Why Old Blood is Bad. tales from the electronic perfusion record. Molly Marko, BS, BSE, CCP Geisinger Health System Danville, Pennsylvania
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1 Why Old Blood is Bad tales from the electronic perfusion record Molly Marko, BS, BSE, CCP Geisinger Health System Danville, Pennsylvania
2 Disclosure I have no financial relationship with any of the companies whose products or materials are discussed here within.
3 Plan of Attack Why blood has the potential to be good Why old blood can be bad What does the electronic perfusion record tell us? Would washing donor RBC s help?
4 Allogeneic Red Blood Cells
5 Why Blood Can Be Good Oxygen Carrying Capacity CaO 2 = (1.34 x Hgb x SaO 2 ) + ( x PaO 2 ) 100% Administration of donor RBC s can increase the CaO 2, thereby increasing oxygenation
6 Why Blood Can Be Good 2,3-Diphosphoglycerate (2,3-DPG) Lowers affinity of Hemoglobin molecule for oxygen oxygen released to tissues
7 Why Blood Can Be Good Adenosine Triphosphate (ATP) Intracellular energy source Intracellular signaling molecule RBC s release ATP in response to hypoxia, ph, and mechanical stress Increase production of nitric oxide (NO) Vasodilator under hypoxic conditions
8 Why Blood Can Be Good Red Blood Cell shape Round, elastic, bi-concave discs Large surface area for O 2 diffusion Flexibility allows RBC s to pass through capillaries as narrow as 3mm Rouleaux formation
9 The Storage Lesion (aka Why Old Blood is Bad)
10 Why Old Blood is Bad Loss of 2,3 DPG Decreases quickly in first 2 weeks of storage to almost undetectable levels Increased O 2 affinity Levels appear to recover post-transfusion Up to 72 hours Studies suggest minimal physiological impact
11 Why Old Blood is Bad Decreased Intracellular ATP 40% days Associated with the reduced oxygen-delivery capacity Can induce RBC shape changes Levels recover in-vivo
12 Source: Salzer U, et al. Vesicles generated during storage of red cells are rich in the lipid raft marker stomatin. Transfusion 2008; 48:
13 Why Old Blood is Bad Morphological changes Biconcave discs Echinocytes with protrusions Spheroechinocytes Formation of microvesicles Loss of membrane phospholipids
14
15
16 Why Old Blood is Bad Morphological changes Decreased membrane deformability Increased aggregability Increased adhesion to endothelium Minimizes ability to flow through microcirculation Influences RBC transport of O 2 to tissues Increased osmotic fragility Hemolysis
17 Salzer U, et al
18 Why Old Blood is Bad Other Changes Potassium Sodium ph Lactate Glucose
19 Salzer, et al
20 Salzer U, et al
21 Loss in Membrane Deformability Independent risk factor for MOF 2,3-DPG, ATP & RBC survivability < 80% DAY DAY Steady rise in K + Steady-state K + Alteration in corpuscular shape ( hemolysis) Increased extracellular lactate, K+, pco2 Decreased ph, bicarbonate Deterioration of gastric intramucosal ph
22 The Word on the Street
23 2872 patients who received 8802 units of blood 14 days old 3130 patients who received 10,782 units of blood > 14 days old Blood older than 2 weeks was associated with a significantly increased risk of postoperative complications as well as reduced short-term and long-term survival
24 Four groups based on PRBC age: <10 days days days >19 days Transfusion of RBCs increased cerebral oxygenation except in those transfused with RBCs stored > 19 days.
25 Two groups: blood 5 days old, blood 20 days old Measured gastric ph as index of gastric oxygenation status No change in oxygenation with any transfusion Blood transfusion worthwhile?
26
27 Studies in Cardiac Surgery Patients Author, year Study type RBC Age Vamvakas, 2000 Retrospective Mean d van de Watering, 2006 Retrospective 13 days 24 days Conclusion From the currently available published data, it is difficult to determine whether there is a relationship between the age of transfused RBC s and outcome in adult patients, except possibly in trauma patients receiving massive transfusion. Wasser, 1989 Pro, Randomized < 12 hr vs 2-5d No diff post-op blood loss Vamvakas, 1999 Retrospective 1 41 days Inc risk pneumonia No change in LOS No diff survival or LOS Koch, 2008 Retrospective <14 d, >14 d Inc mortality, LOS Yap, 2008 Retrospective Median 13 days No effect
28 Loss in Membrane Deformability Independent risk factor for MOF 2,3-DPG, ATP & RBC survivability < 80% DAY DAY Steady rise in K + Steady-state K + Alteration in corpuscular shape ( hemolysis) Increased extracellular lactate, K+, pco2 Decreased ph, bicarbonate Deterioration of gastric intramucosal ph
29 Tales from the Electronic Perfusion Record
30
31 SIII INPUT CDI 500 ANESTHESIA MONITOR INVOS
32 Utilization of the EPR Use of the third timer on the Sorin S3 pump allows us to track transfusion time Three time points: Pre-transfusion Transfusion Post-transfusion Data collected every 20 seconds
33 Utilization of the EPR At the end of each case, data is wirelessly exported to a desktop computer That data can then be exported from the DMS program as an Excel file for evaluation
34 Miscellaneous timer started Miscellaneous timer stopped
35 Pre-Transfusion Data Transfusion Data Post-Transfusion Data
36 Data copy and pasted from master Excel file into separate worksheets based on three time points: Pre-transfusion (1) During transfusion (2) Post-transfusion (3)
37 We now have information separated by time point (pre-, post-transfusion) But what about the different variables?
38 Data separated into worksheets for 18 different variables Pre-, during, and post-transfusion
39 Variables Cardiac Index MAP Temperature Sweep Rate FiO 2 Hemoglobin Invos (Right) Invos (Left) SVR ph SvO 2 SaO 2 PaCO 2 PaO 2 HCO 3 Oxygen Consumption Oxygen Delivery Oxygen Extraction Ratio
40 Variables Cardiac Index MAP Temperature Sweep Rate FiO 2 Hemoglobin Invos (Right) Invos (Left) SVR ph SvO 2 SaO 2 PaCO 2 PaO 2 HCO 3 Oxygen Consumption Oxygen Delivery Oxygen Extraction Ratio
41 Oxygen Extraction Ratio (O 2 ER) Index of global oxygenation Measure of the fractional tissue uptake of oxygen from the blood at the microcirculation level O 2 ER = VO 2 /DO 2 Normal value 30%
42 Data Analysis Transfusion data separated into 3 groups based on blood age Group 1: 0 15 days old Group 2: days old Group 3: days old Multiple, concurrent transfusions of same age counted as same event Multiple, concurrent transfusions of different ages counted as same event but categorized by oldest unit
43 Percent Oxygen Extraction Ratio Group 1 Group 2 Group :00 0:06 0:13 0:20 0:26 0:03 0:09 0:16 0:23 0:29 Time
44 Percent Oxygen Extraction Ratio Group 1 Group 2 Group :00 0:06 0:13 0:20 0:26 0:03 0:09 0:16 0:23 0:29 Time
45 Percent Oxygen Extraction Ratio Group 1 Group 2 Group :00 0:06 0:13 0:20 0:26 0:03 0:09 0:16 0:23 0:29 Time
46 Percent Oxygen Extraction Ratio Group 1 Group 2 Group :00 0:06 0:13 0:20 0:26 0:03 0:09 0:16 0:23 0:29 Time
47 ml O 2 /min Oxygen Delivery (DO 2 ) Group 1 Group 2 Group 3 0:00 0:06 0:13 0:20 0:26 0:03 0:09 0:16 0:23 0:29 Time DO 2 = Q x [(1.34 x Hgb x SaO 2 )]
48 ml O 2 /min Oxygen Delivery (DO 2 ) Group 1 Group 2 Group 3 0:00 0:06 0:13 0:20 0:26 0:03 0:09 0:16 0:23 0:29 Time DO 2 = Q x [(1.34 x Hgb x SaO 2 )]
49 Cardiac Index L/min/m :00 0:07 0:14 0:22 0:29 0:06 0:13 0:21 0:28 Time Group 1 Group 2 Group 3 DO 2 = Q x [(1.34 x Hgb x SaO 2 )]
50 Cardiac Index L/min/m :00 0:07 0:14 0:22 0:29 0:06 0:13 0:21 0:28 Time Group 1 Group 2 Group 3 DO 2 = Q x [(1.34 x Hgb x SaO 2 )]
51 g/dl Hemoglobin Group 1 Group 2 Group :00 0:06 0:13 0:20 0:26 0:03 0:09 0:16 0:23 0:29 Time DO 2 = Q x [(1.34 x Hgb x SaO 2 )]
52 mmhg PaO Group 1 Group 2 Group :00 0:06 0:13 0:20 0:26 0:03 0:09 0:16 0:23 0:29 Time
53 ml/min Oxygen Consumption (VO 2 ) :00 0:06 0:13 0:20 0:26 0:03 0:09 0:16 0:23 0:29 Time Group 1 Group 2 Group 3
54 Percent Venous Oxygen Saturation (SvO 2 ) Group 1 Group 2 Group :00 0:06 0:13 0:20 0:26 0:03 0:09 0:16 0:23 0:29 Time
55 mmhg Mean Arterial Pressure :00 0:06 0:13 0:20 0:26 0:03 0:09 0:16 0:23 0:29 Group 1 Group 2 Group 3 Time
56 Points of Interest Noticeable and consistent differences between the three groups of blood Oxygen extraction least in oldest blood Venous saturation greatest is oldest blood Strongly suggests decreased ability of old blood to release oxygen to microcirculation
57 Limitations Observational study Cannot isolate storage lesion variables to determine cause and effect Limited power of certain variables due to small sample size
58 Somanetics Group 1 Group 2 Group :00 0:06 0:13 0:20 0:26 0:03 0:09 0:16 0:23 0:29 Time
59 Future Direction Continue to collect and analyze data Data analysis to show statistical significance Compute changes in oxygenation variables Correlate data to outcomes Compare washed RBC s to unwashed RBC s Create a multi-institutional data set among other DMS users
60 To Wash or Not To Wash
61 prbcs 3-21 days old Washing prbcs results in very low levels of K+.
62 Free lactate and potassium siginificantly reduced RBC osmotic resistance improved RBC aggregation capacity reduced Deformability and Free Hgb unchanged
63 Mean age of RBC s ~ 15 days Processed RBC s had significantly higher Hct, and lower levels of blood glucose, [K + ], and lactate
64 To Wash or Not To Wash? Research has demonstrated: Decreased potassium load Decreased lactate load Increased hematocrit Within the Geisinger Health System all donor RBC s are washed prior to transfusion in cases utilizing ATX Exception: emergent need for RBC s Negatives to this practice?
65 Take Home Messages After 15 days of storage: 2,3 DPG, ATP, and RBC survivability decreases Clinical significance is inconclusive based on current studies The Electronic Perfusion Record may assist in elucidating these differences The age of donor RBC s has an effect on oxygenation variables
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