14 Jan 09

Acute lung injury after ruptured abdominal aortic aneurysm repair: The effect of excluding donations from females from the production of fresh frozen plasma

Posted in ALI/ARDS, Transfusion medicine at 0:40 by Laci

By S Wright, C Snowden, S Athey, AA Leaver, J-M Clarkson et al

Crit Care Med 2008:36;1796-1802

Transfusion-related acute lung injury may contribute to the development of acute lung injury in the critically ill, due to plasma from female donors containing antileukocyte antibodies. In July 2003, the U.K. National Blood Service stopped using female donor plasma for the production of fresh frozen plasma. Patients undergoing repair of a ruptured abdominal aortic aneurysm receive large amounts of fresh frozen plasma and often develop acute lung injury. We investigated whether the change to male fresh frozen plasma was associated with a change in the frequency of acute lung injury in these patients.

Design
A retrospective, before and after, observational, single-center study.

Setting
Tertiary care center and a regional blood center.

Patients
The study included 211 patients undergoing open repair of a ruptured abdominal aortic aneurysm between 1998 and 2006.

Interventions
None.

Measurements and main results
Primary outcome was the development of acute lung injury in the first 6 hrs after surgery. Secondary outcomes were significant hypoxia (Pao2/Fio2 ratio <300), time to extubation, and survival at 30 days. Groups were well matched and received similar volumes of intravenous fluids and blood components. There was significantly less acute lung injury following the change to male fresh frozen plasma (36% before vs. 21% after, p = .04). At 6 hrs after surgery, fewer patients were hypoxic (87% before vs. 62% after, p < .01). In multivariate analysis, the change in donor policy was associated with a decreased risk of developing acute lung injury (odds ratio 0.39; 95% confidence interval, 0.16ñ0.90). Time to extubation and survival at 30 days were not statistically different between groups.

Conclusions
The policy to exclude female donors from the production of fresh frozen plasma was associated with a decrease in the frequency of acute lung injury in patients undergoing repair of a ruptured abdominal aortic aneurysm.

05 Dec 08

Blood transfusion promotes cancer progression: A critical role for aged erythrocytes

Posted in Transfusion medicine at 20:11 by Laci

By S Atzil, M Arad, A Glasner, N Abiri, R Avraham, K Greenfeld, E Rosenne, B Beilin, S Ben-Eliyahu

Anesthesiology 2008;109:989-997

In cancer patients, allogeneic blood transfusion is associated with poorer prognosis, but the independent effect of the transfusion is controversial. Moreover, mediating mechanisms underlying the alleged cancer-promoting effects of blood transfusion are unknown, including the involvement of donors’ leukocytes, erythrocytes, and soluble factors.

Method
Two syngeneic tumor models were used in Fischer 344 rats, the MADB106 mammary adenocarcinoma and the CRNK-16 leukemia. Outcomes included host ability to clear circulating cancer cells, and host survival rates. The independent impact of blood transfusion was assessed, and potential deleterious characteristics of the transfusion were studied, including blood storage duration; the role of erythrocytes, leukocyte, and soluble factors; and the kinetics of the effects.

Results

Blood transfusion was found to be an independent and significant risk factor for cancer progression in both models, causing up to a fourfold increase in lung tumor retention and doubling mortality rates. Blood storage time was the critical determinant of these deleterious effects, regardless of whether the transfused blood was allogeneic or autogenic. Surprisingly, aged erythrocytes (9 days and older), rather than leukocytes or soluble factors, mediated the effects, which occurred in both operated and nonoperated animals. The effects of erythrocytes transfusion in the MADB106 model emerged immediately and dissipated within 24 h.

Conclusions
In rats, transfusion of fresh blood is less harmful than transfusion of stored blood in the context of progressing malignancies. Further studies should address mediating mechanisms through which erythrocytes’ storage duration can impact the rate of complications while treating malignant diseases and potentially other pathologies.

10 Oct 08

Early achievement of a 1:1 ratio of FFP:PRBC reduces mortality in patients receiving massive transfusion

Posted in Transfusion medicine, Trauma at 18:13 by Laci

By E A Gonzalez, J jastrow, J B Holcomb, L S Kao, F A Moore, R A Kozar

J Trauma 2008;64:247

We previously demonstrated that uncorrected coagulopathy in patients receiving massive transfusion was associated with increased mortality. Based on these findings we implemented early goal directed therapy beginning at the time of injury to approach an optimal plasma:PRBC ratio of 1:1. The aim of the current study was to evaluate mortality after implementation of this practice.

The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital

Posted in Transfusion medicine, Trauma at 18:13 by Laci

By M A Borgman, P C Spinella, J G Perkins, K W Grathwohl, T Repine, A C Beekley, J Sebesta, D Jenkins et al

J Trauma 2007;63:805-813

Patients with severe traumatic injuries often present with coagulopathy and require massive transfusion. The risk of death from hemorrhagic shock increases in this population. To treat the coagulopathy of trauma, some have suggested early, aggressive correction using a 1:1 ratio of plasma to red blood cell (RBC) units.

Methods
We performed a retrospective chart review of 246 patients at a US Army combat support hospital, each of who received a massive transfusion (>=10 units of RBCs in 24 hours). Three groups of patients were constructed according to the plasma to RBC ratio transfused during massive transfusion. Mortality rates and the cause of death were compared among groups.

Results
For the low ratio group the plasma to RBC median ratio was 1:8 (interquartile range, 0:12–1:5), for the medium ratio group, 1:2.5 (interquartile range, 1:3.0–1:2.3), and for the high ratio group, 1:1.4 (interquartile range, 1:1.7–1:1.2) (p < 0.001). Median Injury Severity Score (ISS) was 18 for all groups (interquartile range, 14–25). For low, medium, and high plasma to RBC ratios, overall mortality rates were 65%, 34%, and 19%, (p < 0.001); and hemorrhage mortality rates were 92.5%, 78%, and 37%, respectively, (p < 0.001). Upon logistic regression, plasma to RBC ratio was independently associated with survival (odds ratio 8.6, 95% confidence interval 2.1–35.2).

Conclusions
In patients with combat-related trauma requiring massive transfusion, a high 1:1.4 plasma to RBC ratio is independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage. For practical purposes, massive transfusion protocols should utilize a 1:1 ratio of plasma to RBCs for all patients who are hypocoagulable with traumatic injuries.

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