Transfusion Alternatives in Transfusion Medicine

Publications in this journal

• Article: Can we reduce routine blood ordering in spinal surgery?

  PhD VASILEIOS KOURITAS MD, FRCA STEVE GRAHAM MD, MRCS GAUTAM MARWAH MD, SOTIRIS L. PAPASTEFANOU MD, BcOrth, Dmed
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  ABSTRACT: Spinal reconstruction can be associated with major blood loss; because of the non existence of ordering guidelines, blood products are ordered preoperatively in excessive quantities. The aim of our study was to investigate the efficiency of our ordering routine.The records of 205 spinal surgery patients, over a period of 3 years were reviewed. The crossmatched to transfused (C-T) ratio was calculated for each pathology group and the safe number of units transfused was determined.A total of 929 units were crossmatched, whereas 84 patients required transfusion. In all, 404 units were not used (C-T ratio = 1.8). The greatest number of unused but cross matched units was observed in painful back surgery (C-T ratio = 3.9, P < 0.01 vs. other pathologies). For all the other pathology groups (scoliosis, tumor and fracture) fewer units can be ordered, except in neuromuscular scoliosis group (6 units used on average for each case). For spinal fusion, artificial disc replacement or simple discectomy, a group and save routine is adequate.In conclusion, less blood can be ordered for spinal surgery, except for cases of neuromuscular scoliosis. The blood units crossmatched for painful back surgery, were more than actually needed. With technological advancement historical blood crossmatching policies may need re-evaluation.
  Transfusion Alternatives in Transfusion Medicine 03/2011; 11(4):138 - 142.
• Article: Hyperoxia in the treatment of traumatic brain injury and stroke

  CHRISTOS M. TOLIAS
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  ABSTRACT: Traumatic brain injury and acute ischemic stroke are major causes of mortality and morbidity throughout the world. Treatment in both conditions remains partially successful. In recent years, hyperoxia (increased inspired oxygen concentration), both hyperbaric and normobaric, has shown significant promise as treatment modality in these conditions. We review the recent relevant evidence from human trials and discuss the mechanisms involved in the pathophysiology.
  Transfusion Alternatives in Transfusion Medicine 02/2011; 11(4):148 - 155.
• Article: Therapeutic effects of hyperoxic ventilation during shock

  HAIM BITTERMAN
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  ABSTRACT: Decreased availability of oxygen to metabolizing cells is a major feature of circulatory shock that leads to tissue damage and multiple organ dysfunctions. A wish to alleviate tissue hypoxia underlies the common clinical use of hyperoxic ventilation in shock. Yet, this straightforward approach is met by skepticism that is based on the potential pro-inflammatory effects of hyperoxia and the acknowledged roles of reactive oxygen species and oxidative stress in tissue injury. A steadily growing body of experimental data indicates that hyperoxia exerts an extensive profile of physiologic and pharmacologic effects that improve tissue oxygenation, exert anti-inflammatory and antibacterial effects, augment tissue repair mechanisms, and may also decrease oxidative stress during shock. The currently available preclinical information on the benefits of early use of safe regimens of hyperoxic ventilation alone or in combination with other commonly employed modalities sets the stage for renewal of careful clinical evaluation of oxygen therapy in resuscitation of circulatory shock.
  Transfusion Alternatives in Transfusion Medicine 11/2010; 11(4):156 - 163.
• Article: Effects of administration of iron isomaltoside 1000 in patients with chronic heart failure. A pilot study

  PER R. HILDEBRANDT MD, NIELS E. BRUUN MD, OLAV W. NIELSEN MD, EMIL PANTEV MD, FARZAD SHIVA MD, LARS VIDEBÆK MD, GERHARD WIKSTRÖM MD, LARS L. THOMSEN MD
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  ABSTRACT: Intravenous iron preparations have shown benefit in patients with chronic heart failure (CHF) and iron deficiency. Iron isomaltoside 1000 (Monofer) is a novel intravenous iron compound with low immunological activity of the isomaltoside and low free-iron-related toxicity. The primary objective of this open-label, non-comparative, multicenter pilot study was to test the safety of iron isomaltoside 1000 in patients with CHF and anemia. In addition, its effect on markers of iron deficiency, anemia and on quality of life was assessed. Twenty patients with CHF and iron deficiency anemia attended six visits during the 8-week study period. Iron isomaltoside 1000 was infused at baseline (mean dose 868 mg, range 650–1000 mg). No treatment-related adverse reactions, no acute anaphylactic or delayed allergic reactions and no clinically significant changes in routine clinical laboratory safety tests or vital signs were observed. Markers of iron deficiency, anemia and quality of life improved from baseline with increase in mean value of 49% at 4 weeks in overall quality of life. Iron isomaltoside 1000 administered as a fast single infusion without a test dose to patients with CHF improved quality-of-life assessments and was well tolerated in this pilot safety study.
  Transfusion Alternatives in Transfusion Medicine 11/2010; 11(4):131 - 137.
• Article: The effects of hyperoxic ventilation in the treatment of myocardial infarction

  C. RICHARD CONTI
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  ABSTRACT: Everyone supports the use of oxygen therapy to treat hypoxia secondary to acute myocardial infarction. However, the literature is confusing on the subject of supplemental oxygenation of patients with normal oxygen saturation and uncomplicated acute myocardial infarction, despite the fact that controlled randomized human studies have failed to support the need for supplemental oxygen in the uncomplicated patient. Both normobaric and hyperbaric oxygen must be recognized as a vasoactive substance and thus be considered a drug to which the patient may have an adverse response, particularly in patients whose oxygen saturation is 95% or greater, for example, coronary vasoconstriction.The level of evidence for the use of normobaric oxygenation in uncomplicated acute myocardial infarction patients who were not hypoxemic is based on expert opinion, case studies and ‘standard of care’. Hyperbaric oxygen therapy has not been shown to be beneficial in human studies.Most studies of the use of supplemental oxygen in humans with acute myocardial infarction were performed prior to modern aggressive medical therapy and current thrombolytic or percutaneous coronary intervention therapy. Perhaps a randomized clinical trial in patients with normal oxygen saturations and modern therapy will shed some light on the subject.
  Transfusion Alternatives in Transfusion Medicine 11/2010; 11(4):143 - 147.
• Article: Hemodynamic parameters to guide fluid therapy

  PAUL E. MARIK
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  ABSTRACT: The clinical determination of the intravascular volume can be extremely difficult in critically ill and injured patients as well as those undergoing major surgery. This is problematic as fluid loading is considered the first step in the resuscitation of hemodynamically unstable patients. Yet, multiple studies have demonstrated that only about 50% of hemodynamically unstable patients in the ICU and operating room respond to a fluid challenge. Cardiac filling pressures including the central venous pressure and pulmonary artery occlusion pressure have traditionally been used to guide fluid management. However, studies performed over the last 30 years have demonstrated that cardiac filling pressures are unable to predict fluid responsiveness. Over the last decade a number of studies have been reported that have used heart–lung interactions during mechanical ventilation to assess fluid responsiveness. Specifically, the pulse pressure variation derived from analysis of the arterial waveform, the stroke volume variation derived from pulse contour analysis and the variation of the amplitude of the pulse oximeter plethysmographic waveform have been shown to be highly predictive of fluid responsiveness. While the left ventricular end-diastolic area as determined by transesophageal echocardiography is a more accurate measure of preload than either the central venous pressure or pulmonary artery occlusion pressure, it does not predict fluid responsiveness as well as the dynamic indices. This paper reviews the evolution and accuracy of methods for assessing fluid responsiveness in patients in the ICU and operating room.
  Transfusion Alternatives in Transfusion Medicine 11/2010; 11(3):102 - 112.
• Article: Hyperchloremic acidosis during plasma expansion

  BENOÎT TAVERNIER, SÉBASTIEN FAIVRE, CAROLINE BOURDON
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  ABSTRACT: Many crystalloid and colloid plasma expanders can induce ‘hyperchloremic’ metabolic acidosis. This finding, first reported over 50 years ago, has received renewed interest following the recent availability of ‘balanced’ solutions. Several questions must be addressed and answered before making recommendations with regard to the use of these solutions. Do acidosis and hyperchloremia always go hand in hand? What is the clinical impact of hyperchloremic acidosis? Are all ‘balanced’ plasma expanders equivalent? Should isotonic saline-based plasma expanders be abandoned? Several elements of reflection are summarized in this brief review. On the basis on the currently available literature, it is not objectively possible to propose clear-cut guidelines.
  Transfusion Alternatives in Transfusion Medicine 09/2010; 11:3 - 9.
• Article: Perioperative optimization of oxygen delivery

  BENJAMIN CONTE md, JOËL L'HERMITE md, phd JACQUES RIPART md, JEAN-YVES LEFRANT md
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  ABSTRACT: The concept of perioperative hemodynamic optimization was developed by Shoemaker in the early 1980s. The controversy concerning optimization of oxygen delivery persists as recent studies show that the timing of this optimization appears to be an essential factor. At the initial stage of aggression (operative period, initial phase of septic shock), optimization of volume replacement decreases morbidity and mortality, while at a later period excess volume replacement can be harmful for the patient. The aim of this article is to review the physiological methods and indications for optimization of oxygen delivery.
  Transfusion Alternatives in Transfusion Medicine 09/2010; 11(s3):22 - 29.
• Article: Metabolic effects of plasma expanders

  LAURENT MULLER, JEAN‐YVES LEFRANT
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  ABSTRACT: All plasma expanders exert metabolic effects – either favorable effects such as correction of hypovolemia-induced lactic acidosis or renal failure, or unwanted adverse effects such as hypotonic solution-induced hyponatremia, acid-base disorders such as hyperchloremic acidosis and effects related to buffers associated with plasma expanders (lactate, acetate). The use of crystalloids alone is associated with a risk of interstitial fluid overload responsible for organ dysfunction in anesthesia and intensive care. The exclusive and prolonged use of high doses of colloids is associated with a risk of severe renal failure. Crystalloids appear to be sufficient to correct tissue hypoperfusion induced by moderate hypovolemia. Alternating prescription of isotonic saline and balanced plasma expanders should be able to avoid the metabolic complications of these two types of crystalloids. Administration of colloids is safe when the recommended maximum doses are observed. When administration of a colloid is indicated, a latest generation hydroxyethyl starch solution appears to present the best benefit/risk ratio.
  Transfusion Alternatives in Transfusion Medicine 09/2010; 11(s3):10 - 21.
• Article: Tissue oxygenation parameters to guide fluid therapy

  phd BENOIT VALLET md, EMMANUEL FUTIER md, phd EMMANUEL ROBIN md
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  ABSTRACT: Because tissue hypoxia is a key trigger for organ dysfunction, adequacy of oxygen delivery (DO2) to tissue oxygen metabolic demand is essential during the perioperative period. Optimization of DO2, using either or both fluid loading and inotropic support, to prevent tissue hypoxia in relation to increased oxygen consumption (VO2), could improve outcome. In this context, the use of central venous oxygen saturation (ScvO2), which reflects important changes in the DO2/VO2 relationship and of central venous-to-arterial carbon dioxide difference [P(cv-a)CO2], to address adequacy of oxygen utilization, has shown promising results. The threshold value for ScvO2 at which the risk of impaired tissue oxygenation can be discarded might remain out of reach and the complementary use of P(cv-a)CO2 would provide help to adjust the right DO2 to both VO2 and CO2 production. When applying this dual view, and increasing cardiac output to lower P(cv-a)CO2 below 6 mmHg, the adapted ScvO2 is closer to 73% or 75%.
  Transfusion Alternatives in Transfusion Medicine 08/2010; 11(3):113 - 117.
• Article: Granulocyte mobilization, collection and transfusion – where do we stand?

  RAINER MOOG
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  ABSTRACT: Bacterial and fungal infections are the main cause of morbidity and mortality in neutropenic patients. The transfusion of granulocytes to restore host defenses in severely neutropenic patients has been studied for a long time. However, inadequate dosage of granulocytes and inconsistent efficacy has limited the usage of these transfusions in the past. Recently, the use of mobilizing agents such as granulocyte colony-stimulating factor has renewed interest in these treatment modalities. Some studies have shown a benefit in neutropenic patients transfused with high doses of granulocyte concentrates. A number of tests of granulocyte function can be performed in vitro to assess the quality of granulocyte concentrates, which may be useful to optimize granulocyte collection and storage. Such studies that have examined granulocyte function in concentrates focused on the assessment of viability, chemotaxis, phagocytosis and oxidative burst and showed that granulocyte colony-stimulating factor-mobilized granulocytes can be stored prior to transfusion. Evidence-based benefit of granulocyte transfusion is still lacking and randomized controlled studies are necessary to prove the efficacy of granulocyte transfusion in the era of improved antibacterial and antifungal agents.
  Transfusion Alternatives in Transfusion Medicine 05/2010; 11(2):65 - 71.
• Article: Challenges of meeting the future blood transfusion requirement in England and Wales. Autologous blood transfusion could become an adjunct to the UK blood transfusion program in the future

  ERHABOR OSARO, CHIMA NJEMANZE
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  ABSTRACT: As a resource, allogeneic blood has never been more in demand than it is today. Escalating elective surgery, an aging population, periodic shortages arising from a fall in supply, old and emerging threat of transfusion-transmissible infections and spiraling costs because of various safety introductions have all conspired to ensure that allogeneic blood remains very much a vital but limited asset to the National Health Service. However, there are increasing demands for alternatives/complementary strategies to allogeneic blood transfusion. Autologous transfusion, predeposit autologous donation, acute normovolemic hemodilution and perioperative cell salvage is reliable, cost-effective, safe, does not involve type and screen, not associated with isoimmunization to foreign proteins, is indicated in patients with rare blood groups or complex red cell antibodies, comes handy for some religious sect like the Jehovah's Witnesses as well as being suitable in a significant number of patients undergoing elective surgeries. Autologous transfusion improves postoperative microcirculation, tissue perfusion and reduces the risk of thromboembolism. Benchmarking transfusion activity, ensuring that it is clinically indicated and justified, will help eliminate inappropriate use of blood products and help conserve our allogeneic blood stock. Erythropoietin (EPO) has drastically and significantly altered red cell transfusion practices. There might be many patients groups who would benefit from the use of EPO analogues and thus help conserve the allogeneic blood stock for patients in whom EPO is contraindicated. There is need to formulate policies on ways to seriously and innovatively attract and retain new donors. The National Blood Service and indeed the Department for Health can do well by promoting the use of autologous blood and other alternatives therapies to complement the UK allogeneic blood transfusion program in a bid to solving the periodic and envisage future shortages in allogeneic blood particularly with an aging UK population and increasing concerns about safety arising from old and emerging transfusion-transmissible infections. This will maximize the use of the limited allogeneic blood resource particularly for patients in whom autologous blood transfusion is contraindicated.
  Transfusion Alternatives in Transfusion Medicine 05/2010; 11(2):72 - 81.
• Article: Temporary storage of fresh frozen plasma above −30°C has no negative impact on the quality of clotting factors and inhibitors

  phd RAINER MOOG md, DIETMAR KNOP md, FOLKER WENZEL md
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  ABSTRACT: Fresh frozen plasma (FFP) should be stored at temperatures > −30°C according to national and international guidelines to maintain the stability of clotting factors and inhibitors. In the present report, FFP was accidentally stored at < −30°C due to icing of the freezer. To ensure the quality of the FFPs a battery of tests of clotting factors and inhibitors was performed. Our data demonstrate that temporary storage of FFP at temperature < −30°C does not negatively affect the quality of FFPs. The European requirement of 70% activity of factor VIII was met by all units.
  Transfusion Alternatives in Transfusion Medicine 04/2010; 11(1):8 - 9.
• Article: Erythropoietin and iron therapy in patients with renal failure

  LUCIA DEL VECCHIO, FRANCESCO LOCATELLI
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  ABSTRACT: Anemia, which is a common complication of chronic kidney disease (CKD), may significantly impair quality of life, increase cardiovascular risk and reduce long-term survival if left untreated. Today, erythropoiesis-stimulating agents (ESAs) are the main tool for anemia correction; they can be differentiated on the basis of mean serum half life on short- and long-acting molecules, the latter requiring longer administration intervals. According to international guidelines, the target hemoglobin to be obtained by treatment is between 11 and 12 g/dL. In general, the intravenous route is more convenient for hemodialysis patients, whereas the subcutaneous one is preferable in all other CKD patients. ESA dose requirements are rarely predictable in the individual patient and thus need to be titrated according to hemoglobin increases. In order to achieve ESA effectiveness, patients often need iron supplementation, either orally or intravenously. The intravenous route is the most widely used, especially in hemodialysis patients.
  Transfusion Alternatives in Transfusion Medicine 02/2010; 11(1):20 - 29.
• Article: Donor safety issues in high‐dose platelet collection using the latest apheresis systems

  RAJENDRA CHAUDHARY, SUDIPTA S. DAS, DHEERAJ KHETAN, SHASHANK OJHA, SUNIL VERMA
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  ABSTRACT: The practice of high-yield or double-dose platelet (DDP) collection through automated apheresis is gradually increasing. Very few studies have examined donor safety issues in DDP collection. The present study highlights the process of DDP donor selection as well as the product quality and donor safety issues on 67 donors. All procedures were performed following the departmental standard operating procedure. We observed a significantly higher mean platelet yield with the Amicus separator than the Fresenius separator (5.4 × 1011vs. 5.1 × 1011, P = 0.03). The Fresenius separator processed a mean blood volume of 3974 mL and collected a mean platelet amount of 444.9 mL, and these were significantly higher when compared with Amicus (P < 0.0001). Mean values of procedure-related parameters, such as acid-citrate-phosphate volume, donation time, needle time, processing time and whole blood processed, and donor-related parameters, like citrate toxicity and vasovagal reactions, were significantly higher during DDP than single-dose platelet collection (P < 0.05). We conclude that obtaining eligible donors for DDP from a shrinking donor population with low normal platelet values is a difficult task. Therefore, each transfusion service should set their own guidelines for DDP collection with the objectives of donor safety and optimal product quality.
  Transfusion Alternatives in Transfusion Medicine 02/2010; 11(1):1 - 7.
• Article: The effects of hyperoxic ventilation on tissue oxygenation

  JENS MEIER, PATRICK LAUSCHER, HARRY KERTSCHO, OLIVER HABLER
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  ABSTRACT: Application of high inspiratory oxygen concentrations is an established method to improve arterial oxygen content, oxygen transport and tissue oxygenation. However, in the past years a considerable amount of data have emerged challenging this approach: hyperoxic ventilation (ventilation with pure oxygen, HV) and subsequent hyperoxemia have been accused of inducing unfavorable effects on microcirculation and tissue perfusion, resulting in regional tissue hypoxia. Interestingly, these disadvantegous properties of HV seem to occur predominantly in patients with physiological hemoglobin concentrations and probably play a minor role in anemic patients. In animal experiments the effect of HV on tissue oxygenation and on outcome of several severe pathologic conditions essentially depends on the hemoglobin concentration: HV failed to have a considerable impact on survival of severe hypovolemia or methemoglobinemia (physiological hemoglobin concentration), whereas it convincingly improves outcome of severe normovolemic anemia. The present review discusses a perspective on the effects of HV at different hemoglobin concentrations and its potential to improve oxygen transport and tissue oxygenation especially during moderate and severe anemia.
  Transfusion Alternatives in Transfusion Medicine 02/2010; 11(1):30 - 38.
• Article: Prediction of transfusion requirements in surgical patients: a review

  GIOVANNI INGHILLERI
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  ABSTRACT: Preoperative estimation of transfusion requirements in patients scheduled for surgery is critical to optimize blood management, including costs, and to appropriately select patients who can benefit from alternatives to allogeneic blood transfusion. Three groups of methods for transfusion requirement prediction have been developed. The simplest methods are those that identify patients at risk of requiring transfusion support on the basis of the surgical procedure they are scheduled for and one or two clinical parameters. Preoperative hemoglobin concentration (or red blood cell mass) and age are the most reliable parameters that have emerged from the studies. A second group of methods includes approaches based on the calculation of a risk score obtained by totaling predefined values assigned to the presence or absence of a number of predictors proven to be relevant in affecting transfusion requirements in a given surgical setting. The third group is based on mathematical approaches that define transfusion requirements by comparing the two elements that determine them: the reduction in red blood cell mass induced by surgery (blood loss) and the maximum red blood cell mass that a patient, according to their clinical condition, can tolerate to lose. Experiences reported to date show these methods can all be helpful in clinical practice for predicting transfusion requirements in the individual patient. Selection of the strategy to be used depends on the precision required, the intended use and hospital organization.
  Transfusion Alternatives in Transfusion Medicine 10/2009; 11(1):10 - 19.
• Article: Reticulocyte hemoglobin content in 13 critically ill patients: a preliminary study

  msc GENEVIÈVE PRÉFONTAINE bpharm, msc MARTIN DARVEAU bpharm, CHARAF AHNADI phd, frcpc PIERRE LACHANCE md, OLIVIER LESUR md, msc, phd, frcpc CHRISTINE DROUIN md, msc PATRICE LAMARRE bpharm, msc CARMEN VÉZINA bpharm
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  ABSTRACT: In the presence of inflammation, iron availability for erythropoiesis is decreased, and hemoglobin production is reduced in reticulocytes. The reticulocyte hemoglobin content (CHr) provides a real picture of bone marrow status and could be useful to evaluate iron metabolism in critically ill patients. We conducted a preliminary study to evaluate the feasibility to measure the CHr in the intensive care units of two university hospitals and to evaluate the impact of C-reactive protein on CHr values. The CHr was measured in 14 consecutive critically ill patients hospitalized in the intensive care unit between 48 and 96 hours. One patient with a ferritin concentration < 100 µg/L was excluded to eliminate a possible coexistence of iron deficiency with inflammation. A statistically significant correlation was observed between C-reactive protein concentrations and CHr values (r = −0.588; P = 0.03, n = 13). The results observed in this preliminary study are interesting and could be useful to establish the research protocol for a future study evaluating iron metabolism in critically ill patients. A larger study is feasible and warranted given the results observed in this preliminary study.
  Transfusion Alternatives in Transfusion Medicine 03/2009; 10(4):182 - 188.