Harvard

Anesthesiology Update, May 2016

Does stored blood deliver oxygen to 1ssues?

02
02
02 Walter Sunny Dzik, MD
Massachuse9s General Hospital
02 Harvard Medical School
Boston, MA
02
02
 Does blood deliver oxygen to Hssues?
A fundamental quesHon
Blood is a precious naHonal healthcare resource.
Transfusion: one of the most common procedures:
In the USA, one every 2 seconds.
Worldwide100 million transfusions annually.
Surgery, ICU medicine, organ transplantaHon, and
the treatment of heart disease and cancer all rely
upon transfusion.

Blood availability depends on a stored blood supply.

... and yet, we are not sure if stored RBCs deliver O2 !

 RBC storage duraHon

At the end of the storage period,

Hemolysis in bag < 1%
A radiolabeled small aliquot must demonstrate
75% survival of injected cells at 24 hours.

Storage Dura6on rules do not require demonstra6on

that RBCs deliver oxygen !

Laboratory tes6ng casts some doubt on O2 delivery
 RBC Morphology Changes During Storage
Day 0 Day 10 Day 35

Day 42 Day 50 Day 60

Bessis M, Weed RI, Leblond PF, 1973
2,3 DPG Laboratory Changes During Storage

Benne9-Guerrero E, et al PNAS 2007; 104: 17063-68

Reduced 2,3 DPG: O2 is not released from Hemoglobin
saturaHon
Oxygen
Oxygen satura1on
 2,3 DPG Recovers Aier Transfusion

Un-separated blood (recipient blood)

Separated blood (donor blood)

Heaton A, et al., Br J Haematol, 1989;71:131-6.

 RBC OsmoHc Fragility Increases During Storage
60
Percent Hemolysis

50
65 mM NaCL

40

30

20

10

0
1 7 14 21 28
Days of Storage
Shari S, Dzik W et al Transfusion 2000; 10: 125
 K+ Leaks out of RBC during storage

Benne9-Guerrero E, et al PNAS 2007; 104: 17063-68

 Lactate accumulates in storage bag

Benne9-Guerrero E, et al PNAS 2007; 104: 17063-68

 Loss of RBC deformability during storage
3-7 m capillary
7 m

Day 0 Day 28

Relevy et al. Transfusion 2008; 48:136-46.

Nitric Oxide, from endothelium, causes vasorelaxaHon

free Hb binds (depletes) Nitric Oxide.

 Laboratory Changes in RBCs During Storage
Membrane Enzyme Hgb
Changes Changes Changes

Morphology 2,3 DPG Loss of ATP Nitric oxide

binding
Deformability Oxygen K+ leakage
release

? ? ? ?
In vivo: Insucient Tissue OxygenaHon ?

Crit Care Med 2007 35: 11

 Nine Randomized Trials of RBC Storage Age
Name Population Design n
ARIPI (Canada) Premie infants < 8 d vs standard 377
RECESS (USA) Adult cardiac < 10 d vs > 21 d 1600
ABLE (Canada) Adult ICU < 8 d vs standard 2500
TOTAL (Uganda) Severe anemia <10 d vs > 25 d 300
ABC (USA) Children in ICU < 8 d vs standard 1500
INFORM (Canada) Adult Freshest vs Oldest 25,000
TRANSFUSE (AU) Adult Freshest vs Oldest 5000
Ferrara, Italy Surgical infect < 14 d vs > 14 d 200
Cleveland Cardiac < 14 d vs > 20 d 2800
 3 Randomized Trials on Blood Storage DuraHon
Name Popula1on n Storage Primary outcomes Result
Dura1on
ABLE ICU 2412 8 days vs 90 day mortality No di
paHents usual care
RECESS Cardiac 1098 10 days MulHple organ No di
surgery vs 21 dysfuncHon score
days

ARIPI Premature 377 <8 days vs NecroHzing coliHs; No di
infants usual care CNS bleed;
ReHnopathy;
Lung dysplasia;
Death

Conclusion: No increase in measurable side-eects

Tissue oxygenaHon by transfusion in severe
anemia and lacHc acidosis (TOTAL)

02
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02
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 O2 delivery has been hard to study
AcHvely bleeding paHents are unstable/complicated.
Non-bleeding paHents: transfusion is prophylaxis.

Mild
Hospital anemia anemia
with cardiac
Cri1cal
compensaHon
anemia

Profound anemia: RBC Tx
unable to support
aerobic metabolism

5% 10% 15% 20% 25% 30% 35% 40%

Hematocrit
Africa: Children have profound anemia
 T R A N S F U
What happens without oxygen ?S I O N M E D I C I N E
A B
Glucose
Norm
Cytoplasm NADH NAD+
HIF-1
Pyruvate Lactate
LDH
NAD+ PDH
NADH Hypo
PDK-I
Acetyl CoA HIF-

O2 CO2 +
TCA cycle
H2O
NADH ADP
Mitochrondria NAD+ ATP

Dzik WH, CserH-Gazdewich CM, Stowell CP Transfusion 2013; 53: 1168

Tissue hypoxia results in

 Severe Anemia in Uganda
Children presenting for urgent transfusion with average Hb = 3.8 g/dL.
No heart or lung disease; no trauma, shock, pressors, mech ventilation
Global ischemia with lactic acidosis due to inadequate RBC mass.

Eligibility: 6-60 months + Hgb 5 g/dL + Lactate 5 mM

1-10 days 25-35 days

Pre-storage leukoreduced AS-3 RBCs: 10 mL/kg over 120 minutes

Primary outcome: Clearance of lactic acidosis

Secondary outcomes:
Cerebral tissue oxygen saturation by near infra-red spectroscopy
Changes in clinical signs and laboratory tests
30-day follow up health status
PaHent Enrollment: Feb 2013 through May 2015 in Uganda
N=827 Screened: Age 6-60 mos; Hb 5 g/dL
N=478 Lactate < 5 mM

N=349 Met Inclusion (Hb 5 g/dL & Lactate 5 mM)

N=59 Excluded (malnutriHon,

prior transfusion, in extremis )

N=290 Consented & randomized

N=145 Shorter (1-10 days) N=145 Longer (25-35 days)

N=5 Died during rst 24 hours N=3 Died during rst 24 hours
 CharacterisHcs of two study groups
1-10 Days 25-35 Days
Age, median (IQR), months 26.5 (18.5-39.6) 25.5 (15.0-39.9)
Female / Male 71 / 74 67 / 78
Temperature, mean (SD) 37.6 (2.2) 37.4 (1.2)
Mean Arterial Pressure (SD) 73.6 (12) 72.4 (12)
Heart rate, mean (SD) 157.8 (17) 163.0 (18)
Respiratory rate, mean (SD) 53.8 (11) 55.5 (11)
Arterial O2-sat, mean (SD) 97.2 (5) 97.5 (4)
Supplemental O2 19 (13%) 13 (9%)
Hemoglobin, mean (SD) 3.6 (1.3) 3.7 (1.3)
Lactate, mM mean (SD) 9.2 (3.4) 9.5 (3.4)
Malaria 81.4% 80.0%
Sickle cell 12.4% 14.5%
 Design: RBCs 10 mL/kg during hours 0-2 by infusion pump.
145 38
Shorter Shorter Assessment at hour 4
2nd dose (same unit @ 10 mL/kg) hour 4-6, if:
R Hb < 5 g/dL
Longer Longer
Hb 5-6 g/dL and Heart rate > 140 /min
145 47

0 2 4 6 8 24 30 day
Hours follow up

Vital signs and clinical assessment

O2-saturaHon (nger pulse oximetry)
Hemoglobin
Whole blood lactate
Hour 0, 4, 24: Electrolytes, anion gap, BUN, Cr, BNP
Hour 0-2: Cerebral Hssue oxygen saturaHon (non-invasive)
 Design: RBCs 10 mL/kg during hours 0-2 by infusion pump.
145 38
Shorter Shorter

R
Longer Longer
145 47

0 2 4 6 8 24 30 days
Hours
Median Median
8 days 32 days
 Primary Outcome: Clearance of Lactic Acidosis

Shorter Longer Dierence Non-

(1-10 d) (25-35 d) Longer-Shorter inferiority
(95% CI)
ProporHon with Lactate 3mM .58 .61 +0.03 p< 0.0001
at hour 8 (.49-.66) (.52-.69) (-0.07 to )
Secondary Outcome: Cerebral tissue O2 saturation
Vital signs
Electrolyte response
 Clinical response
Coma / stupor Respiratory distress

30 day follow-up Shorter Longer Dierence p-value

Returned to .93 .86 .07 0.13
good health (.85 - .97) (.78 - .92) (-.16 to .02)
Fatal outcome 7/145 10/145 0.02 0.45
 6 DisHnguishing Features of This Study

1. Highly informaHve cohort with global ischemia.

2. LacHc acidosis due to pure anemia without confounders
for Hssue oxygenaHon:
cardiac impairment, Hssue injury, hypoxia,
hemorrhage, shock, pressors, mech venHlaHon.
3. Extremes of RBC storage duraHon tested.
4. Same rate and same volume per kg of RBCs.
5. Transfused dose was substanHal:
1 dose = 60% of recipient rbc mass
2 doses= 90% of recipient rbc mass
6. Primary endpoint not subject to observer bias.

 Conclusion

In children presenHng with severe anemia and lacHc

acidosis, transfusion of RBCs stored 25-35 days was not
inferior to RBCs stored 1-10 days for oxygen delivery as
measured by:
resoluHon of lacHc acidosis,
improvement in clinical symptoms,
normalizaHon of vital signs,
correcHon of laboratory abnormaliHes, and
improvement in cerebral Hssue oxygen saturaHon.

The results document the in vivo ecacy of stored RBCs
transfused to paHents in criHcal need of oxygen delivery.
A Dhabangi and Coauthors

Eect of Transfusion of Red Blood Cells With
Longer vs Shorter Storage DuraHon on
Elevated Blood Lactate Levels in Children With
Severe Anemia: The TOTAL Randomized
Clinical Trial

Published online December 5, 2015

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