Long-term granulocyte transfusion in patients with malignant neoplasms.

Thirty-eight episodes of culture-documented antibiotic-resistant bacterial or fungal infection in patients with malignant neoplasms were treated with daily granulocyte transfusions until the infection improved or the patient died. Cumulative summation temperature plotting allowed easier interpretation of recipient fever response. Seventy-one percent of recipients had a favorable response to transfusion. There was no difference in mortality between patients treated with cells collected by filtration (FL) or intermittent flow centrifugation (IFCL) leukapheresis techniques. Transfusion reactions were more than twice as common with FL than IFCL collected cells. Seventy-four percent of recipients were alive 21 days after completion of transfusions; of the ten deaths, five could be classified as granulocyte transfusion failures. This study suggests that long-term granulocyte transfusion may be required in infected recipients when autologous granulocytes do not return after chemotherapy.

Transfusion-associated hepatitis and AIDS. What is the risk?

Infectious complications have been, and will continue to be, a problem in recipients of blood transfusions. Steps to exclude high-risk donors and to test for antibody to HIV, antibody to hepatitis B core antigen, and alanine aminotransferase almost surely have a beneficial effect on the blood supply. The risk of transfusion-transmitted infectious disease will never be nonexistent, and each transfusion will always have to be considered in terms of benefit versus risk. Patients and physicians need to understand that an absolutely safe blood supply is an unattainable goal, but that current approaches to donor selection and testing are highly effective in minimizing the risk of transfusion-transmitted infection.

Transfusion-transmitted diseases other than AIDS and hepatitis.

Although the major diseases transmitted by transfusion today are AIDS and hepatitis, many others also are known. These include CMV, syphilis, Chagas disease, babesiosis, parvovirus B19, malaria, Epstein-Barr infection, and many others that have been reported only once or twice. Reducing the risk of transfusion-transmitted diseases is a problem for donor centers where donor screening and laboratory testing for possible carriers is undertaken. Physicians should be aware that the potential for disease transmission is always present when transfusions are administered.

Testing in the years ahead: new pressures and new concerns.

In the past, testing by blood banks was intended primarily to ensure product quality or donor safety or to meet existing regulations. As a result of recent pressures, especially the AIDS epidemic, additional reasons to test have become evident. Although some of these reasons are not easy to accept, it is appropriate to review them and to evaluate a new approach to reaching blood bank decisions that have public policy implications. It is suggested that The Institute of Medicine of the National Academy of Sciences sponsor a new and permanent structure for this purpose.

Transfusion-associated fatalities: review of Bureau of Biologics reports 1976-1978.

Review of the 70 transfusion-associated fatalities reported to the Bureau of Biologics (BOB) between 1976 and 1978 revealed 44 acute hemolytic reactions, two delayed hemolytic reactions, five fatalities associated with acute respiratory failure, two cases of bacterial contamination, one graft-versus-host reaction (GVHR), ten cases of hepatitis, and six fatalities not associated with transfusion. Thirty-eight of 44 acute hemolytic reactions were due to ABO incompatibility. Clerical confusion was the cause of 33 of 37 cases in which error could be defined.

Chemical and hematological changes in stored CPD blood.

Blood was drawn from ten healthy volunteer donors into citrate-phosphate-dextrose (CPD) anticoagulant and placed on the quarantine shelf of the blood bank refrigerator. Plasma dextrose, sodium, potassium, chloride, bicarbonate, GOT, LDH, and hemoglobin as well as WBC, hematocrit, MCV, MCHC, whole blood pH, and ammonia were measured on all samples initially and at one, two, seven, 14, 21, and 28 days of storage at 4 C. Whole blood lactate also was analyzed serially on five of the units. An additional 27 units of CPD bank blood (two to 21 days of age), routinely processed, handled, and stored by the blood bank, were submitted to the same analyses on the day of administration to the patient. Five of these processed units, 21 days old, were resampled at 28 days. Results of the analyses are presented and discussed. The most pronounced changes were seen for dextrose, potassium, bicarbonate, lactate, LDH, ammonia, and hemoglobin. Plasma dextrose and bicarbonate declined in concentration while potassium, lactate, LDH, ammonia, and hemoglobin rose with storage. In general, changes in the regularly processed, singly sampled bank units were greater than those observed in the specially processed, quarantined units sampled serially. This study indicates that routine transportation, processing, and handling of bank blood may lead to increased biochemical alteration.

Un-cross-matched blood for emergency transfusion. One year's experience in a civilian setting.

One year's experience (56 cases) in the use of un-cross-matched blood for emergency transfusion in a large civilian teaching hospital showed that 49 transfusions were given as un-cross-matched, group-specific (ABO and Rh) blood in emergencies. Seventy-seven percent (43) of blood requests were for patients with trauma, unexpected massive intraoperative hemorrhage, or ruptured aneurysm. The indications for emergency transfusion were questionable in ten cases. There were no adverse effects noted even though complete serologic testing had not been done. While the use of un-cross-matched blood is usually safe, the potential for serious reaction exists. Overuse should be discouraged.

Unusual response to ABO incompatible blood transfusion.

Three units of group A blood were inadvertently administered to a group O recipient during surgery without evidence of hemoglobinemia, hemoglobinuria, hypotension, disseminated intravascular coagulation, acute renal tubular necrosis, or other signs and symptoms of transfusion reaction. The recipient had normal concentrations of IgG, IgA, and IgM as well as complement (C3) prior to transfusion and anti-A agglutinins titered to 64 (titer of 128 by the antiglobulin technic). Seventeen hours following the transfusion, 28 per cent of the circulating red blood cells were group A (equivalent to 475 ml of packed cells); they were eliminated by day 5 without evidence of hemoglobinuria, hemoglobinemia or hyperbilirubinemia. Anti-A titers (antiglobulin) had risen from a posttransfusion low of 4 to 4,096 by day 10. After treatment of serum with 2-mercaptoethanol, however, hemolytic activity which was first noted on day 5 was lost and the antiglobulin titer dropped to 24 which suggested that most of the anti-A produced in response to the transfusion was IgM rather than IgG. The anti-A titer had dropped to essentialyy pretransfusion levels and the majority of anti-A present was IgM by day 91. The recipient suffered no untoward effects from the transfusion and was in good health three months following the transfusion.

Plasmapheresis using the IBM 2991 blood cell processor.

The IBM 2991 Blood Cell Processor, normally used to wash or deglycerolize red blood cells, has been modified to permit serial plasmapheresis using a small roller pump, an adapter line and the disposable processing set usually used for cell washing. Blood is withdrawn from the donor, pumped into the plastic centrifuge bag and the plasma removed after centrifugation. Donor erythrocytes are pumped from the processing bag to a reservoir bag from which they are returned to the donor by gravity. Multi-unit plasmapheresis to harvest plasma for transfusion or to remove plasma as a therapeutic measure is possible using the modified system. A four-unit plasmapheresis can be done in 65 to 75 minutes at a cost of $27.61, including disposables and technologist labor. This modification allows the IBM 2991 to function for red blood cell washing and as an efficient instrument for plasmapheresis.

Chemical and hematologic changes in stored CPDA-1 blood.

Blood was drawn from ten healthy volunteer donors into citrate-phosphate-dextrose adenine (CPDA-1) anticoagulant and placed on the quarantine shelf of the blood bank refrigerator. Plasma glucose, sodium, potassium, chloride, bicarbonate, glutamic-oxaloacetic transaminase, lactate dehydrogenase (LDH) and hemoglobin as well as white cell count, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin concentration, whole blood pH, lactate and ammonia were measured on all samples initially and at one, seven, 14, 21, 28, and 35 days of storage at 4 degrees C. Whole blood lactate was analyzed serially on five of the units. The most pronounced changes were seen for glucose, potassium, bicarbonate, lactate, LDH, ammonia, and hemoglobin. Plasma glucose and bicarbonate declined in concentration while potassium, lactate, LDH, ammonia, and hemoglobin rose with storage. As expected, these changes differed little from those found with steroid blood collected in acid-citrate-dextrose or citrate-phosphate-dextrose.

A review of recent events related to surrogate testing of blood to prevent non-A, non-B posttransfusion hepatitis.

A workshop sponsored by the Food and Drug Administration was held recently during which available data were reviewed concerning surrogate testing of blood donated for transfusion in order to reduce the risks of posttransfusion non-A, non-B hepatitis. Clinical studies from which the efficacy of testing for alanine aminotransferase and antibody to hepatitis B core antigen (anti-HBc) could be predicted indicated such testing would be useful, although several studies using tests for anti-HBc developed recently questioned their effectiveness. Different approaches to establishing the cut-off values for the screening tests were presented and difficulties regarding test standardization were discussed. The legal, ethical, and medical implications for donors of surrogate screening programs in the United States also were considered. A meeting sponsored by the private sector that included representatives of the major blood banking organizations and was convened to discuss the workshop proceedings and nationwide screening of the blood supply also is summarized.

Effect of blood volume on sweating rate and body fluids in exercising humans.

Five relatively fit men performed cycle ergometer exercise (65-70% VO2max) for up to 30 min at 30 degrees C, 40% rh. The data from control (normo-volemic), hypovolemic [8.7% reduction in blood volume (BV) induced by diuretics], and hypervolemic [7.9% expansion of BV induced by infusion if isotonic serum albumin] tests revealed significant effects of BV on body fluid and sweating responses. During control exercise, BV decreased an average (+/- SE) 370 +/- 64 ml at 20 min. A significantly smaller loss occurred after 20 min of hypovolemic exercise (270 +/- 29 ml). The decrease in BV during 30 min of hypervolemic exercise (541 +/- 43 ml) was significantly greater than during control (421 +/- 50 ml). Blood volume reduction also significantly altered the control of sweating rate independent of changes in plasma osmolality. The slope of the sweating rate-to-esophageal temperature relationship (SR/Tes) was significantly reduced from the mean value of 1.07 +/- 0.16 and 1.09 +/- 0.18 mg X min-1 X cm-2 X degrees C-1 during control tests, measured from the chest and arm, respectively, to 0.64 +/- 0.11 and 0.63 +/- 0.11 mg X min-1 X cm-2 X degrees C-1 during hypovolemia. The SR/Tes slope was unchanged in hypovolemia over active tissues (calf). Hypervolemia had no effect on the control of sweating at any site. Both the body fluid and sweating responses during hypovolemia act to conserve circulating blood volume during exercise.

Effect of acute alterations of blood volume on circulatory performance in humans.

Six subjects exercised (60% VO2 max) in a 35 degree C environment on the day prior to (C1) and 1 h after withdrawal (PW) of 10% of each subject's blood volume, and 2 wk later on the day prior to (C2) and 1 h after infusion (PI) of the stored blood. Esophageal and mean skin temperatures (Tes and Tsk), forearm blood flow (FBF), cardiac output (Q), heart rate (HR), and blood samples were taken at intervals. Blood withdrawal had no major effect on either Q or stroke volume (SV), as plasma volume was largely restored prior to exercise. Following blood infusion Q and SV during exercise were significantly increased 1.4 1.min-1 and 15 ml.beat-1 above C2 levels and HR was significantly reduced at any Tes. Blood withdrawal decreased the slope of the FBF:Tes relationship. The resulting decrease in cutaneous perfusion caused a significantly greater body heat storage during PW. In contrast during PI, the slope of the FBF:Tes relation was somewhat increased. We conclude that cardiac stroke volume and cutaneous blood flow vary in proportion to changes in absolute blood volume. The rise in body temperature during exercise was significantly greater in hypovolemia but was not significantly reduced following volume expansion.

Effect of blood volume on forearm venous and cardiac stroke volume during exercise.

Five healthy men exercised at 65-70% of maximum O2 uptake (VO2 max) for 30 min in an ambient temperature of 30 degrees C. Duplicate experiments were conducted at three levels of plasma volume:control, hypovolemia, in which blood volume (BV) was reduced an average of 490 ml (9.7%) with diuretics, and hypervolemia, in which BV was increased an average of 440 ml (7.8%) by infusing an isotonic solution containing 5% human serum albumin. Marked venoconstriction occurred during exercise in all conditions and persisted despite large increases in deep body temperature. The degree of venoconstriction was similar during control and hypervolemic conditions, but was potentiated during hypovolemia. The observed venoconstriction appeared to consist of two components: an early one related to autonomic adjustments at the onset of exercise, and a later one possibly related to progressive decreases in cardiac filling. Heart rate, cardiac stroke volume (SV), and cardiac output during exercise were significantly affected by changes in BV. During hypovolemia the average differences from control values were 10 beats X min-1, -14 ml, and -2.2 l X min-1, respectively; during hypervolemia the differences from control were -7 X min-1, 10 ml, and 1.0 l X min-1, respectively. The pattern of SV over the course of exercise indicates that pooling of blood in veins may be quantitatively more important than plasma water loss in reducing cardiac filling pressure in the heat.