The Age of Stored Donated Blood Age of Stored Blood

The Effects of Stored Donated Blood on Recipients Melissa Tilley Mentor: Tandi Ngwenyama, Department of Veterinary Intensive Care Unit Date: 12/13/13

The Age of Stored Donated Blood

INTRODUCTION Research Problem: Blood transfusions are necessary for patient survival in sever hemolytic situations. Even though blood transfusions are lifesaving, they can also place the patient (animal) at risk if there is an adverse reaction. An adverse reaction will compromise the health of the recipient and could ultimately result in a delay of recover or even death. By discovering the effects of the aged stored donated blood has on recipients we can help to decrease or even eliminate blood transfusion reactions. Purpose of Research: The purpose of this study is to conclude weather or not the age of stored donated blood will affect the likelihood of a blood transfusion reaction from the recipient. Research Questions: This study is designed to answer the following questions: 1. How long can blood be stored before the red blood cells begin to break down? 2. How does the illness requiring administering of the blood transfusion affect the length of the storage of the blood? 3. What is the longest storage time we should allow? 4. What is the safest method of storage, such as filtered, whole blood, at what temperature? Significance of Study: This study will promote safe storage techniques, timelines and use of stored donated blood in veterinary hospitals. By understanding these correct methods we can decrease the possibility of blood transfusion reactions in patients (canines) and can encourage a safer recovery. By decreasing blood transfusion reactions we will decrease donated blood waste along with the expenses used for additional hospital care after a rejection. Ultimately this research will better society by giving a higher level of hospitalization care for patients.

The Age of Stored Donated Blood LITERATURE REVIEW Introduction All over the world people are impacted by the amount of instances of blood transfusion rejections that patients (animals) are expressing by not being completely compatible with the donors blood. Currently it is possible for a patient to have an adverse reaction to a blood transfusion and patients must be watched closely during the process of administration. An

adverse reaction to a blood transfusion can be life threatening. The symptoms that a rejected blood transfusion causes will delay the recovery process and could result in the death of someones pet. By finding the safest methods for blood storage and preservation we can decrease the risks of a recipient having a reaction. Blood transfusions are administered due to many life threatening issues. By discovering the effects of the age that stored donated blood has on recipients we can help to decrease or even eliminate blood transfusion reactions. Reasons for Administering a Blood Transfusion The most common purpose for administering a transfusion is to replace lost blood volume. Transfusions are also given to increase the blood's ability to carry oxygen to the tissue, to improve immunity, or to correct blood-clotting problems. This means that the animal receiving the transfusion is already very ill, and a reaction to the donated blood will only decrease their chances of recovery. During a blood transfusion a patient must have all vital signs reviewed every fifteen minutes (Purohit 83-88). By making blood transfusions safer for animals, recovery time is decreased and clients finances are saved with better procedures done efficiently the first time. There are several reasons why a blood transfusion would be necessary for a patient.

The Age of Stored Donated Blood In a study by Graham (1949), findings show evidence that blood transfusions can help correct a hemorrhagic event. Severe hemorrhaging is a common reason why blood transfusions are necessary. Animals odds of survival highly decline without transfusion assistance (Graham 97-111). Graham states that the effects of the transfusion are desirable when you look at the improvement of the patients who were treated. His results show that 90 percent of the patients who were not treated with a blood transfusion died because of hemorrhage in the first six months. In his study none of the untreated patients passed from hemorrhage in their first year (Graham 97-111). Even though this study is over a half of a century old, it still holds relevance. Not only can it currently be replicated, with our current increased knowledge of canine transfusions we have increased these patients likelihood and length of survival. Grahams study (1949) used whole blood for their transfusions, which is blood taken from a donor and transfused into a patient without the filtering of plasma, platelets, or white blood cells. Currently practices will filter out white blood cells to encourage the acceptance of the blood transfusion. Filtering Out White Blood Cells Since Grahams study we have learned that white blood cells can cause additional complications. Filtering out the white blood cells helps increase the likelihood of the acceptance of a blood transfusion. According to Smith (1993) white blood cells can cause fever and infection to the recipient. Ninety-nine percent of white blood cells can be filtered out of the whole blood. As long as there is a minimum of 90 percent of the white blood cells filtered out of the donated blood there generally will not be a reaction by the recipient (Smith 810). Because of these findings practices no longer use whole blood for blood transfusions. Even though current

The Age of Stored Donated Blood practices filter out white blood cells, adverse reactions still occur in blood transfusions. The occurrence of transfusion rejections creates a need for safer transfusion practices. Stored Blood and Abnormalities Blood transfusions can become safer by investigating if there is a decrease in acceptance of a blood transfusion due to the amount of time that the donated blood was stored. Dawidson states that the longer the blood is stored the more the red blood cells break down, making it difficult for a recipient to accept the new blood into their system. When looking at stored whole blood the platelet and white blood cell amounts have been shown to decline (Dawidson 51-57). A study done by Dawidson (1975) shows that during the storage of blood many abnormalities form. These abnormalities can cause the patient to reject the donated blood. One abnormality that can develop when you store blood is microparticles. Microparticles develop and create issues during a blood transfusion which makes it more difficult for the recipient to accept the transfusion. Micropartiles encourage the blood of an inactive protein prothrombin to convert to thrombin, and can lead to inflammation (Wenhe 886-893). This can cause transfusion related acute lung injury (Hargett 329-340). There are other issues as well that can occur during the storage of blood. Platelets, white blood cells and fibrin (PWF) form aggregates in which increase in size and number as storage time increases (Dawidson 51-57). When using stored blood for a transfusion all of these abnormalities can develop indicating that the risk of death rises for the patient. Solomon states from his research that older blood caused more severe lung damage, hemorrhage, and thrombosis (Solomon 1663-1672). Blood transfusions can save the life of a patient, but given all of the issues with the storage of blood, a transfusion can also cause a patient to become more ill. When a blood transfusion is administered, it is because a patient is unlikely to survive without it.

The Age of Stored Donated Blood Delivery of Oxygen One reason why a blood transfusion would be administered would be to improve the delivery of oxygen to the tissue. If oxygen in the tissue is insufficient then the body will attempt to maintain it by increasing cardiac output. As the haematocrit (the ratio of volume of red blood cells to the total volume of blood) decreases to 25 percent or below, oxygen in the tissue begins to decline (Pape 250-258). In Thompsons study (1979) he found that by storing blood less oxygen is delivered to the patient upon delivery compared to the administration of a fresh blood transfusion (Thompson 207-210). During his study he attempted to see if the assistance of steroids, prednisolone, would assist in increasing the amount of oxygen in the blood as it does with human medicine. At the end of his study he shows that steroids do not assist in the increase of oxygen in the blood. His data shows that fresh blood is better to use over stored blood because of the amount of oxygen that is decreased during the storage process. To minimize the possibilities of an adverse reaction from a blood transfusion the blood must have been properly collected, processed and stored (Lanevschi 447-454). In Thompsons study he shows that fresh blood is better for the patient. However, fresh blood is not always available, stored blood is the only available resource. By taking necessary procedures, such as proper collection, practices can help to improve the likelihood of the acceptance of the stored blood during a blood transfusion. Proper Storage When storing blood there are necessary procedures that must take place in addition to proper collection. While storing blood you must add anticoagulants and preservatives to the blood. If the addition of anticoagulation and preservations are not accurately completed then the stored blood will not be as beneficial to the recipient and could possibly lead to a rejection (Lanevschi 447-454). Anticoagulants, such as heparin, are added to the blood so that it will not

The Age of Stored Donated Blood clot during the storage process. Preservatives, such as citrate dextrose, are also are added to lengthen the life of the stored blood (Lanevschi 447-454). Currently practices are able to preserve stored blood up to forty-two days (Wenhe 886-893). In a study conducted by Solomon (2013) found that the animals who received older stored blood were less likely to survive. They had higher instances of shock and higher pulmonary artery pressures (McCullough 1492-1492). Conclusion The amount of blood transfusion reactions during blood transfusions due to incompatibility between donors and recipients is too large and is affecting both patients and clients. By being efficient the first time and make blood transfusions safer for patients practices can decrease their recovery time. Scientists knowledge needs to increase about blood transfusions because they are necessary for survival in severe hemorrhagic situations. A blood transfusion will increase their chances of survival. As scientists have discovered, whole stored blood is not the ideal way to administer blood transfusions. Practices must filter out the white blood cells to avoid the additional risks that they place on the recipients. As Dawidson (1975) shows, the longer we store red blood cells the more abnormalities form. These abnormalities make it difficult for a recipient to accept the blood transfusion. By storing blood we are delivering less oxygenated blood to the patient than if we were to use whole blood. Since we cannot always use fresh whole blood practices must properly collect and administer additives to preserve the blood so that recipients have the best opportunity of receiving the transfusion. THEORETICAL FRAMEWORK Enhancing knowledge on the age of stored donated blood and its affects to recipients is crucial. The most influential knowledge associated with this process is the creation of abnormalities in stored blood over time. A study conducted by Dawidson shows that these

The Age of Stored Donated Blood abnormalities make it more difficult for a recipient to accept the donated blood into their system without creating an acute reaction. This project is based on the theory that the longer blood is stored, the more abnormalities will form in the blood making it unsafe to use in blood transfusions. In addition to Dawidsons findings, Wenhe, Solomon and Hargett also contribute to the effects of aged stored blood on recipients. Their findings all show that stored blood for blood transfusions abnormalities can develop, which gives an increased risk of an adverse reaction and death for the patient. METHODOLOGY Data Collection: Data collection will consist of non-experimental studying of documentations from previous records over the last ten years involving canine blood transfusions and their results from Washington State Universities (WSU) Teaching Hospital. This information will be able to grant me the knowledge of the likelihood of a blood transfusion reaction and the possible reasons as to why a reaction occurred. The format that I will be using is the ex post facto design. I will be using qualitative research to better understand the complexes of blood transfusions and the current storage techniques and guidelines. This methodology will be able to grant me ability to be able to build a theory with the observations that I find with the research of documentation provided to me. Data Location: The documents that I will need access of are located at WSU Teaching Hospital in Pullman Washington. These documents will be provided to me by Dr. Jane Wardrop from the Clinical Pathology Department at the WSU Teaching Hospital. This location can be found at 205 Ott Rd #1002, Pullman, WA 99164. Their telephone number is (509)335-0711. I will be required to stay at this location with the documents during my time of research. I will not be permitted to remove the documents from the WSU Teaching Hospital.

The Age of Stored Donated Blood Data Obtained: The documents will be provided to me by Dr. Jane Wardop in the Clinical Pathology Department. Due to privacy laws I will not be permitted to remove the documents from the location of the WSU Teaching Hospital. I will be permitted to have access to these documents while in a private room at the Teaching Hospital. Data Characteristics: This data will include the patients name, sex, breed, age, blood type, temperature, hematocrit, the donors name, breed of donor, age of donor, age of the stored blood, date of the transfusion, previous blood transfusions, reasons for blood transfusion, sign of reaction to the blood transfusion (if one occurred), their next temperature value, their seconds donors name (if a second one occurred), breed of donor, age of donor, age of second donor blood, date of second transfusion, sign of reaction to the blood transfusion (if one occurred), if they recovered, date released from the hospital. I have attached an excel example format for this data collection on the last page of this document. Data Analysis and Interpretation: My methodology will look for consistency in the data that I will collect. With the assistance of the excel sheet that I have created I will be able to find a pattern if older stored donated blood effects the likelihood of an acceptance or decline of a blood transfusion. I will also be looking at breed differences between the donor verses the recipient. In addition, I will see if there is a pattern between the ages of the donors and recipients and if that may have an effect on the acceptance or decline of a blood transfusion in recipients. For example: if I am able to see a consistency of blood transfusion rejections with stored blood aged over 23 days old, I will be able to form a theory that blood at the age of 23 days or above form a larger amount of abnormalities. Also that stored donated blood should not be used past the age of 22 days.

The Age of Stored Donated Blood LIMITATION OF THE STUDY The limitations for this study will consist of viewing documentations from WSU Teaching Hospital only. This data collection will not consist of any other populations. My collection of data will not require any funds for this research. Funds will not be a limitation for my research. My additional limitations will consist of the proper and complete documentation of the students and staff at the WSU Teaching Hospital. I may be limited to the amount of data that I can collect from some patients if charting was not completed properly. Limitations of time as my college career of a full time students schedule may cause me to adjust schedule to time manage appropriately. WORKING SCHEDULE Scholar: Melissa Tilley, Animal Science Faculty Mentor: Tandi Ngwenyama, Department of Veterinary Intensive Care Unit Effects of Stored Donated Blood on Recipients McNair Research Project Timeline December 2013 Find compatible faculty mentor Come up with potential projects Decide on project Develop excel sheet for data collection Start project journal to record ideas about current project and future projects. begin writing literature review write methodology apply for SROP

The Age of Stored Donated Blood January 2014 spring classes begin Set regular meetings with faculty mentor Finalize project with faculty mentor Develop project timeline Begin reviewing documentation Finish writing literature review Prepare for oral proposal presentation Apply for SROP

February 2014 Continue to review documentation

March 2014 Continue to review documentation Data analysis Begin writing research section

April 2014 Present five-minute research progress report to McNair Cohort Finish writing results section Begin writing conclusion/discussion section

May 2014 Finish writing conclusion/discussion section Begin GRE Prep course Attend SROP

The Age of Stored Donated Blood June 2014 Assemble and rehearse oral presentation for symposium Finish written report for project Finish GRE Prep Attend SROP

July 2014 Turn in final written report of project Rehearse oral presentation of final project Present final project at annual WSU McNair Symposium Attend SROP

August 2014 Take GRE Fall classes begin

September 2014 Create research poster for upcoming poster exhibition and national conference

October 2014 Present poster at annual WSU McNair poster exhibition Plan for National McNair Conference in November

November 2014 Present project, oral or poster, at McNair National Conference

The Age of Stored Donated Blood BUDGET ESTIMATE 1. Researcher 2. Research assistants 3. Stationary 4. Typing and Binding 5. Enhanced data collection program Total Rs 0 Rs 0 Rs 1,000/Rs 2,000/Rs 1,000/Rs 4,000/CHAPER/PLAN ORGANIZATION OF THE STUDY Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Introduction Review of Literature and conceptual Framework Methodology An Introduction of the Study Area Data Analysis and Interpretation Findings, Conclusions and Recommendations.

The Age of Stored Donated Blood REFERENCES -Dawidson, Ingemar. "Pulmonary Microemobolism Associated with Massive Transfusion." PubMed. 181.1 (1975): 51-57. Print. -Graham, John. "Canine Hemophilia." Rockefeller University Press. (1949): 97-111. Print. - Hargett, Leslie. "On the origin of Microparticles: From "platelet dust" to meadiators of intercellular communication." Pulmonary Circulation. 3.2 (2013): 329-340. Print. -Lanevschi, Anne. "Principles of transfusion medicine in small animals." Can Vet J. 42.6 (2001): 447-454. Print. -McCullough, Jeffrey. "Red cell storage: does duration matter?." Blood. 121.9 (2013): 14921492. Print. - Pape, Andreas. "Clinical evidence of blood transfusion effectiveness." Blood Transfus. 7. (2009): 250-258. Print. -Purohit, S. "Canine Blood Transfusions." Intas Polivet. 13.1 (2012): 83-88. Print. - Smith, Richard. "Filtering white cells from blood for transfusion." BMJ. 306.6881 (1993): 810. Print. -Solomon, Steven. "Mortality increases after massive exchange transfusion with older stored blood in canines with experimental pneumonia." Amer Soc Hematology. 121.9 (2013): 1663-1672. Print. - Thompson, FN. "Oxygen affinity in stored canine blood: the effect of prednisolone." Can J Comp Med. 43.2 (1979): 207-210. Print. -Wenhe, Jy. "Microparticles in Stored RBC as Potential Mediators of Transfusion Complications." Transfusion. 51.4 (2011): 886-893. Print.