The unrecognized effects of the volume and composition of the resuscitation fluid used during the administration of blood products.

BACKGROUND: Recent publications have reported the severe adverse events associated with blood products but have not considered the effect of the volume and composition of the resuscitative fluids infused with the blood products. METHODS: Injury leads to cellular reaction characterized by insulin resistance during which glucose cannot enter muscle and fat cells. In all cells, mitochondrial pyruvate dehydrogenase activity is decreased during insulin deficiency leaving cells deficient in substrates needed to power the Krebs cycle and make ATP. RESULTS: d-ß-Hydroxybutyrate, a normal ketone body metabolite, enters cells on the monocarboxylate transport mimicking the action of insulin and bypassing the enzymatic block at PDH. Metabolism of ketone bodies increases efficiency of mitochondrial energy production and cellular ATP level. CONCLUSION: Infusion of 250 ml of 600 mM Na d-ß-hydroxybutyrate solution, with the same osmotic strength as the hypertonic NaCl solution currently being used, would correct insulin resistance, provide energy substrates for cells to produce ATP, correct the tendency of injured tissue to swell due to decreased energy of ionic gradients and correct acidosis observed in hemorrhage.

Severe adverse events associated with hemoglobin based oxygen carriers: role of resuscitative fluids and liquid preserved RBC.

Severe adverse events have been observed following the infusion of hemoglobin based oxygen carriers in patients subjected to elective orthopedic procedures, cardiopulmonary bypass surgery, and vascular surgical procedures. Along with all three of the hemoglobin based oxygen carriers, the patients received Ringer's D,L-lactate as the resuscitative fluid, Ringer's d,l-lactate in the excipient medium for the stroma free hemoglobin, and liquid preserved red blood cells that had been stored at 4 degrees C for longer than 2 weeks. The Ringer's d,l-lactate solution has been shown to be toxic in both animals and patients. The current formulation of Ringer's lactate contains only the l-isomer which has been shown in animals to be less toxic than the d-isomer of lactate. In a recent publication morbidity and mortality have been reported associated with the length of storage of red blood cells at 4 degrees C in patients subjected to reoperative cardiac surgery. Current clinical studies to assess the safety and therapeutic effectiveness of a hemoglobin based oxygen carrier (HBOC) must consider the effects of the composition of the resuscitation solution (Ringer's L-lactate), the composition of the excipient medium (Ringer's L-lactate or 0.9% NaCl) for the hemoglobin based oxygen carrier, and the length of storage of the liquid preserved red blood cells infused with the hemoglobin based oxygen carrier.

Use of supernatant osmolality and supernatant refraction to assess the glycerol concentration in glycerolized and deglycerolized previously frozen RBC.

BACKGROUND: Human RBC are frozen at a mean temperature of -80 degrees C (with a range of -65 degrees C to -90 degrees C) with a mean concentration of 40% w/v glycerol (with a range from 36% w/v to 45% w/v) for at least 10 years. After thawing and deglycerolization the RBC should have a residual glycerol concentration of about 1%. We conducted three studies to measure the supernatant osmolality and supernatant refraction in RBC frozen with 40% w/v glycerol and stored at -80 degrees C for as long as 16 years. The measurements were made before and after deglycerolization. STUDY DESIGN AND METHODS: In the first study, one hundred and three (103) units of RBC were glycerolized to achieve a concentration of 40% w/v glycerol in an open system and frozen at -80 degrees C for as long as 16 years. In the second study, 106 units of RBC were glycerolized to achieve a concentration of 40% w/v glycerol and in an open system and frozen at -80 degrees C for a mean of 14 years. In the second study, the RBC were deglycerolized using the Haemonetics ACP215 instrument before being stored at 4 degrees C in the AS-1 or AS-3 additive solution. In the third study, fifty-five (55) units of RBC were glycerolized to achieve a 40% w/v glycerol concentration in the functionally closed system of the Haemonetics ACP215 instrument containing the high separation bowl and frozen at -80 degrees C for at least 2 months. These RBC also were deglycerolized using the Haemonetics ACP215 and were stored at 4 degrees C in the AS-3 additive solution. Before and after deglycerolization, measurements also were made of the freeze-thaw recovery and the freeze-thaw-wash recovery values, the percent hemolysis, supernatant hemoglobin level, supernatant osmolality and supernatant refraction. RESULTS: The supernatant osmolality provided an accurate estimate of the glycerol concentration in the thawed RBC before deglycerolization but the supernatant refraction did not. However, after deglycerolization, both the supernatant osmolality and the supernatant refraction gave accurate estimates of the glycerol concentration in the RBC. CONCLUSION: The osmolality measured in the osmometer of the thawed supernatant of the glycerolized RBC provided an accurate estimate of the glycerol concentration but the percent refraction measured in the Palm Abbe refractometer did not. Both the osmolality and percent refraction in the deglycerolized washed RBC provided accurate estimates of the residual glycerol.

Salvaging of liquid-preserved O-positive and O-negative red blood cells by rejuvenation and freezing.

BACKGROUND: The RBC inventory is subject to seasonal highs and lows. When the inventory is high, units may be lost due to outdating and when the inventory is low, elective surgical procedures may have to be postponed until sufficient blood is available. This study was done to determine if universal donor O-positive and O-negative RBC subjected to various methods of transportation could subsequently be rejuvenated and frozen to be used for inventory control with satisfactory results. MATERIALS AND METHODS: Units of blood were collected at two different military facilities and processed as whole blood (WB) or packed RBC. The liquid stored WB or RBC units were subjected to transportation, with or without air dropping, as part of a military exercise. The units were kept at 4 degrees C with wet ice during transportation to the NBRL for evaluation. The quality of the liquid preserved RBC was evaluated before rejuvenation and freezing and after the freeze-thaw-wash procedure. Following frozen storage at -80 degrees C, the RBC were thawed and deglycerolized using the Haemonetics 115 cell washer. In addition to measurements of freeze-thaw and freeze-thaw-wash recovery, other in vitro assessments of RBC quality were made. RESULTS: The results demonstrate acceptable quality for RBC subjected to transportation, with or without air dropping, following rejuvenation and freezing. CONCLUSION: We consider it a prudent practice for liquid preserved O-negative and O-positive RBC collected at various blood collection sites to be sent to a specific facility where the universal donor RBC can be rejuvenated and frozen as a stockpile for inventory control.

A comparison of the acute hemodynamic and delayed effects of 50% exchange transfusion with two different cross-linked hemoglobin based oxygen carrying solutions and Pentastarch.

BACKGROUND: Hemoglobin based oxygen carrying solutions (HBOC) have been designed to combine the beneficial effects of colloidal solutions with oxygen carrying capacity. Clinical trials in humans using HBOCs have had variable results. METHODS: We used a rodent 50% exchange model to compare Hemolink and Hemopure HBOC to autologous blood and Pentastarch solution. We monitored hemodynamic parameters, hemoglobin clearance, weight gain and hematocrit over a five-day period. RESULTS: Acute hemodynamic effects between the two HBOCs were similar with mild vasoconstriction. Cardiac output, systemic vascular resistance and renal function were similar to that seen with blood. HBOC's were associated with hemoglobinuria with a half-life in the circulation of 13.8 hrs for Hemolink and 19.2 hrs for Hemopure. Animals resuscitated with HBOCs exhibited delayed weight gain. CONCLUSION: Hemodynamic effects in rodents exchange-transfused with blood, Hemolink, or Hemopure were similar. The delayed weight gain observed with the HBOCs must be investigated.