Washing red blood cells and platelets transfused in cardiac surgery reduces postoperative inflammation and number of transfusions

Abstract

Objective Children undergoing cardiac surgery with cardiopulmonary bypass (CPB) are susceptible to additional inflammatory and immunogenic insults from blood transfusions. We hypothesize that washing red blood cells (RBC) and platelets transfused to these patients will reduce post-operative transfusion-related immune modulation and inflammation. Design Prospective randomized controlled clinical trial. Setting University hospital pediatric cardiac intensive care unit. Patients Children from birth to 17 years old undergoing cardiac surgery with CPB. Interventions Children were randomized to an unwashed or washed RBC and platelet transfusion protocol for their surgery and postoperative care. All blood was leukoreduced, irradiated, and ABO identical. Plasma was obtained for laboratory analysis: pre-op, immediately, six and 12 hours after CPB. Primary outcome was the 12-hour post-CPB interleukin (IL)-6: IL-10 ratio. Secondary measures were IL levels, C-reactive protein (CRP), and clinical outcomes. Measurements and main results 162 subjects were studied, 81 per group. 34 subjects (17 per group) did not receive any blood transfusions. Storage duration of blood products was similar between groups. Among transfused subjects, the 12-hour IL ratio was significantly lower in the washed group (3.8 v. 4.8; p=0.04) secondary to lower IL-6 levels (post-CPB: 65 v.100 pg/ml; p = 0.06; 6 hour: 89 v.152 pg/ml; p = 0.02; 12-hour: 84 v.122 pg/ml; p = 0.09). Post-operative CRP was lower in subjects receiving washed blood (38 v. 43 mg/L; p = 0.03). There was a numerical, but not statistically significant decrease in total blood product transfusions (203 v. 260) and mortality (2 v. 6 deaths) in the washed group compared to the unwashed group. Conclusions Washed blood transfusions in cardiac surgery reduced inflammatory biomarkers, number of transfusions, donor exposures, and were associated with a non-significant trend towards reduced mortality. A larger study powered to test for clinical outcomes is needed to determine whether these laboratory findings are clinically significant.

Induction of Pluripotent Stem Cell-Derived Cardiomyocyte Toxicity by Supernatant of Long Term-Stored Red Blood Cells in Vitro

“…In addition, adverse clinical outcomes were more common especially in critically ill patients [11-13]. A study by Cholette et al found that transfusion of washed RBCs and platelets during cardiac surgery reduced postoperative inflammation and number of transfusions [14]. However, several recent large prospective randomized-controlled trials (RCTs) have examined the harmful effects of transfusing long-term stored RBCs, and found no statistical significant difference in the in-hospital mortality among a general population of hospitalized patients [15], frequency of 5 major adverse outcomes among premature low-birth-weight infants [16], 90-day mortality among critical care patients [17] and Multiple Organ Dysfunction Score following cardiac surgery [18].…”

Haem is associated with thrombosis in neonates and infants undergoing cardiac surgery for congenital heart disease

“…Seven (of 15) patients in the thrombosis group and 13 (of 24) patients in the non-thrombosis group received washed red cells as per their original study assignment [9] ( Table 1). The thrombosis group had significantly more central shunt procedures and tetralogy of Fallot repairs compared to the non-thrombosis group, otherwise surgeries for underlying congenital cardiac diseases did not differ significantly.…”

“…All patients were previously enrolled in a randomized trial of washed blood transfusions as previously reported [9]. The protocol was approved by the URMC Research Subjects Review board.…”

Diagnostic and therapeutic medical devices for safer blood management in cardiac surgery: systematic reviews, observational studies and randomised controlled trials

“…47 However, a RCT of red cell washing in paediatric cardiac surgery patients failed to show a clinical benefit, although there was a reduction in a measure of inflammation (IL-6 : IL-10 ratio). 46 Importantly, no adverse effects of this technique were reported in recipients. Standard cell saver devices use low-speed centrifugation with resuspension in normalised saline without apparent detriment to human autologous or allogenic red cells.…”