Mechanical hemolysis in pediatric patients associated with rapid transfusion and one-way valve

Influence of Peripherally Inserted Central Catheters With Proximal Valves on Red Blood Cell Hemolysis During Transfusion

The aim of this study was to verify the occurrence of hemolysis after infusion of packed red blood cells (PRBCs) in 12 peripherally inserted central catheters (PICCs) with a proximal valve, according to size and infusion rate. This was an experimental in vitro study performed under laboratory-controlled conditions, and the sample was composed of 12 PICCs with proximal valves (3F and 4F catheter). Twelve type A+ aliquots from 10 PRBCs were analyzed preinfusion and postinfusion according to PICC size and infusion rate. Hemolysis markers, total hemoglobin (g/dL), hematocrit (%), free hemoglobin (g/dL), potassium (mmol/L), lactate dehydrogenase (U/L), and rate of hemolysis (%) were studied. Data were analyzed using analysis of variance and Bonferroni multiple comparison tests. After the infusions in 3F PICCs, an increase was seen in rate of hemolysis (P = .003) and free hemoglobin (P = .014), in addition to a reduction in total hemoglobin (P = .002), with significant influence of minimum and maximum flow rates on the rate of hemolysis. The study finding indicated that the smaller catheter size and the infusion rate influenced variations in some hemolysis markers, but the alterations observed in the hemolysis markers would not contraindicate the infusion of PRBCs by 3F and 4F PICCs with proximal valves.

Effect of modern infusion pumps on RBC quality

BACKGROUND

Mechanical stress on red blood cells is associated with using infusion pumps for blood administration. Current standards in North America leave it to healthcare facilities to consult with manufacturers about infusion pump safety for transfusion; studies on various pumps and red blood cell (RBC) conditions are scarce.

STUDY DESIGN AND METHODS

RBC units were pumped through four infusion pumps on d22 (22 days postcollection), d40, d28 after gamma irradiation on d14 (I14d28), and d22 after irradiation on d21 (I21d22). For each experiment, three units were pooled and split among four bags. Samples were collected at gravity and after pumping at clinical nonemergency rates. Hemolysis %, microvesicles, potassium, lactate dehydrogenase, mechanical fragility index levels, and morphology evaluations were performed (n = 5-6).

RESULTS

Hemolysis levels of Piston and Linear Peristaltic pump samples were not different from hemolysis of corresponding gravity samples. Peristaltic samples had significantly higher hemolysis compared to gravity, and other pumps, however, maximum mean difference was limited to 0.05%. Pumping at 50 mL/h resulted in the highest hemolysis level. Change in hemolysis % due to pumping was significantly higher in d40 and I21d22 units. No combination of pumps and RBCs conditions led to hemolysis >0.8%. Besides hemolysis, lactate dehydrogenase release was the only marker that demonstrated some differences between infusions via pump versus gravity.

CONCLUSION

The pump design affects the degree of hemolysis. However, for all tested pumps and RBC conditions, this increase was minimal. Hemolysis measurement on d40 and I21d22 at 50 mL/h were concluded to be appropriate parameters for pump evaluation.

Impact of different syringe pumps on red cells during paediatric simulated transfusion

BACKGROUND

Critically ill patients frequently need blood transfusions. For safety, blood must be delivered via syringe infusion pumps, yet this can cause red cell damage and increase the rate of haemolysis.

AIMS AND OBJECTIVES

To evaluate biochemical and haemolytic markers of red blood cells transfused in three different types of syringe infusion pumps at two different infusion rates (10 and 100 mL/h).

DESIGN AND METHODS

A lab-based study using aliquots of 16 red blood cell bags was undertaken. Haemolysis markers (total haemoglobin [g/dL], haematocrit [%], free haemoglobin [g/dL], potassium [mmol/L], lactate dehydrogenase [U/L], osmolality [mOsm/kg], pH, degree of haemolysis [%]) were measured before and after red blood cell infusion and exposure. Three different syringe infusion pumps brands (A, B, and C) were compared at two different infusion rates (10 and 100 mL/h).

RESULTS

Total haemoglobin fell significantly in all red blood cell units during manipulation (pre-infusion: 26.44 ± 5.74; post-exposure: 22.62 ± 4.00; P = .026). The degree of haemolysis significantly increased by 40% after manipulation of the red blood cells. Syringe infusion pump A caused a 3-fold increase in potassium levels (3.78 ± 6.10) when compared with B (-0.14 ± 1.46) and C (1.63 ± 1.98) (P = .015). This pump also produced the worst changes, with an increase in free haemoglobin (0.05 ± 0.05; P = .038) and more haemolysis (0.08 ± 0.07; P = .033). There were significant differences and an increase in the degree of haemolysis (P = .004) at the infusion rate of 100 mL/h.

CONCLUSIONS

Syringe infusion pumps may cause significant red blood cell damage during infusion, with increases in free haemoglobin, potassium, and the degree of haemolysis. Some pump types, with a cassette mechanism, caused more damage.

RELEVANCE TO CLINICAL PRACTICE

In many intensive care units, bedside nurses are able to consider infusion pump choice, and understanding the impact of different pump types on red blood cells during a transfusion provides the nurses with more information to enhance decision-making and improve the quality of the transfusion.

When might transferrin, hemopexin or haptoglobin administration be of benefit following the transfusion of red blood cells?

PURPOSE OF REVIEW

After transfusion, a percentage of red blood cells undergo hemolysis within macrophages. Intravascular exposures to hemin and hemoglobin (Hb) can occur after storage bag hemolysis, some transfusion reactions, during use of medical assist devices and in response to bacterial hemolysins. Proteins that regulate iron, hemin and Hb either become saturated after iron excess (transferrin, Tf) or depleted after hemin (hemopexin, Hpx) and Hb (haptoglobin, Hp) excess. Protein saturation or stoichiometric imbalance created by transfusion increases exposure to non-Tf bound iron, hemin and Hb. Tf, Hpx and Hp are being developed for hematological disorders where iron, hemin and Hb contribute to pathophysiology. However, complexed to their ligands, each represents a potential iron source for pathogens, which may complicate the use of these proteins.

RECENT FINDINGS

Erythrophagocytosis by macrophages and processes of cell death that lead to reactive iron exposure are increasingly described. In addition, the effects of transfusion introduced circulatory hemin and Hb are described in the literature, particularly following large volume transfusion, infection and during concomitant medical device use.

SUMMARY

Supplementation with Tf, Hpx and Hp suggests therapeutic potential in conditions of extravascular/intravascular hemolysis. However, their administration following transfusion may require careful assessment of concomitant disease.