The Effect of blood Storage Time Before & After Transfusion

Ahmad Sh. SilmiStaff Specialist in Hemayology

Recruit Transfuse blood 

Screen Donor Pretransfusion Testing

Collect & Prepare Monitor & evaluate

Infections/disease tests Medical Decision to transfuse 

 

 

 

 

 

 

 

 

 

 

Blood Safety

Transfusion Safety

Transfusion Safety in the Hospital

Transfusion Sept 2003

Storage lesion

Storage lesion is an amalgamation of reversible and irreversible changes that begin after 2 to 3 weeks of storage

Problems with stored pRBC’s

1. Reduced ability of Hgb to release bound oxygen at tissue level (2,3 DPG)

2,3 DPG levels become undetectable after two weeks of

storage. Levels are restored within 72 hours after transfusion

Does red blood cell storage affect clinical outcome? When in doubt, do the experiment. Transfusion Vol 49 July 2009

“storage lesion”

Problems with stored pRBC’s

1. Reduced ability of Hgb to release bound oxygen at tissue level (2,3 DPG).

2. Reduced RBC deformability = potential to block capillary beds

“storage lesion”

RBC squeezing through a capillary bed

Problems with stored pRBC’s

1. Reduced ability of Hgb to release bound oxygen at tissue level (2,3 DPG)..

2. Reduced RBC deformability = potential to block capillary beds

3. Storage lesion (age dependent defect) = potential to block capillary beds

More Is Known About the Risks of Blood Transfusion Than the

Benefits!

Problems with stored pRBC’s

1. Reduced ability of Hgb to release bound oxygen at tissue level (2,3 DPG)

2. Reduced RBC deformability = potential to block capillary beds

3. Storage lesion (age dependent defect) = potential to block capillary beds

4. Activation of recipients immune system

Transfusions & Infection

Each unit of blood increases the risk of a nosocomial infection by up to 50%!

Transfusion increases the risk of postoperative infections after cardiovascular surgery J Am Coll Surg 2006 Jan;202

An alternative scoring system to predict risk for surgical site infection complicaating coronary artery bypass graft surgery Infect Control Hosp Epidemiol 2007 Oct;

Transfusion of red cells is associated with increased incidence of bacterial infection after colorectal surgery; a prospective study Transfusion Feb 2003

Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient Crit Care Med 2002 Vol 30 #10

Transfusion Practice and Blood Stream Infections in Critically Ill Patients Chest 2005:127

Blood transfusions correlate with infections in trauma patients in a dose-dependant manner Am Surg 2002:68

Storage Depletes RBC Nitric Oxide Bioactivity

Altered parameters in Stored RBC

BiochemicalMetabolic

Biomechanical Oxidative

SNO-Hb ↓RBC Storage Lesions Tatsuro Yoshida PhD Presentation to AABB

42-Day Post-storage pRBC Characteristics Vox Sang 1998;75:212-217

CharacteristicCharacteristicPre-storagePre-storagePost-storagePost-storage

pHpH6.86.86.46.4

ATP (μmol/g Hb)ATP (μmol/g Hb)4.14.12.92.9

DPG (μmol /g Hb)DPG (μmol /g Hb)9.09.00.30.3

Potassium (mEq/L)Potassium (mEq/L)2.42.46363

Glucose (mg/dl)Glucose (mg/dl)608608402402

Plasma Hb (mg/dl)Plasma Hb (mg/dl)3939372372

Hemolysis (%)Hemolysis (%) ----0.610.61

Byproducts of Stored RBC’s

1.Released heme and iron from ruptured cells

2.Shed microvesicles

3.Loss of lipid and protein products from damaged RBC’s

4.Activated RBC adhesins

Properties of stored red blood cells: understanding immune and vascular reactivity Spinella et.al Transfusion 2011

FDA Requirements

Membrane fragments (lipids) shed from almost all cell types. They have been

implicated in immune suppression .

Byproducts of Stored RBC’s

“All of these materials and activities are normal parts of the RBC life cycle, but they are concentrated in space and time by the RBC storage and transfusion process.”

Properties of stored red blood cells: understanding immune and vascular reactivity Spinella et.al Transfusion 2011

The effect of red-cell age on outcomes

• Inverse association between changes in gastric intramucosal pH and the age of transfused blood for patients who received red cells stored for more than 15 days

• evidence of splanchnic ischemia developed in patients given older blood

Marik PE,. Effect of stored blood transfusion on oxygen delivery in patients with sepsis. JAMA 1993

Blood Transfusion MorbidityStudy of 12,000 CAB patients at Cleveland Clinic

Post-Op ComplicationNon-Transfused patientsTransfused patients

New onset of renal failure requiring dialysis

0%1.81%

Post-op ventilator support > 72 hours

.44%9.14%

Serious post-op infection (includes sepsis and mediastinitis)

.24%5.03%

Cardiac Morbidity(Includes Low Cardiac Index (< 1.8), high dose inotropic support > 4 hrs, post-op MI with IABP or VAD)

.05%3.03%

Neurologic Morbidity.37%2.41%

Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting – Koch, et al. ,Critical Care Medicine 2006

Blood Transfusion MorbidityStudy of 12,000 CAB patients at Cleveland Clinic

Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting – Koch, et al. ,Critical Care Medicine 2006

“Transfusion is the single factor most reliably associated with increased

postoperative morbid events. Each unit of red cells transfused is associated with

incrementally increased risk for adverse outcome”.

So what do we do with all of

this?

FDA Requirements

1.Hemolysis must be no greater than 1% at the end of storage, and

2.RBC recovery rates must be greater than 75% one day after transfusion

Does the storage duration of blood products affect outcomes in critically ill patients Spinella et al, Transfusion August 2011

First proposed in 1942 and based onstudies that defined “peak” oxygen

delivery in animals

10/30 Rule*

*Keep Hgb at 10gm and Hct at 30%

10/30 Rule*

*Keep Hgb at 10gm and Hct at 30%

How low can we go?

How low can we go?

• In animal studies, ECG ST segment changes are observed once Hgb falls below 5 g/dL

• Both human and animal studies have demonstrated that Hgb’s < 3 g/dL are “maximally life-threatening.”

Time course and etiology of death in patients with severe anemia Transfusion Vol 49 July 2009

So what does this mean?

1.Understand that transfusions may lead to worse outcomes.

So what does this mean?

1.Understand that transfusions may lead to worse outcomes.

2. It is reasonable to infer that older stored blood may lead to worse outcomes!

So what does this mean?

1.Understand that transfusions may lead to worse outcomes.

2. It is reasonable to infer that older stored blood may lead to worse outcomes!

3. Washing older stored blood may reduce morbidity.