Hemodynamic oxygen transport and 2,3-diphosphoglycerate changes after transfusion of patients in acute respiratory failure

Abstract

The goals of management of patients with respiratory failure include improving arterial oxygenation with PEEP and red cell transfusion to maintain oxygen carrying capacity, both of which contribute to improving tissue oxygen delivery. However, standard CPD-stored blood is rapidly depleted of 2,3 diphosphoglycerate (2,3 DPG) and ATP, with resultant inadequacy of the red cell oxygen transport function. In 15 patients requiring mechanical ventilation with PEEP whose initial Hct less than or equal to 35%, we studied the effect of transfusion of 7 ml/kg of CPD-stored packed red blood cells on hemodynamic and oxygen delivery variables, pulmonary venous admixture (QA/QT), and erythrocytic P50, 2,3 DPG and ATP concentrations. Hemodynamics were not significantly altered by transfusion. 2,3 DPG decreased significantly from 14.5 +/- 1.1 to 13.1 +/- 1.5 mcmol/g Hb (mean +/- SD, p less than 0.05). There was no significant change in P50 or ATP. QA/QT rose significantly, from 20.1 +/- 7.8 to 28.9 +/- 12.3% (mean +/- SD, p less than 0.02). In our patients, an increase in arterial oxygen content obtained by transfusion was not followed by any associated decrease in cardiac work, as implied by solution of equations for oxygen delivery and oxygen consumption. The rise in QA/QT is undesirable in patients requiring PEEP, since it complicates management of their mechanical ventilatory support.

Blood Tranfusion in Critically Ill Patients: State of the Art

“…Similarly, Kahn et al in 1986 85 showed that in critically ill patients, hemodynamic variables were not altered significantly by RBC transfusion; however, 2,3 DPG concentrations decreased significantly. More recently, the role of blood transfusion as a means toward improving oxygen transport was evaluated in 19 critically ill patients with sepsis syndrome.…”

“…85 It has been associated with various blood products including whole blood, packed red blood cells, apheresis, or whole blood-derived platelets, fresh frozen plasma, granulocytes, intravenous immunoglobulin, and cryoprecipitate. 85 The first cases of what was likely to have been TRALI appeared in the literature in the early 1950s, and approximately 20 years later an association with leukoagglutinins was suspected as the cause. 122 It was still another 15 years before the first case series was published 122 with diagnoses based on clinical symptoms.…”

Hemodynamic aspects of multiple organ failure

“…Hahn et al [14] studied the effects of increasing the hematocrit from 0.24 to 0.40 in ARDS patients: cardiac output remained constant, pulmonary shunt increased, and oxygen uptake did not change. Forst et al [15] investigated the effects of increasing hematocrit from 0.28 to 0.38 in ARDS patients, and found a decrease in oxygen delivery without changes in oxygen uptake.…”

Can We Optimize Long-Term Outcomes in Acute Respiratory Distress Syndrome by Targeting Normoxemia?

“…Theoretically, strategies to augment cardiac output and improve oxygen carrying capacity through transfusion would increase oxygen delivery. However, a complicated relationship exists between macrohemodynamics and the microcirculation (61); transfusions may not increase oxygen transport in the manner predicted (62,63); and the use of intravenous fluids (64), vasoactive agents (65), and transfusions (45) has each been associated with adverse consequences. An alternative approach would be to reduce the cerebral metabolic rate of oxygen consumption through targeted temperature management or pharmacologic coma.…”