Duration of Red Cell Storage Influences Mortality After Trauma

Abstract

Background Although previous studies have identified an association between the transfusion of relatively older red blood cells (RBCs) (storage ≥14 days) and adverse outcomes, they are difficult to interpret because the majority of patients received a combination of old and fresh RBC units. To overcome this limitation, we compared in-hospital mortality among patients who received exclusively old versus fresh RBC units during the first 24 hours of hospitalization. Methods Patients admitted to a Level I trauma center between January 2000 and May 2009 who received ≥1 unit of exclusively old (≥14 days) vs. fresh (<14 days) RBCs during the first 24 hours of hospitalization were identified. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for the association between mortality and RBC age, adjusted for patient age, Injury Severity Score, gender, receipt of fresh frozen plasma or platelets, RBC volume, brain injury, and injury mechanism (blunt or penetrating). Results One thousand six hundred forty-seven patients met the study inclusion criteria. Among patients who were transfused 1 or 2 RBC units, no difference in mortality with respect to RBC age was identified (adjusted RR, 0.97; 95% CI, 0.72–1.32). Among patients who were transfused 3 or more RBC units, receipt of old versus fresh RBCs was associated with a significantly increased risk of mortality, with an adjusted RR of 1.57 (95% CI, 1.14–2.15). No difference was observed concerning the mean number of old versus fresh units transfused to patients who received 3 or more units (6.05 vs. 5.47, respectively; p = 0.11). Conclusion In trauma patients undergoing transfusion of 3 or more RBC units within 24 hour of hospital arrival, receipt of relatively older blood was associated with a significantly increased mortality risk. Reservation of relatively fresh RBC units for the acutely injured may be advisable.

Stiffness increase of red blood cells during storage

“…Regulations in many countries specify 42 days (6 weeks) as the shelf life for stored red blood cells (RBCs), and a first-in-first-out inventory management approach is standard. Large-scale clinical studies involving 200-1800 patients indicated that patients transfused with older RBCs tend to have a higher risk of mortality than those receiving fresher RBCs [1][2][3][4] .…”

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

“…Our search strategy is shown in Figure 2. 31 Murrell et al 36 Phelan et al 35 Spinella et al 32 Weinberg et al 33 Weinberg et al 30 Weinberg et al 34 No Definitions for the age of stored blood varied among the 7 studies. Blood was considered old if it was in storage 14 days or longer, 30,33,34 longer than 14 days, 31 or 28 days or longer.…”

“…31 Murrell et al 36 Phelan et al 35 Spinella et al 32 Weinberg et al 33 Weinberg et al 30 Weinberg et al 34 No Definitions for the age of stored blood varied among the 7 studies. Blood was considered old if it was in storage 14 days or longer, 30,33,34 longer than 14 days, 31 or 28 days or longer. 32 One study 35 used the mean age of all units received within 14 days to define new blood and the mean age of all units stored 21 days or longer to define old blood, and 1 study 36 developed a composite variable that was defined by the proportionate age of each blood unit averaged over all units transfused and then multiplied by the total number of units transfused.…”

“…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. 28 Three of the studies [32][33][34] included in our review suggested that an increased overall volume of transfused blood likely reflects greater injury with an inherent increase in mortality.…”

Impaired Red Blood Cell Deformability After Transfusion of Stored Allogeneic Blood But Not Autologous Salvaged Blood in Cardiac Surgery Patients

“…14,15 Although the current "shelf life" of stored blood is 42 days, there is evidence that after some duration of RBC storage, perhaps even 15-21 days, the capacity for tissue oxygen delivery is diminished. [16][17][18] In fact, studies have described adverse outcomes, 19,20 including increased mortality, 21,22 in patients who receive blood that has been stored for longer durations. Another concern is the potential adverse effects of cardiopulmonary bypass (CPB) and the resulting injury to the RBC cell membrane.…”