987 and 1988 to 11 in 1989, when r-HuEpo was licensed in the United States (p <.01) and fell to 2 in 1990 (p <.01). The proportion of patients who became transfusion-independent increased from 34 percent in 1989 to 69 percent in 1990 (p <.001). These data demonstrate that r-HuEpo significantly decreases transfusion requirements of patients with chronic renal disease.

Transfusion-associated circulatory overload in orthopedic surgery patients: a multi-institutional study.

Although recognized as a serious complication of hemotherapy, few data are available on the incidence of transfusion-associated circulatory overload (TACO). Detailed demographic and clinical information was obtained from records of 382 Medicare patients undergoing total hip or knee replacements (and receiving transfusions) from January 1992 to December 1993 at five Massachusetts hospitals. Seventy-eight percent of the patients were women with a mean age of 77 years. Thirty-two percent had co-morbidities including myocardial or coronary disease. Transfusion-related complications and comorbidities were identified and reviewed by transfusion experts. Patients were excluded from consideration if non-transfusion factors such as myocardial disease could have contributed to the development of acute pulmonary edema. Four (3 females, 1 male) patients (1.05%) developed TACO postoperatively. Mean age of these patients was 84 years (range, 75-101) versus 77 years for non-TACO. The mean intraoperative estimated blood loss was 375 mL. Each patient received only 1-2 units of red blood cells prior to onset of TACO, and in two cases only autologous blood was used. The mean positive fluid balance was 2,480 mL. The mean pretransfusion hematocrit prior to circulatory overload (CO) was 26.0 percent. Symptoms were reversed with diuretics. Length of stay was significantly prolonged by these incidents. TACO is a frequent and serious event in an orthopedic surgical setting. It is associated with advanced age, increased health care costs, and may occur in the setting of modest transfusion volumes. The utilization of conservative transfusion criteria and fluid management in the perioperative setting may decrease the incidence of this complication in this population.

Anti-Uz found in mother's serum and child's eluate.

A saline-reactive antibody, anti-Uz, that reacted stronger with S+ than with S- red blood cells (RBCs) and failed to react with U- or ficin-treated RBCs has been previously reported. We describe an antibody of similar specificity in the postpartum serum of an untransfused woman and the eluate from her fourth child's cord RBCs. The mother's RBCs typed S-s+U+, He+(weak), and appeared to have normal glycophorin A and B content, as deter- mined by immunoblotting. The direct antiglobulin test (DAT) and the autocontrol were negative. Her serum reacted stronger with S + RBCs only in the antiglobulin phase, and failed to react with U- or ficin-treated RBCs. The antibody was adsorbed completely by S-s+U+ RBCs, proving that anti-S was not present. Monocyte monolayer assay results with S+s-U+ and S-s+U+ RBCs indicated that transfusion of incompatible blood would not result in significant hemolysis. The child's cord RBCs typed S-s+. The DAT was 3+ with anti-IgG, and an eluate prepared from these RBCs had the same reactivity as the maternal serum. The child showed no clinical signs of hemolytic disease of the newborn. In contrast to previous reports, these results suggest an immune form of anti-Uz.

Transfusion and lung injury.

The respiratory tree has been viewed as an infrequent site of injury arising as a complication of transfusion. In recent years, this view has changed as investigators have shown that two complications--circulatory overload and transfusion-related acute lung injury--are relatively frequent events. Circulatory overload is a result of hypertransfusion to individuals at risk, the very young or old recipient. The reaction is due to fluid infusion which overwhelms the capacity of the left ventricle, resulting in pulmonary edema. While rarely fatal, studies have shown that such incidents result in intensive care and extended hospitalization. In the setting of orthopedic surgery, 1% of elderly patients undergoing hip or knee surgery experience circulatory overload. These events are associated with autologous, as well as allogeneic red blood cells (RBC) and fresh frozen plasma. Transfusionists need to be vigilant with transfusion therapy in this population. Phlebotomy and supplemental oxygen are the key therapies. Transfusion-related acute lung injury (TRALI) is the adult respiratory distress syndrome due to transfusion. It is associated with a significant morbidity and mortality of 5-14%, making it the third most common cause of death from transfusion in developed countries. It is characterized by the onset of acute respiratory distress, bilateral pulmonary edema and hypoxemia. It occurs within 1-2 hours of transfusion of a plasma-containing blood product. All blood components have been associated with the reaction, and rarely, intravenous immune globulin. There is no recognized profile of individuals at increased risk for TRALI. There are two purported mechanisms of injury; the vast majority of cases are associated with passively transfused complement-activating antibodies. These antibodies are either HLA (Class I or II) or granulocyte-specific. These antibodies appear to act as mediators, which result in granulocyte aggregation, activation, and microvascular pulmonary injury. With appropriate respiratory intervention, 80% of patients recover within 96 hours of the original insult. There are no permanent pulmonary sequelae.

Red blood cell transfusion practices in patients undergoing orthopedic surgery: a multi-institutional analysis.

This retrospective review analyzed and compared transfusion practices in patients undergoing orthopedic surgery in five Massachusetts hospitals with current practice guidelines; opportunities for improvement were identified. Patient-specific clinical information and data about transfusion practices were obtained from the medical records of 384 Medicare patients undergoing orthopedic surgery between January 1992 and December 1993. The number of patients who donated autologous blood preoperatively differed significantly among hospitals as did the number of autologous units that were unused. The number of blood units transfused at each transfusion event also differed significantly; some surgeons transfused > or =2 units in the majority of their patients, while others transfused 1 unit at a time. This variation in practice was not explained by differences in patients' clinical status. The mean pretransfusion hematocrit was higher for autologous versus allogeneic blood, suggesting more liberal criteria to transfuse autologous blood. Nearly half of all transfusion events were determined to have been potentially avoidable. Avoidable transfusions were also three to seven times more likely with autologous than with allogeneic blood. Significant inter-hospital differences existed in the number of elective surgery patients exposed to allogeneic blood. The major determinant of allogeneic blood use in these patients was the availability of autologous blood. Each additional autologous blood unit available decreased the odds of allogeneic blood exposure twofold. Differences in intraoperative and postoperative blood salvage use also were noted. These findings indicate that significant variations in practice exist. Comparative data enabled hospitals to identify and target specific areas for improvement.