Blood transfusion in the critically ill: does storage age matter?

Abstract

Morphologic and biochemical changes occur during red cell storage prior to product expiry, and these changes may hinder erythrocyte viability and function following transfusion. Despite a relatively large body of literature detailing the metabolic and structural deterioration that occurs during red cell storage, evidence for a significant detrimental clinical effect related to the transfusion of older blood is relatively less conclusive, limited primarily to observations in retrospective studies. Nonetheless, the implication that the transfusion of old, but not outdated blood may have negative clinical consequences demands attention. In this report, the current understanding of the biochemical and structural changes that occur during storage, known collectively as the storage lesion, is described, and the clinical evidence concerning the detrimental consequences associated with the transfusion of relatively older red cells is critically reviewed. Although the growing body of literature demonstrating the deleterious effects of relatively old blood is compelling, it is notable that all of these reports have been retrospective, and most of these studies have evaluated patients who received a mixture of red cell units of varying storage age. Until prospective studies have been completed and produce confirmative results, it would be premature to recommend any modification of current transfusion practice regarding storage age. In 1917, Frances Payton Rous and J.R. Turner identified that a citrate-glucose solution allowed for the preservation of a whole blood unit for up to five days, thus facilitating the formative practice of blood banking. Later, Loutit and Mollison of Great Britain developed the first anticoagulant of the modern era, known as acid-citrate-dextrose (ACD). ACD extended the shelf life of refrigerated blood to 21 days, and ACD remained in wide spread usage until the 1960s, when it was replaced by citrate-phosphate-dextrose (CPD) and citrate-phosphate-dextrose-adenine (CPDA) solutions that increased shelf life to 35 days and 42 days respectively. More recently, additive solutions containing saline, adenine, and dextrose have been developed to augment red cell survival following transfusion, although without any direct increase in storage duration. It is now well appreciated, however, that a number of morphologic and biochemical changes occur during red cell storage prior to product expiry, and these changes may hinder erythrocyte viability and function following transfusion. Despite a relatively large body of literature detailing the metabolic and structural deterioration that occurs during red cell storage, evidence for a significant detrimental clinical effect related to the transfusion of older blood is relatively less conclusive, limited primarily to observations in retrospective studies. Nonetheless, the implication that the transfusion of old, but not outdated blood may have negative clinical consequences demands attention. The purpose of this report is to describe the current understanding of the ...

Impact of the age of stored blood on trauma patient mortality: a systematic review

“…14 In the trauma patient population, we identified 4 singlecentre retrospective studies examining the impact of storage lesion using a cutoff of 14 days to denote old blood. While studies have varied in their inclusion criteria, particularly the number of units transfused, there is a trend toward studies reporting an increase in adverse patient outcomes following transfusion of older blood, including multiorgan failure, 26 longer ICU/hospital length of stay, 27 pneumonia 44 and other major infections 17,45 and all-cause mortality. 30,[32][33][34] Trauma patients who receive large volumes of blood as part of massive transfusion protocols may have an increased risk of death compared with those who receive smaller total volumes of old blood, suggesting that a dose effect of older blood may exist for various outcomes.…”

Red Blood Cell Storage Duration Is Associated with Various Clinical Outcomes in Pediatric Cardiac Surgery

“…The clinical relevance of these changes is controversial, with no consensus regarding a cut-off for fresh or old RBCs. An increase in infection rates and morbidity following transfusion of old blood has been described [2,3,4,5,6,7,8,9,10,11]. Other groups did not find a correlation between the storage time of transfused RBCs and patient outcome [12,13,14,15,16].…”

Nutritional Supplementation of Donors May Improve Outcomes Following the Transfusion of Stored Red Blood Cells

“…These investigations have assessed post-transfusion differences in clinical outcomes not only in adults but also in the pediatric population. Studies have reported an increase in morbidity and mortality upon transfusing older stored RBCs in situations such as acute trauma requiring large volumes of transfused blood, cardiovascular surgery, adult critical care, and pediatric medicine (Gorman et al, 2008;Nee et al, 2010;Gauvin et al, 2010;Vandromme et al, 2009).…”

“…Previous publications have shown the benefits in providing a metabolic substrate to maintain ATP (Zimrin & Hess, 2009;Wang et al, 2012) and DPG levels during the storage (Dawson et al, 1981a(Dawson et al, , 1981bSt. Cyr, Ericson, & Johnson, 2010, 2014. Taking a metabolic supplementation for at least 5 days could benefit subsequent blood donations.…”