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J Thorac Cardiovasc Surg 2004;127:949-952
© 2004 The American Association for Thoracic Surgery

Surgery for congenital heart disease

The metabolic effects of fresh versus old stored blood in the priming of cardiopulmonary bypass solution for pediatric patients

^a Department of Anesthesia and Intensive Care, Sheba Medical Center, Tel-Aviv University, Tel-Aviv, Israel,
^b Department of Pediatric Cardio-Thoracic Surgery, Sheba Medical Center, Tel-Aviv University, Tel-Aviv, Israel,
^c Department of Transfusion Medicine, Sheba Medical Center, Tel-Aviv University, Tel-Aviv, Israel

Received for publication March 23, 2003; revisions received May 14, 2003; revisions received June 29, 2003; accepted for publication July 10, 2003.

^* Address for reprints: Ilan Keidan, MD, Department of Anesthesiology and Intensive Care, Chaim Sheba Medical Center, Tel Hashomer, 52621 Israel
keidan{at}012.net.il

	Abstract

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OBJECTIVES: Pediatric cardiopulmonary bypass involves the creation of a large obligatory priming reservoir. Packed red blood cells are an essential part of the cardiopulmonary bypass priming solution in children. The storage media in packed red blood cells might cause significant acid-base, glucose, and electrolyte imbalances, which have been associated with severe complications. The purpose of the present study was to evaluate the metabolic effects of fresh (5 days) versus old (>5 days) stored packed red blood cells added to the priming solutions of pediatric patients undergoing cardiac surgery.

METHODS: Blood samples were drawn from cardiopulmonary bypass priming of 30 consecutive pediatric patients undergoing cardiac surgery. Patients were divided into 2 groups. Fresh (5 days old) stored packed red blood cells were added to the priming solution in group 1, and old (>5 days old) stored packed red blood cells were added to the priming solution in group 2. In each group blood samples were drawn from the packed red blood cells on arrival to the operating room and from the priming solution immediately after packed red blood cells were added and after 20 minutes of prime circulation. Samples were also collected at the beginning of cardiopulmonary bypass and after 30 minutes. The last sample was collected on arrival to the pediatric intensive care unit. The levels of potassium, glucose, and lactate and the acid-base balance were analyzed in each sample.

RESULTS: There was a linear increase in potassium levels in packed red blood cell samples with increasing packed red blood cell age, ranging from 5.4 to 18.4 mEq/L. Significant differences in the concentrations of potassium, glucose, and lactate and the acid-base balance were found when comparing old and fresh packed red blood cells in samples taken during the packed red blood cell and early prime time. Those differences resolved after 20 minutes of reconstitution of the priming solution. The age of the packed red blood cells had no effect on the samples taken during bypass and those taken in the pediatric intensive care unit.

CONCLUSION: The significantly higher concentration of potassium and lactate and lower pH in old stored packed red blood cells has a minimal effect on the final constitution of priming solution before and during cardiopulmonary bypass in children undergoing corrective cardiac surgery.

Many institutional protocols advocate limiting the use of PRBCs in priming solution for the CPB or ECMO circuit to relatively fresh stored PRBCs to avoid such complications. The supply of fresh PRBCs is limited and might create delays. We prospectively evaluated the effect of length of storage of PRBCs on the final constitution of the priming solution before and after CPB in children undergoing corrective cardiac surgery. Specific attention was given to potassium, lactate, and glucose levels and the acid-base balance.

	Materials and methods

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Blood samples were drawn from CPB priming solutions of 30 consecutive pediatric patients undergoing cardiac surgery. Fresh PRBCs were preferred, and patients would only receive old PRBCs if no fresh blood was available. Priming solution consisted of Plasmalyte, albumin, and fresh (5 days) stored PRBCs in 18 patients and Plasmalyte, albumin, and old (>5 days old) stored PRBCs in 12 patients. Blood samples were first drawn from PRBCs (stored at 4°C in citrate-phosphate-dextrose-adenine 1 [CPDA-1] preservative solution) immediately after irradiation with 2500 rad and transportation into the pediatric cardiac operating room. This unit of PRBCs was then added to the CPB priming solution. In all patients, we used the VPCML plus oxygenator and tubing (Cobe Cardiovascular) fitted for patient weights of 4 to 30 kg. The CPB priming solution was created according to our institutional protocol, which includes adding 1 unit of PRBCs (280 ± 50 mL) to 450 mL of Plasmalyte, 20 mL of albumin 25%, and medications (methylprednisolone, mannitol, cefazolin, heparin, and bicarbonate). Once the unit of PRBCs was added to the priming solution, a second sample was taken from the CPB priming solution. Circulation of the priming solution with low flow of air at room temperature was started, and a third sample was taken after 20 minutes. Another set of blood samples was drawn when the patients were first connected to the CPB pump and after 30 minutes. The last blood sample was drawn on arrival to the pediatric intensive care unit (PICU) after the conclusion of the operation. Comparisons between corresponding variables at different times in each group were carried out by using the Student t test. Correlation between potassium levels and age of the PRBCs was determined by using the Pearson correlation test for parametric variables.

	Results

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Thirty infants and children undergoing corrective cardiac surgery were included in the study. In 18 patients the PCPB circuit was primed with fresh stored CPDA-1 PRBCs and in 12 patients with old stored CPDA-1 PRBCs. No statistical difference between the groups was detected in terms of age (1.2 ± 1.8 vs 0.9 ± 2 years, P = .23; age range, 3 days-5 years), weight (10.5 ± 5.8 vs 8.5 ± 6.5 kg, P = .2; weight range, 4-20 kg), and duration of CPB (102 ± 58 vs 115 ± 75 minutes, P = .47). The mean storage time in the fresh stored PRBC group was 2.7 ± 1 days (median, 3 days) and was significantly shorter compared with the storage time of the old stored PRBC group (11 ± 7.2 days; median, 8 days; P = .005). There was a significantly lower concentration of potassium in fresh PRBCs compared with that seen in PRBCs stored for 5 days or more (9.2 ± 2 vs 15 ± 6.8 mEq/L, P < .02). A positive correlation was found between the age of the PRBCs and their potassium concentrations (r = 0.4, P = .035, Figure 1). Adding those PRBCs to the priming solution caused a significant increase in the potassium level at priming time 0 (4.9 ± 0.7 vs 5.9 ± 0.6 mEq/L, P = .003) but diminished at priming time 20 (4.5 ± 0.7 vs 4.8 ± 0.8 mEq/L, P = .15), once CPB had begun (3.39 ± 0.45 vs 3.69 ± 0.38 mEq/L, P = .06), and on arrival to the PICU (3.4 ± 0.84 vs 3.8 ± 0.36 mEq/L, P = .17). Glucose levels were significantly lower in old PRBCs (153 ± 133 vs 300 ± 75 mg/dL, P = .01): the trend continued during early priming (28 ± 14 vs 77 ± 19 mg/dL, P < .01) but resolved after 20 minutes of priming (65 ± 30 vs 82 ± 16 mg/dL, P = .2). No difference in blood glucose levels was detected in samples taken at the beginning of CPB and on arrival to the PICU. A similar improvement in acid-base balance was noted once priming solution circulation continued for 20 minutes (Table 1).

View larger version (7K): [in this window] [in a new window]   Figure 1. Correlation between days of PRBC storage and potassium levels.

	Discussion

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Our results clearly demonstrate that although fresh PRBCs are more metabolically balanced than stored PRBCs, there is no significant difference in the composition of the solution after 20 minutes of prime circulation. Furthermore, we found no statistical difference in the analysis of blood samples during CPB and in the PICU after the operation, regardless of the different priming solutions used. One of the major concerns with prolonged storage is excess potassium in the red cell supernatant, which could cause cardiac problems. The problem of posttransfusion induction of clinically significant hyperkalemia might be exacerbated by irradiation of PRBC concentrate to prevent graft-versus-host disease,⁷ but this effect seems to be minimized once the PRBCs are irradiated after storage, as in our study. At a storage temperature of 4°C, the red cell sodium-potassium pump is essentially nonfunctional, and intracellular and extracellular levels gradually equilibrate. In addition, the hemolysis that occurs during the storage period results in increased potassium levels in the supernatant. However, because the total volume of plasma in red cell concentrates is low (70 mL), the total potassium burden is small.⁸ The addition of PRBCs to a relatively large balanced solution decreases significantly the potential adverse effects associated with the relatively larger load of potassium and lactate. The pH of CPDA-1 is acidotic (5.5). When this solution is added to a unit of freshly drawn blood, the pH of the blood immediately decreases to approximately 7.0 to 7.1.⁹ As a result of accumulation of lactic and pyruvic acids by metabolism and glycolysis, the pH of PRBCs continues to decrease. A large portion of the acidosis can be accounted for by the high partial pressure of carbon dioxide. However, once priming solution circulates with adequate ventilation, acid-base imbalance caused by the increase in the levels of carbon dioxide resolves within minutes of the circulation. In this study we did not investigate the effects of old stored blood on oxygen affinity and delivery, the rate of hemolysis, or the level of cytokines and vasoactive mediators because these determinations were beyond the scope of the study.

In conclusion, our findings show that as far as potassium levels and acid-base balance are concerned, PCPB priming can be safely performed with stored PRBCs if the priming solution is circulated for 20 minutes before the initiation of CPB.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Gabriel Amir Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Keidan, I. Articles by Mishali, D. Search for Related Content PubMed PubMed Citation Articles by Keidan, I. Articles by Mishali, D. Related Collections Anesthesia