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The
Hematologic
Response
tion
to
Accomplished
Wounding
by
Large
Stored
A Study
H.
WILLIAM
Bj
T
HIS
STUDY
States
LT.
is-as
Army
undcrtakcmn
inn order
pm’a(’ti(’ed
by Americani
military
surgeons
has-c
tioni
of casualties.
seriously
Thirty
isoumided
by
the
of blood
durimig
the
M.
JOHN
Surgical
Research
evemi
hours
more
These
of blood
is, of course,
to
be
men
is collected
miot ssit.hout
compounded
of it is tern
by
inn the
to
tiscnity
the
fact
United
days
days.
All of the blood
positive,
amid is used
its hazards.
the
that
most
States
old
is from
w-ithout
may
uniiiersal
donors.
(‘ross matchimig
United
t.n’ansftnsed
his
hazards
It
the
as
into
resus(’itation
a
amid
the lives of mamny casualties
Use of sumch large amounts
ssoulld
blood
tramisported
it. is unsed.
of
transfusiomi
be
for
of the
amid
I)cfore
Team
hospitals
inn Korea.
Ouir
use of blood for resuscita-
required
to sase
shock.
MC
CAPTAIN,
of blood
the forsvard
bold inn the
arid
fesv
HOWARD,
methods
surgery.
As a conisequmenice
it has been possible
ssho previously
might
has-c (lied of irresersihle
seem
of
in Korea
present
teams
at
ini(’reasimngly
pints
man
AND
to evaluate
surgical
become
Resuscita-
Transfusions
Casualties
MC
COL.,
to
Blood
of Battle
CROSBY,
and
umsed
i)y
at first
the
ili
air
to
is discarded
glance
ssoummided
Korea.
after
Most
tss-enty-one
That
is to say, it. is group
0,
regardless
of the blood
group
Rh
of
recipient.
present
study
is-as undertaken
to determine
of massive
transfusions
amid to learmi if the
rrh
effects
of blood
dli(’d
tell,
they
rarely
group
did
elevated
coumitered.
amid
The
of recipienit
The
anything
after
large,
deleterious.
rapid
pathogcmiic
amounts
hematologic
the
fore,
is more
respomise
effects
of the
a study
of these
men
that
required
ss-ounnds
of patients
thani
technical
work
Research
Team
attached
until
niid-January
that
it supported.
on
woumided.
line.
Often
stations
ranging
froni
Arnny,
t.he
carried
The
The’
they
along
is-c is-crc
able
to
potassium
hemoglobin
undoubtedly
there
is-as
Department
is-as
is’cre
resulted
no eiidence
was
miot
cnn-
in some
loss
clinical
of
by
usually
received
(WHC)
about
Hematology,
or
of
20.5 years. The
D.C.,
Medical
and
the
helicopter
the
blood
group
Service
the
from
hours
pat.ient.s
after
or
plasma
were
included
Graduate
Surgical
Research
Korea.
Subnnitt.ed
July
27,
1953;
accepted
for
publication
439
October
of tine
from
behind
several
whole
of
laboratory
Korea,
miles
within
All
Army
Washington,
in
several
transfusions
was
be separated
report.,
there-
not
rFhis
in the
Hospital
ambulance
line of evacuation.
average
could
tramisfusioni.
METHODS
us
located
brought
received
tranisfusiomi
the
Surgical
-ere
of
Center,
Army
of
were
the
to
AND
by one
hospital
had
18 to 24. The
Medical
out.
to time 46th
Patients
the
Army
was
1953.
nnedical
From
plasma
as
plasma
of transfusions.
MATERIALS
The
Reed
the
reactions.
from
stations
of
blood
inn A recipiemnts
as ss’ill be shossmi,
but
(‘dlis,
Insofar
tranisfusiomis
of 0
use
red
tranisfuisioni
contribute
miot. Escmi
what., if amiy, an’c the harmful
age of the l)bood and the differ-
26,
1953.
late
Surgical
infanmtrv
the
1952
October
(livision
battalion
they
had
aid
been
substitutes
yoummg,
at
their
ages
Caucasians,
School,
Team,
NeWalter
U.
S.
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440
LARGE
groes,
TRANSFUSIONS
OF
STORED
BLOOD
Nisei,
Puerto
Ricans,
and South
Koreans.
Our study
involved
thirty-seven
patients,
was so severely
injured
as to require
blood transfusion.
None of the patients
had been burned.
The size of the transfusions
varied
from 2 pints
to 42. Eighteen
of the
patients
were given 9 pints or more.
Because
the Ashby
studies
were
especially
valuable,
we tended
to select patients
of other
than
group
0. A battery
of hematologic
studies
was
carried
out on each patient.
In most cases the observations
were
performed
serially
and were
terminated
when
the patient’s
condition
permitted
further
evacuation.
During
the period
of the study
1620 pints
of blood
were
used
at the
hospital.
No hemoglobinuric
reactions
each
of whom
occurred.
The
side
hematocrit
and
of heparinized
centrifuged
Dacie11
in which
After
thorough
blood
at
2000
g for
20 cu.
mm.
of whole
mixing
the
cells
measured
blood
were
in Wintrobe
Red
cell
were
counted
tubes,
counts
diluted
were
in 5 ml.
in a standard
filled
done
by
of normal
counting
at
the
the
bed-
method
saline
chamber.
of
(1:250).
I)ifferential
(Michael
agglutinate
the
0.3 ml. of the above
red cell
a small test tube containinig
an estimated
5 mg. of dried
anti-A
or anti-B
Reese).
This caused
agglutination
of the patient’s
own red cells
but did not
transfused
group
0 cells. After
30 minutes
the tube was centrifuged,
the
unagglutinated
cells
agglutination
Ashby
was
35 minutes.
(the
suspension
into
serum
agglutinable
fore
arrival
and
15,000
cells
were
counts
at
the
per
technic)
were
resuspended
were
not always
hospital.
Cu.
mm.
counted;
was
where
and
the
two
pipeting
in
because
were
total
values
by
counted
baselines
making
the
out
possible
Where
In
carried
red
were
a counting
of
chamber.’7
transfusions
given
possible,
the
count
counts
and
Ashby
cell
almost
equal
at
least
to
varied
Baseline
in-
patients
be-
between
counts
at
cells
were
3000
7000
least
1500
counted.
The
Ashby
counts
were of value
to establish
the ratio of donor
(group
0) red cells
B, or AB) red cells after transfusion.
Serial
Ashby
counts
revealed
alterations
ratio.
An increase
of agglutinable
native
red cells suggeste(1
a loss of transfused
to native
(A,
inicrease
of inagglutinable
tions
transfused
cent
cells
per
day.
White
cell
the
direct
mm.
counts
were
about
modified
to
use
per
read
was
after
The
plasma
of
warm
red
of transfused
could
be
doubly
red
cells
group
diluted
0
cells
as
When
was
taken
frigerated
to
represent
1 hour
to
The
Dacie’s
at
normal
the
rate
An
condi-
of
0.85
per
and
as
final
group
was
the
A or
titer
of blood
that
plasma
at
ml.
blood
resuspended
carries
anti-A
large
or
and
an
Clumping
against
of specific
A or
plasma
blood,
were
elsewhere,10
was
indicator,
The
an
aqueous
solu-
cent
low.6
Xornial
of bank
transfusions
were
were
volume
etc.
into
the
were
A,
the
B,
of a 2 per
The
of the
0 cells
than
anti-B
test
was
indicated
against
recipient.
presence
or
of foreign
AB.
heparinized
plasma.
tested
at the same
B cells
or
a saline
hemoglobin
as
antii)odies
0
who
1:4,
anti-A
30 per
by
cu.
counts
the
Because
just
anti-B
equal
of 1:2,
with
out
per
plasma.
lightly
plasma
with
m.
The
of
serum
serum
B.
515
of recipients
in
mixed
and
mixed
as
obtained
transfusions
plasma
been
reticulocyte
about.
in the
were carried
to 300,000
described
probably
of plasma.
the
had
Normnal
dihydrochloride
are
100
counts
is 200,000
hemoglobin,
henzidine
of
dilutions
higher
range
Cold
cent
suspension
carried
out
nonnspecific
0
agglutinins.
arid
There
was
time. Seruni
of
against
aggluti-
cells,
the
difference
The
tubes
were
re-
5 C., centrifuged
for 1 minute
at 400 rpm
and
chilled
again
for 5
they were shaken
and read.
Agglutination
was rated
from
1 to 4 plus. One
but definite
clumps;
at 4 plus
all red cells were clumped
in one or two masses.
suspensions
where.8
when
saline
titer
for
minutes
before
plus was small
The
well
per
measured
in titer
to give
the
the
Platelet.
Brecher.’
by
results
blood
after
in
were
with
in saline
nation.
Under
cells
normal
spectrophotonneter
been
if,
detected
titers
smear
than
5 mg.
0
learn
or no difference
was
cells.
native
way.
The
specimens
had
usual
for
these
than
cells
to
a dried
described
Jr.
from
the
on
as
rather
employed
is less
agglutinin
little
of native
generated
Cronkite.4
method
a Coleman
was
interest
antibodies
The
base
determined
starte(1,
It was
blue,
cent.
on
hemoglobin
blood
counted
benzidine
benzidine
plasma
a loss
newly
in the
and
methylene
0.6
were
of
suggested
by
performed
were
of new
usually
tion
replaced
of Brecher
Reticulocytes
results
are
0 cells
the
17
method
solution
ing
group
of
cells.
at
were
direct
also
Coombs
instructions.1’
examined
test
at 37 C.
for
incomplete
Details
adsorbed
of t.hese
procedures
antibodies
are
was
described
performed
elseaccord-
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1.-The
TABLE
Circulating
Red
Cells After
Transfusion
Transfu-
sion
Blood
group
Patient
Day
n
postop.
a
,
of Group
Ina-
Pro-
Total
gluti-
RBC
nable
RBC
portion
mil-
lion/
Cu’
mm.
million!
con.
mm.
of
donor
RBC
% of
total
0 Blood
Hct
MCV
cu, p
Anti A cold
agglutinin
Tr at 1:8
‘r/3
A
Multiple
A
lacerations
of
9
m4,16
0 Potop.
6.66
4.27
6-4
55
83
1
5.75
3.59
62
48
83
3
5.25
3.40
65
5
521
5.10
3.47
3.34
67
67
41
44
44
78
84
88
0
0
0
4.70
4.71
(14,000)
2.41
0
51
39
45
83
95
0
intestine
10
P
Massive
wound
lower
A
of buttocks
back,
laceration
of
6
11
OPreop.
OPostop.
and
I
4. 43
250
56
36
81
rec-
3
3.67
.90
6
2.86
1.23
52
43
8
3.08
30
24
26
29
38
41
34
82
84
84
81
84
85
77
78
80
93
turn
M
A
Penetrating
wound
chest,
diaphragrio
of
and
9
10
right
liver.
OPreop.
360
0 Postop.
I
2
4.53
4.85
3
H
wound
of
diaphragm
Penetrating
chest,
lung,
A
8
mm
G
tion
wounds
of legs
of right
femoral
with
8
17
80
42
83
10
0 Poetop.
1
5.10
4.38
4.34
1.64
3.39
3.17
32
77
73
43
39
39
84
89
90
0
1:32
2
4. 77
4.37
4.24
4.38
4,34
3. 46 73
3. 15 72
2.7565
2.74
63
2.53
58
41
38
35
36
37
86
87
83
82
85
1: 16
5.65
7.01
7.20
5.90
(11,500)
0
4.72
67
4.81
67
3.9367
6.50
5.06
2.91
4
6
11
Penetrating
Died
Bilat.
30 hrs.
chest,
Mult.
wounds
8 hrs.
-
58
84
90
90
71
91
K
A
7 12-14
of femur
II
81
OPostop.
2.67
2.82
38
6
4.71
5.09
57
A
55
-
-
4.70
5.37
5.38
4.64
3,99
4.53
2.75
58
3.14 58
2.69
58
1.79 45
3.2572
39
41
47
37
34
38
83
76
87.5
80
85
84
6.4
5.82
4.28
4.21
m.8235
arm,
n
11
thigh
E
including
A
5
A
613
2
0 Preop.
OPostop.
1
10
1
A
412
OPostop.
12
chest
-
1:4
1:2
0
0
-
tr
0
-
0
0
R foot
U
Thigh,
-
59
65
53
46
46
1
OPreop.
0 Postop.
Q
Amputation
0 Aid station
0 Postop.
postop.
fracture
Right
of abdomen.
32
46
46
artery
13 13
:3.4
5
see-
A
2.3453
2.2355
43
39
35
9
I
wound
0
59
61
55
1:4
0
0
0
1:4
1:2
0
0
0
trace
0
0
2.13
2.24
1.78
m
A
2.68
2.97
2.42
m:8
-
4.93
5.77
505
right
and
liver
Multiple
4
0 Postop.
4.40
4.39
4.02
1.2741
(7,000)
-
abdomen
1
V
Multiple
wounds
A
of
.1
N
Face and
OPreop.
OPostop.
extremities
A
2
light
51
80
37
47
81
0
0
35
82
0
24.5
2
4.85
4.30
1.83
26.5
1.5028.5
4
3.54
1.2728
5
I
0
-
38
90
38
33
78
77
0
0
30
85
0
3.41
1.2328
28
82
0
13
0 Postop.
4.74
0.90
19
38
80
0
4.36
4.85
0.97
0.98
22
20
38.5
88
11
1
1
L foot
Amputation
Multiple
310
1.57
(5,500)
l.7l
-
-
0
tratl:8
1.2223
40
76
0
5.58
0.9617
48
86
0
3.90
0.90
30
77
A
2
0
A
29-Il
1
5.29
R
B
29
1
AB
2
1
wounds
skull
Multiple
light
wounds
Multiple
light
wounds
T
16
441
23
AntiB-0
Anti
A tr
at 1:8
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442
LARGE
TRANSFUSIONS
OF
STORED
BLOOD
H
The
Bank
The
Bkod
plasma
hemoglobin
determinatiomis
performed
revealed
an average
of 34 mg. of hemoglobin
of the bottles
the plasma
hemoglobin
exceeded
hemoglobin
gradually
it was about
the plasma
heparimiized
normal
The
post-transfusion
technic
are
presented
The
Patients
50 mg. Inn blood
hemoglobin
was
blood
draw-mi
survival
mg.
of differential
table
1.
at
the
Time
study
of
84
per
In
blood
3 per
(‘cnt
tine
the plasma
25 mg. per
(‘emit
plasma
hemoglobin
100
ml.
; at.
The
is usually
studied
results
at
of
2 to 3 mg.tm#{176}
by means
of the
of some
of these
studies
is-as
Admission
carried
out
of these
multiple
patients
The
had
svas
long.
was
svas
usually
about
the hematocrit.
platelet
in
of
of bank
carefully
dm’ass-mi inito ACI)
solution
5 to 6 mg. The plasma
hemoglobimi
aggluntination.
(table
2). The
but inn omne case
elevation
pints
of plasma.
In
into an oiled syringe
of bank
blood
is-as
mission
to the hospital
to 25,000
per cu. mm.
time
100
ml.
iii
adequate
An
on 300
100
was less than
50 mg.
As the blood
aged,
increased.
At. temi days
the aserage
is-as about
tsventy
days
our hospital,
Ashby
per
w-ounds
count
on
patient
w’ho
the
svas
blood
of the
admission
4 million
hut
The
plasma
one
omi the
of eleven
patienits
uponn
leukocyte
count
ss’as high,
usually
it was 40,000
amid in amiother
49,000.
legs.
w-as
In
the
or high.
meami corpuscular
hemoglohini
w-as
receiving
both
normal
evacuation
The
ad-
20,000
Both
time
red
cell
count
volume
is-as low amid so
normal
exceptimig
a slight
a transfusion
of
is-hole
blood
at
the
admission.
TABLE
Evacu-
Patient
at Time
2.-Patients
of
Admission
Treat-
Wound
Plasma
ment
(hours)
en
Leuko-
Platelets
.
million!
Hct
100 ml.
route
con. mm.
cu.
Trans([)inof
mm.
blood)
K
Ext
5
0
46
71
-
23
0.75
7
M
Chest
3
0
29
80
2.5
17
1 .25
9
P
Abd
2
iGel
39
83
1.6
24
-
6
Q
Ext
5
2Dex
31
86
3.8
25
-
6
2B1
.
It
Ext
2
50
90
0.8
19
-
2
T
Ext
10
2 All)
31
76
0.5
40
0.8
2
U
Abd
5
1 Dex
46
80
S
0.26
4
V
Ext
2
1 Alb
35
82
-
27
EE
Ext
10
7 BI
32
82
2.6
49
0.54
FF
Chest&
22
0.26
GG
Abd
23
0.25
Ext
Abd
whole
=
abdominal;
blood;
Alb
fled
the
gelatinn;
Hct
time elapsed
the
transfusion
=
=
0
4
1 BI
32
79
2
1 Dcx
37
80
Ext
200
extremity;
=
of 25 per
cc.
MCV
hematocrit;
between
is stated
wounding
as
Dcx
cemnt
an
index
=
and
of
the
500
=
serum
.
11
-
cc. of .6%
albuniin;
mean
-
Gel
corpuscular
=
Dextran;
5tIX)
volume.
admission
to
the
surgical
severity
of
the
wound.
3
-
cc.
Bl
of
9
9
13
=
3 per
500
cent.
Evacuation
hospital.
cc,
of
moditinne is
The
size
of
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
WILLIAM
H.
3 .-Le
TABLE
CROSBY
ukocytes
AND
JOHN
1)0 ring
Hourly
(X 1000 per cu. mm.)
_______________________
Counts
28
2
3
4
5
6
7
27
23
17
21
18
23
16
15
11
10
1
Ext;
Abd
3
AM
4
Chest;
5
Chest;
6
Ext;
7
Multiple
S
Abd
9
Pelvis;
10
Fenniur
11
Ext
12
Abd
13
Buttocks;
19
11
8
9
10
14
Abd;
ext
20
35
43
32
24
15
AM;
ext
5
5
5
5
16
Ext;
back
36
69
39
26
17
Abd
29
24
11
7
15
Ext
20
17
18
i)
Chest
37
17
20
AM
27
37
2016
13
8
6
6
3
11
ext
42
49
35
42
34
29
34
39
ext
33
27
26
21
19
15
16
gangmene
19
26
32
13
12
10
14
14
14
15
21
22
12
7
11
11
7
9
13
25
13
15
4
ext
ext
.
ext.
; abd
abdominal;
=
other
abd
1
2
Abd
ext
After
13
11
9
19
18
17
19
24
14
8
These
1
10
1
31
21
14
29
33
24
22
5
19
5,
22
20
24
19
13
16
29
23
26
24
a later
series
are
patienits
2
6163
of
20
,
than
those
of
Operation
Leukocyte
amid
platelet
coumit.s
sescnnteeni
patients
of this
The
ascrage
preopcratisc
platelet
The
13
22
ext n-emity.
=
3
tables.
Time Patients
(‘oumit
usually
coumits
leukocytc
dcmonnstn’ated
performed
the
s-arious
amid
all but
24,000
ivas
rose
ssas
i)efOre
mi
series.
(‘ount
l)m’eoperatiie
(‘ounit is-as 450,000
ages
do miot include
patiemits
It
Surgery
________________
Preop
the
and
Leukocyte
443
HOWARD
Resuscitation
Wound
Patient
M.
although
per
with
after
operation
in two
mm. ;
hemoclast.ic
cu.
before
and
pattermis
of
are
availal)le
tss-o the leukocyte
count
per cu. mm. ; postoperative
patienits
it fell.
reactions.9
during
The
510,000.
postoperative
operat.iomi
reactiomi
to
on
dropped.
15,000.
aserage
These
aser-
A se(’ond
series
at hourly
initersals.
injury
amid
of
transfusion
3). Inn this second
series patiemit.s
3, 12, 15, and 17 probably
represent
hemoelastic
reactiomis
characterized
by ann abrupt
disappearamice
of leimkocytes
amid
platelets
and a conicidenit
fall of i)lood
pressure.
A most
sesere
reaction
of this
sort is-as emicotnntcred
inn the patient
presented
belois’ as case I. At the conclusion
(table
of operation
to
his
17,000.
375,000.
svas
A mild
is-as
from
it
this
tenidemicy
1 1 , 150.
patient.
ooze
from
per
cu.
(‘ounit
Six
the
cut
of
t.o cause
surfaces
2700,
amid his platelet
the platelet
in silicone,
leukocyte
different.
Inn none
enough
mm.
is-as
is-as 90 minutes
operatiomn
sen-crc
to
to 500
lcukoryte
time
after’
is-as
fibrinolysis
fell
the
(‘lotting
hours
houn’s
t’trltum’c
count
later
time
Eight
tw-enty-foun’
blood
hours
At this
poor.
reaction
leinkocyte
Fiic
organisms
the
and
(‘ount
patients
(‘lot
ssas
is-crc
is’ith
(‘oumit.
count.
retraction
3510
amid
idemitified
the
at
inn a
hemoclastic
bleedimig.
ss’as
noted
inn several
patients
is’ho
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
444
LARGE
.
4 .-J?eticulocyte
BLE
TA
TRANSFUSIONS
OF
Response
STORED
to
BLOOD
A oem
ia
(Ifter
fl(lin(J
lloni
Replacement
Patient
Blood
I%l
group
total
S
,
A
B
\,-
,
Ageolwound
Hematocrit
36
11
20
8
50
.
‘
8
,
65
3
A
25
5
x
A
90
FF
0
-
lxceptiiig
FF
there
is a possibility
by
foreign
becomes
more
remote
each
such
antibodies
dennonstrate
receised
tranisfusiomis
was little
1OClll)li
al)le to
retraction,
tin-ity
after
in
inn these
a loss
of
was
was
transfusion.
vitro
the
more
than
50
omn a basis
prothrombin
comnversion.
tendemicy
per
nomne
to bleed.
The
be
cause
plasma.
of
tinese
destroye(l
as
is-as
found
possil)ility
was
it possible
l)atients
Further
the
phew-ere
lack
test
pheinomenioni
that
of the
adjun-anits
factor
underlay
of labile
has
not
of
sometimes
indicated
one
clot
a(’-
one-stage
amoiniitimig
tests
factor,
that
of this
that.
a defect
of labile
said
they
The
patients
the clottinig
time,
is-crc mnormal.
Prothrombin
of activity.
lack
It cannot
beenn
0
day.
indicating
cent
have
group
first
3.2
in excess
of 20 pimnt.s. The 1)lceding
of amnnoyannce
to the surgeomis
is-ho
prolonged,
of a relatine
2.0
‘
38
may
In
after
4.4
3.4
32
transfused
studied.2#{176} It
is-as mu(’h
5.1
27
reticulocytes
the
of I)amiked
blood
more
thami a source
patiennts
time
26
30
,
conitrol
it easily
by pressure.
Inn these
platelet
counnt,
arid touriiiquet
test
prothromhinn
defect
day
3.6
9
from
1.2
I
32
7
that
isoantibodies
(C’jC)
RBC)
60
appeared
mild
,
A
1
to
by-aius7d
A
‘
N
to
1
yet
the
of
the
been
estab-
lished.
Reti(’ulocyte
counts
were domne on fifteemi patiennts.
Inn eight
the ret.iculocyt.es
is-crc less thann 1 per cent before
amid after operation.
Inn six there
were more thamn
1 per cent i)Ut inn nione more thann 2 per cent. Inn one patient
the reticulocytes
percenitage
ss’as 1 .6 before
operationn
arid 0.6 afterssard.
Fin-c to temn days after operationi
reticulocytosis
reticulocytes
had
svas
not
developed
appropriate
The plasma
hemoglobin
operation
(table
5) . The
is-ho
had
2 to
9 pints
received
from
of blood)
per 100 ml. inn five
tw’enty-tss’o
patiemit.s
(‘omicelitration
these
had
three
plasma
is-hi(’h
plasma
the
hemoglobin
per
hour.
100
ml.
During
per
hemoglobin
parenntly
hour.
2 to
the
37
svas
degree
of anemia
the
returned
is-as usually
was carried
pints
plasma
of blood.
In
hemoglobimi
cases.
rFhe
w-as 18 mg.
to
w-as
present,
miormal
is-ithimi
w-as
40
normal.
or
It
is-as
decreased
at
severe
shock
These
results
a connsequenice
rates
the
do
rate
not
remained
of continnuimig
that
varied
the
include
slightly
low-
is-as
the
2.2
patients
elesated
grade
to
loss-cr:
hemolysis
mg.
of
all
operation.
In
patients,
the
five
in
the
rate
shock,
at.
the
8 mg.
per
100
ml.
0.7
1.3
mg.
per
inn is-hom
for
30
hemoglobin
after
In
of
after
patiemits
received
Ics’el
plasma
hours
higher.
from
of clearanice
number
ahos-e
hemoglobin
tis-elve
mg.
the
4).
elevated
immediately
out omn tiscnty-t.ss’o
seveii
mcmi (is-ho had
average
postoperative
With
three
exceptions,
level
but
(table
is’as measured
frequenit.ly
eiiough
t.o establish
w’as cleared
from
the blood.
In patients
not
concelntrationi
as
anemia
to
concentration
determimiation
postoperative
hemoglobin
the pigmemit
w-here
to
the
ses-eral
(table
plasma
(lays,
6).
ap-
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WILLIAM
5.-The
TABLE
H.
Effect
CROSBY
of Large
AND
JOHN
Transfusions
M.
445
HOWARD
on the Patients’
Plasma
Hemoglobin
Average
plasma
Size
Age of
blood
(days)
transfusion
(pints
0
Patient
of
‘O
0
0
Patient’s
1
I
20
hemoglobin
(mg/looml.)
Rate
bmood
11
47
(after
31
6 1)ts.
of
Hb postop
ml./hour)
Postop
Preop
26
of decline
l)lasma
(mg/mOO
__________________
(mg./
100 ml.)
A
plasma
Hbof
transfused
5
preadmis-
sion)
AA
O
23
18-19
82
2
13
37
11(26
21
25
102
I
pts.)
16
(11
29
(after
14 pts.)
(after
6
(after
4 pts.
40
-
pts.)
G
A
11
,A
I
17
8
8
A
31
11
3
22
13
13
12
8
-
4
-
pts.)
in
6 hrs.)
NR
58
5 out.
0.7
10
15
30
25
19
12,14
Is.
A7
BB
0
M
A9
V
A
3
10
31
1
A
6
11
19
1.6
19
0.8
27
0.8
It
13
‘10
‘B
DD
11-12
2
I
0
‘9
15
11
2.5
of
shock
in
smock
-
-
I
18
-
11
-
3
-
1.2
-
‘
23
4
(after
11
Pts.
in
90’)
Q
A
6
12
S
13
6
16
‘o
19
36
15-16
9
I
2.5
3.9
(after
4 pts.
(after
7 pts.
7.8
4.6
5
inn
hrs.)
2.6
30
2.5
preadmis-
sion)
FF
0
9
13
24
6
(after
(;G
,
X
0
‘13
‘A’lS
0
1111
\
0.8
A
Severe
33
19
2.2
16-19
36
39
2.5
132
28
1.5
:35
14-15
renal
ai)dOmilial
16
31
22
insufficiency
ssoumid.
admissiomi
recein-ed
t.w-emit.y-four
hours.
He
shock
part
per
arid
39
100
lois-er
mg.
possible
ml.
The
the
to
hemoglobinemia
relate
He
time
the
the
of
other
abdomen.
at
15
developed
His
inn moderate
mg.
‘8
4 pts.)
inn tw-o patients
to
received
pinnt
den-elopmemnt
of pathogenic
hospital
4 pints
the
time.
of
Plasma
patiennt
last
our
had
being
of low-er
concentration.
of this
series.
been
delayed
during
his
hemoglobin
ann extremely
18 pints
is-as
blood
had
of blood.
given.
nephromn
The
His
ss-oumnd
nephrosis
highest
was
si-as
of the
to
level
the
7
pelvis
hemoglobin
of these
an
than
ali(I
operation
plasma
Iii mneither
had
more
operation
after
severe
One
svas
mcmi si-as it
presemice
of plasma
hemo-
of
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
446
6.-Effect
TABLE
LARGE
TRANSFUSIONS
of a Large
Transfusion
OF
STORED
of Group
Total
D a te
5.42
Nov.
23
6.65
Nov.
24
6.65
Nov.
25
Nov.
26
6.65
5.71
Nov.
27
6.64
6.1:3
Nov.
Dec.
1
6.69
Dec.
4
7.10
Case
I).
in
Note
Penetrating
rennove(l
seven
hours,
the
1 :2
tine
,
81
‘
83
Coonibs
test.
nieg
.
19
21
‘
1:128
18
1:64
of
cold
agglutinins
The
patient
The
niild
cmicountercd
patient
AA.
cases
fusiomi
did
not.
of
t.etamiy
of (‘itrated
imije(’tiOlis
of
were
Dec.
were
patiemit
cal(’ium
appeare(l
saliva
single
may
at
but
have
were
a titer
tine
mech-
present
in
There
were
of 1 :4 against
moot secrete
clinically.
because
l)een
postop.
did
0
of native
probably
agglutirnimis
continual
The
a
no
group
A substance
patient
‘s clinical
improvement.
series
basis
102
was
of
patient
but
glucoriate
loss
(lays,
hour
group
hours.
a progressive
an
intestinal
of
mg.
pen’ 100 ml.
inn the
insufficiemicy.
the
Oil
The
and
14 pints
half
several
withini
they
of this
remnal
one
Anti-B
of
given
agglutininis
in his
blood
nnixed
and
for
apparent.
one
of
indicating
gone
niot
developed
blood.
1:16
1:8
was
two
eliminate(1.
was
develop
(‘C.
anti.&
1 sshen
period
in any
He
1:64
‘
0
patient
cells
specific
B substance
entire
.
abnormal
l)hcllomenon
this
81
of
red
but
until
:3.1)
2000
The
a l)eriod
The
secreted
inemolytic
throughout
globin
within
operation
5.2
,
2.3
,
cavity.
cells
,
92
84
5.40
abdomen.
remnained
time
nnonnspecific
the
of donor
red
85
I
0
l)roPortion
native
at. the
cells.
them
hemolysis.
0
No
67
cold
1:125
I)irect
I
,
I
5.74
‘
hemoglobin
mt ravascular
of
course
5.52
peritoneal
10 of
plasma
wlnereby
of
from
increasing
The
of a nuild
wound
were
cells.
red
,
6.51
conitents
titer
agglutinin
of anti-A
14
29
anismu
Titer
:35
,
5.26
AR
ml.)
64
,
rc(l
Group
Plasma
hemoglobin
(mg./
‘
tot,’l
5.49
7.81
of
I
8.55
22
blood
a Patient
I
l)0St0P.
Nov.
in
RBC”
tion of
of
m):mc.1.
21
Nov.
,
(millions
RBC
.
______________________
S hrs.
ORlood
Propor-
( mi
Ri?.Cions
,
BLOOD
hypocalcemia
is-ho
improved
had
from
tetanny
sshenn
did
his
n’apid
not
t.n’anns-
r’espomnd
to
hypen’ventilation
is-as
(‘Omitl’Olle(i.
All
0
blood
blood
5101i,
used
the
blood
isoant.ibodies
the
replace
ishicii
The
tested.
AB
against
tramnsfusioni
amntibodies
inn detail
agaimnst
A and
his
anti-B
Coombs
Where
patients,
the
Inn most
oss-n
plasma
agglut.imnimis
test
for
the
anti-A
ther’e
native
cells
cases,
the
is-hem
he
es-eli
is-as
red
w-ith
donor
persisted
inicomplete
cells
(table
si-as
group
0.
cells
had
persisted.
In brief,
persisted
The
beemi
is-crc
gin’emn
plasma
The
of this
ssork
that
the specific
of a fess patients
rapidly
enough
of
B. After
tramisfuto find if specific
results
it is-as foumnd
inn the plasma
isoagglutiniins
had
removed
blood
are
(‘old
of
from
virtually
to
mio case in
inn the plasma
of patients
of group
B oi’ AB.
amntibodies
si-as also
nnegatis-c
inn all patients
plasma
agglutinnin
definite
study
of groups
A arid
A, B, amid AB is-as examimned
in another
report.8
group
A red (‘ells
plasma
this
red
of gm’oups
A amid B red
AB.
recipient’s
during
against
of patiemnts
agaimist
described
agglutinnins
groups
for
(‘onntaimns
persisted
es-idennce
6).
Where
of
group
mi high
of specific
the
0.
We
titer
hemolyt.ic
replacememnt
found
in the
plasms
activity
of native
of A
01’
directed
red
cells
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
WILLIAM
H.
CROSBY
AND
JOHN
M.
447
HOWARD
donor
red cells ivas 80 to 90 per cent complete,
the sloss destruction
of miative
comntiniued,
even
imi the absence
of demonstrable
group-specific
anntibodies.
This
hcmolytic
a(’tivity,
ishich
is-as demonstrated
by laboratory
methods
is-as a
loss- gr’ade process
aind had mionne of the chimnical manifestations
that are asSOciate(l
by
cells
isit.ii
incompatible
hemolyt.ic
Ini additioin
isounnded
mcii
cells
before
been
had
loss
of
activity
there
that destroyed
red
(‘ells
not
due
t.o sequestration.
is-as
lytic
pinemnomcmnomn
sen-crc
the scscrcly
hncmolytic
(table
shock.24
blood
isounnded
there
act.isit.y
during
from
l)lood
volume
5,
days.
The loss
all probability,
In
determimnations
and
J.J
the
period
during
solume
failed
to accoinnt.
for all of the
demonstrated
by serial
deter-
are
is-as
it
demonstrated
examples
of the
this only
or is-hen
acute
of resuscitation.
is-as cs-idemnce i)y cell surn-isal
the period
of five to fifteen
is-ounded
meni often
comnn-ales(’ence
(table
amid
plasma
iolumc
the
falling
due
to
amiemia
arid
not
true
ann almost
linear
plasma
is-ho
Inn these
tra(’ted.
It
hemo-
Inn mamny
studies
days
is suspected
abnom’mally
great
The
tiso
paticmnts
ancmi(’
a.t
had
the
1)een
blood
of
of a moderate
after
wounding
measured
by
developed
acute
or modem’ate
inn the
other
the
red
cell
a loss
of
per
cenit
ill
Ii
hilin’ubinemia
hiase
bcenn
at
foinmnd
Variation-s
of Mean
\ariations
of
is-iio
is-crc
scs-erely
sion
(table
2).
ssithimi
the
to
a day
be
begain
with
the
count
fell
time.
to
of red
red
(‘cli
the
mass
extent
amid
that
the
cells.
red
bosvel
patients
inistnfficiemncy
(‘linical
evidemncc
prior
to this,
of uremia
from
5.24
the
33
milliomi
tine
not
became
as show-li
23
of red
in
cu.
Paticlit
developed
(MCV)
is-en’e
Them’e
l)y changes
cells
is-as
mm.
to
pre-
hours;
tselnty-four
had
is-ho
rapidly
of uremia.
loss
to
per
Neither
patients
into
cells.24
shois-
hours.
or
is-as usually
renal
fell
Other
w-ounded
severe
onnset
from
the
4.65
million,
hemoglobiniemia
remial
iiisinfficiency
icteric.24
Volume
corpuscular
ss-oumnded.
Immediately
it. again
the
omily
into
actis-it.y
the
Corpuscula.r
meann
to
hematocrit
tivelity-follm’
bet.is’cen
loss
the
mass
is-crc shossii
t.o he
polycythcmi(’
patients
in
polycythemic
tagged
hemolytic
but
omne patient
exist.
is lost
inn the
ssho
counts,
to
for the
plasma
they
hematocrit
anemic
during
of red (‘dl
polycythemic
sserc
those
with
abdomimial
volume
is-as measinred
amid foumnd to he comi-
s-olume
that
amid
occurred
whcnn
time
slight
inn the Ashhv
(‘ipitoins.
In
that
total
founid
t.o become
the plasma
to become
measurements
Excepting
to compemisat.e
temided
patients
The
coumit
hemodilutiomn
expamided
Patients
ssounnds.
cell
is-as
Inn gemieral,
nohinmc
al)domenn.
red
tended
1 ). By
hemodilution.24
relationship
hematocrit.
01’
(‘omput.ed
1).
The more
seserely
ean’ly days
of their
the
B,
oc(’urred
es.idence
inn ses-erely
and transfused
red
cells, suggestimng
sequestratiomi,
but.
congestion
ss’ith a high hematocm’it.
Patients
that
is-as
natise
first tw-o postoperative
I)leeding
ss’as slight.
Some
a delayed
mixing
of the tagged
red
o(’clnm’m’cd iihemi there
was generalized
then’e
is-as
amid after tn’amisfusion
‘which
adminnistered.24
It was also
miniationis
of h)lood n-olume
during
the
mnot. tltne to hemorrhage.
Post.operatis-e
was
reactions.
hemolytic
hemolysis
This
imndiscn’iminnat.ely.
determiinations
blood
that
t.ranisfusionn
to this specific
of nonspecific
1)e(’ame
s-olume
The
MCV
after
transfusiomn
abmnormahiy
ss’as
uniformly
the
lois-
found
lowMCV
(table
isas
1).
at
ill
the
niormal
Thereafter
all
time
patients
of admis-
but
imsually
it gradually
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
448
LARGE
returned
tosvard
TRANSFUSIONS
mnormal.
The
OF
changes
STORED
in MCV
svere
spondimng
changes
inn the hemoglobin
smears
amid inn the counting
chamber
concentration
there
is-as
red
of MCV.
cells
lis’ing
96
to accounnt
for
in the
same
Inn six of the
/.L,
the
sector
eight
reduction
of the combat
the MCV
is-as
BLOOD
The
zone
90.5
nnot accompannied
by
corre-
of the whole
blood.
Inn blood
nio evidence
of fragmenitatiomi
of
MCV
as the
±
of eight
patients
normal
soldiers
ramnge(1
from
86 to
1.0.
DISCUSSION
The
appcaramnce
pennded
alid
upomi
of
caused
during
factors.
the produ(’tiofl
is-as nnot possible
it
amnemia
several
the
Red
cells
days
that
w’ere
lost
folloss’ed
inn other
of red cells ss’as probably
impaired.
to define
the degree
of activity
resuscitation
ss-ays
Except
of each
de-
than
bleeding
in a genneral
of the
ss-ay,
that
factors
anemia.
‘i’/ie Loss a,! Red
Transfusion
I)uring
the
(Jells
that
refrigerated
progressively
after
Become
storage
imicrcasimng
(‘irculation
Had
nnumber
trannsfusiomn.
Nonviable
of
blood
of red
cells
t.sso
sseeks
After
red cells has-c become
nonviable;
at three
Tine Ashby
technic
has been ividely
used
stored
blood.
evidenice
Ashby
of loss
Iiideed,
though
is-crc
of transfused
inn most
time
counts
cases
no
the
more
used
cells
blood
the
first
about
but
actually
for
solution
ACI)
a
in
10 per
of the
cennt
the
nonviable.”
survival
they
tw-enity-four
(‘ells
Used
of suri-ival
25 per (‘ennt arc
post-trannsfusion
study
Inn the
transfused.
Blood
is’it.h
of storage
presemit
during
Stored
inicapable
ss-eeks about
to study
the
of donor
was
the
presern-ed
become
inn the
proportion
in
shoss’ed
hours
(table
increased
I).
(luring
interpretation
of
little
that.
of this
ob)ser-
(‘ertainn points
must
he bornie in mind.
We must
presuppose
that
the
of mnonnviable
red cells inn these
patients
is-as at least
as great
as others
has-c
loss
ob-
vat.ion
sersed
inn miormal
recipiemits
examimned
important.
differenices
inn the ss-ounded
I The postoperatis-e
Ashby
counnt
unider
better
comndit.ionns.
patiennt:
ss’as mnot a true refiect.ionn
.
fusioni
baselinne.
surgery
of
ginenn
2.
of the
several
posttransand
blood
much
seriously
is’ere
unidoubtedly
surgery
an
gomie ss’henn the
postoperatise
inndeterminnate
proportionn
sample
of
the
svas finnally
donnor
red
red
cells
taken.
cells
is-as
lost
i)leeding.
3.
There
amounit
The
are
as eight. hours
were consumed
inn the resus(’itationn
ssouinded
mcmi. The
mnonnviable
red (‘ells inn the first
As
During
through
rIhere
svas,
specific
donior
hours
table
4.
0 plasma
loss
cells,
alters
hence,
after
Inn sonic
loss
inito
increase
of nnative
a recipiemnt
of natin-e
to
of donor
Ann outstannding
patiemits
blood
make
agaimnst
proportiomi
apparenit
trannsfusiomi.
a spe(’ifi(’
transfused
donor
red
example
red
cells
of
whemn a large
of another
(‘clls
inn the
this
blood
group.
inn fan-or
first.
reaction
of tine
tss’emnty-foimr
is shosvin
in
6.
of
5.
si-as
the
the
ann expansioni
mnit.udc
ss’ill be shoisnn,
as
of group
volume
of
tine
Sen-crc
donnor
channge
ivounds
annd
w-ho
the
rcceii-ed
circulatimng
the
large
blood
imnterpret.atiomn
trannsfusionns
volume
amid
is-as
of Ashby
became
polycyt.hemic,
demonstrated.24
counts
difficult
(‘lnanges
umiless
the
inn
ma.g-
is kmnoss-mn.
appear
recipient
to
cells
be
associated
alike.
witii
nnonspecific
hemolytic
activity
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
WILLIAM
For’
to
5
these
rcasomis,
the
compute
the
imicm’ease
per
en.
is
hours
believed
to occur
in
to tine plasma.
Fn’om
all of these
dcstm’uctionn
ci-emi
cells,
i)Iml’dcni
The
Whneni
Cells
group
group,
the
againnst
is-arm
0,
blood
of the
recipienit.
cold
agglutininns,
0 plasma
exceptimng
inn the
such
case
a high
hnemolytic
of the
titer
reactions
pooled
darngerous
of
cuiect.
tssennt.y-four
1)tnrimng
tine
this
amid
then’c
matter
pat.iennts
is-ho
their
hours
a paticnnt.
is-as
umndcr
of
m’eplacinng
scieral
such
was
it was
possible
red
had
or days
Fresh
a tcmptat.iomn
i)eenn gin-cnn
ownn
red
cells
it ofteni
blood
is-as
to
ask
18
amid
became
an-ailable
for
umniversal
is-as
This
or
of
patiennt
20
pinnt.s
mnecessary
from
group-specific
donnor
blood
abon-e
(‘ells
that
decreased
is presumed
mis
to
a highi
oss-mi blood
to note
(‘limnical
titer
group.
tinat
tine
n’eactn)nl.
impros-cd.
ss-itin similar
0. How-en’er,
ssounnds
tinere
of
existed
group
domior
to gin-c
troops
blood
i)lood,
amid
rather
imn
thins
plasma.
additiomnal
inn the
inn
is
a potemntial
0
(‘ells
he
example
progressisely
There
by
demon-
ann outstanndimng
of others
of group
plasma
reactioni
n’ecipiemit’s
mioted
to demonstrate
importamice.
acute
su(’h
the
It is important
produce
any
the
tharn that
they being
No
of
1).
cells
slossly.
did riot
donors
produces
It
6 is shosvnn
againnst
amid
damngcrous
blood
of nnatin-e
(table
actis-e
connsist.
antibodies,
against
proportioni
active
clinical
a
of another
amid Emcrsonn’3
this.
patient
great
red
impose
amntibodies
The
the
tranisfinsionis
obsers-ationi
to
specifically
A recipients.tm5
Inn table
left his circulatiorn
these
anit.ii)odies
of these
by their
ai)ility
to
of transfused
group
to be nnomnpatinogcnic
donor.
that
tramnsfusiomn
ssa.s rio less rapid
inemolysis
occurred,
a
to
n-irtimally
After
are
incomplete
group
the
pigment
post.t.ransfusion
loss
appear
amid anti-B
confirm
that
after
Inn this
he
mio such
danngcn’
to
time
situationi
show’ed
specifically
antii)odies
actinity
of
conivaiesccnnce
ss-hom
annti-A
after
occurs
if
red cells
a recipient
that
World
War II Ebert
directed
specifically
isoamitibodies.
of rcactiomi.
agglutimnilns
Tine foreign
inemolyti(’
His
not.
into
amntibodies
ow-mn observations
hours
of tranisfused
sort.
cold
Our
hemoglobimi
Isoantibodies
antibodies
into
amid
durimig
patients.
universal
of pathogenic
(‘Otnlnt.s usually
the
durinig
of this
the
The
did
hemolysins,
svhenn trannsfused
plasma.
Ashby
tine
it
The
is-as obscm’sed
in this series.
During
stn’at.etl
that
mild hemolytic
activity
A or B red cells is-as riot. unncommoni
the
that
is transfused
w-ith
millioni
rcleasinmg
great.
tramnsfusionns,
of Transfused
carries
without
not
to Activity
0.5
about
of plasma
to conclude
of the
should
hemolysis
svhich
of most
nioniviable
system
massive
With
1)100(1
miomnviahility
studies
ivas
possible
tramisfusions,
from
ot.incm’s is’hich
cannot
1)c demonstrated
excepting
red cells from the (‘irculation.’7
The imncompatibility
for the recipient’s
red cells is generally
believed
elimimiatc
or
The
by
small
cells
riot
method.
pinit. of
mann
of intravascular
AA). The loss
justified
domnor
plasma
cells
of red
mechanism
unniversal
the
red
J)ue
agglutinninns,
pcr’hnaps
man-c
excretory
of Red
Loss
1)100(1
of
the
lipOli
size
ivas
Ashby
1 received
loss
it
the
A sinigle
average
to nnomnviability
w-ith
givein,
by
intrude.
reti(’tnloenndothelial
due
inn asso(’iat.iomn
an
449
HOWARD
was
transfusiomn.
it seems
cells
riot
evidenice
(patient
the
M.
cells
inn table
after
data
of red
of
little
5) dcmomnstrated
little
i)lOOd has detcn’iorated
red
did
patients
inndicate
JOHN
trannsfusionn
problems
six
tssemnty-four
AND
mnomnviable
count
last
counts
first.
(table
stored
of
these
The
CROSBY
a massive
imnagglutilnable
mm.
ilnagglutinable
tine
wheni
proportion
trannsfusiomns
nahler
H.
blood
neighborhood
thnani
to
conn-
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
450
LARGE
tinnue svith group
w-ere formidable.
TRANSFUSIONS
0, unniversal
Ninnety-five
OF
more
judgmennt
BLOOD
donnor 1)lood. The proi)lems
of type amid cross match
per cent or more of the red cells inn snub a paticnnt.’s
(‘irculation
may
have
been replaced
by
group
oni the basis
of the agglutinnatiomn
innvolved
STORED
than
onne
group
0. The idenntificat.ionn
of his
of less thami 5 per cennt of the red
should
expect
of most
isoagglutiniins
persisted
inn the patiennt’s
plasma,
mi table 6, it. was impossible
to match
his blood
techmnicians.
was
believe
also
possible
that
both
reactiomis.
several
such
No
of the
that
Sil(’h
to
group-specific
are
occurred
Korea
iii
had
blood
procedures
reactionn
hospitals
rcactiomns
also page
i)lOod,
it
give
of these
actually
durimig
cross match
if blood
transfusioni
of 0 blood!.
without
danngerous
crossmat(’hing.
anid
this
study,
is-c foumnd
circumst.amit.ial
occurred.
See
the
may
lead
1)ut
We
to
inn the
records
esidennce
abstract.
several
to
durimig
foreigni
of
imndi(’atc
of Case
KK.
455. When
a man
has been
gin-cnn a large amoumit
of unisersal
is recommemnded
that
he (‘onntinnue
to receise
unis-ersa.l
donor
should
he nneed subscqucnnt
trannsfusions
this time it seems
fairly
certaimn that the
his
foreigmn
as they did in the pat.iemnt show’n
ss’it.h donnor blood
of his hereditary
group.
It was possible,
of course,
to obtaini
a sat.isfact.ony
ssere drasvn
from the patienit
before
the heginnmiimig of the
It
If
ois’mn
(‘ells
See
donor
blood
a period!
of tiso is-ceks.
isoanntibodies
si-ill i)c gone
After
from
cir(’ulation.
The
Loss
of
of Red
Cells
Associated
with
Damage
or Destruction
of Large
Amounts
Tisnue
The members
of the Surgical
Hcsearch
“Abdominal
cases
become
polycythemic
Team
had
es-ohs-ed
; amputees
a rule
anemic.”
become
was a good
onie, arid its applicability
is-as especially
svounnded
of each category.
The most obvious
difference
w-ounnd was the amount
of tissue
that. w’as damaged
ohs-ions
hetweenn
or destroyed.
of thumb:
The
rule
inn the severely
the tnso types
of
A ses-ere
ab-
dominal
case may have
beenn ss-ounnded
by a sinigle small-armsmissile
that. perforat.ed
the stomach
amid colomn to cause massis’e
contaminnatiomi
of the peritomieum,
often
svith little
loss of blood.
This
patient
ss’ould deselop
a refracton’y
type
of
shock
and
svas
(‘ehls
ssould
fill
then
the
gin-cnn 8 to 12 pints
relaxed
annd
sluggish
of i)lood,
pan’ts
inn the
of his
expectationn
that
circulation.
When
the
his
red
blood
pressure
rc(’overed
the patient
sometimes
became
plethoric
amid conngested,
arid!
sometimes
show’cd
signs of incipient.
pulmonnary
edema.
His hematocl’it.
svould lie
i)etsseenn
55 amid 65. I)urinng
the period
of (‘omns-alescemn(’e
ssheln he was ulider
our
oi)servationn
the hematocrit
might
recede
slowly
(case A, table
1 ; case 1), tai)le 6;
abstra(’t
i)ilateral
of (‘ase AA).
high
thigh
tournniquet.s
develop
complete
inn
place
The patiemnt.
amputation
he might
who stepped
reacted
quite
be gis-enn
t.ss-els’e
onn
a
lanid
amid
Wit.h
transfusions
inn tsso
congestiomi
mnor a high hematocrit.
He might
es-cnn reqtnin’e
his operation
and he might
nneed alnOt.her
t.rannsfusioni
the
because
of amnemia.
(Abst.racts
of cases B, S amid .J.J are
of t.his trannsfused
blood has nnot. beeli pros-ed.
(1ertaiinly
examples
inn shock,
or
did
if
not
they
is-crc
shoss
evidence
their
blood
pressures
of sequestration
soon
that
tissues.
hot
re(’os-ered;
si-as
suffered!
hours
and
more
blood
next.
sometimes
all
a
competent
tlay
of this.)
it is-as not
ing. Some
of it. may have been ext.ras-asated
into ssounided
is-as a possibility
hut. not a likely
one: these
patiennts
may
studies
nninne
differently.
by
to
or so
The
lost
niot
fate
blee(l-
Sequestration
es-er
have
l)lOod
bcenn
volume
ehncountered
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
WILLIAM
H.
CROSBY
AND
JOHN
M.
451
HOWARD
inn the
plethoric
abdominal
case amid is’hich
revealed
itself as delayed
miximng of
injected
tagged
n’ed cells.24 We are left ssith the possibility
of hemolysis
ishi(’h
inncludcs
the destructionn
of extras-asated
blood.
This appears
to be a fairly
good
During
possibility.
(a
\Von’ld
of patiemits
tehidency
term
that.
ct al.5
implies
the
Oh
fusionis
II ses’cral
traumatic
of
the
of computations
came
the
to
investigatorstm4’
to
mass
of
that
be(’ome
i)lood
red
w-cll
the
01’
innt.o
t.ai)lc
I
declimne
has
of domnor red
loss
of
coumit.
and
nno aniemia
isas
riot
isas
at
ated
fell
nnotining
at
(‘ounits
of red
cells
The
thani
Reed
is-ith
Such
a paticmnt.
actually
h)einig
is-as
the
thighs,
possible
use
The
qf Red
mnephritis
a resmmlt of
Tine severely
nnephromn
fallimng
hemat.ocrit
10 poinits
Cells
to
that
5 per
the
for
at
the
Ashby
to
mnephrosis)
per
day,
to
cause
usually
hours.
our
tincressithn
the
is-crc
is-as
bilateral
patient,
.LJ.
inn Italy
donnor
adequate
anemia.
The
hemolysis
a(’ute
become
may
has
Renal
cell
greatly
isouhi(l
and
cared
inn the
equal
for
patient.
importanice
ampmnta-
t.ramnsftnsion
isas
Team
inn Italy
ennough
anid
tine
to
use
is recommended
n’apidiy,
and
thereafter.
of
it
san-c
his
of arten’ial
that
tine
n’epeatediy
Insufficiency
anemia
has
and
impeded
post-traumatic
amnemic
rapidly,
volume.24
happeni
surs’ii’al
ss’ho
a h)ila.tcral
rapidly
moors
conntimnmncd.
the
tramnmati(’
ampmntation
It ni-as reported!
that
of blood
forty-eight
Acute
of
si-ith
sshile
a sloss
Field! Research
innjectionn
of red
This
cells.
rcplaccmcnit.
s-igorously
It
An-my’s
ivith
with
amid a shrinikinig
associated
0
surgeomns
too
anemia
S.
the
abnnormal
sshno develop
red
is-as
counnts
the
bleedinig.
patiemit
least
persistent.
of replacement
Inn patient
(‘chit
inn a patient.
of
to speed
is knoss-mn
inn tw-enty-fommr
hemolysis
not
U.
Associated
tis-o factors:
svoumnded
(lower
at
rate
replacement
i)e life sas-inig
in smnch cases.
It
patient
i)e dieterminned
a(’curateiy,
annd
m’esmnsrita.tioni
Los-s
Acute
iseli
H).
h)ut
of
of domior
normal
transfusion
a patient
tm’amnsfuse
these
of
The
kmioss’n
severe
The
pressure
may
liemOglOi)ihi
dimnm’ing
to
of air
si-as
(les-elop
similan’
The
tranisfmmsioins
might
a wounnd
not
thoroimghly
is-ho
II ol)sers-ed
ssas
where
in lam’ge amounts
alndi
administered.
life.2
es-idencc
Inn patiennt
S (case abstracts)
the loss
of the patiennts
of this series
were es-acm-
miot to push
\Var
\\om’ld
dmnn’ilng
P it fell
Hospital
ii’olnndl
mapidly
the
day
the
see case P, table
I,
cases,
A amid! H inn
proportioni
(patiemnt
(‘emit per
to
that. after the first feis’ iseeks
of conns-alescenncc
at the time of ss-ounidinng bc(’amc
nnormal.
of the distinictionn
h)ctii-ecn
the abdominal
significanice
ann abdominnal
tiohi.
a day
(‘chit
per
Inn pat.iemnt
amputation
misc 1)100(1
dossmn,
declinning
mnomns-iai)ihity.
1 per
mcmi. It is-as importanit
these
with
Army
t.ranisfused
(‘linnical
slosved
annd ahnemia
appeared.
cent per day. Ses-eral
imidicated
traumatic
cells
with
rapidly
of 2.5
des-eloped.
to Walter
These
red
to do
a n’atc
adequate,
least 12 per
them
inn the
(‘ells is less
(‘dl
the
the
(For examples,
the abdominal
of comnvalcsccnncc.
B. Compare
ss’as apparent
This
the
period
of case
.) Whenn
hemolysis
to
the
ai)stract.
of tramis-
contribute
is-c have
arrived
at the
this particular
hemolytic
Inn some patients
it. per-
loss
sist.cd
Cleghorni
anid size
must
of red cells. On the basis
of similar
computations
same coni(’lusionn.
Furthermore,
it seemed
probable
that
process
rapidly
subsided
i)ut dlid miot always
disappear.
oligemic
cells).
s-olume
hemolysis
upomn the
markedly
(‘irculating
of (‘ir(’ulatinig
conclusionn
commented
23
amputatiomns
a reductiomi
basis
gin-cnn,
\Var
is-ith
The
t.cmn days
dimimnished.
i)eemn sinossnn
to
he
erythropoiesis.m6
remnal ihnsufficiency
as ren-ealed
by
hcmat.ocrit
after
The
may
ivoumndimng
loss
of red
‘#{176}
a
fall
is-hen
cells
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
452
LARGE
TRANSFUSIONS
imi the uremic
patient
is-as
rui)ihnemia.
The
reticulocyte
before
the
creased
red
omns. t of uremia,
at.
cell
7’Ire
the
same
but
time.
it fell
This
of
is poinnted
the
out
Bone
BLOOD
by hemoglobimnemia
somewhat
inncreascd
belosv
may
1 per
have
ssounded
mamn may
has
published
i)ecln
hemoglobini
take place
at
at
marrosv
Marrow’s
above
that
develop
amnemia,
amid that
the amnemia.
During
the
1)0mw
accompanied
coumit
si-as
STORED
beeni
or marked
biliinn these
patienits
ccmnt eveni
though
imndicatiomi
an
anemia
iii-
of impairment
of
product.ioin.
Inadequacy
It
not
OF
manny
hcmolysis
first
w-eek
destroy
to
Response
of
the
severely
w-ounndcd
iscrc
prone
to
is probably
a factor
inn the pat.hogcmncsis
of
or temi days
of (‘onvalescenncc
a sesterely
his red
cells
that
the
suggest
to A nernia
at. 3 to 5 times
adult
normal
the
humann
i)onne
rate.
marross-
Evidennce
produce
can
6 to 8 times
the normal
rate;
blood
dest.rmnctioni
(-ann therefore
6 to 8 times
the niormal
rate is-ithout
appearaince
of amncmia.7
The
of
the
seriously
wounndied
mcmi
did
miot compennsate
to
this
extent..
Wheni
they
destroyed
their
red cells at only
four times
the nnormal
rate,
they
became
aniemic.
Reticulocyte
counnts also showed
evidehnce
of impaired
responise
to amncmia
(table
4). With
ann hematocrit
of 25 OhiC ss-ould
expect
a rcticmmlo(’yte
of 15 to 20 per
(‘OUhit
Pigment
Metabolism
If the
innto the
plasma
mg.
300
the plasma
plasma
the
enidot.hchial
cemit. inistead
of hemoglobin
of am average
hemoglobin
same amount
system
arid
of 5 per
from
1 ml. of n’ed (‘ells
size man
(plasma
volume
paticmnt.s
as
B amid
JJ,
nnot
(‘ase
approach
(AA).
nariai)ly
Ill
the
The
smnl)sided
patiennt.s
evidennce
(AA)
bilirubin
shiowed
a similar
imicrease
one
of this
si-as
a typical
tional.
pam’alytic
It
threshold
6).
series
w’hose
case.
has
bcenn
ileus
almost
or
of the
moderate
urinnary
plasma
JJ
mioted
by
per
little
fhe
Surgical
nnormal
is-as
quality
to poor
cells
exceeded
the
to
red
sen-crc
of
The
Team
reasomn
per
iso-
the
plasma
shadowed
AA
is-as
100
that
for
of tranis-
ni-as
bilirubini
thnis
ml.
is’oumnded
rarely
defecate
durimig
the
first.
week
or temn days.
by
tine only
Patient
is-as
patiemits
has
B
excepivithn
nnot i)ecmn
estai)liShed.
Clinnical
jaumndicc
is-as rarely
encoumntcred
inn other
patiemnts.
rate
of excretionn
of bile pigment
inn the feces could
mnot. be st.udicd
because
sesercly
in-
sloss-
transfused
is-ounids
that
plasma
Research
jaumndiced.
by
Patienit
4 mg.
elen-ationn
a single
iii
almost.
dtnc
cles-ationi
rio
except
of natis-e
excrctionn.2m
of pig-
hemoglobinn
hemolysis
biphasic
bihirubini
ml.)
return
ss-ith
cvidenncc
Hemoglobinnuria
(lid
of plasma
hemoglobin
100
pat.iennts
with
became
is-as
of plasma
hours.
urobilimiogemn
Patiennt
alssays
mg.
tis-elve
dcstructionn
Inn most
a slight,
of
(130
of imntravascular
to
there
remainns
oi)scure.
Imndeed, the len-el
elevat.ionis
ns-ithinn
or due
(table
alitii)O(iics
that
removal
series.
or moderate
to nnormal
ssith
l)lood
fused
of its
of this
rennal
slight
of being
released
into
the
to bihirui)inn inn the reticuloinn the plasma
at the same
bilirubirn
0.35 mg. per 100 ml. Inn tine face of a
to involve
hunndreds
of ml. of red cells, as is-ith
it is remarkable
mcnit liberationn.
The route
mnot appear
inn arty patienit
(lid!
is-crc released!
at omne time
3000 ml.),
it. ss-ould
raise
10 mg. per 100 ml. If innstead
of hcmoglobinn
is-crc degraded
if all of the bilirubin
appeared
time,
it w’ould raise the plasma
hemolytic
process
that
appeared
su(’h
cenit..
The
the
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
WILLIAM
The
Leukocytes
and
Leukocytes
Although
from the
H.
CROSBY
AND
JOHN
M.
453
HOWARD
Platelets
of blood
preserved
mi ACD sohmtiomn are mnomnviablc.17
be visible
inn tine stored
blood
they
disappear
immediately
of the recipient..
The t.ramisfusionns
given
to some
patients
of
amid
platelets
they
may
(‘irculat.ion
this series is-crc large enough
s-irtually
to replace
their oss-mi blood
ss’ith i)lood that
sias,
inn effect.,
free of leukocytes
ahnd platelets.
The
leukocyte
count.
ivas
niot
seriously
depressed
by large tramnsfusionns
(table
3). The
productioni
of nness leukocyt.es
is-as adequate
to prcs.-ennt leukopennia.
The platelet
level is-as generally
mmaffected
i)y diilutionn
Inn fact,
the
amid
ad!cqtnatc
time
the
amid clot
sersat.ionis
and
or rcpla(’emennt
platelet
of
counnt.s
platelets
Chattcrjea22
fall
paticnnts
is poinnted
and
It
sen-crc
and
as
someis-hat
thrombocytosis.
platelets
judged
i)y
at. sarianice
of leukocytes
other
lesels.
amid
si-as
i)leednig
with
annd platelet
oh-
Stefannini
a marked
treated
for hemolytic
disease
fall
of the
tramnsfusiomns
because
of gastroinntestinnal
patiennts
inn the presenit
series
is-crc
seseral
hours
This
large
compctennt
drop
tramnsfusionis.2#{176}
of
of
of small
amounts
of compatible
plasma,
es-cnn
has fomnnd that
exchange
trannsfusionn
causes
a
inn inifamnts
inncurred
the
are
i)y large
production
onn Icukocyte
a slight.
tranisfusion
Desforges’2
of platelets
t.o svithst.annd
result.s
reported
gin-cnn massive
omnt that
the
injuries
t’yt.osis
the
blood
The
seemed
of tramnsfusiomn
have
platelets
fohlow-ing
ihi niormal
subjects.
profound
These
effect
patient’s
imicreased.
themsels-es
retraction.
the
of the
usually
i)cfore
transfusioni
(‘oniditionning
may
isithomrt
des-elopinng
transfmnsions
w-hich
has-c
niewi)ornn
hemorrhage.
(‘onnditiomned
es-oked
cnnai)led
a lack
by
Icuko-
the
patients
of leukocytes
or
platelets.
Changes
in the Mean
The
sesercly
iolume
of the
i)ecome
normal
Corpuscular
w-oumnded
red
againi
as t.he cell
cells
inncn’eascd.
may
in
turnn
studied
(‘eli
of the
per
The
adrenial
cent.
volume
The
han-c
i)cchn
Thorne
hemoglobihi
cort.isonne.
studies
On ses-cral
to
his
in
small
amid
the
mcamn
changes
shifts
Because
that
is-hicin
of
h)ccame
small
electrolytes.
have
follosvinng
of MCV
cortex.
the
iii
the
this
sariabie
ins-ols-e
shock
there
occun’red
the
severely
(‘hanige
or
corpmns(’uiar
onn admission,
tennded
againn
to
t.hercaften’
of fragmcntationn
of red cells amid the
blood
did nnot change.
This
ihndicates
(‘ollai)orators27
concemntrationi
Tine
problem
described
svoundcd
may
taken
chaniges
of
reflect
into
hi
ACTH
amid
a stimmnlationn
is-as sometimes
i)e
is h)eing
similar
admimnistration
inn MCV
shomnld
inn the inndividual
of water
ss-hichn
as great
accomnnt
iii
as 15
blood
trauma.
Reaction
occasionns
amid platelets
associated
sequemnt
sen-era!
hours
prete(!
to has’e beemi
innn-olses,
resuscitation
related
and
it. is suggested
Hemoclastic
channges
ss’as ai)hnormahly
w-as mno es-idennce
of the si-hole
Cells
soiume
decreased
the hemoglobimn
(‘oniccnntratiomn
The channges
in solumc
thus
is-crc due to shifts
further.
red
the Red
connsistennt
MCV
during
(tables
1 amid 2). There
hemoglobimn
connccmntration
that
showed
(‘ehls. The
of
Volume
inn additiomn
with
ann abrupt
a suddemn
drop
amid profounnd
inn blood
the commits gradually
recos-en’ed
a mannifestation
of a Inemoclastic
t.o amn abrupt
disappearanncc
fall
pressure.
Dmnrinig
(table
3).
n’cact.iomn,
of w’hite
of leukocytes
cells
This
the
nsas
a rcactionn
annd
sill)-
imntcn’that.
platelets,
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
454
LARGE
o(’curs
peptone,
ssho had
suspe(’tcd
ini(’ompat.ible
blood
tramisfusionn,
etc. We oI)scrs.ed
the reaction
imi mcii
severe
ai)dominal
is-ounids
with gross soiling
of the peritonneum.
It svas
that. the rea(’tionn
may
have
beeni due to (‘ointamnnatiomn
of the 1)lood
via
EjJ’ects
inn rcsponnse
the lymphatics
a blood
culture
of Massive
course
manny
of the
revealed
types
of the
of
diaphragm.
the presence
plasma.#{176} The
innjurious
agemnts:
hemoclastic
foreign
protein,
I)uring
the hemoclastic
reactiorn
of six different.
organisms.
inn
Transfusions
of the
En-idcnce
inn the
to
systems
BLOOD
chamiges
main
emizyme
STORED
reactionn
olie
glohulimi
OF
manny
stream
inn the
TRANSFUSIONS
deleterious
effects
of omnr innvestigatiomn.
of massin’e
transfusionis
Pmnlmonnary
conngcstiomi
did
not
materialize
appeared
inn several
pat.iennts
is-ho sverc gin’eni large rapid
t.rahnsfusionis,
but. full blow-ni left-sided
heart.
failure
sias not emncoumntered.
It is sigmniflcant
that
these
patienits
ivere healthy
i)eforc
they
w’ere wounndcd,
amid they
is-crc 20 years
of age. Fibrinolysis
did riot.
o(’(’ur
as a clilii(’al
hemorrhagic
state
nnor (‘ould it. he dcmomnstrated
mi nncul)at.ed
(‘lots. This is at variance
w-ith cin.-iliani experieni(’c
ssit.h massis-e
t.ranisfusionis
durinng
operatioins
annd
The
for
widespread
cancer;
severe
hemorrhagic
plasma
hemoglobimn
that the blood
globini
would
Followinig
had
have
large
mild
reactions
of the
degrees
transfusions
of
.
during
shipmcmnt
if rcfrigcratiomn
stored
high.
givemi
are
commonplace
have
occurred
from
time
to time.2s *
bannk blood
is-as nnot. unduly
high, ann indication
been w-ell preserved
been
much
higher
recipienits
ssas hot especially
plasma
of the bamik blood
of fibrimnolysis
blood
It. w-as
them
the
usually
(table
les-els
of free hemomiot beemn adequate.
The
had
plasma
of the
hcmoglobinn
same
5), amid that
order
of
as that.
hemoglobin
the
of the
rapidly
(us-
appeared.
Even
though
10 to 20 per cent. of the red cells may
have
heenn nionviable
their
hemoglobin
ss’as mnot released
into
the blood
stream
is-here it is-ould
impose
ann excretory
hurdenn
orn the kidmncys.
Among
the (‘asualties
iii Korea
it.
has niot i)eenn possible
to relate
the inicidenice
of post-traumatic
menial insufficiency
hemoglobinemia.
shock
amid the
with
deep
It had
innfusionn
i)een showmnms that
of mct.hemoglobimn
the
combination
solutions
inn dogs
of
cain
prolonged
produce
a renal tubular
lesion similar
to that of post-traumati(’
renal insufficiency
nnephromn mnephrosis).
The (‘oncentratiomi
of plasma
hemochromagenn
that.
ihi these
dogs was 800 to 2000 mg. per 100 ml. This severe
hcmoglobinicmia
demomnstrable
ho
fimsion
centratiOhis
cein’es
all
1952
four
to
inn the
ransfusions
edge.
less
and
blood
The
thans
U. S.
The
1 per
were
surgical
hospitals
by
cent
amoing
Major
were
react
patients
no
that
who
C. P. Artz,
They
bleedinig
among
on
received
MC,
the
this
occurred
and
patients
S.
Army
than
by
of post-
is-crc
inn tine
ions
course
were
of winonn
we
of
cnn-
of mniassive
incoagulahilit.v
is estinnated
mi
given
apparemnt
Connnnander
re-
insufficiency.
rennet
10 pints
and
Army
evidence
fibriniolytic
infornna.t.ionn
more
U.
rennal
with
oc(’urred,
5
IT.
transfusions
several
inn Korea.
excessive
i)ased
Cemnter
post-trainsthese
cohi-
m’ea.ction
of the
des-elop
thousand
fatalities
ions
is-ho
to that
sixty
it is l)rObai)le
characterized
There
Forces
transferred
Over
transfusion
Center
Treatment
\Tatiomns
ss’ere
study
of fibrimnolytic
fronn
Navy.)
this
w-as innadedluate
or i)rief. The
Korea
has not approached
inncompat.ible
Renal
United
patienits
forward
inn vitro.
rate
conimunications
MC,
of the
iii
ann ohs-ious
rare.
hemoglobinuria.26
Subsequent
of shed
been
patietit.s
onnly
counntered
ss’hcrc
have
trainsfusiomn
*
if hypotcnnsionn
cmncount.ered
except
these
and
In
lesioni
inemoglobinemia
(low’er
occurred
(‘aused!
have
kniow
to
have
II.
N.
blood.
been
(Personal
Grant,
-
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
WILLIAM
Korea
111
glohini
inn the
use
rFii
helps
pathogenesis
of
unniversal
CROSBY
AND
JOHN
place
inn proper
of post-traumatic
donor
blood
inn the
455
HOSVARD
perspective
the role of free hemorenal
ilisufficiemncy.
combat
zonic is a saluahle
militan’y
to
can
be
camn be
match,
Because
mainitained
estal)lished
tr’ansfusion
he started
t ramnsfusion
earn
iiile
inncompat
i)loOd
is used.
admitted
That
to
as soonn as a patient
is admitted.
reactionns
that
innevitably
occur
onnly
four
cases
of
post-transfusion
eliminates
the
group
specific
hemoglobinuria
is-crc
cases
the
Inn two cases there
apparenitly
is-as a mistake
otiner tis-o is-crc similar
to patiemnt KK w’hose
i)einig
(!itiohis
It also
is-here
Henna! Treatmenit
Center
inn 1952 indicates
that
ihicompat.il)le
reactiomis
are rare unnder this system.
It is of interest
that each of these
restnlted
from the misc of group
specific
blood that was locally
procured.26
tratisfusion
is-hat
they
arc,
it is riot
curred.
It is’as fortunate
that there
The blood
that was seint to Korea
universal
ous
M.
onily onne blood
group
is irnvolved
ann adequate
reserve
is-ith fess-er unnits of 1)lood. Small
but effective
bamiks of blood
at the foris-ard
aid stations.
By eliminnating
the miecd for a cross
expedient.
four
This
1952.
H.
donors
ivere
in typing
or cross
matching.
case is abstracted
beloss.
Field
surprising
that
occasional
is-as little need for local
was obviously
correctly
adequately
errors
procurement
typed
and
The
coIn-
have
c-
of blood.
the danger-
identified.’
SUMMARY
1 . 1)mnring
ssouniding
the
third
studied
is-as
is-inter
campaign
inn thirty-sen-cnn
inn Korea,
casualties
the
at
hematologic
the time
of massive
t.rannsfusionns
reaction
initial
of
to
re-
suscitation.
2.
Tine
Of
particular
results
imnterest
of
labile
factor
effect
ni paticints
ss’as
the
effect
of blood-high
nionns’iai)le
platelets
storage
actisity,
w-ho received
plasma
arid
as much
arid
as 20 to 30 pimits
in less
The
loss
of transfused
red
cells
because
tinami expected.
3. At the time of rcsus(’itatiohn
arid shortly
loss
of
(‘irctnlatinig
red cell mass
iii patiehnt.s
tissue
become
with
It
destruct.ionn.
mechahnism
isith l)ilateral
scscrely
severe
anemic
shock
example)
did
smith patients
ishose
During
often
tended
lytic
5.
Unniversal
processes
if onie
the
becamnse
early
to become
anemic.
plus a relatis-e
donor
blood,
of
than
inoniviability
six hours.
was
rio
mon’c
thereafter,
there
is-as a remarkable
ssith
is’ounnds
that
innolsedl
mu(’Ii
the
loss
is-as
less
tissue
fashion.
due
amnemia
rapid
damage
After
to
hemolysis
l)ut
had
signs
from
appeared
trannsfusionns.
(lacerated
tine
to
transfusions
he
carried
out
of congestion.
sen-crc
ivounds
to he the
innhihitionn
of red cell formation.
group
0, is’as used inn all trannsfusiomns.
resulted
plasma
group.
This
Patients
colon,
for
moderate
Transfusions
to develop
recuperationi
The
large,
to use
nivolved
of a tcnidcmncy
days
i)lood!.
potassium,
low
little
dicleterious
of red cells may
be so rapid
that
a pat.icmit
of the legs and an adequate
hemost.asis
w-otmld
hesitated
is-oumnds
of
miot group
0 the massive
transfusions
by red cells of amiother
group.
The patiennt’s
bodies
against
red cells of his hereditary
blood
red! cells
by transfused
antibodies
is-as observed.
who
arc
that
nnot destroy
red! cells
inn this
often
he(’ame
polycythemic.
r’atinen’ ginigerly
4.
is belies’ed
is umnkmiois-ni. The loss
traumatic
amputation
of stored
hemoglobinn
leukocytes-had
the
result
patients
of hemo-
In
patietits
the virtual
replacement.
sometimes
cont.ainned
antiGradual
hemolysis
of native
was nnot a chihiical hcmolytic
iii
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456
LARGE
reaction
annd
did
TRANSFUSIONS
nnot appear
OF
to be
STORED
detrimental
BLOOD
to the
.
patiennt
presenice
The
of
the foreign
ss-ith blood
antibodies
made
it impossible
inn some (‘ases to crossmatch
the patient
of his hereditary
group
arid suggested
a somnree of daniger
inn attemptimig
tranisfusiomis.
After
transfusion
ssith the unnis.crsal
donnor blood
has heguni,
such
it is recommended
least
.
that
no channge
be
made
to blood
of ainother
group
wecks
have
elapsed.
6. No
inicompatible
transfusiomn
reactions
is-en’e enncommnntered.
(‘last.i(’ rcactionns
may
have
been
caused
by gross
(‘onntaminatiomn
stream
from the site of wounnds
or from the pcrit.onneal
cavity.
ABSTRAcTS
Case
9:00
p.m.
ma
condition
descending
teries
colon
ivere
was
and
was
of whole
without
Throughout
period
Age
22,
the
at
At
been
wasfounid
in actions
the
any
proportion
left
hemoblood
femoral
his
0 red
cells
and
the
in the
hospital
at
of the
brachial
surgery
ar-
the
hematocrit
trarnsfusion,
Novemnber
the
lacerations
and
of surgery,
further
of group
p.mnn.,
to
to havemultiple
resuscitation
conclusion
given
5:00
admitted
was
The
During
Scs’eral
of the
CAsEs*
mesentery.
repaired.
blood.
the
He
from
were
having
this
shock.
bleedimng
Both
9 pints
later
per’
of moderate
perforated.
given
(lays
H EPRESENTATIVE
OF
Age 20, weight
145, blood group
A, was wounmdcd
multiple
penetrating
wounnds of the abdomen.
He
A:
13, with
patiennt
was
55.
hematocrit
Ten
was
circulatiomi
44.
remained
65
cent.
Case
AA:
Novennber
17,
stomach,
to
inig
this
tine
23 pints
time
hospital,
he
was
more
These
mg.
per
never
The
were
ml.,
100
became
patiemit’s
plasma
all
of the
the
of all
same
bilirubin
plasma
lot
2.1
which
mg.
8.1 mg.,
It
slowly.
morning
3.8 mg.
the
of which
60 on
the
first
oni
Dur-
Twenty-omie
of
hemoglobin
82 mg
per
ml.
100
during
this
a break
in refrigeration
plasma
hemnoglobin
was
plasma
hennoglobin
was
The
patienmt
ml. The
was
day
in shock
examined
that
postoperative
was
was
blood
am.,
surgery.
nt plasma
the patient’s
nnext
was
reminoved.
had
of
diaphragm,
during
23 pints
suggested
p.m.)
The
on the third
was
pints
9:30
lung,
lie
shock
5 pints
of the
the
in action
left
muscle.
into
kidney
old,
of
(9:00
bilirubin
receded
left
days
operation
His NPN
hematocrit
His
chest,
psoas
wennt
hemoglobin
average
left
in the
again
nineteen
wounded
his
lodged
and
of blood.
the
after
oliguric.
and
or
average
ml., plasma
100
kidney,
seriously
penetrated
resuscitated
23 pints
double
0, was
group
which
eighteen
Immediately
per
24 mg.
given
thani
blood
left
was
were
bottles
occurred.
102
165,
fragment
pancreas,
the
or more.
was
study.
weight
a mortar
of blood
ml.
100
which
had
by
spleen,
a(imisSiOnn
of
until
two
was
indirect.
67 mg.
postoperative
per
100
(lay.
Fifteen
days
later
it was 48.
Case B: Age 19, weight
140, blood
group
A, was seriously
wounded
in action
5:00
p.m.,
November
15, when he stepped
on a land mine. The injury
necessitated
high amputation
of
1)0th
thighs.
He was admitted
to the hospital
at 9:00 p.m. having
received
6 pints
of blood
cii route.
The tourniquets
on isis thighs
were competent.
Donor
red cells represented
63 per
cent
of
4000
ml.,
the
givenn
6 more
blood.
His
cent
total
in
Plasma
pints
blood
Six hours
activity
2 mg.,
aid
Tine
station.
150()
ml.
transfused
patient’s
*
did
donor
Details
bilirubin
was
It
after
be found
was
surgery
native
plasma.
hematocrit
any
the
36.
time
volunie
tinne
of
possii)le
operation,
of his
transfused
mg.,
the
blood
0.4
he
volume
mg.
was
pt”
(Ashby)
He was
100 ml.
given
8 more
pints
of
ml. After surgery
the
donor
red
cells
were
87 per
was 39; plasma
hennoglobinn
31 mg; plasma
bilirubinn
2.3
cells were 98 per cent of the total.
He had
been
given
no
in shock
at
total
1500
the
operationn
40,
i)ilirubirn
During
many
in
2.6
not
circulation
thereafter.
may
red
antibodies
plasma
circulation
exceed
was
ml., plasma
100
operation.
Presumably
patient.
mis
not
hematocrit
per
before
hematocrit
the
Followimig
in
The
34 mg.
blood
The
later
of ant.i-A
blue).
circulation.
meanwhile.
trannsfusionn
was
of
loss
of the total.
mg.
his
hemoglobin
plus
of red
in the tables.
cells
for
ml.
this
blood
transfusiomn
adniissionm
1000
cells
At
The
after
to accoumnt.
red
beenn
his
volume
was
to
be
plus
2600
1300
ml.
which
had
time
had
eliminated
plasma
was
accounnted
for
cc.
inn time
of re(i
cells
been
lost
miii.
3500
started
by
(Evans’
at. tine
battalion
was
as follows:
14 pimsts
which
during
the
hemoglobin
of
blood
were
iii the
operat.ion
and
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
WILLIAM
i)y specific
hennolysis
which
is the e(luivalent
Case
Age
DD:
a sminall-arms
copter
pints
chest
at
at
4:30
of i)iOod
ivas
clavian
vein.
He had
was
transfusion,
hemoglobin
of the
I: Age
Case
December
He
admitted
to
preparatory
more
pints
nnixed
l)IOod
was
appeared
rose
to
aind
Case
stepped
red
ml.
accident.
was
an
accident
witnessed
by
and
He
by
and
Within
thirty
minutes
to
reapphied
the
the
100
there
had
was
given
6 more
lie
to
not
Age
mine.
of
fell
the
tourniquets
The
transfusion
into
shock.
The
returned
ward
to the
blood
which
the
no
pints
become
19,
was
for
and
39. The
At this
0.7 mg
some
the
of
and
was
The
slowed.
they
could
induction
and
the
of
patient
tourniquets
period
had
of resuscitation
of i)anlk
morning
it was
stumps
Inis-as
left fcmoral
was begun.
Upon
amputated.
the
blood
before
stopped,
the
he
consciousness
32 pints
from
whets
minute.
transfusion
time the plasma
A day later
the
were
sur-
after
per
recovered
The
next
oozing
stumps
8
surgery.
received
was
blood.
was
without
of
huntimng
stump
of the
transfusion
was
approxi-
of his thighs.
The
applied
tourniquets,
continued.
negligible.
chromium)
was
minutes
dislodged
loss
i)lood.
At the
38, and
he was
hemoglobin
hematocrit
of
The
his
is-as 2
was 28,
thighs.
patient
He
recov-
oliguric.
blood
group
were
pints
The
anesthetic
the patient
blood
He
edema.
was
ward
loss
hematocrit.
except
of fresh
to the
4 more
bleeding
of blood.
of
1)100(1
injection
the
8
liters
congestion
amid
the heminatocrit
while
the
of
given
conclusion
rate
and
became
blood.
subsequent
(luring
the
There
adniitted
given
amid
been
did
KK:
enemy
He was
was
again
20 pints
the
forty-five
down
on
intra-arterial
pulmonary
of fresh,
locally
procured
ml. and the plasma
bilirubin
and
an
patient
five hours
4 pints
Case
room
2 liters
return
almost
transient
He so-as then
occupied
ered.
operating
competent
timnie of his
received
Two
volume
at
about
4 pints
was
radioactive
blood
respiratory
bottles.
A surgeon
cut
been
inserted
a rapid
developed
with
arms
givcni
Otherwise
injured
our
His
mnn.
At
nng. The
9:00
p.m.,
jejununi.
surgery.
amputation
hospital
who
hospital
cu.
11.5
am.,
of pulmonary
the next hour
severely
both
was
6:00
abdomen.
total
traumatic
on
He
at
reaction
‘was
sub-
Pen’ liter.
p’
in action,
amid proximal
throughout
the
left
connclusionn
The blood was elevern
was 47. His red cell volume
colono
his
puiseless;
commenced
the
had
with
100 ml.
tagged
from
exsanguinated,
lost.
recovered.
remained
ler
cells
the
mEq.
room
hemoclastic
to
4.65
the
20,000
hemoglobin
had signs
59. During
was
soldiers
him
was
morning.
from
Therefore,
a severe
At
wounded
fell
patient
time
ml.
7600
per
operating
(red
medical
he had
but
he
anesthesia
givern
this
plasma
the next
the
removed
the
the
23 mg.
blood.
was
transverse
pressure
were
brought
were
pressure,
way
again
to
at
two
pumping
air into
when
a canonula
amid l)lood
0mm the
am.
had
was
transfusions
speeded
artery
3:00
count
seriously
the
went
be
shoulder
of his
of
hematocrit
A, was
His blood
patient
ami)Ulaflce
occurred.
travemnous
flog.
This
iatient’s
determination
to
in the
a laceration
cell
and
averaged
at
hematocrit
from
concentration
penetrated
of surgery
volume
ml. of red cells
1800
to the hospital
by hehileft chest.
He was given
room
at 6:30
rn
When his
11 pints
white
died thirty
hours
after
operation.
JJ: Age 21, weight
170, blood
group
0,
on a land mine causing
a high bilateral
stopped
had
cell
to
wounded
operating
given
potassium
contents
the
was
He
am.
conclusion
His
10,200
he
blood
hospital
int.estinntl
accidently
to
100 ml. His
was 4.17 mEq.
that
8:00
volume
niatelv
lie
by
plethoric.
the
per
operation.
64 ; blood
show-ed
gery.
i)loOd
. At the
slight.
p.m.
transfused
the
to
of
8:00
fragment
amounts
hemorrhage
The
a shell
was
taken
next. morning
the
was
1550 ml.
20, weight
170, blood group
1, by
was
1)loOd
i)e
old.
0,
457
HOWARD
discrepancy
bank
blood.
severe
his plasma
plasmna
(radiochronnium)
and
and
M.
17. He was evacuated
a massive
hemothorax
of the
a sudden
7:00
The
of
JOHN
December
operation
hemoglobin
was 23 mg.
the Plasma
potassium
days
AND
group
p.m.
Plasflna
11:00
to fourteen
blood
p.m.,
there
Between
of tinis rapid
160,
3:00
before
opened
CROSBY
native
red cells.
of about
10 pints
19, weight
missile
arriving
four
of
H.
B,
severe
hospital
and
was
at 5:30
t.aken
to
wounded
seriously
is-ounds
of
am.
the
the
having
operating
head,
in action
abdomen,
received
room
9:00
1)0th
2 pints
at
8:00
p.m.,
July
22,
legs,
and
left
of blood
en
route.
where
laparotomy,
by
arm.
He
crani-
otomy,
annd dei)ridement.
of the ext.remities
were
carried
out.
When
he left. the operating
rooni at 12:00
noon
he had received
a total of 17 pints
of group
0 blood
thirteen
to fifteen
(lays old. His plasma
hemoglobin
was 55 mg. per 100 ml.; plasnna
potassium
was 5.8 rnEq.
ler
liter;
was
resumed.
hematocrit
The
43. That
patient
was
evening
given
because
6 pints
of unsteady
of fresh
group
blood
B blood.
pressure
During
the
this
transfusion
transfusion
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
458
LARGE
tue
I)atient’s
tainned
l)C
blood
pressure
tion
he
the
but
produced
This
fell
mg. of hemoglobin
990
liter.
During
norepinsephrimne,
i)V
TRANSFUSIONS
is-as
further.
His
ml.
100
Tine
night
the patiemit’s
i)lood
it fell the mnext. morning
485
l)atient
even
per
OF
ml.
of urine
not
one
but
nnone
series.
The
135, blood
group
both
necessitatinng
BLOOD
plasma
was
found
plasma
potassiuni
pressure
and the
was
l)atient
after
of our
STORED
to
i)e (lark
at this
red
and
timne was
con-
6.4 mEq.
maintained
al)ovc
100 nim. Hg
died
at. noon.
After
his opera-
hemoglobinemia
appeared.
information
was
obtained
from
hospital
rec-
ords.
Case
ssith
S: Age 22, weight
multiple
isas
wounds
given
3 l)iflts
of
of blood
l)ital
at
operation
7:00
am.
He was
it was estimated
volume
was
ysis
During
tine
evacuation
equivalent.
We
of ai)out
assume
l)
that
the
transfusion
lost;
at the
battalion
aid station
in shock.
On the
that
50 pa”
cent
Therefore,
during
the
be accounted
2900
in
(radiochroniium)
surgery
of his
1100
ml.
ml.
must
beeni
had
surgery
cells
at the
2900
2460
nil.
Hematocrit
ivas
30.
The
in
at the
replaced
was
less
his
blood
amid hernol-
than
400
of whole
bank
hos-
before
amnd thntt
by bleeding
He
ml.
blood
blood
of red
which
is about
is
37.)
he was wounded.
He received
were lost by reasonn of nonthe operatiomn
1000 ml. had been
1400 nil. would
leave
1500 ml. to
Before
nil.
less
On
of 800
declinne
22,
leg.
performed
lost
of
left
He arrived
ml.
December
The
24,
plasma
his
red
volume
Ashby
counnt
between
24 indicated
that. the transfused
cells is-ere being replaced
at a rate
of 12
at a time is-hen most or all nonviable
red cells would
have bcenn removed.
tine Ashby
count
is characteristic
of hemolytic
disease
is-mere the bone
re(l cells
for replacement.
The
l)atienst’s
reticulocyte
count
on December
was
tine
before
outside,
operation.
a discrepancy
December
of
counts
of 6 Iimnts
hennatocrit
for.
lost;
after
ml.,
(The
cent,
were
hntd
46. lie
a total
be accounted
nil.
of Ashby
during
given
cells.
20 per
arid en route.
l)lood
ann.,
1:30
annputat.iomn
basis
was
ml. of red
2000
circulation
700
was
of red
had
400
his
ivas
he
of which
operation
for
and
in actiorn
nnid-thigh
never
patient
ml.
1100
viability.
wouinded
B, was
approximately
normal.
Hemat.ocrit
1000 nil. of his own red cells.
Loss
perhaps
cells.
legs,
the
cell
volume
(Evans
Blue)
23 arnd
December
per cent per day,
Such a change
in
marrow
produces
24
was
4.4
per
hibernial
inn Corea,
le reactionn
hematologic
inn trcnnta-septe
s-ulnneratos
al tempore
de
br
cent.
SuMMAJII0
I . Durante
le tcrtie
vulneramennto
csseva
campannia
studiate
resuscitation
innitial.
2. Le effecto
de massive
intercsse
special.
de hemoglobina
nonviabile
INTERLINGUA
trainsfusiomnes
Le resultatos
dcl
e potassium
plachettas
IN
de
inn le plasma,
recipente
usquc
10 o 15 litros
erythrocytas
perdite
pauco
inn minius
a causa
que
immagazinate
esseva
de sanguinne--i.e.
basse
e lcucocytas-habcs-a
funndite
sannguinnc
immagazinnage
sex
altc
actin-itat.c
del
effecto
mnocivc
horas.
de mnonivial)ilitatc
Le
a
factores
labile,
super
e
pat.ient.es
quanntit.ate
miomi excedeva
de
(‘onternto
dc trarnslo que
essesTa
expectate.
3.
Al
tempore
perdit.a
in
de
extcnndite
destructionn
sed le mechannismo
rapide
hemostase
que
rcsuscit.atioin
le volumimne
de
e
circularnte
bren-cmemntc
crythrocytas
de texito.
Omn supponc
morn es cogmnoscite.
Le
un patiente
‘on
poterea
devcnnir
traumatic
gravememnte
plus
t.osto
gestionn.
in iste
deviniva
cautcmennte
mannicra.
polycyt.hemic,
a causa
de br
il
haheva
inn pat.icnntcs
un
granide
conn n’ulnneres
quc iste perdita
se debe a hemolyse,
pcrdit.a
dc erythrocytas
pote esser
a
si
amputat.iomn
bilateral
dcl gambas
e adequate
annemic si omn hesitas-a
de emplear
massive
e rapide
t.ransfusionnes.
Patiennt.es
corn sen-cr
minnus extenndite
destructionn
de texito
(colon
eva crythrocytas
frequemntememntc
depost,
Post
cuje
lacerate,
choc
s-ulnnercs
n’epresenntava
umn
per exemplo),
nnonn destru-
moderate
transfusiomnes
c trannsfusionies
del)en-a
tendemntia
a mamnifcstar
t.al patienites
esser
cxe(’ut.atc
symptomas
de corn-
From www.bloodjournal.org by guest on June 14, 2017. For personal use only.
WILLIAM
4.
H.
le prime
Duranntc
(lmleint.emcint.e
dies
tcnndcva
a
hemolyt.ic
processos
CROSBY
AND
JOHN
be recuperation
devennir
M.
ab
n-ulnnen’es
. Le annemia
anemic
conjunnctementc
459
HOWARD
sever
pares-a
conn unn innhihitionn
be pat.ienntcs
csser
relatise
fre-
le result.ato
de
formation
de
del
cr’yt.hnocytas.
5. Lc sanguine
dc domnat.orcs
universal,
qui rnonn pcrtinncva
fusionics.
Inn pat.ienntes
r’esult.an-a
pract.icamennte
inn urn reimplaciamento
dcl pat.iennte
a n-ices
gruppo
sannguinnec.
comntinncva
Hemolyse
tn’ansfundit.e
esses-a
obsers-ate.
nnocin-e
el pat.icnnte.
par’en-a
esser
casos
inn n’ennden’
gruppo
hcreditari.
nnullc
t.rannsfusionn
sia
mnon esseva
Le presentia
dcl pat.iente
imidica
urn
sanngmninnc
facite
contra
native
urn clinic
periculo
gruppo
de sanguinne
erythrocytas.
Le
be cryt.hrocyt.as
crythrocyt.as
plasma
de su hcreditan’i
per annticorpon’es
react.ionn
hemolytic
e nomi
dcl annticorporcs
result.an-a
inn alicunn
inicompatibile
corn le samnguinc
dc su
possihile
dcl
del
inn omnnc transtrannsfusionnes
inn tentar
universal,
de unn altere
tal
ii es
gruppo
trannsfusionnes.
recommcnidatc
quc
usque
duo
al minnus
ha passatc.
sept.imannas
Nullc
curn’eva
de
Isto
esseva
usatc
0 le massin-c
total
annticorporcs
gradual
de
sannguinic
de
tn’amnsfusiones
6.
Ic
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Post
gn’uppo 0,
a! gn’uppo
i’eactionnes
urn
grossc
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conitaminationnes
dcl sanguine
ab
esses-a
inn(’onnt.rate.
Ii
oc-
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rcsult.ate
sitos vulnneral
o al) be cavitate
pen-
nnumero
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1954 9: 439-460
The Hematologic Response to Wounding and to Resuscitation
Accomplished by Large Transfusions of Stored Blood: A Study of Battle
Casualties in Korea
WILLIAM H. CROSBY, LT. COL. and JOHN M. HOWARD, CAPTAIN
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