The viability of autologous human red cells stored in additive solution 5 and exposed to 25 degrees C for 24 hours

New ultraviolet C light-based method for pathogen inactivation of red blood cell units

BACKGROUND

Pathogen inactivation (PI) technologies for platelet concentrates and plasma are steadily becoming more established, but new PI treatment options for red blood cells (RBCs), the most commonly used blood component, still need to be developed. We present a novel approach to inactivating pathogens in RBC units employing ultraviolet C (UVC) light.

METHODS

Whole blood-derived leukoreduced RBCs suspended in PAGGS-C, a third generation additive solution, served as test samples, and RBCs in PAGGS-C or SAG-M as controls. Vigorous agitation and hematocrit reduction by diluting the RBCs with additional additive solution during illumination ensured that UVC light penetrated and inactivated the nine bacteria and eight virus species tested. Bacterial and viral infectivity assays and in vitro analyses were performed to evaluate the system's PI capacity and to measure the RBC quality, metabolic, functional, and blood group serological parameters of UVC-treated versus untreated RBCs during 36-day storage.

RESULTS

UVC treatment of RBCs in the PAGGS-C additive solution did not alter RBC antigen expression, but significantly influenced some in vitro parameters. Compared to controls, hemolysis was higher in UVC-treated RBC units, but was still below 0.8% at 36 days of storage. Extracellular potassium increased early after PI treatment and reached ≤70 mmol/L by the end of storage. UVC-treated RBC units had higher glucose and 2,3-diphosphoglycerate levels than controls.

CONCLUSION

As UVC irradiation efficiently reduces the infectivity of relevant bacteria and viruses while maintaining the quality of RBCs, the proposed method offers a new approach for PI of RBC concentrates.

Rapid clearance of storage-induced microerythrocytes alters transfusion recovery

Permanent availability of red blood cells (RBCs) for transfusion depends on refrigerated storage, during which morphologically altered RBCs accumulate. Among these, a subpopulation of small RBCs, comprising type III echinocytes, spheroechinocytes, and spherocytes and defined as storage-induced microerythrocytes (SMEs), could be rapidly cleared from circulation posttransfusion. We quantified the proportion of SMEs in RBC concentrates from healthy human volunteers and assessed correlation with transfusion recovery, investigated the fate of SMEs upon perfusion through human spleen ex vivo, and explored where and how SMEs are cleared in a mouse model of blood storage and transfusion. In healthy human volunteers, high proportion of SMEs in long-stored RBC concentrates correlated with poor transfusion recovery. When perfused through human spleen, 15% and 61% of long-stored RBCs and SMEs were cleared in 70 minutes, respectively. High initial proportion of SMEs also correlated with high retention of RBCs by perfused human spleen. In the mouse model, SMEs accumulated during storage. Transfusion of long-stored RBCs resulted in reduced posttransfusion recovery, mostly due to SME clearance. After transfusion in mice, long-stored RBCs accumulated predominantly in spleen and were ingested mainly by splenic and hepatic macrophages. In macrophage-depleted mice, splenic accumulation and SME clearance were delayed, and transfusion recovery was improved. In healthy hosts, SMEs were cleared predominantly by macrophages in spleen and liver. When this well-demarcated subpopulation of altered RBCs was abundant in RBC concentrates, transfusion recovery was diminished. SME quantification has the potential to improve blood product quality assessment. This trial was registered at www.clinicaltrials.gov as #NCT02889133.

Compliance with temperature and time requirements during in-hospital distribution of blood components: A national survey among transfusion services

INTRODUCTION

Temperature and time conditions during storage and distribution of blood components (BC) and their permissible deviations are strictly regulated. The degree of compliance with these requirements in daily practice of transfusion services (TS) is not well known.

MATERIALS AND METHODS

We conducted a survey among Spanish hospital TS covering different aspects of BC management in their daily activity.

RESULTS

Eighty-three TS managing 56 % of total transfusions answered the survey. Monitoring of red blood concentrates (RBC) temperature during in-hospital distribution was routinely performed by only 12 % of the TS. The main criterion for BC re-entry into the stock was the total time spent outside controlled temperature. Up to 41 % of the TS apply the "30-minute rule" to distributed RBC, while most services use a 60-minute rule for PC. No adverse events were detected when RBC that had remained longer than 30 or 60 min outside the TS were transfused. Fresh frozen plasma is usually thawed 2 h preissue and stored at 4 °C up to 24 h.

DISCUSSION AND CONCLUSIONS

In the Spanish context, the 30- and 60-minute rules for re-entry of RBC and PC into the TS stock are loosely followed. Feedback for a large number of TS suggests that the extension of the 30-minute RBC rule to at least 60 min is feasible, if other safety requirements are met. Flexibility with some requirements could help reduce product loss without deleterious effect on BC safety.

Transition to 37°C reveals importance of NADPH in mitigating oxidative stress in stored RBCs

The RBC storage lesion is a multiparametric response that occurs during storage at 4°C, but its impact on transfused patients remains unclear. In studies of the RBC storage lesion, the temperature transition from cold storage to normal body temperature that occurs during transfusion has received limited attention. We hypothesized that multiple deleterious events might occur in this period of increasing temperature. We show dramatic alterations in several properties of therapeutic blood units stored at 4°C after warming them to normal body temperature (37°C), as well as febrile temperature (40°C). In particular, the intracellular content and redox state of NADP(H) were directly affected by post-storage incubation at 37°C, as well as by pro-oxidant storage conditions. Modulation of the NADPH-producing pentose phosphate pathway, but not the prevention of hemoglobin autoxidation by conversion of oxyhemoglobin to carboxyhemoglobin, provided protection against storage-induced alterations in RBCs, demonstrating the central role of NADPH in mitigating increased susceptibility of stored RBCs to oxidative stress. We propose that assessing RBC oxidative status after restoration of body temperature constitutes a sensitive method for detecting storage-related alterations that has the potential to improve the quality of stored RBCs for transfusion.

The Value of Radio Frequency Identification in Quality Management of the Blood Transfusion Chain in an Academic Hospital Setting

Background

A complex process like the blood transfusion chain could benefit from modern technologies such as radio frequency identification (RFID). RFID could, for example, play an important role in generating logistic and temperature data of blood products, which are important in assessing the quality of the logistic process of blood transfusions and the product itself.

Objective

This study aimed to evaluate whether location, time stamp, and temperature data generated in real time by an active RFID system containing temperature sensors attached to red blood cell (RBC) products can be used to assess the compliance of the management of RBCs to 4 intrahospital European and Dutch guidelines prescribing logistic and temperature constraints in an academic hospital setting.

Methods

An RFID infrastructure supported the tracking and tracing of 243 tagged RBCs in a clinical setting inside the hospital at the blood transfusion laboratory, the operating room complex, and the intensive care unit within the Academic Medical Center, a large academic hospital in Amsterdam, the Netherlands. The compliance of the management of 182 out of the 243 tagged RBCs could be assessed on their adherence to the following guidelines on intrahospital storage, transport, and distribution: (1) RBCs must be preserved within an environment with a temperature between 2°C and 6°C; (2) RBCs have to be transfused within 1 hour after they have left a validated cooling system; (3) RBCs that have reached a temperature above 10°C must not be restored or must be transfused within 24 hours or else be destroyed; (4) unused RBCs are to be returned to the BTL within 24 hours after they left the transfusion laboratory.

Results

In total, 4 blood products (4/182 compliant; 2.2%) complied to all applicable guidelines. Moreover, 15 blood products (15/182 not compliant to 1 out of several guidelines; 8.2%) were not compliant to one of the guidelines of either 2 or 3 relevant guidelines. Finally, 148 blood products (148/182 not compliant to 2 guidelines; 81.3%) were not compliant to 2 out of the 3 relevant guidelines.

Conclusions

The results point out the possibilities of using RFID technology to assess the quality of the blood transfusion chain itself inside a hospital setting in reference to intrahospital guidelines concerning the storage, transport, and distribution conditions of RBCs. This study shows the potentials of RFID in identifying potential bottlenecks in hospital organizations’ processes by use of objective data, which are to be tackled in process redesign efforts. The effect of these efforts can subsequently be evaluated by the use of RFID again. As such, RFID can play a significant role in optimization of the quality of the blood transfusion chain.

Measuring Post-transfusion Recovery and Survival of Red Blood Cells: Strengths and Weaknesses of Chromium-51 Labeling and Alternative Methods

The proportion of transfused red blood cells (RBCs) that remain in circulation is an important surrogate marker of transfusion efficacy and contributes to predict the potential benefit of a transfusion process. Over the last 50 years, most of the transfusion recovery data were generated by chromium-51 (⁵¹Cr)-labeling studies and were predominantly performed to validate new storage systems and new processes to prepare RBC concentrates. As a consequence, our understanding of transfusion efficacy is strongly dependent on the strengths and weaknesses of ⁵¹Cr labeling in particular. Other methods such as antigen mismatch or biotin-based labeling can bring relevant information, for example, on the long-term survival of transfused RBC. These radioactivity-free methods can be used in patients including from vulnerable groups. We provide an overview of the methods used to measure transfusion recovery in humans, compare their strengths and weaknesses, and discuss their potential limitations. Also, based on our understanding of the spleen-specific filtration of damaged RBC and historical transfusion recovery data, we propose that RBC deformability and morphology are storage lesion markers that could become useful predictors of transfusion recovery. Transfusion recovery can and should be accurately explored by more than one method. Technical optimization and clarification of concepts is still needed in this important field of transfusion and physiology.

Multi-omics Evidence for Inheritance of Energy Pathways in Red Blood Cells

Each year over 90 million units of blood are transfused worldwide. Our dependence on this blood supply mandates optimized blood management and storage. During storage, red blood cells undergo degenerative processes resulting in altered metabolic characteristics which may make blood less viable for transfusion. However, not all stored blood spoils at the same rate, a difference that has been attributed to variable rates of energy usage and metabolism in red blood cells. Specific metabolite abundances are heritable traits; however, the link between heritability of energy metabolism and red blood cell storage profiles is unclear. Herein we performed a comprehensive metabolomics and proteomics study of red blood cells from 18 mono- and di-zygotic twin pairs to measure heritability and identify correlations with ATP and other molecular indices of energy metabolism. Without using affinity-based hemoglobin depletion, our work afforded the deepest multi-omic characterization of red blood cell membranes to date (1280 membrane proteins and 330 metabolites), with 119 membrane protein and 148 metabolite concentrations found to be over 30% heritable. We demonstrate a high degree of heritability in the concentration of energy metabolism metabolites, especially glycolytic metabolites. In addition to being heritable, proteins and metabolites involved in glycolysis and redox metabolism are highly correlated, suggesting that crucial energy metabolism pathways are inherited en bloc at distinct levels. We conclude that individuals can inherit a phenotype composed of higher or lower concentrations of these proteins together. This can result in vastly different red blood cells storage profiles which may need to be considered to develop precise and individualized storage options. Beyond guiding proper blood storage, this intimate link in heritability between energy and redox metabolism pathways may someday prove useful in determining the predisposition of an individual toward metabolic diseases.

Donor-variation effect on red blood cell storage lesion: A close relationship emerges

Although the molecular pathways leading to the progressive deterioration of stored red blood cells (RBC storage lesion) and the clinical relevance of storage-induced changes remain uncertain, substantial donor-specific variability in RBC performance during storage, and posttransfusion has been established ("donor-variation effect"). In-bag hemolysis and numerous properties of the RBC units that may affect transfusion efficacy have proved to be strongly donor-specific. Donor-variation effect may lead to the production of highly unequal blood labile products even when similar storage strategy and duration are applied. Genetic, undiagnosed/subclinical medical conditions and lifestyle factors that affect RBC characteristics at baseline, including RBC lifespan, energy metabolism, and sensitivity to oxidative stress, are all likely to influence the storage capacity of individual donors' cells, although not evident by the donor's health or hematological status at blood donation. Consequently, baseline characteristics of the donors, such as membrane peroxiredoxin-2 and serum uric acid concentration, have been proposed as candidate biomarkers of storage quality. This review article focuses on specific factors that might contribute to the donor-variation effect and emphasizes the emerging need for using omics-based technologies in association with in vitro and in vivo transfusion models and clinical trials to discover biomarkers of storage quality and posttransfusion recovery in donor blood.

Measures of stored red blood cell quality

Blood banking underpins modern medical care, but blood storage, necessary for testing and inventory management, reduces the safety and efficacy of individual units of red blood cells (RBCs). Stored RBCs are damaged by the accumulation of their own waste products, by enzymatic and oxidative injury, and by metabolically programmed cell death. These chemical activities lead to a complex RBC storage lesion that includes haemolysis, reduced in vivo recovery, energy and membrane loss, altered oxygen release, reduced adenosine tri-phosphate and nitric oxide secretion, and shedding of toxic products. These toxic products include lysophospholipids that can cause transfusion-related acute lung injury, free iron that can potentiate infections and cause inflammation, and shed microvesicles that can scavenge nitric oxide and potentiate inflammation and thrombosis. However, most of the obvious negative outcomes of RBC storage are uncommon and appear to be related to exceptionally bad units. Generally, the quality of stored RBCs is highly related to the conditions of storage, so refrigerator temperature, intact bags, residual leucocyte counts and visible haemolysis remain excellent general measures. Specific biochemical measures, such as adenosine 5'-triphosphate (ATP) and 2,3-diphosphoglycerate (DPG) concentrations, calcium and potassium content or lipid breakdown products, require specialized measures that are not widely available, involve destructive testing and generally reflect only a part of the storage lesion. This review describes a number of components of the storage lesion and their measurement and attempts to access the utility of the measures.

Impact of constant storage temperatures and multiple warming cycles on the quality of stored red blood cells

BACKGROUND

Red blood cells (RBCs) are routinely stored in liquid state at temperatures below 6°C, and RBC unit core temperature should not exceed 10°C during transport. Since the critical temperature of 10°C was chosen mostly arbitrarily, this study investigated the effect of both constant temperature settings as well as multiple rewarming cycles on stored RBCs with respect to morphology, biochemical parameters and haemolysis.

MATERIALS AND METHODS

Buffy coat-depleted filtered RBCs were used as standard products. RBCs were stored at 1-6°C (reference group, n = 12), 13 and 22°C (test groups, n = 12 each) or stored at 1-6°C and warmed up five times to 10, 13, or 22°C for a period of 24 h each. Various biochemical parameters were measured weekly. RBCs were further investigated using electron microscopy.

RESULTS

Red blood cells stored constantly at 13 or 22°C showed stable haemolysis rates until day 28 and day 14, respectively. RBCs stored at 1-6°C with five warming-up periods to 10, 13 or 22°C each lasting 24 h (total 120 h) did not exceed the limit of the haemolysis rate at the end of storage. Differently shaped erythrocytes were found in all samples, but more crenate erythrocytes appeared after 42 days of storage independent of temperature profiles.

CONCLUSION

Red cells can be kept at constant temperatures above 6°C without apparent harmful effects at least until day 14, whereas multiple warming cycles for no longer than 24 h at 10, 13 or 22°C with subsequent cooling do not cause quality loss as assessed using the in vitro assays employed in this study.

The 30 minute rule for red blood cells: in vitro quality assessment after repeated exposure to 30°C

BACKGROUND

Red blood cells (RBC) may be out of temperature control only for 30 minutes before they must be discarded, but evidence for this rule is weak. We investigated the effect on RBC quality of multiple exposures to 30°C.

STUDY DESIGN AND METHODS

RBC units made after 24 hours of whole blood ambient hold were pooled and split into adult and pediatric units and exposed to permitted deviations (5-hr core temperature 10°C, 12-hr surface temperature 10°C). Test units were exposed to 30°C once, twice, or three times on each of Days 15, 17, and 21, for 30 or 60 minutes. Negative controls were not exposed to 30°C; positive control was exposed to 30°C for 24 hours.

RESULTS

Adult units exposed once for 30 or 60 minutes (×3 occasions) showed no more hemolysis than negative control. Units exposed to 30°C for two or three periods of 60 minutes showed more hemolysis from Day 28. Hemolysis in pediatric units exposed for 30 minutes (×3) was not increased but units exposed to one or two periods of 60 minutes (×3) showed higher hemolysis. No differences were seen in supernatant potassium. ATP remained at an acceptable level on Day 28 in all but positive controls.

CONCLUSIONS

There was no evidence of significant damage to RBC after exposure to 30°C for three periods of 30 minutes. Multiple exposures of 60 minutes caused limited damage but this was within current regulatory limits if there were three or fewer exposures, suggesting that a 60-minute rule may be feasible.

Repeated short-term warming of red blood cell concentrates has minimal effect on their quality

BACKGROUND AND OBJECTIVES

Blood components must be stored under controlled temperature conditions, for reasons of component quality and safety. However, there are occasions when components may be exposed to conditions outwith the defined limits. This study aimed to generate prospective data on the effect of red cell exposure to extremes of temperature.

MATERIALS AND METHODS

Study 1: red cell concentrates (RCC) in saline, adenine, glucose and mannitol (SAGM), made after ambient overnight hold of whole blood, were exposed to either +22°C or -2°C for up to three periods of 3 h on days 3, 8 and 15 of storage, followed by a 5 h exposure on day 29. Study 2: RCC in SAGM were exposed to 25°C for 24 or 48 h from day 2. In vitro markers of cell quality were measured during storage to 43 days, and compared with control units that had been stored at 2-6°C.

RESULTS

Multiple short-term exposures to +22°C or -2°C did not cause any significant changes to pH, haemolysis, supernatant potassium, cellular ATP, 2,3-DPG, or deformability, when compared to control units. Exposure of RCC to 25°C for 24 or 48 h caused a significant fall in pH, ATP, and deformability.

CONCLUSION

Red cells may be damaged by prolonged exposure to warm temperatures, but repeated short-term exposure to 22°C or -2°C does not appear to affect the in vitro quality of RCC. It is important to note that no bacterial growth studies were performed during this study.

Scientific problems in the regulation of red blood cell products

BACKGROUND

For the past 30 years, red blood cell (RBC) storage systems have been licensed in the United States based on the demonstration that 24-hour in vivo recovery was greater than 75% and hemolysis was less than 1%. Now additional requirements for storage system licensure have being added. The meaning and value of these new requirements have been questioned.

STUDY DESIGN AND METHODS

The literature regarding the performance of present and suggested new tests for RBC licensure was reviewed.

RESULTS

(51) Cr 24-hr in vivo recovery has an intrinsic 4% error of measurement whereas the error in measures of hemolysis is less than 0.1%. Both measures have large donor-dependent end-of-storage variability; nevertheless, they have successfully guided RBC storage system development for six decades. Adenosine 5'-triphosphate and 2,3-diphosphoglycerate are difficult to measure accurately and international shared-sample studies suggest 6 and 11% coefficients of variation across laboratories. There is no readily available way to measure the oxygen equilibrium curve accurately. The new failure criteria provide no useful information and randomly fail good products.

CONCLUSIONS

Attempts to expand the useful regulatory requirements for RBC storage system licensure are limited by poor understanding of the storage lesion and its effect of RBC performance. Measures of (51) Cr 24-hour in vivo recovery remain critical and resources for this measure are limiting. The interaction between limited testing resources and large donor variability remains a major limit on RBC storage system development. It is important that new required tests contribute meaningful information and not make development and licensure of better products more difficult.

Ambient overnight hold of whole blood prior to the manufacture of blood components

Blood services routinely separate whole blood into components that are then stored under different conditions. The storage conditions used for whole blood prior to separation must therefore be a compromise between the needs of the red cells (which benefit from refrigeration) and plasma and platelets (which are better preserved at ambient temperature). For many years, the approach has been to manufacture plasma and platelet components on the day of blood collection, and to refrigerate any unprocessed blood for manufacture into red cell components on the following day. However, this can make it challenging to maintain adequate stocks of all components. The European practice of 'ambient hold' of whole blood for up to 24 hours prior to processing allows greater flexibility in blood component manufacture, and the data reviewed suggest there is relatively little impact on the quality of red cell or plasma components, and an improvement in the quality of platelet components.

Immunoregulatory effects of stored red blood cells

Some clinical studies have identified potential adverse patient outcomes associated with RBC storage length. This may in part be due to the release of potentially hazardous bioactive products that accumulate during storage and are delivered at high concentrations during transfusion. In this situation, a proinflammatory tissue microenvironment may be established that can alter immunoregulatory mechanisms. This review highlights some of the potential immunomodulatory effects of stored RBCs that may be responsible for adverse transfusion reactions.

Effect of rate and delay of cooling during initial cooling process: in vitro effect on red cells

BACKGROUND

Whole blood is stored at room temperature (RT) until processing into components. After separation and filtration, the RCC has to be cooled from RT to +2 - 6°C. Different start times of the cooling process and different cooling rates can be encountered in daily routine. The effect of these parameters of the initial cooling of leucoreduced red cell concentrates (LR-RCC) on in vitro quality is not known.

METHODS

In paired experiments (n=12), LR-RCCs in SAGM were cooled immediately after preparation from RT to +2 to +6°C either 'fast' (within 2½ h) or 'slow' (within 10-24 h) or 'slow' after a holding period of 6, 12, 18 or 24 h. Units were then stored at +2-6°C for 42 days and sampled at regular intervals for in vitro analysis.

RESULTS

Irrespective of the start time and cooling rate during the initial cooling process, all units maintained good in vitro quality up to Day 42 with haemolysis <0·8%. Adenosine triphosphate (ATP) levels remained >2·7 μmol/g Hb in 99% of all units up to Day 35. Differences in pH, ATP content and 2,3-DPG content between the groups were largest at Day 2 or 3 but generally disappeared during storage.

CONCLUSION

Start time and cooling rate of the initial cooling process had minor effects on in vitro quality of red cells. LR-RCCs can be stored up to 24 h before cooling down to +2-6°C without deleterious effects on in vitro parameters during 42-day storage.

Current issues relating to the transfusion of stored red blood cells

The development of blood storage systems allowed donation and transfusion to be separated in time and space. This separation has permitted the regionalization of donor services with subsequent economies of scale and improvements in the quality and availability of blood products. However, the availability of storage raises the question of how long blood products can and should be stored and how long they are safe and effective. The efficacy of red blood cells was originally measured as the increment in haematocrit and safety began with typing and the effort to reduce the risk of bacterial contamination. Appreciation of a growing list of storage lesions of red blood cells has developed with our increasing understanding of red blood cell physiology and our experience with red blood cell transfusion. However, other than frank haemolysis, rare episodes of bacterial contamination and overgrowth, the reduction of oxygen-carrying capacity associated with the failure of some transfused cells to circulate, and the toxicity of lysophospholipids released from membrane breakdown, storage-induced lesions have not had obvious correlations with safety or efficacy. The safety of red blood cell storage has also been approached in retrospective epidemiologic studies of transfused patients, but the results are frequently biased by the fact that sicker patients are transfused more often and blood banks do not issue blood products in a random order. Several large prospective studies of the safety of stored red blood cells are planned.

The effect of storing whole blood at 22 degrees C for up to 24 hours with and without rapid cooling on the quality of red cell concentrates and fresh-frozen plasma

BACKGROUND

Storage of whole blood (WB) for less than 24 hours at ambient temperature is permitted in Europe, but data directly comparing storage with and without active cooling are lacking, which was investigated and compared to current standard methods.

STUDY DESIGN AND METHODS

WB was stored in one of four different ways for 24 hours after donation before processing on Day 1 to red cell concentrates (RCCs) in saline-adenine-glucose-mannitol and fresh-frozen plasma (FFP; n = 20 each): 1) at 22 degrees C in plastic trays, 2) in cooling devices (Compocool II, NPBI), 3) at 4 degrees C, or 4) processed from WB without storage less than 8 hours from donation (Day 0).

RESULTS

2,3-Diphosphoglycerate (2,3-DPG) in RCCs were lower after ambient storage compared with those processed on Day 0 or after 4 degrees C storage. Rapid cooling slowed the loss of 2,3-DPG but levels were undetectable by Day 21 with any method. On Day 42 of RCC storage, there was no significant difference between storage methods in levels of adenosine triphosphate or hemolysis. Potassium levels were lower in RCCs from WB stored at ambient compared with those produced on Day 0, regardless of the use of cooling plates. FFP produced from WB on Day 0 or after storage at ambient with or without active cooling met UK specifications (>75% of units >0.70 IU/mL Factor VIII).

CONCLUSION

These data suggest that RCCs and FFP produced from WB that has been stored at ambient temperature with or without active cooling are of acceptable quality compared with those produced using current standard methods in the United Kingdom.

Warm storage of whole blood for 72 hours

BACKGROUND

In field emergency medicine, fresh whole-blood units are stored at room temperature up to 24 hours or occasionally longer. Few data exist on the integrity and in vitro functional properties of whole blood stored warm beyond 24 hours.

STUDY DESIGN AND METHODS

Ten citrate phosphate dextrose solution whole-blood units were collected and divided into two equal volumes. One-half of each unit was stored at 19 degrees C and the other half was stored at 25 degrees C, encompassing the accepted range for room temperature storage. At 6, 24, 48, and 72 hours, aliquots were collected from each unit and whole blood analyzed for cell counts, gases, and clotting function with thromboelastography, red cells for intracellular analytes, platelet (PLT)-rich plasma for aggregometry, and the supernatant for hemoglobin, potassium, glucose, lactate, and plasma clotting studies.

RESULTS

Whole-blood units stored at room temperature maintained cellular counts and coagulation activity for up to 72 hours. Units stored at 19 degrees C demonstrated greater RBC adenosine triphosphate and 2,3-diphosphoglycerate (DPG) content and stronger responses in PLT aggregation studies when compared with 25 degrees C storage. No significant hemolysis was observed, and no bacterial growth was detected.

CONCLUSION

Storage of whole blood at room temperature for 72 hours leads to marked reductions in pH and DPG, but the observed reduction in PLT function and plasma coagulation factor activity was surprisingly modest compared to literature values. These findings should prompt additional investigation, given their potential importance for whole blood processing and field-expedient transfusion.

Planning for pandemic influenza: effect of a pandemic on the supply and demand for blood products in the United States

BACKGROUND

Influenza causes episodic pandemics when viral antigens shift in ways that elude herd immunity. Avian influenza A H5N1, currently epizootic in bird populations in Asia and Europe, appears to have pandemic potential.

STUDY DESIGN AND METHODS

The virology of influenza, the history of the 1918 pandemic, and the structure of the health care and the blood transfusion systems are briefly reviewed. Morbidity and mortality experience from the 1918 pandemic are projected onto the current health care structure to predict points of failure that are likely in a modern pandemic.

RESULTS

Blood donor centers are likely to experience loss of donors, workers, and reliable transport of specimens to national testing laboratories and degradation of response times from national testing labs. Transfusion services are likely to experience critical losses of workers and of reagent red cells (RBCs) that will make their automated procedures unworkable. Loss of medical directors, supervisors, and lead technicians may make alternative procedures unworkable as well.

CONCLUSIONS

Lower blood collection capacity and transfusion service support capability will reduce the availability of RBCs and especially of platelets. Plans for rationing medical care need to take the vulnerability of the blood transfusion system into account.

Freeze-dried whole plasma: Evaluating sucrose, trehalose, sorbitol, mannitol and glycine as stabilizers

Several groups report stability results for freeze-dried whole plasma intended for use as a transfusion product [Hellstern P, Sachse H, Schwinn H, Oberfrank K. Manufacture and in vitro characterization of a solvent/detergent-treated human plasma. Vox Sang 1992;63:178-185; Trobisch H. Results of a quality-control study of lyophilized pooled plasmas which have been virally inactivated using a solvent detergent method (modified Horowitz procedure). Beitr Infusionsther 1991;28:92-109; Hugler P, Trobish H, Neuman H, Moller, Sirtl C, Derdak M, Laubenthal H. Quality control of three different conventional fresh-frozen plasma preparations and one new virus-inactivated lyophilized pooled plasma preparation. Klin Wochenschr 1991;69:157-161; Krutvacho T, Chuansumrit A, Isarangkura P, Pintadit P, Hathirat P, Chiewsilp P. Response of hemophilia with bleeding to fresh dry plasma. Southeast Asian J Trop Med Public Health 1993;24:169-173; Chuansumrit A, Krasaesub S, Angchaisuksiri P, Hathirat P, Isarangkura P. Survival analysis of patients with haemophilia at the International Haemophilia Training Centre, Bangkok, Thailand. Haemophilia 2004;10:542-549]. Plasma coagulation properties are substantially impaired in these freeze-dried plasmas, while pH levels are close to alkaline. In this work, plasma supplemented with 60mM sucrose, trehalose, mannitol, sorbitol or glycine was freeze-dried. The samples were subjected to forced degradation at 40 degrees C for 10 days in order to quickly evaluate the effectiveness of the different stabilizers. Initial PT, APTT and TT values were 14.4+/-0. 5s, 31.4+/-1.5s and 18.3+/-0.6s, respectively. At the end of the degradation period, PT, APTT and TT were substantially prolonged, and were 19.1+/-0. 5s, 43.1+/-0.6s and 26.1+/-1.0s, respectively. In the presence of glycine, at the end of the degradation period, PT, APTT and TT values remained close to the initial values and were 15.5+/-0. 4s, 35.7+/-0.9s and 19.4+/-0.2s, respectively. Percent activities of the coagulation factors V, VII, VIII, IX, X and the coagulation inhibitors protein C, protein S and antithrombin III were recorded. Factors V and VIII were most prone to degradation. Factor V and VIII activities, in control plasma, were approx. 44+/-3.5% and 58+/-2.3%, at the end of storage. In contrast, much higher factor V and VIII activities were maintained in the lyophilized glycine-supplemented plasma: approx. 60+/-3.5% and 74+/-7.0%, correspondingly. The most stable protein was protein C, which showed no signs of degradation under the testing conditions of this study. All tested stabilizers provided protection. Glycine, however, outperformed all tested polyols, providing superior preservation of plasma clotting properties. Thermograms of 60mM glycine in water and 60mM glycine in plasma show that, in the presence of plasma, glycine does not crystallize. The process of freeze-drying caused a complete loss of plasma pCO(2) (gas) and a substantial increase in plasma pH. Citric acid was found to be a suitable pH adjuster for lyophilized/rehydrated plasma.

Hypertonic resuscitation and blood coagulation: in vitro comparison of several hypertonic solutions for their action on platelets and plasma coagulation

Resuscitation with hypertonic saline (HS) appears to aggravate bleeding in a model of uncontrolled hemorrhage [J. Trauma 28 (1988) 751; J. Trauma 29 (1989) 79; Arch. Surg. 127 (1992) 93]. This property may be related to the anticoagulant effects of HS on plasma clotting factors and platelets [J. Trauma 31 (1991) 8]. The hypothesis in this study is that a hypertonic solution can be developed that would not disturb the blood coagulation mechanism and could be used as an alternative to hypertonic saline.HS and four different 2400 mosM solutions containing monosaccharides and/or glycine were screened for their in vitro effects on plasma clotting times and platelets. Significant prolongations falling outside the normal range were detected in prothrombin time (PT) and thrombin rime (TT) when only 5% of the volume of normal plasma is HS. Platelet function as measured by extent of shape change (ESC) induced by ADP and aggregation induced by thrombin were also critically impaired by HS at a 5% dilution. All alternative solutions-hypertonic glucose, sorbitol, glycine, glucose/glycine, glucose/mannitol/glycine, sorbitol/glycine-caused a significantly reduced impairment in platelet function and the plasma coagulation system. Hypertonic glycine showed a unique ability to fully preserve the function and integrity of the plasma coagulation system. Considering the pre-deposition of the trauma patient to coagulopathy, administration of HS which clearly is a potent anticoagulant and anti-platelet risks further aggravating the coagulopathy. In contrast, hypertonic glycine preserves the blood coagulation mechanism and exhibits the potential for numerous therapeutic applications. Therefore, prompt evaluation of hypertonic glycine as a resuscitative fluid is highly desirable.

A multicenter study of in vitro and in vivo values in human RBCs frozen with 40-percent (wt/vol) glycerol and stored after deglycerolization for 15 days at 4 degrees C in AS-3: assessment of RBC processing in the ACP 215

BACKGROUND

The FDA has approved the storage of frozen RBCs at -80 degrees C for 10 years. After deglycerolization, the RBCs can be stored at 4 degrees C for no more than 24 hours, because open systems are currently being used. Five laboratories have been evaluating an automated, functionally closed system (ACP 215, Haemonetics) for both the glycerolization and deglycerolization processes.

STUDY DESIGN AND METHODS

Studies were performed at three military sites and two civilian sites. Each site performed in vitro testing of 20 units of RBCs. In addition, one military site and two civilian sites conducted autologous transfusion studies on ten units of previously frozen, deglycerolized RBCs that had been stored at 4 degrees C in AS-3 for 15 days. At one of the civilian sites, 10 volunteers received autologous transfusions on two occasions in a randomized manner, once with previously frozen RBCs that had been stored at 4 degrees C in AS-3 for 15 days after deglycerolization and once with liquid-preserved RBCs that had been stored at 4 degrees C in AS-1 for 42 days.

RESULTS

The mean +/- SD in vitro freeze-thaw-wash recovery value was 87 +/- 5 percent; the mean +/- SD supernatant osmolality on the day of deglycerolization was 297 +/- 5 mOsm per kg of H(2)O, and the mean +/- SD percentage of hemolysis after storage at 4 degrees C in AS-3 for 15 days was 0.60 +/- 0.2 percent. The paired data from the study of 10 persons at the civilian site showed a mean +/- SD 24-hour posttransfusion survival of 76 +/- 6 percent for RBCs that had been stored at 4 degrees C for 15 days after deglycerolization and 72 +/- 5 percent for RBCs stored at 4 degrees C in AS-1 for 42 days. At the three sites at which 24-hour posttransfusion survival values were measured by three double-label procedures, a mean +/- SD 24-hour posttransfusion survival of 77 +/- 9 percent was observed for 36 autologous transfusions to 12 females and 24 males of previously frozen RBCs that had been stored at 4 degrees C in AS-3 for 15 days after deglycerolization.

CONCLUSION

The multicenter study showed the acceptable quality of RBCs that were glycerolized and deglycerolized in the automated ACP 215 instrument and stored in AS-3 at 4 degrees C for 15 days.