An audit of blood component therapy in a Canadian general teaching hospital.

As part of a quality assurance program a retrospective audit of transfusion practices for packed red blood cells, fresh frozen plasma and albumin was undertaken with predetermined criteria in a general teaching hospital. Of 520 transfusion episodes with 1218 units of packed red blood cells given to 297 patients 88% were considered appropriate; of 106 episodes with 405 units of fresh frozen plasma given to 83 patients 90% were deemed appropriate; and of 187 episodes with 320 units of albumin given to 99 patients 64% were considered appropriate. The results of this audit, when compared with those of other surveys of blood use in a similar population, suggest that pretransfusion approval of requested components would reduce the number of inappropriate transfusions.     

Preparation of leukocyte-poor erythrocyte concentrates using a simple aspiration technic

Depletion of leukocytes from red blood cells can prevent transfusion reactions in HLA-sensitized patients. We describe a simple technique of aspiration of the buffy-coat after centrifugation of red blood cells concentrates, less than 6 days old. This method can remove 87% of the leukocytes. The average leukocyte count after aspiration is 2 x 10(8). This method is inexpensive and does not require any special equipment.     

Collection, storage and transfusion of blood stem cells for the treatment of hemopoietic failure.

Migration of hemopoietic stem cells via the blood to sites of stem cell need is a principle that becomes established during the embryonic development of hemopoiesis and can be observed in the adult whenever bone marrow transplantations are being performed. The regular presence of stem cells in the peripheral blood lends itself to the study of their collection, storage, and use for transfusion purposes in cases of bone marrow failure. Both in dog and in man, granulocyte-macrophage progenitor cells (CFU-C) can be collected by leukapheresis from the blood in large quantities, particularly if the yield is increased by the administration of mobilizing agents such as dextran sulfate, and appear to be an indicator for the presence of stem cells. For collection and storage, a closed plastic bag system has been developed that allows the safe handling of the cells. The loss of CFU-C from freezing and thawing with DMSO as a cryoprotective agent is only 10%-20%. If frozen and thawed mononuclear leukocytes are transfused into 1200 rad whole-body X-irradiated autologous or allogeneic recipient dogs, a hemopoietic take is observed when 0.2 X 10(5) CFU-C are present among the mononuclear leukocytes (MNC). Graft-versus-host disease can be avoided in the allogeneic situation when a purified CFU-C rich cell fraction is being transfused. In man collection and storage of MNC including CFU-C is feasible and may eventually become a therapeutic tool.     

Frozen-thawed red cells--standard article for hospital use?

The freezing and storing of glycerol protected red cells allows the present 20---40 day limitation of red cell storage to be indefinitely lengthened. Although frozen thawed cells are more expensive to prepare than ordinary packed cells, the longer shelf-life of the red cells, the reduced risk of hepatitis transmission, and the reduction of immunization against leuko- and thrombocytes, are all advantages which out-weighed this additional cost. To effect an increase in their use, frozen thawed cells could be distributed from central blood banks to hospitals were they would be stored until needed for transfusion. Thawing and washing would necessarily be done by the hospital blood bank personnel.     

Leukocyte depletion for safe blood transfusion

Leukocytes have ability to distinguish between self cells (body own cells) and foreign (allogenic) cells on the basis of human leukocyte antigen (HLA) proteins that are present on the cell membrane and are effectively unique to a person. During allogenic blood transfusion a person receives large number of allogenic donor leukocytes and these are recognized as foreign cells by the recipient immune system which leads to several adverse reactions. To avoid such leukocyte-mediated adverse reactions leukodepleted blood transfusion is required. Leukocytes can be separated on the basis of size, dielectric properties, by affinity separation, freeze-thawing and centrifugation but all these methods are time consuming and costly. Filtration is another method for leukocyte depletion that is comparatively less expensive and more efficient as it gives more than 90% leukodepletion of blood along with minimal cell loss. However, present filtration procedures also have some limitations as they work efficiently with blood components but not with whole blood and show non-specific adhesion of large number of platelets and red blood cells along with leukocytes. All the currently available filters are costly, which has been a major reason for their limited application. Therefore, demand for a more efficient and cost-effective filter is high in medical community and scientists are attenpting to improve the efficiency of currently available filters. The present review gives an overview of the significance of leukodepleted blood transfusion and focuses on different methods for leukocyte depletion and challenges involved in all these technologies.     

An optical method for the determination of platelet count in platelet samples contaminated with red blood cells.

We present a simple photometric method to determine the total concentration of platelets present in a sample independently of red blood cell concentration. Standard optical density curves for platelet samples ranging in concentration from 0 to 1.5 x 10(9) cells/ml and contaminated with red blood cells ranging in concentration from 0 to 0.03 x 10(9) cells/ml are determined. A study of the absorbance spectra of red blood cells and platelets suggests that by calculating the absorbance difference between two wavelengths, an estimate of red blood cell concentration can be made. Then, in the second step of this two-step method, the individual absorbance measurements at the two wavelengths are matched to the standard values determined previously to derive an estimate of platelet concentration. In a trial of 62 unknown platelet samples contaminated with red blood cells, the standard deviation for the error in platelet count was 0.16 x 10(9) cells/ml with a mean difference of 0.011 x 10(9) platelets/ml. We conclude that our method may be useful in laboratories not equipped with electronic cell counters as well as in applications such as the development of noninvasive measurements of platelet concentration in platelet transfusion packs.     

Collection of hematopoietic stem cells from canine peripheral blood and their ability to regenerate hematopoiesis]

A procedure is presented for the collection of a large number of hemopoietic stem cells from the peripheral blood of dogs by means of a single leukapheresis using the NCI-IBM Blood Cell Separator. In the course of a leukapheresis of about 285 min duration a mean of 23 x 10-9 leukocytes is collected from the blood. The hemopoietic stem cells among such separated leukocytes initiate repopulation of bone marrow within 10 days after whole body X-irradiation with 1200 R. The cell numbers in a defined histological section of femoral bone marrow are evaluated 9 to 10 days after irradiation and subsequent autologous transfusion of 6.72 x 10-9 separated mononuclear leukocytes. The results indicate that the bone marrow cell numbers of transfused dogs are significantly greater than in dogs given only 1200 R and reach a level of approximately 49% of the normal value. Possible ways of increasing the yield of hemopoietic stem cells from the peripheral blood will be considered.     

Human red blood cells with normal or improved oxygen transport function prepared and frozen in the primary polyvinyl chloride plastic blood collection container.

This is a report a a new system for freezing human red blood cells in the same polyvinyl chloride plastic container in which the blood is collected and separated into components. This polyvinyl chloride plastic collection bag with integrally attached transfer packs for blood collection, component separation, red blood cell biochemical modification, freezing, storage, and post-thaw dilution before washing, represents a major advancement in the freeze-preservation process. The label with the donor's blood type and identification number affixed to the bag at the time of collection remains in place throughout the freezing and thawing process. The transfused red blood cells are of superior quality, and the processing cost is less than with other methods of freeze-preservation. There is a lower risk of contamination with these red blood cells because manipulation of the product is kept at a minimum. "Rejuvenation", a bioengineering process by which outdated red blood cells can be salvaged, can be incorporated into the preservation process using one of the attached transfer packs of the primary collection bag. This process has been introduced as a possible means of alleviating the dramatic blood shortages which occur periodically. Red blood cells may also be "rejuvenated" after storage in the liquid state to increase their 2,3 DPG and ATP levels to 150 to 200% of normal, and these red blood cells with improved oxygen transport function have been administered to anemic patients with and without cardiopulmonary insufficiency, patients undergoing cardiopulmonary bypass and treatment with hypothermia during cardiac surgery, and in instances where nonhemolytic transfusion reactions might be expected.     

Use of platelet concentrate in eastern Ontario.

To better understand the reasons for the increasing use of platelet concentrate in Canada, we undertook a 4-month study of platelet concentrate transfusion in six eastern Ontario hospitals in 1985. A total of 4801 units of platelet concentrate were transfused on 687 occasions to 303 patients; the average number of transfusions per patient was 2.3, the average number of units per transfusion 7.0 and the average number of units per patient 15.8. The cardiovascular service used the largest proportion of units (28%), aortocoronary bypass grafting being the most common procedure. The mean pretransfusion platelet count for the medical and oncology services was about 30.0 X 10(9)/L, compared with 155.5 X 10(9)/L for the cardiovascular service. An increment in platelet count 1 hour after transfusion was noted with 238 (75%) of the transfusions for which the data were available; the average increment was 3.4 X 10(9)/L per unit of platelet concentrate transfused. When the data for patients who did not respond were excluded, the average increment was 6.9 X 10(9)/L. Single-donor platelet concentrate was requested for only half of the transfusions to which no response was detected. The current medical literature supports the appropriate use of platelet concentrate in patients with thrombocytopenia due to chemotherapy, but prophylactic platelet transfusion for patients undergoing cardiovascular bypass procedures is being questioned. We advise continued surveillance of the use of these products and re-evaluation of the aims of platelet transfusion therapy.     

Platelets and leukocytes in the lungs after acute hypobaric hypoxia

To determine if decompression from sea level causes aggregation and embolization of platelets or leukocytes to the lungs, we have measured the accumulation of 51Cr-labeled platelets or 111In-labeled leukocytes in the lungs of rabbits decompressed to 440 or 350 Torr for 18 or 40 h. To be certain that any increased accumulation of labeled platelets (or leukocytes) in the lungs was not just caused by an increased pulmonary blood volume we also labeled the rabbits red blood cells with 59Fe. There was no detectable accumulation of labeled platelets in the lungs on decompression. In control animals there were 22 times as many labeled leukocytes in the lungs as could be accounted for by the volume of blood in the lungs. In experimental animals at 326 Torr for 18 h this figure was reduced to 13.6. Hypobaric hypoxia caused an increase in circulating granulocytes from a mean of 3.3 +/- 1.6 X 10(9)/l to 5.3 +/- 2.1 X 10(9)/l. (P less than 0.005). Our results suggest that decompressions to 6,100 m for 18 h does not cause platelet sequestration in the lungs but does cause a significant reduction in leukocytes in the lungs and a peripheral granulocytosis.     

Initial personal results of a technic of removing leukocytes by filtration on cotton fibers (Imugard Ig 500, Terumo)

The technical parameters of blood filtration through cotton Imugard IG 500 filters were evaluated. Sixty units of red cell concentrates were filtered. The mean value of the residual leukocytes indicated a leukocyte depletion greater than 98%, disregarding the unit age and the filtration temperature. The number of residual leukocytes was below 1 X 10(8) in 94% of the filtered units and less than 0.3 X 10(8) in 68%. The number of residual platelets was less than 1 X 10(10) in 92% of these units.     

Anti-IgA-mediated transfusion reactions in Canada.

During a 6-year period (1977 to 1982) blood samples from 152 Canadian patients were referred to the national reference laboratory of the Canadian Red Cross Society because the referring hospitals had not been able to determine the cause of the patients'' severe nonhemolytic transfusion reactions. Twenty-one patients were found to be IgA deficient, and 12 of them had strong class-specific anti-IgA antibodies, which were presumed to have been responsible for the reactions. The spectrum of symptoms that accompanied these violent reactions was documented for 10 of the patients. As a probable minimum, the incidence of anti-IgA-mediated reactions averaged 1.3 per million units of blood or blood products transfused during this period.     

Where does blood go? Prospective observational study of red cell transfusion in north England

ObjectiveTo collect population based information on transfusion of red blood cells.DesignProspective observational study over 28 days.SettingHospital blood banks in the north of England (population 2.9 million).ParticipantsAll patients who received a red cell transfusion during the study period. Data completed by hospital blood bank staff.ResultsThe destination of 9848 units was recorded (97% of expected blood use). In total 9774 units were transfused: 5047 (51.6%) units were given to medical patients, 3982 (40.7%) to surgical patients, and 612 (6.3%) to obstetric and gynaecology patients. Nearly half (49.3%) of all blood is given to female recipients, and the mean age of recipients of individual units was 62.7 years. The most common surgical indications for transfusion were total hip replacement (4.6% of all blood transfused) and coronary artery bypass grafting (4.1%). Haematological disorders accounted for 15.5% of use. Overall use was 4274 units per 100 000 population per year.ConclusionIn the north east of England more than half of red cell units are transfused for medical indications. Demand for red cell transfusion increases with age. With anticipated changes in the age structure of the population the demand for blood will increase by 4.9% by 2008.

What is already known on this topic

There have been no systematic population based surveys on use of red cells in the United KingdomStudies in France and the United States have shown that more than half of transfused red cells go to surgical patients

What this study adds

In the north of England over half of red cells are given for medical indicationsRates of red cell transfusion rise steeply with advancing ageSmall increases in the number of elderly people will have large effects on demand     

Preparation of leukocyte-poor erythrocyte concentrates by glycerin treatment and washing

The discontinuous washing procedure of red cell concentrates with saline was modified in order to improve the removal of leucocytes and platelets. It was achieved by glycerolization and deglycerolization without freezing and thawing. The elimination rate of leucocytes amounted to 99.9% and of platelets to 97.4% related to whole blood. A unit of red cell concentrate prepared from 400 ml of donated blood contained a total of (0.001 +/- 0.003) X 10(9) leucocytes and (2.35 +/- 1.33) X 10(9) platelets. The relatively high elimination rates are comparable with those obtained by filtration and cryopreservation, respectively. The whole procedure performed in glass bottles required one hour more than washing three times without glycerolization. A further improvement of the procedure should be directed towards saving time in processing and towards lowering the loss of red cells that is still 20%.     

Preservation of erythrocytes by freezing in liquid nitrogen. Use of an I.B.M. blood regenerator]

The freezing of blood permits preservation of red cells over long periods of time, several months or years. Leucocyte and platelet contamination of red cell concentrates to be frozen is negligible. The amount of the various red cell metabolites (2.3 D.P.G., A.T.P., etc.) is maintained. Washing of thawed red cells removes the remaining plasma proteins and cell residues. The freezing method employed is that of Row et al. The protector used is 28% glycerol added in equal amounts to red cell concentrate to be frozen. The blood bag is kept in liquid nitrogen at -- 196 degrees C. Thawing takes place in a water bath at 45 degrees C. Wash solution is the IBM Blood regenerator. The solution used for removing glycerol is hypertonic natrium chloride. The following parameters have been investigated: --hemoglobin level; --osmotic fragility; --the amount of 2.3 D.P.G.; --residual glycerol after thawing; and clearance of leucocytes and platelets following each step of the protocol. Preliminary data regarding these features and therapeutic efficiency of processed blood are satisfactory.     

Effect of hematocrit on cerebral blood flow with induced polycythemia

Cerebral blood flow (CBF) is lowered during polycythemia. Whether this fall is due to an increase in red blood cell concentration (Hct) or to an increase in arterial O2 content (Cao2) is controversial. We examined the independent effects of Hct and Cao2 on CBF as Hct was raised from 30 to 55% in anesthetized 1- to 7-day-old sheep. CBF was measured by the radiolabeled microsphere technique before and after isovolemic exchange transfusion with either oxyhemoglobin-containing erythrocytes (in 5 control animals) or with methemoglobin-containing erythrocytes (in 9 experimental animals). Following exchange transfusion in the control animals, Hct rose (30 +/- 1 vs. 55 +/- 1%, mean +/- SE), Cao2 increased (15.1 +/- 0.8 vs. 26.7 +/- 0.9 vol%), and CBF fell (66 +/- 9 vs. 35 +/- 5 ml X min-1 X 100 g-1). Because the fall in CBF was proportionate to the rise in Cao2, cerebral O2 transport (CBF X Cao2) was unchanged. Following exchange transfusion in the experimental animals, Hct rose (32 +/- 1 vs. 55 +/- 1%) but Cao2 did not change. Nevertheless, CBF still fell (73 +/- 4 vs. 48 +/- 2 ml X min-1 X 100 g-1) and, as a result, cerebral O2 transport also fell. The latter cannot be attributed to a fall in cerebral O2 uptake, as cerebral O2 uptake was unaffected during each of these conditions. Comparison of the two groups of animals showed that approximately 60% of the fall in CBF may be attributed to the increase in red cell concentration alone. It is probable that this effect is due largely to changes in blood viscosity.     

A high-performance liquid chromatographic method for the determination of tocopherol in plasma and cellular elements of the blood.

A rapid sensitive, and reproducible procedure is described for the analysis of alpha-tocopherol in blood cells and plasma using high-performance liquid chromatography and fluorometric detection. The cardinal feature for the increased sensitivity of this high-performance liquid chromatographic procedure is that the fluorometric analysis was carried out at a short excitation wavelength (205 nm) which increased the sensitivity of 20-fold over the usual excitation wavelength of 295 nm. Tocopherol levels can be measured in as little as 50 microliters of plasma and 200 microliters of erythrocytes. The tocopherol contentof plasma, red blood cells, platelets, polymorphonuclear leukocytes, and lymphocytes of normal subjects and subjects ingesting additional quantitites of vitamin E are reported. The values for the white cells are approximately 30 times higher than those of the red blood cells (polymorphonuclear leukocytes 4.47 +/- 0.62 micrograms/10(9), lymphocytes 3.89 +/- 0.85 micrograms/10(9), and erythrocytes 1.40 +/- 0.14 micrograms/10(10) cells). The tocopherol contents of the plasma and all the cellular elements of the blood were increased by oral feeding with vitamin E.     

Cryopreservation of human granulocytes.

Granulocyte preservation was undertaken using hydroxyethylstarch for both sedimentation of red cells and cryopreservation of buffy coat white cells from CPD whole blood. Buffy coats were mixed with HES to a final concentration of 4% (w/v) and hematocrit of 30%, and sedimented in inverted plastic syringes. The leukocyte enriched (100–500×) supernatant was frozen at 2.0 °C/min to ?80 °C (and stored frozen up to 3 months). Alternatively, sedimented leukocytes were frozen after a slow addition of 10% DMSO to 5%. Tubes were thawed at 37 °C, and DMSO was removed by dilution with Hank's solution containing CPD and centrifugation. The pellets of granulocytes were resuspended in Normosol.Buffy coat from 10 units yielded 60 ± 9.7% of the available whole blood leukocytes, of which 43 ± 14% were recovered after sedimentation in HES. Freezing in DMSO yielded all, 101% of the prefrozen leukocytes. Postthawed viability of granulocytes was estimated morphologically and by their ability to inhibit the rate of growth of E. coli. Complete inhibition was observed at a ratio of one E. coli to one granulocyte. Postthawed granulocytes were characterized by high myeloperoxidase activity and exclusion of trypan blue. Approximately 25% of the total available granulocytes in CPD whole blood were recovered.     

Evaluation of human peripheral blood leukocytes for mast cell tryptase

Murine monoclonal and goat polyclonal antibodies against tryptase, the dominant neutral protease and protein component in secretory granules of human mast cells, were used to assess the presence of tryptase in peripheral leukocytes. Carnoy's fluid-fixed cytocentrifuge preparations of enriched populations of lymphocytes, monocytes, eosinophils, and neutrophils showed no reactivity with anti-tryptase antibodies by a sensitive indirect immunoperoxidase procedure. Dispersed human lung mast cells showed strong granular cytoplasmic staining with both antibodies, whereas only approximately 50% of the peripheral blood basophils detectable with Wright's stain were detected with anti-tryptase antibodies, and these showed a staining pattern that was faint, granular, and cytoplasmic at high concentrations of antibody. At lower antibody concentrations mast cell staining was still intense, whereas basophils were not stained. Extracts of neutrophils and lymphocytes of up to 90% purity had undetectable amounts of tryptase by an ELISA sandwich immunoassay, as well as undetectable enzymatic activity with tosyl-L-gly-pro-lys-p-nitroanilide (a sensitive substrate for tryptase) in the presence of soybean trypsin inhibitor. Extracts of basophil-enriched (6 to 50% purity) preparations contained 0.046 +/- 0.013 pg of tryptase per basophil by the immunoassay along with 2 X 10(-9) +/- 0.8 X 10(-9) U of tryptase-like enzyme activity per basophil, compared with corresponding values of 12 pg, 480 X 10(-9) U of tryptase per human lung mast cell. Thus very small amounts of tryptase are present in human basophils (approximately 0.4% of that found in mast cells), but not in other peripheral leukocytes.     

Improving the quality of washed and buffy coat-free erythrocyte concentrates]

Washing buffy-coat free erythrocyte concentrates three times in bottles used for blood storage will diminish their leukocyte content to 0.22 +/- 0.11 x 10(9) per TE (= 9% of the initial value in whole blood, and the thrombocyte content to 0.3 +/- 0.5 x 10(9) per day (= 2% of the initial value in whole blood). Even 50% of leukocytes (mainly lymphocytes) and 80% of thrombocytes are eliminated simply by buffy coat separation. 30% of erythrocytes are lost by the washing process. Due to increasing haemolysis (0.22%) a subsequent storage of 24 hours should not be exceeded for washed erythrocyte concentrates. Further quality parameters, such as morphological index, pH, ATP, 2,3-P2G and K+ and Na+, were investigated. As far as selected quality parameters are concerned, washing erythrocyte concentrates three times in bottles for blood storage may be compared with washing them once in blood bags. The present findings confirm the conclusion that the washing of erythrocyte concentrates with a solution of sodium chloride in order to eliminate leukocytes may for the most part exclude non-haemolytic febrile transfusion reactions, but not immunization. More effective procedures of eliminating leukocytes, such as filtration, TTK or even glycerin, treatment of erythrocyte concentrates without cryoconservation, are indispensable.