Armour, Sarah

Background: Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) are leading causes of transfusion-related morbidity and mortality. Soluble factors in erythrocyte supernatant may increase risk for these complications. The authors hypothesized that point-of-care allogeneic erythrocyte washing may be an effective intervention to mitigate elevations in soluble factors as well as physiologic responses associated with transfusion-associated respiratory complications in the setting of cardiac surgery. Methods: This is a two-center, nonblinded, randomized clinical trial evaluating point-of-care washed versus standard issue allogeneic erythrocyte transfusions administered during or on the day of cardiac surgery. The primary analysis was performed via modified intention to treat. The primary outcomes assessed were changes in intermediate markers of lung injury as well as cardiopulmonary physiologic responses to erythrocyte transfusion. Secondary outcomes included the duration of intensive care unit and hospital stay, durations of mechanical ventilation and oxygen supplementation, presence of TRALI or TACO, and mortality. Results: Among 154 analyzed patients (81 washed, 73 standard issue), the median age was 66 yr, and 77 (50.0%) were women. The median (interquartile range) number of allogeneic erythrocyte units transfused on the day of surgery was 3.0 (2.0 to 5.0) in the washed erythrocyte group and 3.0 (2.0 to 4.0) in the standard issue group (P = 0.13). No between-group differences were identified in any of the assessed recipient lung injury biomarkers (all P values > adjusted alpha). Durations of intensive care unit stay (median [interquartile range], 3.0 [2.0 to 5.0] vs. 3.0 [2.0 to 4.0] days; P = 0.117) and hospital length of stay (12.0 [9.0 to 17.0] vs. 12.0 [9.0 to 17.0] days; P = 0.801) were similar, as were the number of ventilator-free days at day 28 (27.0 [27.0 to 27.0] vs. 27.0 [26.0 to 27.0]; P = 0.699) and oxygen-free days at day 28 (24.0 [19.0 to 26.0] vs. 24.0 [22.0 to 26.0]; P = 0.400). No significant differences were noted in mortality rate or in incidence rates for TRALI, TACO, and acute kidney injury. Conclusions: Among patients undergoing cardiovascular surgery with high risk of erythrocyte transfusion, point-of-care washing of allogeneic erythrocyte transfusions did not mitigate changes in intermediate markers of lung injury or cardiopulmonary physiologic responses to erythrocyte transfusion and was not associated with improved clinical outcomes.

Introduction: An elevated blood pressure (mean arterial pressure, MAP) response to exercise is an independent predictor of hypertension (HTN) development. HTN is highly prevalent in postmenopausal females. Postmenopausal, compared to premenopausal, females have a higher MAP at rest and during exercise primarily due to higher systemic vascular resistance (SVR). Studies using small muscle mass exercise have suggested that postmenopausal females have augmented increases in MAP from rest to exercise. However, it is unclear if postmenopausal females have augmented MAP responses from rest to exercise during whole-body exercise. Hypothesis: We hypothesized that postmenopausal females would have greater increases in MAP and smaller decreases in SVR from rest to peak exercise than premenopausal females. Methods: Normotensive premenopausal (n=16; age: 30±7 yrs; BMI: 23±4 kg/m 2 ) and postmenopausal (n=14; age: 57±7 yrs; BMI: 27±4 kg/m 2 ) female participants performed an incremental cycling test until task failure. Blood pressure was measured by manual sphygmomanometry, cardiac output (Q) via open-circuit acetylene wash-in technique, and SVR was calculated. Data are reported at rest and peak oxygen uptake (VO 2 ). Data are also reported as % change from rest to VO 2 peak. Results: Postmenopausal females had higher MAP and SVR at rest and at VO 2 peak than premenopausal females (all, p<0.05). Postmenopausal, compared to premenopausal, females had lower Q at VO 2 peak commensurate with the lower achieved VO 2 peak (p<0.01). Resting MAP was positively related to MAP at VO 2 peak in postmenopausal females (r=0.85, p<0.01), but not premenopausal females (p=0.22). % change in MAP from rest to VO 2 peak was not different between groups (Post: 18±8 vs. Pre: 18±9%) (p=0.94). However, postmenopausal females had smaller % decreases in SVR from rest to VO 2 peak (Post: -44±7 vs. Pre: -54±8%) and smaller % increases in Q compared to premenopausal females (Post: 113±31 vs. Pre: 162±50%) (both, p<0.01). Conclusion: Our findings indicate that postmenopausal and premenopausal females have similar increases in MAP from rest to VO 2 peak; however, the mechanisms contributing to the MAP response differed by menopausal status. Postmenopausal females relied on smaller decreases in SVR, whereas premenopausal females had greater increases in Q. These findings provide important insight into the mechanisms contributing to the clinically relevant higher MAP response during exercise in postmenopausal females.

Hydroxocobalamin (vitamin B12a) is an emerging treatment for vasoplegic syndrome (VS) associated with cardiopulmonary bypass (CPB). Given its cost and scarcity, an institutional guideline for its use as a rescue treatment in cases of suspected VS was developed. Hemodynamic variables and vasopressor requirements were reviewed for a series of 24 post-CPB patients who received B12a. Favorable changes in hemodynamic parameters and vasopressor requirements were seen after B12a administration although guideline criteria for VS were inconsistently met. These findings support the continued study of B12a in patients with CPB-associated VS.