Max M. Strumia

Significance of Measurement of Plasma Volume and of Indirect Estimation of Red Cell Volume

Total blood volume (TBV) and red cell volume (RCV) determinations have become an established diagnostic procedure in a variety of conditions; they are being used increasingly to estimate the requirement of blood transfusion. A common laboratory practice is to determine indirectly the RCV and/or the TBV by measuring the plasma volume (PV) and the venous hematocrit (VH). This procedure is technically simple and has been made popular by a number of semiautomatic electronic devices. In the healthy population we find results of the direct and the indirect measure of the RCV to be not statistically different, although they may differ by as much as ± 10% in individual cases. Larger discrepancies between the results of the two methods have been reported in patients by numerous investigators.

Preservation of Whole Blood in Frozen State for Transfusion

Addition of sugars to whole citrated human blood permits freezing and thawing with recovery of a large percentage of erythrocytes. Survival of erythrocytes thus frozen, transfused without further modification after thawing, has been satisfactory after 6 months of storage at –93�C.

Survival of Red Cells

IN all conditions involving acute or chronic deficit of hemoglobin, the effectiveness of blood transfusions is due, in different measure, to the capacity of the red cell to survive in the recipient’s circulation. It might appear, at first, natural to base the measure of such capacity on the comparison of survival of transfused red cells with the normal span of red cells in circulation. However, i t is necessary to consider the fact that a physiologically acceptable measure of the red cell life span must be obtained with a method which does not involve any extracorporeal transit of blood, since damage to red cells would result otherwise, and cause an accelerated loss of cells from circulation. Such procedure was followed by Shemin and Rittenberg,zo who tagged a normal subject’s own red cells by oral administration of N15 labelled glycine. With this method, the average life span of red cells was found to be 127 days. However, the red cells involved belonged to a limited number of generations, covering approximately a three-week period. Red cells involved in a transfusion, on the other hand, are of a mixed age and subject to extracorporeal trauma; their survival could not be compared with that of an unharmed, limited age population of red cells. A significant finding from the classical experiment of Shemin and Rittenberg was the variation found in the life span of normal red cells: red cells began to disappear from circulation after 80 days, suggesting that in normal subjects some degree of random red cell destruction exists. Other cells lived beyond the 127-day period: this “tailing” was later shown by Dornhorsta Red Cells

THE DEVELOPMENT OF PLASMA PREPARATIONS FOR TRANSFUSIONS

Excerpt Experimentally plasma or serum was used as far back as 1871 by Bowditch1and a year later by Luciani.2A very extensive bibliography of the earlier experimental works on serum and plasma is c...

Transfusion of Long Stored Whole Blood or Washed Red Blood Cells Incubated with Adenine and Inosine

Full unit autotransfusions of long stored ACD blood, incubated with adenine and inosine at 37 C., were given to healthy young male volunteers. Red cells of blood stored for 35 days showed, after regeneration, a significant increase in ATP and a 24‐hour posttransfusion survival of 78.8 per cent (70.9–85.9%); red cells of blood stored for 42 days, thus regenerated, showed a similar increase in ATP and a 24‐hour posttransfusion survival of 75.6 per cent (71.5–80.6%). These results were not significantly different from those obtained with 10‐ml token autotransfusions of blood similarly treated, the posttransfusion survival of red cells in token transfusions being 78.8 per cent for blood stored 35 days prior to regeneration with adenineinosine and 74 per cent for blood stored for 42 days prior to regeneration. Available data on toxicity of adenine and inosine have been critically reviewed: Chance of direct toxic effects with the small amounts involved may be dismissed when few transfusions are involved; however, uric acid overload must be considered when multiple transfusions are required within a short period of time. A single washing with saline‐glucose solution reduces by 90 per cent the concentration of un‐metabolized adenine and inosine, and of the product of their metabolism, hypoxanthine. The washing procedure involves a loss of only 0.55 per cent of the total red blood cell population; washing additionally reduces the amount of free hemoglobin. Washing has no effect on the ATP or red blood cell viability, and is recommended when multiple transfusions of cells treated with adenine and inosine are required in a short period of time.

Effect of Multiple Additions of Adenine-Inosine on the Function of Stored Erythrocytes

Prolongation of the viability of red cells in vitro has been the goal of many investigations. Freezing of red cells is theoretically a good solution; it is not as yet practical except under special conditions. Addition of nucleotides, as supplied by adenine (1) and, preferably, of adenine and a nucleoside, inosine (2-4), has achieved considerable success. However, while searching for longevity, study of the function of stored cells has been neglected. Valtis and Kennedy reported (5) that the affinity of hemoglobin for oxygen increases with storage of blood in acid-citrate-dextrose (ACD) solution in the cold. With this increased affinity, oxygen release to tissue is decreased; several hours are required for partial restoration of normal oxygen release. Such delay may have serious consequences in the case of acute blood loss. In 1967, Benesh and Benesh (6) and Chanutin and Curnish (7) found that certain phosphorylated compounds, particularly adenosine triphosphate (ATP) and 2, 3-diphosphoglycerate (2,3-DPG) control the oxygen affinity of hemoglobin; ATP and 2, 3-DPG appear to have a similar effect on a molar basis (8). Adenine added to ACD blood, while increasing the useful period of storage to 35 days, was found to increase the oxygen-hemoglobin affinity (9); incubation of stored ACD blood with inosine at 37—° was found to restore partially ATP, 2,3-DPG, and oxygen dissociation (8, 9). Bunn et al. (9) state that when inosine was added to ACD-adenine blood at the time of collection, oxygen affinity increased much more slowly; addition of inosine at 20 days of storage and incubation at 37°, showed improvement of the level of 2,3-DGP and ATP, with decreased oxygen affinity. Valeri and Hirsh (10) found that the ATP of stored ACD cells increases rapidly after transfusion, but 2, 3-DPG increases more slowly, being above the 50% level at 24 hr postransfusion and requiring 11 days to reach the maximal level.

Effect of Lactose, Dextran and Albumin on Recovery and Survival of Frozen Red Cells

We have studied the effect of albumin and dextran, with and without previous modification with lactose, on the recovery and posttransfusion survival of red cells subjected to rapid freezing and thawing.

Agglutinability of Red Cells After Long-Term Storage in the Frozen State

A description of a simple method for preservation of red cells modified by lactose‐dextrose solution in the frozen state at —93 C. The agglutinability as measured by a titration of anti‐sera vs. fresh and frozen cells was maintained after periods of storage of up to three years for the blood factors A, B, C, D, E, c, e, K, k, M, N, and Fya. S and s were also still reactive after freezing and thawing.

ALTERATIONS IN BANKED BLOOD, WITH SPECIAL REFERENCE TO HEMOSTASIS.

A review of the literature on the subject of coagulation factors in stored blood and of the effect of massive transfusions of stored blood in hemostasis reveals profound differences of opinion. Tullis’ studied platelets separated by elution from cation-exchange resins and stored in a medium containing sterile gelatin solution a t refrigerator temperature. In vitro studies included evaluation of the morphology, of the clot-promoting ability, and of the thromboplastic activity of platelets. Platelets were assayed in a two-stage prothrombin-conversion system: the prothrombin-conversion activity was found to be preserved for 10 weeks. On the basis of these in vitro studies and of results of four platelet transfusions to two patients with thrombocytopenia due to marrow failure, t he author concluded tha t platelets appear to be metabolically relatively inert and to be susceptible to preservation for periods of time f a r in excess of the other cellular elements. Soulier e t al.? found tha t in stored blood, Factor V was reduced to about 25 per cent in 21 days ; Factor I1 was practically unchanged fo r up to 21 days, while Factor VII increased perceptibly. Factor VIII was found to be diminished, but a n exact measurement was not possible because of the increasing “global” thromboplastic activity. This they attr ibuted to a thromboplastic factor present in stored blood, even af te r removal of platelets. In the experience of Soulier, clot retraction was greatly diminished at one week and practically zero at 21 days. Seventy-five per cent of the platelets were found present in the blood af te r 21 days of storage. Mustard,:’ in 1956, noted contrasting results in the reported studies of platelet survival and presented a detailed critical study of platelet survival in vitro by a battery of tests including platelet counts, platelet morphology, calcium-clotting time, prothrombin consumption, one-stage prothrombin time and alumina/plasma-thromboplastin activity. The authors found an “unexpectedly” good survival of platelets. These amounted to a n average of 50 per cent at seven days; 16-41 per cent at 21 days. They found tha t a f te r the first three days, platelet count becomes very variable. One interesting observation is tha t the thromboplastin generated by platelets stored 21 days was 56-170 per cent of tha t of the first day. The calcium-clotting time was found to remain normal for the entire period of storage, whereas the prothrombin-consumption time was consistently more than 60 seconds. One important statement is tha t platelets during collection are subject to

Effect of Sugars on Erythrocytes Preserved at 0° to −3°.

Summary Sucrose and lactose exert a preserving effect upon erythrocytes when stored at 0°C to −3°C. Sixty-four transfusions of blood thus stored for periods of time up to 47 days have shown good survival of the transfused cells. In the experiments in vivo the concentration of sugars varied from 3 to 5%. The experimental conditions were not always necessarily optimal for red cell preservation, and therefore the limits of storage are not maximal and will most likely be extended in future work. No attempt has been made to study the mechanism of action of the sugars on the preservation of red cells.