Refreezing previously thawed fresh-frozen plasma. Stability of coagulation factors V and VIII:C.

With the growth in autologous blood programs and the increased scrutiny of the indications for transfusion of fresh-frozen plasma (FFP), an increase has been seen in the number of occasions on which FFP was requested and thawed but then not transfused. The coagulation properties of FFP units that were refrozen and then rethawed were therefore studied. Fifty-eight units of plasma were studied, with each experimental unit of FFP paired with an identical control unit. Experimental units were frozen, stored at -65 degrees C, thawed, stored at 1 to 6 degrees C for various periods of time up to 24 hours, and then refrozen, stored at -65 degrees C, rethawed, and stored again in the refrigerator for up to 24 hours. Control units were frozen once at the time the experimental units were first frozen and thawed once at the time of the second thaw of the experimental units. Aliquots of plasma were sampled periodically and were later batch-tested for prothrombin time (PT), activated partial thromboplastin time (aPTT), and factor V and VIII:C activity. The results of coagulation testing of the twice-frozen plasmas were always within the normal range. There was a slight but statistically valid prolongation of the PT and aPTT and a decrease in the factor V and VIII:C levels for twice-frozen plasma compared with control plasma. The greatest decline occurred in the level of factor VIII:C. The measured deterioration in coagulation of twice-frozen FFP is unlikely to be of clinical importance. Refreezing FFP may eventually prove useful for rare donor, autologous, and massive transfusion programs.

Evaluation of the appropriateness of blood and blood product transfusion using preset criteria.

The use of 1930 units of blood or blood products during 765 transfusion episodes in 560 patients was reviewed. This represented one-half of all transfusions in a large medical center over a 2-month period. By clearly defined, present criteria, 42.3 percent of the episodes were found not to be appropriate. Whole blood and platelet transfusions were used more appropriately than those of red cells, cryoprecipitate, and fresh-frozen plasma. Blood transfusions were used more appropriately in the management of acute bleeding or anemia associated with cardiovascular problems. Three groups of patients were especially prone to inappropriate transfusions: those with end-stage renal disease or terminal cancer and cancer patients on chemotherapy. Age, sex, and specific hospital wards were not associated with inappropriate use. Most unjustified episodes occurred as a result of the overestimation of the immediate risk incurred by withholding transfusion.

Experimental allergic neuritis: effect of plasma infusions.

The effect of intravenous fresh frozen plasma (FFP) and artificial plasma infusions upon the clinical course of chronic experimental allergic neuritis (EAN) in the rabbit was investigated. A total of 12 animals allocated to treatment groups received rabbit FFP or a gelatin plasma expander Haemaccel (Hoechst) and were compared to 13 control non-treated animals. Animals receiving Haemaccel at a rate of 15 ml/kg/day for 7 days showed no significant clinical benefit at any stage. However, animals receiving 15 ml/kg/day FFP for 8 days showed significant clinical benefit during treatment initiated at the onset of definite neurological symptoms of EAN (Mann-Whitney U test, day 4 post-allocation P less than 0.05; day 6 post-allocation P less than 0.01; day 8 post-allocation P less than 0.05). Relapse was observed after cessation of treatment such that comparisons of clinical scores at day 14 and 22 post-allocation revealed no significant differences. Analysis of plasma anti-myelin IgG levels by ELISA showed that non-immunogenic plasma volume expansion decreased anti-myelin IgG concentrations immediately by an average of 34% but had no long-term effect. In contrast, anti-myelin IgG concentrations in FFP infused animals were significantly decreased, compared to controls, when measured 24 h after the last infusion (Student's t-test P less than 0.05). Identical percentage weight losses for both control and treatment groups post-allocation indicated that this decrease was immunologically mediated and not due to plasma dilution. Similar plasma cortisol concentrations measured in both groups showed no significant artifactual induction of endogenous steroid production. Infusions of FFP during early disease progression are able to mediate clinical remission in animals with chronic EAN.

Algorithms for evaluating the appropriateness of blood transfusion.

Medicare regulations and the guidelines of the Joint Commission on Accreditation of Healthcare Organizations require assessment of the appropriateness of transfusions by a hospital committee. A set of criteria maps for component transfusion review by nurses or technical personnel was designed, tested, and modified. The algorithms were based on written guidelines developed by a group of physicians. In the first part of the study, 196 medical records of patients from medical and surgical diagnosis-related groups with the highest utilization of blood (Group I) were screened. Forty patients were excluded because of a preexisting transfusion protocol. Of the remaining 156 patients, 146 (94%) received red cell transfusions, of which 96 percent were indicated, 1 percent not indicated, and 3 percent controversial. Thirty-five patients (22%) received fresh-frozen plasma transfusions, of which 69 percent were indicated, 11 percent not indicated, 17 percent controversial, and 6 percent indeterminate. In the second part of the study, medical records were screened from 99 randomly selected patients who had received red cell transfusions (Group II), and the results were similar to those in Group I. Physician review was necessary in 20 percent of the transfused patients screened with the criteria maps. It is concluded that algorithms for transfusion review can be developed and used easily to fulfill regulatory and accreditation requirements and to plan focused educational programs.

Changing patterns of blood transfusions in four sets of United States hospitals, 1980 to 1985.

Annual transfusion activity between 1980 and 1985 was surveyed in four sets of United States (US) hospitals, which together accounted for 4.8 percent of the red cell (RBC) transfusions in the US in 1980. Total RBC transfusion rates (total RBCs transfused/1000 hospital admissions) increased between 1980 and 1982 but remained nearly constant between 1982 and 1985. Plasma transfusion dynamics followed a similar pattern, whereas the preoperative deposit of autologous blood by patients accelerated rapidly after 1982. These changes appear to reflect responses to the acquired immune deficiency syndrome epidemic. In contrast, total platelet transfusion rates grew by 76 percent during the 6-year period, approaching total RBC rates by 1985. This is the first reported evidence in such a large sample of transfusions that total RBC transfusion rates have moderated.

Thawing of fresh-frozen plasma with a new microwave oven.

In the Federal Republic of Germany fresh-frozen plasma (FFP) is still the most important therapeutic agent for acquired coagulation disorders. However, thawing by waterbath (WB) requires about 30 minutes, which is too slow in emergency situations and carries the risk of bacterial contamination of the FFP. There are conflicting data about the use of microwaves for thawing. Therefore, we examined a new microwave oven (MWO; 2450 +/- 50 MHz), which was developed with our cooperation and allows thawing of FFP in 5 minutes, heating FFP to a surface temperature of 21.5 degrees C. A shaking WB (30 min, 37 degrees C) was also used in parallel for comparison. We measured activated partial thromboplastin time (aPTT), nonactivated PTT (NaPTT), fibrinogen, factors VIII:C, X, and XI, fibrinopeptide A, beta-thromboglobulin (beta-TG), thrombin-AT III-complexes, factor VIII-related antigen, C3c, C4, and the plasticizer di(2-ethylhexyl)phthalate (DEHP) in 84 units of FFP as paired samples from 42 double aphereses. Immediately after thawing there was no significant difference in the coagulation test results of FFP with low-cell contamination, regardless of the thawing procedure. Two hours later, after storage at room temperature, FFP thawed by MWO showed even less change than that thawed by WB (NaPTT, p less than 0.01; FX, p less than 0.01). The differences became more evident in comparison with FFP with higher cell contamination and could be observed immediately after thawing (FVIII:C p less than 0.001; FXI, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Inflammation after blood injection into a synovial-like space is a result of the cellular component rather than the plasma.

The rat subcutaneous air pouch, a model for a synovial-like space, has been used to study the effect of blood as an inducer of inflammation. Six-day-old pouches were injected with autologous whole blood, with plasma or with blood cell pellets. We found significantly more inflammation and proliferation of pouch lining in pouches injected with whole blood or with the blood cell pellets than with the plasma. After the injection of blood or the cell component, large numbers of hemoglobin crystals and lipid droplets were found in the pouch fluid and were associated with erosions of the pouch membrane.

Blood component use in orthotopic liver transplantation.

Blood component use during orthotopic liver transplantation (OLT) was evaluated after an initial 23-month experience with 37 consecutive transplant procedures. Blood component support of OLTs in 24 adult and 13 pediatric patients was reviewed. Adult procedures required intraoperatively a mean of 24.5 units of red cells (RBCs), 38.7 units of fresh-frozen plasma (FFP), 26.1 random-donor platelets (RDP), and 12.2 units of cryoprecipitate (Cryo); pediatric procedures required 4.8 units of RBCs, 5.8 of FFP, 3.9 of RDP, and 1.2 of Cryo. RBC salvage constituted 17 percent of the RBCs transfused intraoperatively. Intraoperative support in adult and pediatric OLT patients accounted for the majority of the total components required for the entire hospital stay. OLT blood component use constituted 1.3, 7.0, 3.6, and 8.1 percent of hospital-wide use of RBC, FFP, RDP, and Cryo, respectively, during the period of the study.

Seroconversion to human immunodeficiency virus (HIV) in hemophiliacs. Relation to lymphadenopathy.

The authors studied the natural history of human immunodeficiency virus (HIV) exposure in 187 hemophiliacs followed for an average of 45 months. Overall, 55 percent developed antibody specific for HIV and 21 percent developed persistent generalized lymphadenopathy. Most patients seroconverted sometime between early 1982 and the end of 1984. Four patients developed acquired immune deficiency syndrome (AIDS) and four seropositive patients developed idiopathic thrombocytopenia (ITP). One of the four patients who developed AIDS and three of the four with ITP had preexisting lymphadenopathy. None of the 10 patients with lymphadenopathy or the 20 asymptomatic patients was seropositive for human T-lymphotropic virus, type I. Although seropositivity and lymphadenopathy have been found in many of the authors' patients, few have developed clinical disease that can be related to HIV infection.

Quality assessment of transfusion practice in elective surgery.

A program of quality assurance (QA) was adopted to improve blood transfusion practice in elective surgery at a large urban hospital. For this purpose, a cooperative multidisciplinary group was formed, key indicators were identified, and an organization was set up. Data collected by this organization in the 1-year period needed for implementation of the program indicated that blood misuse was common practice. In fact, overrequest, overtransfusion, excessive reconstitution of whole blood (i.e., concurrent transfusion of red cells and fresh-frozen plasma), and underuse of predeposit were found in all ten surgical departments of the hospital. In a pilot study, data were collected from one surgical department during and after the implementation phase of the QA program; comparison of these data showed a postimplementation reduction of about two thirds in overtransfusion, whereas overrequest, reconstitution of whole blood, and predeposit rates remained unchanged. These results prompted continuation of the program in order to reach a definitive evaluation of its effectiveness.

Blood use in liver transplantation.

During the first 5 years (1981-1985) of the liver transplantation program in Pittsburgh, a total (preoperative, intraoperative, and postoperative) of 18,668 packed red cell units, 23,627 fresh-frozen plasma units, 20,590 platelet units, and 4241 cryoprecipitate units was transfused for the procedures. This represents 3 to 9 percent of the total of blood products supplied by the Central Blood Bank to its 32 member hospitals. Six hundred thirty-six (636) transplants were performed on 485 patients in two hospitals: the Presbyterian University Hospital (564 beds) and Children's Hospital of Pittsburgh (236 beds). All of the blood components used in the operations were procured and released by the Central Blood Bank. This report describes some of these findings.

Reduction of fresh-frozen plasma use through a daily survey and education program.

In an attempt to reverse a tendency toward the inordinate use of fresh-frozen plasma (FFP), the Transfusion Committee in a large tertiary care hospital distributed guidelines based on those derived at a Consensus Development Conference at the National Institutes of Health in 1984. In addition, the use of FFP was surveyed daily and supplemented by a one-on-one educational program for the attending and house staffs. In 2 years, these steps resulted in a 77 percent decrease in the number of units of FFP transfused.

Plasma exchange in severe erythema nodosum leprosum.

Four patients with severe erythema nodosum leprosum were treated by plasma exchange and/or fresh frozen plasma infusions after failure of classical therapy. After the procedures, the patients improved rapidly; with a follow-up between 4 and 7 years after the last plasma exchange, no clinical relapse was noted. The replacement fluids were variable; the most beneficial procedure seemed to be plasma exchange replaced with fresh frozen plasma. Elimination of circulating immune complexes, replacement of a lacking plasma factor are possible mechanisms of action. Plasma exchange may also work like a regulator of immune mechanisms, since it has been shown that there is a depression of suppressor cells in erythema nodosum leprosum.

Why is fresh-frozen plasma transfused?

A three-part study to determine the reasons for fresh-frozen plasma (FFP) transfusions at hospitals in southeastern Wisconsin was conducted. During a 1-month period, hospital transfusion services reported that patients undergoing open-heart surgery received 42 percent, medical patients 26 percent, noncardiac surgery patients 23 percent, neonatal patients 1 percent, and other patients 7 percent of the FFP transfused. In the second phase of the study, the records of 102 patients receiving FFP during a 1-month period at two teaching hospitals were reviewed. Justification for the FFP transfusion was provided in the hospital chart for only 11 percent of the transfusion episodes, although abnormal results of coagulation studies or signs of hypovolemia were recorded for an additional 51 percent. Frequently, FFP and red cell (RBC) transfusions were given during the same transfusion episode. In the third phase of the study, clinicians completed a questionnaire specifying their "trigger" for prescribing FFP: bleeding (43% of episodes), abnormal coagulation studies (26%), signs/symptoms of hypovolemia (16%), and "other" (15%). They judged that the FFP transfusion was effective in 47 percent of transfusion episodes and ineffective in only 6 percent. These findings indicate that FFP is used mainly as a source of coagulation factor replacement in hospitals served by The Blood Center of Southeastern Wisconsin, that justification for FFP use rarely is provided in patient records, that both FFP and RBCs are frequently transfused together, and that clinicians believe FFP is beneficial for their patients. Educational efforts addressing appropriate use of FFP should be initiated.

Contribution of circulating formed elements to prostanoid production in complement-mediated lung injury in sheep.

Incubation of plasma with zymosan results in complement activation. Infusion of this "zymosan-activated plasma" (ZAP) into the superior vena cava in sheep results in pulmonary leukostasis, pulmonary hypertension with generation of thromboxane (TXB), and hypoxemia. To examine the contribution of circulating formed elements to TXB generated when ZAP is infused, we studied four pairs of sheep in a cross-circulation model. Acetylsalicylic acid (ASA) irreversibly acetylates cyclooxygenase and blocks TXB production. Four hours after an intravenous dose of ASA (10 mg/kg), no circulating ASA was detectable by high-pressure liquid chromatography. Infusion of ZAP in ASA-treated animals resulted in no pulmonary hypertension and no rise in serum TXB levels. Treated animals were then cross-circulated with untreated sheep through cannulas that attached a carotid artery of each animal to a jugular vein of the other, creating simultaneous arteriovenous fistulas between the animals. A roller pump maintained cross-circulation flow at 450 ml/min for 15 minutes. This resulted in greater than 80% mixing of the circulating blood volumes of each pair of animals, verified by measurement of an intravascular marker. After cross-circulation the ASA-treated animals were still unable to generate TXB in response to ZAP infusion. Untreated animals had a typical response when infused with ZAP after cross-circulation, with elaboration of large amounts of TXB. Since the treated animals with circulating, nonaspirinated formed elements showed no response and the untreated animals with similar blood composition had a normal response, we conclude that circulating formed elements do not contribute significantly to the TXB recovered from sheep infused with activated complement components.