ORIGINAL CONTRIBUTION
Specialized Blood Filters and Fresh Whole Blood Cornelius Olcott IV, MDt Robert C. Lim, Jr, MD* San Francisco, California
P l a t e l e t c o u n t s a n d platelet f u n c t i o n s w e r e d e t e r m i n e d in f r e s h w h o l e b l o o d b e f o r e a n d after it p a s s e d t h r o u g h t w o t y p e s o f s p e c i a l i z e d transf u s i o n filters. B o t h filters w e r e c a p a b l e o f t r a p p i n g 20% to 40% o f the f u n c t i o n a l platelets, n e c e s s a r y for h e m o s t a s i s , e s p e c i a l l y if h e p a r i n w a s u s e d as the a n t i c o a g u l a n t . W h e n fresh w h o l e b l o o d is n e e d e d to treat the b l e e d i n g p a t i e n t w h o h a s a l r e a d y r e c e i v e d m a s s i v e b l o o d transfusions, t h e s e s p e c i a l i z e d filters s h o u l d p r o b a b l y n o t be used.
This s t u d y was u n d e r t a k e n to de. t e r m i n e t h e effect of two commonly u s e d f i l t e r s on p l a t e l e t c o u n t and p l a t e l e t function. The use of acid cir. r a t e dextrose (ACD) a n d heparin as an a n t i c o a g u l a n t was also tested.
Olcott C, Lim RC: Specialized blood filters and fresh whole blood. JACEP 5: 510-511, July 1976. filters, ultrapore transfusion, effect on platelets.
The two specialized u l t r a p o r e ill. ters e x a m i n e d were U l t i p o r e Trans. fusion F i l t e r (Pall) a n d t h e Swan~ Dacron wool t r a n s f u s i o n filter (Exi t r a c o r p o r e a l ) . B l o o d w a s obtaine I f r o m s i x h e a l t h y v o l u n t e e r s whi w e r e k n o w n n o t to be t a k i n g any m e d i c a t i o n t h a t affects p l a t e l e t func., tion. W h o l e blood, 100 cc, was c01 lected by p h l e b o t o m y into TA-6 plas! tic bags - - one c o n t a i n i n g 15 cc of A C D s o l u t i o n a n d t h e o t h e r 375 u n i t s of aqueous h e p a r i n . Blood from each b a g was tested. Baseline values for hematocrits, p l a t e l e t count, plate. let a g g r e g a t i o n induced by adenosine d i p h o s p h a t e (ADP), e p i n e p h r i n e an~ c o l l a g e n w e r e o b t a i n e d . E a c h bag w a s t h e n e m p t i e d , b y gravity, t h r o u g h o n e of t h e filters. Finally, the p l a t e l e t count a n d function of a p o s t f i l t r a t i o n s p e c i m e n were deter~ mined.
INTRODUCTION W h e n p a t i e n t s p r e s e n t to t h e e m e r g e n c y d e p a r t m e n t in profound shock from h e m o r r h a g e , r e s u s c i t a tion includes t h e infusion of stored b a n k blood. A l t h o u g h necessary, this carries w i t h it a n u m b e r of risks and p o t e n t i a l complications, such as alt e r a t i o n s in t h e c o a g u l a t i o n system l e a d i n g to S e c o n d a r y b l e e d i n g , depression of o x y g e n - c a r r y i n g capacity of the red cells, increased acid load and :the introduction of cellular aggregates and debris from the s t o r e d blood. T h e l a t t e r h a s b e e n Presented at the annual ACEP/EDNA Scientific Assembly in Las Vegas, Nevada, October 1975. From the Department Emergency Services* and Surgeryt University of California, San Francisco General Hospital, San Francisco, California. Supported by N a t i o n a l I n s t i t u t e s of Health GM #18470. Address for reprints: Robert C. Lim, Jr, MD, Associate Professor of Surgery, University of California, San Francisco General Hospital, San Francisco, California 94110.
Page 510 Volume 5 Number 7
shown to be responsible for m u l t i p l e p u l m o n a r y microemboli, a major cont r i b u t i n g factor to the p o s t t r a u m a t i c r e s p i r a t o r y insufficiency syndrome, ie, "shock lung. ''1-4 There are specialized filters to remove microaggregates and debris from stored b a n k blood as it is inf u s e d i n t o t h e p a t i e n t . 5 -1° I n t h e management of severely injured, h e m o r r h a g i n g p a t i e n t s , t h e s e spe -cialized filters m a y be of g r e a t benefit if l a r g e a m o u n t s of blood a r e a d m i n i s t e r e d . However, w h e n massive a m o u n t s of blood a r e u s e d , a bleeding d i a t h e s i s will ensue. 4 This h a s led us to e s t a b l i s h a policy of u s i n g fresh w a r m blood in these situations. A l t h o u g h t h e r e a p p e a r s to be no q u e s t i o n a b o u t t h e effectiveness of specialized filters when infusing s t o r e d b a n k blood, t h e i r u s e f u l n e s s w h e n f r e s h b l o o d is t r a n s f u s e d is questionable. These-filters might keep out functional p l a t e l e t s necess a r y for h e m o s t a s i s in the b l e e d i n g t r a u m a patient.l°, 11
METHODS AND MATERIALS
RESULTS The d a t a shows t h a t 20% to 40~00fi p l a t e l e t s were removed by the filtersI ( T a b l e ) . W h e n t h e b l o o d w a s a~'l t i c o a g u l a t e d w i t h h e p a r i n , the p l a t e l e t s were more adhesive and~ g r e a t e r p e r c e n t a g e of t h e functional p l a t e l e t s w e r e r e m o v e d (p
Specialized Blood Filters and Fresh Whole Blood Cornelius Olcott IV, MDt Robert C. Lim, Jr, MD* San Francisco, California
P l a t e l e t c o u n t s a n d platelet f u n c t i o n s w e r e d e t e r m i n e d in f r e s h w h o l e b l o o d b e f o r e a n d after it p a s s e d t h r o u g h t w o t y p e s o f s p e c i a l i z e d transf u s i o n filters. B o t h filters w e r e c a p a b l e o f t r a p p i n g 20% to 40% o f the f u n c t i o n a l platelets, n e c e s s a r y for h e m o s t a s i s , e s p e c i a l l y if h e p a r i n w a s u s e d as the a n t i c o a g u l a n t . W h e n fresh w h o l e b l o o d is n e e d e d to treat the b l e e d i n g p a t i e n t w h o h a s a l r e a d y r e c e i v e d m a s s i v e b l o o d transfusions, t h e s e s p e c i a l i z e d filters s h o u l d p r o b a b l y n o t be used.
This s t u d y was u n d e r t a k e n to de. t e r m i n e t h e effect of two commonly u s e d f i l t e r s on p l a t e l e t c o u n t and p l a t e l e t function. The use of acid cir. r a t e dextrose (ACD) a n d heparin as an a n t i c o a g u l a n t was also tested.
Olcott C, Lim RC: Specialized blood filters and fresh whole blood. JACEP 5: 510-511, July 1976. filters, ultrapore transfusion, effect on platelets.
The two specialized u l t r a p o r e ill. ters e x a m i n e d were U l t i p o r e Trans. fusion F i l t e r (Pall) a n d t h e Swan~ Dacron wool t r a n s f u s i o n filter (Exi t r a c o r p o r e a l ) . B l o o d w a s obtaine I f r o m s i x h e a l t h y v o l u n t e e r s whi w e r e k n o w n n o t to be t a k i n g any m e d i c a t i o n t h a t affects p l a t e l e t func., tion. W h o l e blood, 100 cc, was c01 lected by p h l e b o t o m y into TA-6 plas! tic bags - - one c o n t a i n i n g 15 cc of A C D s o l u t i o n a n d t h e o t h e r 375 u n i t s of aqueous h e p a r i n . Blood from each b a g was tested. Baseline values for hematocrits, p l a t e l e t count, plate. let a g g r e g a t i o n induced by adenosine d i p h o s p h a t e (ADP), e p i n e p h r i n e an~ c o l l a g e n w e r e o b t a i n e d . E a c h bag w a s t h e n e m p t i e d , b y gravity, t h r o u g h o n e of t h e filters. Finally, the p l a t e l e t count a n d function of a p o s t f i l t r a t i o n s p e c i m e n were deter~ mined.
INTRODUCTION W h e n p a t i e n t s p r e s e n t to t h e e m e r g e n c y d e p a r t m e n t in profound shock from h e m o r r h a g e , r e s u s c i t a tion includes t h e infusion of stored b a n k blood. A l t h o u g h necessary, this carries w i t h it a n u m b e r of risks and p o t e n t i a l complications, such as alt e r a t i o n s in t h e c o a g u l a t i o n system l e a d i n g to S e c o n d a r y b l e e d i n g , depression of o x y g e n - c a r r y i n g capacity of the red cells, increased acid load and :the introduction of cellular aggregates and debris from the s t o r e d blood. T h e l a t t e r h a s b e e n Presented at the annual ACEP/EDNA Scientific Assembly in Las Vegas, Nevada, October 1975. From the Department Emergency Services* and Surgeryt University of California, San Francisco General Hospital, San Francisco, California. Supported by N a t i o n a l I n s t i t u t e s of Health GM #18470. Address for reprints: Robert C. Lim, Jr, MD, Associate Professor of Surgery, University of California, San Francisco General Hospital, San Francisco, California 94110.
Page 510 Volume 5 Number 7
shown to be responsible for m u l t i p l e p u l m o n a r y microemboli, a major cont r i b u t i n g factor to the p o s t t r a u m a t i c r e s p i r a t o r y insufficiency syndrome, ie, "shock lung. ''1-4 There are specialized filters to remove microaggregates and debris from stored b a n k blood as it is inf u s e d i n t o t h e p a t i e n t . 5 -1° I n t h e management of severely injured, h e m o r r h a g i n g p a t i e n t s , t h e s e spe -cialized filters m a y be of g r e a t benefit if l a r g e a m o u n t s of blood a r e a d m i n i s t e r e d . However, w h e n massive a m o u n t s of blood a r e u s e d , a bleeding d i a t h e s i s will ensue. 4 This h a s led us to e s t a b l i s h a policy of u s i n g fresh w a r m blood in these situations. A l t h o u g h t h e r e a p p e a r s to be no q u e s t i o n a b o u t t h e effectiveness of specialized filters when infusing s t o r e d b a n k blood, t h e i r u s e f u l n e s s w h e n f r e s h b l o o d is t r a n s f u s e d is questionable. These-filters might keep out functional p l a t e l e t s necess a r y for h e m o s t a s i s in the b l e e d i n g t r a u m a patient.l°, 11
METHODS AND MATERIALS
RESULTS The d a t a shows t h a t 20% to 40~00fi p l a t e l e t s were removed by the filtersI ( T a b l e ) . W h e n t h e b l o o d w a s a~'l t i c o a g u l a t e d w i t h h e p a r i n , the p l a t e l e t s were more adhesive and~ g r e a t e r p e r c e n t a g e of t h e functional p l a t e l e t s w e r e r e m o v e d (p
