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Studies of Blood Volume and Transfusion Therapy in the Korean Battle Casualty

Medical Science Publication No. 4, Volume 1

STUDIES OF BLOOD VOLUME AND TRANSFUSION
THERAPY IN THE KOREAN BATTLE CASUALTY*

CAPTAIN THEODORE C. PRENTICE, MC
FIRST LIEUTENANT JOHN M. OLNEY, Jr., MC
MAJOR CURTIS P. ARTZ, MC
CAPTAIN JOHN M. HOWARD, MC

During the years 1952-53 in the Korean War, there was a trend toward giving increasingly large amounts of blood throughout resuscitation. It was not unusual to administer to the critically injured soldier 15 to 30 pints of blood on the day of injury. Much of the blood was given after the control of obvious hemorrhage. The desirability of this practice was often questioned, but was based on the belief that adequate resuscitation (i. e., stabilization of blood pressure and pulse rate at relatively normal levels, subsidence of clinical symptoms and signs of shock) was principally a function of restoration of blood volume. Likewise, during and after surgery, maintenance of blood volume seemed to be the most critical factor in the recovery or death of the wounded patient. The present studies of blood volume in battle casualties were therefore undertaken in an effort to evaluate these clinical impressions by more objective, quantitative methods, particularly with reference to the desirability and necessity for massive transfusions. All blood used in the Korean theater was either type O, banked blood or, rarely, fresh compatible blood.

Several previous studies relative to blood volume following wounding have been carried out (1, 7, 10). In general, these investigations have stressed primarily the clinical status of the patient as correlated with his blood volmne at the the time he entered the hospital. For several reasons, we decided to place our emphasis principally on blood volume in the postoperative rather than the resusitative phase of the patient's course. (1) It was felt that more could be learned about the adequacy of transfusion and its effect in maintaining blood volume through resuscitation and surgery. In particular, determinations at this time would provide quantitative answers as to the necessity for large transfusions. (2) In most instances adequate hemostasis was achieved at this time allowing for adequate mixing of the labeled


*Presented 20 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center. Washington, D. C.


164

cells or dye without significant loss during mixing. (3) Likewise, the rapid administration of blood or colloids was not necessary here, so that mixing phenomena of labeled cells and dye could be observed without being confounded by concomitant mixing of other fluids rapidly infused for resuscitation.

Those patients, therefore, whose blood volumes were determined with labeled red cells were studied during the first 12 to 48 hours after surgery. Where the dye T-1824 was used it was often necessary to wait until the day following surgery to avoid interfering effects due to elevated plasma hemoglobin.

Methods

Labeled Red Cell Method

Labeling of red cells was carried out using radioactive chromium as the tagging material. Chromium51 was used in preference to p32 because of the more lasting incorporation of Cr5l in the red cells as compared to p32. Since with the method used negligible escape of Cr5l from the red cells occurs within the first 24 hours, prolonged study of mixing could be carried out and serial volumes determined without the necessity of relabeling new cells. The following is the method used for labeling the red cells and calculating the blood volume.

    1. Preparation of labeled red blood cells.

      (a) Ten cc. of sterile, physiologic saline and 150 to 200 microcuries of radioactive chromium are placed in a sterile, glass-stoppered flask.

      (b) Fifteen cc. of fresh heparinized "O" blood* is added to the centrifuge flask.

      (c) The flask is placed in an incubator at 38° C. and allowed to react for 1 hour, mixing gently every 10 minutes.

      (d) The red cells are washed 3 times with sterile saline.

      (e) The washed red cells are suspended in 2 volumes of saline and stored at refrigerator temperature until ready for use.

      (f) If the cells are to be stored for several hours before use, they are resuspended in 2 volumes of plasma obtained from bank blood.

    2. Red blood cell volume determination.

      (a) The labeled red cell suspension is thoroughly mixed and aspirated into a syringe of suitable volume.

      (b) At least 2.5 cc. of labeled blood from the syringe is placed into a tared volumetric flask as a standard, weighed, and made to volume with distilled water.


*Fresh labeled "O" cells were used in preference to the patient's cells so that a source of labeled cells would be readily available on short notice whenever needed.


165

      (c) The syringe containing the material to be injected is weighed together with the needle to be used for injection.

      (d) The remaining labeled blood is injected intravenously and the syringe and needle are immediately weighed without rinsing.

      (e) Blood samples are collected 20 and 40 minutes after injection and as indicated thereafter until mixing is complete. In most cases, multiple samples were taken until the last 2 aliquots differed by less than 5 percent.

      (f) The hematocrit of each sample is carefully determined. At least 3 hematocrits were obtained on each patient.

      (g) Exactly 5 cc. of each whole blood sample is pipetted into a counting test tube. Likewise, duplicate 5 cc. samples of standard are pipetted into counting tubes.

      (h) All standards and samples are counted in a well-type scintillation counter.*

    3. Computations.

The blood volume is calculated using the standard dilution formula

        C1V1=C2V2 or V2=(C1V1)/C2

where C1 = cpm/cc.of injected material
V1 = volume of injected material
C2 = cpm/cc. of patient's blood
V2 = volume of patient's blood.

In this instance:

    (C1=cpm/cc. of diluted standard x volume to which standard was diluted)/Weight of labeled blood used as standard
    V1=Weight of syringe and needle before injections minus weight after injection.
    C2=cpm/cc. of patient's blood after adequate time for mixing of labeled cells has been allowed.
    V2=Resultant calculated blood volume.
    TRCV=Hematocrit x total blood volume.
    Plasma volume = total blood volume minus TRCV.

Dye Method

When the dye T-1824 was used for plasma and blood volume determination, the technic of Gregerson, et al., (8, 9) was utilized wherein three plasma samples were taken at 13 to 15, 30 and 45 to 60-minute intervals. The dye concentration of each sample was measured and plotted against time. The curve so obtained was extrapolated linearly back to zero time to correct for dye loss during the mixing period. This value at zero time gave the theoretical concentration of dye that would have occurred in the plasma if uniform mixing had been effected at the instant of injection and none of the dye had been


*Standard scintillation counting technics were used.


166

excreted. Where abnormal plasma hemoglobin levels or an interfering cloudiness were suspected the samples were discarded. Each reported determination was made on the basis of three valid samples with the exception of those so indicated where extrapolation was on the basis of only two. When only one plasma level was obtained or when a linear plot did not result the observation was discarded. The total blood volume was calculated from the plasma volume and the hematocrit value. Where simultaneous blood volumes were determined by using labeled cells and dye, the two were administered separately via different veins to avoid error through loss during changing of syringes.

In calculating the total blood volume from the plasma volume or red cell volume, no correction factors were used to effect the possible error introduced by differences between venous and total body hematocrit. The estimated normal blood volume used for the dye method was 8 percent of body weight, and for the labeled red cell method 70 cc./kilo body weight (2).

Control

    1. Radio Chromium, Red Cell Tag

      (a) Fresh red cells labeled with Cr51 and resuspended in 2 volumes of saline showed a transfer of 1.5 percent of the total radioactivity to the suspending medium in 36 hours. When bank blood plasma was used for resuspension less than 0.5 percent of the total radioactivity appeared in the supernatant fluid.

      (b) Counting of multiple samples of standard Cr5l solution, a total of 10,000 counts for each sample gave a standard deviation of 1.6.pereent.

      (c) The red cell volumes of several normal individuals were determined as indicated in table 6. Three duplicate determinations done several days apart gave volumes differing by 0.5, 1.7 and 4.2.percent of the total. In each instance the second determination was made with cells that had been stored 6 hours after labeling with Cr51.

    2. Evans Blue Dye

      Nine patients who received no transfusions had multiple plasma volume determinations during their postoperative course. Using these volumes and the hematocrit to compute the red blood cell volume it was found that the results were constant within an estimated variation of S. D. = ±5 percent.

Results

The results are tabulated in tables 1 through 3.

Careful evaluation of mixing was carried out during the first 60 to 90 minutes in all patients to make sure that the volume was calculated from completely mixed samples. Samples were taken until successive counts differed by less than 5 percent. Furthermore, because it was suspected that relatively sequestered areas of blood might exist in some


167

of these patients (5, 13, 15), later samples were taken in nine individuals. It was reasoned that if such areas existed and they were not completely sequestered, late samples might have mixed into larger volumes which were not apparent in earlier samples. The results of these studies are seen in table 2. It can be seen that even though the early samples had reached a plateau and agreed with one another within less than 5 percent, later samples taken at varying intervals revealed slightly greater apparent volumes in most instances. In all but Case No. 1, the later samples also fell within less than 5 percent of one another. The interpretation of these findings is open to some question owing to the possibility of selective destruction of labeled cells. Two patients were given hexamethonium after the early mixing of labeled cells was complete. It was felt that if slowly mixing, stagnant areas of blood existed, the opening of arterioles and increased flow caused by hexamethonium might improve the circulation through such sites with more complete mixing of labeled cells therein. This process, if it occurred, would increase the measured blood volume. In the two instances, sufficient drug was administered to lower the systolic pressure from the range of 120 to 130 down to 90 to 100. Neither individual showed any increase in volume at intervals of 30 to 60 minutes thereafter.

The postoperative blood volume measurements revealed one outstanding result, namely, that large transfusions were a definite necessity in many of these patients and very rarely resulted in overtransfusion. In fact, regardless of the amount of blood received, the vast majority of patients emerged from surgery with some deficit of total blood volume. Of the 25 patients studied with dye none revealed an initial postoperative blood volume greater than normal. In only 3 patients out of 28 studied with Cr51 labeled red cells was overtransfusion present, and in none of these was there any evidence of cardiorespiratory difficulty. This was probably due to the fact that the degree of overtransfusion was minimal. Two of the three overtransfused patients were followed with successive blood volume measurements. In one instance, the red cell volume returned to normal in 9 days and in the other in 7 days. The latter's course, however, was complicated by jaundice and purpura apparently due to thrombocytopenia. Of the three overtransfused patients, one had an abdominal wound and the other two had thoraco-abdominal wounds. They received 7,000, 7,000 and 1,500 cc. of blood respectively.

Clinical State

In general, varying degrees of hypovolemia were tolerated very well by the group during this postoperative period. Fourteen or 58 percent of the weighed patients studied with labeled cells showed


168

deficiencies of 15 percent or more of the average normal for their weight. We would class this group as definitely undertransfused. The average deficiency for these patients was 32 percent. However, of the 14 patients only 3 were in shock, these patients showing deficiencies of 38, 43 and 52 percent, respectively. The others were doing well postoperatively with no clinical evidence of shock. The average amount of blood which had been received prior to the blood volume determination in this hypovolemic group was 6,740 cc. This figure is in contrast to the group whose deficit was less than 15 percent. Their average replacement was 3,187 cc. or less than half that of the hypovolemic patients. The results were even more striking in the patients studied with dye. Fourteen of the 18 patients whose weights were known and whose normal blood volume could therefore be calculated revealed a deficit of greater than 15 percent. Their average deficit was 31 percent. All these patients were doing well postoperatively with no clinical evidence of shock. Their blood requirement pattern was similar to that of those studied with labeled cells, the group with greater than 15 percent deficit having received 7,785 cc. and the group with less than 15 percent deficit receiving 4,160 cc. Thus those individuals who had required the most blood remained the most hypovolemic following surgery. It was in this group that the most massive transfusions were required.

In only one patient did shock exist in the presence of a normal blood volume. This patient had received severe head injuries, with shell and bone fragments in the brain substance. In addition, there were severe facial injuries and a compound comminuted fracture of the left humerus. This patient had received 4,500 cc. of blood prior to the blood volume determination, which measured 96 percent of normal for his weight. The volume was done 3 hours before his death at which time his pulse was 140 to 160, respiration 40 to 50, B. P. 120/100 dropping to 90/70 during the succeeding hours. He died in severe pulmonary edema. The severe brain injury was undoubtedly of paramount importance here and may well explain the shock picture in the presence of a normal blood volume.

When the patients are placed in categories dependent upon the location of their wounds, several trends relative to blood volume and blood requirements come to light. In view of the relatively small numbers of patients, these trends must be considered tentative. They seem to be dependent primarily on one fundamental factor, the presence or absence of large areas of muscle injury. In the extremity wounds where a large amount of muscle injury was almost invariably present, large amounts of blood were necessary during resuscitation and surgery. Yet when the blood volume was determined postoperatively by either method, all members of the group fell in the hypovolemic class


169

with deficits in volume of 15 percent or more and an average hematocrit of 36.5.

On the other hand, those who had abdominal wounds, though they had received a similar amount of blood as compared to those with extremity wounds, revealed postoperative blood volumes more closely approximating normal and an average hematocrit of 45.8. The excess loss of blood from wound of muscle is easily understood when one considers the local pathology involved in wounds caused by implements of war. Although there may be only a small wound of entrance, there is a large amount of destruction of the underlying muscle. This is particularly true in high-velocity missile wounds. Bleeding from the large mass of damaged muscle continues from the time of injury until operation. During this time, the blood loss is greater than the observer generally realizes. The importance of other factors, such as hemolysis and trapping of blood, as added mechanisms for the causation of these low blood volumes is not fully known at the present time.

Relation of Hematocrit

Table 3 illustrates 10 patients with extremity wounds on whom serial postoperative hematocrits were done. They show a consistent fall in hematocrit. One factor which may contribute in part to this effect is the rise in plasma volume observed in many hypovolemic convalescent patients. A rising plasma volume and falling hematocrit were noted in the absence of any significant change in the total red cell volume indicating a dilution effect as being at least partially responsible for the falling hematocrit.

As has been previously reported, hemoconcentration characteristically follows severe intra-abdominal injuries (1). This is probably due to the loss of plasma in excess of red cells into the bowel wall, mesentery and peritoneal cavity. Serial postoperative hematocrits in patients with abdominal injuries are compared with the postoperative changes following wounds of the extremities in table 3. Because hemoconcentration and plasma loss were so frequently quite marked, surgeons often administered dextran as an adjunct to blood transfusion therapy during and after repair of major intra-abdominal injuries. This was true during much of the time when these data were collected.

Comparative Blood Volumes

In 15 patients, simultaneous blood volume determinations were carried out using labeled red cells and T-1824. The results are recorded in table 4. In general the methods agreed fairly well, the average difference being 16.3 percent and falling in the range of difference found by previous investigators in normal individuals. In three patients, however, the discrepancy was considerably larger (26 to 39 percent), the dye volume being larger in all instances. All of


170

these individuals had severe abdominal wounds; two of the three had lacerations involving the liver. This would suggest that the same factor causing hemoconcentration in such patients allows for leakage of dye out of the vascular system with resultant falsely high plasma and blood volume determinations. Peters (12) has commented previously on the loss of the dye, T-1824, from the blood stream particularly in the liver vasculature. The involvement of the liver in two of these three cases is therefore of added interest and significance. These data suggest that under certain circumstances the dye method may not be a reliable one.

Discussion

The impression was originally gained by those in the North African-Mediterranean Theater (1) that blood loss rather than any other factor was responsible for shock in the wounded patient. Their findings indicated that the presence or absence of shock as well as its degree upon admission to the hospital was directly correlated with the deficiency in blood volume present at that time. The present studies lend support to those findings and extend the concept to the surgical and postoperative period where it is seen that tremendous amounts of blood are often necessary to maintain the blood volume close to normal range. Of the 52 patients studied, 31 or 59.6 percent required over 10 pints of blood. In other words, over half of the patients studied required complete replacement of their blood volume. Of these 31 patients, 9 required 20 pints or roughly twice their blood volume. This group emphasized well the real necessity in some patients for massive transfusions. The average deficiency of blood volume in these 31 individuals after receiving such massive transfusions was still 25.2 percent.

In addition to the problem of how large a circulating blood volume was necessary for these patients was that of how effectively the blood transfused had increased that volume. Possibly present in almost every patient observed but becoming more apparent with the larger volumes of transfusion, was an apparent discrepancy between the amount of blood transfused and that actually measured after operation. This volume deficit appears to consist of both plasma and red blood cells. As examples the data of table 5 were extracted from table 1 and arbitrary estimates of admission blood volume made. Most of these patients were chosen as examples because the volumes involved were large enough to make errors in estimation of initial volume relatively insignificant. They demonstrate an average deficit of 5,373 cc. with a range from 1,600 to 7,900 cc. Likewise 10 patients requiring postoperative transfusions were studied with one or more determinations of their plasma volume with Evans Blue for up to 7 days after wounding. The results are tabulated in table 7. When a transfusion intervened between two determinations, the change in


171

circulatory red cells measured was significantly less than that expected in 6 of 12 instances. None of these patients showed clinical reason to suspect red cell loss.

It was because of these consistently low blood volumes after large transfusion and the discrepancy between the volume of blood infused and that measured thereafter that such concern was shown over the possibility of incomplete mixing of labeled cells in relatively sequestered areas of blood volume. If large amounts of blood were pooled in areas relatively inaccessible to mixing, falsely low total blood volumes would be the result. Although the blood volumes calculated from late samples were slightly greater than those calculated from early ones, in no instance did they result in a blood volume of 5,000 cc. or over. One of the nine patients (table 2) showed an increase of 1,565 cc. in blood volume as calculated from the late samples. He had previously been resuscitated with only 2,500 cc. of blood. Seven of the remaining eight patients (one patient-no data) received 10,500, 10,000, 8,500, 7,500, 7,000, 3,500 and 3,500 cc. respectively, and the blood volume increase when calculated from the late samples as compared with the early samples was 600 cc. or less in every instance.

Likewise in the two patients given hexamethonium no increase in blood volume occurred concomitant with the fall in blood pressure. Furthermore, in those patients who had received massive transfusion and survived, none developed clinical or laboratory evidence of overtransfusion during their postoperative course. If such a pooling mechanism as has been postulated existed early, one would expect a reversal of this process during clinical recovery with mobilization of substantial amounts of trapped blood and some resultant evidence of overtransfusion. In no instance did such occur. Although these data are not sufficient for positive conclusions, they do not support the concept that a significant amount of pooling existed in these patients receiving massive transfusions.

Further answers to this question might be obtained by two approaches. (1) Weigh the patient on an accurate scale when he enters the hospital. When resusitation and surgery are completed, weigh again and determine the blood volume. Where such large volumes of infused blood are involved, one should see significant gains in weight if most of the blood has been retained; little or no change if it is being lost externally as fast as it is being infused. Correlating the postoperative blood volume with change in weight would thus help clarify the question of loss versus pooling. Obviously if most of the bleeding was into the tissues little would be learned by this procedure. (2) Determine the blood volume postoperatively with chromium-labeled cells. Determine the hemoglobin to Cr51 ratio in blood and in tissue biopsies such as muscle. If large amounts of blood are sequestered in the tissues and inaccessible to the labeled cells, the hemo-


172

globin to chromium ratio will be increased considerably in the tissues.

The quality of bank blood used for transfusion was investigated (3), and so far as indicated by the indices used (plasma Hgb, plasma potassium, and osmetic fragility) this blood was comparable to that available in the United States.

Investigation by means of the Ashby count, was reported previously (3), indicates that in a small portion of A, B and AB receipts receiving large amounts of O blood there will be a destruction of the patient's own cells extending over several days but this is relatively infrequent and usually involves volume changes much smaller than those reported here.

The relative importance of hemolysis of recipient and donor cells as a contributing cause for the large requirement of blood replacement in these patients is not fully known at the present time. These patients do not show overt clinical manifestations of rapid blood destruction such as chills, fever and jaundice. Moreover, the average plasma hemoglobin done immediately after surgery in 22 patients who had received an average of 12 pints of blood each day was only 18 mg. per 100 cc. (3), (normal 5 mg. per 100 cc). Since the intravenous infusion of 10 to 16 gm. of Hg. (equivalent to hemolysis of 60 to 100 cc. of blood) in normal individuals will induce plasma Hg. levels of greater than 300 mg./100 cc. (6, 11), the levels found in these postoperative patients would be indicative of minimal intravascular hemolysis. The rate of plasma Hg. clearance is of course a factor here. The most rapid clearance rate found in the group studied was 5 mg. per 100 cc. per hour which would be insufficient to lower a significantly high concentration of Hg. to the levels found even over a period of many hours.

Likewise the observed bilirubin levels in a similar group of patients (14) would correspond to a relatively small degree of blood destruction. The rate of plasma clearance, principally by the liver, is again a critical factor here and the necessary data for such evaluation in these patients are not at hand. The infusion of 16.4 gm. of Hg. (6) (equivalent to hemolysis of approximately 100 cc. blood) in a normal individual resulted in a plasma bilirubin concentration of 1.4 mg. for 100 cc. 10 hours later, with a gradual fall thereafter and remaining greater than the pre-injection level 24 hours later. Clearance of bilirubin in the wounded patient, where impaired hepatic function has been shown by others (1, 14) would be expected to be slower than in normals. Therefore the 6-hour postoperative average level of 2.5 mg. per 100 cc., which is the highest level reached in any of the preoperative and postoperative specimens, would imply relatively small amounts of hemolysis.

The postoperative hematocrit afforded a relatively poor index to the requirements for transfusion. Because of rapid changes in


173

plasma volume which take place independently from changes in red cell volume after extensive blood loss, the hematocrit gives little information about the actual red cell volume at any given time. By the same token any conclusions concerning the status of total blood volume drawn from hematocrit data alone are likely to be in error.

Conclusions

Blood volume determinations have been carried out postoperatively in 52 wounded patients. These patients required large amounts of blood to maintain them through the phases of resuscitation and surgery. Generally patients with extremity wounds, where large amounts of muscle destruction had taken place, required the largest amounts of blood and still remained the most hypovolemic following surgery. However, no matter where the injury was located, if considerable areas of muscle were involved, large amounts of blood were usually required.

Overtransfusion occurred in only three instances and in no case was it of sufficient degree to cause cardiorespiratory symptoms. The error in most cases was undertransfusion rather than overtransfusion.

Hematocrit determinations in the postoperative period are not a reliable index to the requirement for blood.

Where simultaneous blood volumes were determined with labeled cells and dye, the difference between the two was 16 percent, the dye volume being greater in all but four instances. However, in severe abdominal wounds, especially with liver involvement, the discrepancy was much larger. Here the dye volumes were greater by 26.8, 33 and 39 percent. This probably represents increased capillary permeability and gross vascular damage in the involved area with resultant leakage of dye.

The discrepancies between the large amounts of blood given and the small blood volumes determined thereafter are explainable on three possible bases: (1) Trapping of large amounts of blood in a sequestered state which mixes slowly or not at all; (2) hemolysis of large amounts of donor and/or recipient erythrocytes; (3) continued loss of blood either externally or into the tissues during the preoperative, operative and postoperative periods. The latter is believed, at the present time, to be the most important of these factors.

Acknowledgment

We wish to express our sincere appreciation to Colonel William S. Stone, Commandant, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C., and to Colonel Richard P. Mason, Commandant, Far East Medical Research Unit, for their continued encouragement and support of the project.


174-175

Table 1A. Blood Volume Determined With Radioactive Chromium


176-177

Table 1A. Blood Volume Determined With Radioactive Chromium-Continued


178

Table 1A. Blood Volume Determined With Radioactive Chromium-Continued


179

Table 1B. Blood Volume Determined With T-1824


180-181

Table 1B. Blood Volume Determined With T-1824-Continued


182-183

Table 1B. Blood Volume Determined With T-1824-Continued


184-185

Table 1B. Blood Volume Determined With T-1824-Continued


186

Table 2. Blood Volume as Related to Time of Sampling


Case No.

Early samples

Late samples

Difference

Time interval (minutes)

Volume

Time interval (hours)

Volume

4

20, 40

3,280

1, 2

3,660

380

9

15, 30, 45

3,960

22

4,064

104

10

20, 40, 60

3,208

6, 14, ¾, 28

4,773

1,565

12

20, 40

3,660

1, 2½

3,660

0

18

20, 40

3,835

1, 5

4,055

220

21

40, 60

4,790

4,790

0

25

30, 60

4,400

4½, 5½

4,775

375

28

No early samples

-----

1, 2, 5

3,210

-----

17

20, 40, 60

2,700

3

3,373

603

Table 3. Hematocrit Changes During Resuscitation, Operation and Convalescence

Hematocrit

Abdominal Injuries

Patient No.

Admission

Postoperative

Days post operative

1

2

3

4

5

6

1

32

52

38

39

39

40

-----

-----

2

44

42

47

40

-----

-----

-----

-----

3

40

-----

64

62

-----

-----

-----

-----

4

50

61

66

-----

65

-----

-----

-----

5

43

45

50

55

48

47

-----

-----

6

63 (albumin*)

52 (albumin*)

42

41

47

45

45

-----

7

34

51

44

40

43

45

45

49

8

48

-----

46

-----

49

43

40

39

9

-----

59

52

49

45

45

43

44

10

41

43

57

-----

-----

-----

-----

-----

Extremity Injuries

1

40

43

34

-----

23

-----

-----

-----

2

-----

41

41

39

36

-----

-----

-----

3

-----

42

44

38

33

-----

-----

-----

4

36

35

35

34

29

32

-----

-----

5

36

44

43

36

31

32

-----

-----

6

-----

47

44

37

39

32

-----

-----

7

41

38 (blood*)

47

42

40

36

35

-----

8

42

44

38

37

36

36

-----

-----

9

37

35

32

31

33

33

-----

-----

10

36

35

35

34

29

-----

-----

22

*Intravenous therapy.


187

Table 4. Comparison of Simultaneous Blood Volumes Determined With Chromium-Labeled Red Cells and T-1824

Case No.

Cr51

Dye

Difference

Diagnosis

Percent difference

3

4,523

4,100

-423

(See table 1.)

9. 8

4

3,280

3,611

4,580

4,920

+1,300

+1,309

33. 1

30. 5

5

3,832

5,700

+1,868

39. 1

9

3,964

3,490

-470

12. 8

10

3,208

3,995

+787

19. 7

12

3,660

4,150

+490

12. 6

16

4,808

5,080

+272

5. 5

18

4,055

3,940

-115

2. 8

19

2,581

2,680

+99

3. 8

20

4,273

5,600

+1,327

26. 8

21

4,535

4,790

5,540

5,050

+1,005

+260

20. 2

5. 3

22

4,430

4,470

+40

. 8

29*

4,071

3,860

-211

5. 1

*This patient tested preoperatively, therefore not included in table 1.

Table 5. Showing Discrepancy Between Blood Received and Blood Volume Thereafter

(a)

Patient No.

(b)

Weight (kg.)

(c)

Estimated B. V. on admission (cc.)1

(d)

Volume transfused (cc.)2

(e)

Postoperative
B. V. (cc.)3

(f)

Deficit (cc.)4

(g)

Remarks

30

84

2,700

6,500

54,400

4,800

Abdominal wound.

32

78

2,500

7,500

54,600

5,400

Abdominal wound.

34

65

2,100

7,000

53,600

5,500

External wound.

37

61

2,000

8,500

54,100

6,400

External wound.

38

-----

2,500

3,000

53,900

1,600

See note.7

41

78

2,500

10,500

55,100

7,900

See note.7

5

-----

2,500

6,000

63,800

4,700

Abdominal wound.

11

96

3,000

6,500

65,700

3,800

External wound.

15

76

2,500

9,500

64,200

7,800

External wound.

1Estimated as 40 percent of normal.
2Volume of whole blood received during resuscitation and operation.
3The circulating blood volume measured several hours to 1 day after operation.
4Columns (c) and (d) less column (e).
5Measured with Evans Blue and hematocrit.
6Measured with Cr51 and hematocrit.
7These patients entered with tourniquets in place above traumatic amputations and underwent uneventful amputations with minimal blood loss and had thereafter only the clean amputation wounds.


188

Table 6. Red Cell Volumes as Determined with Radio-Chromium

Normal Subjects

(a)

Date

(b)

Subject

(c)

Weight (Kg.)

(d)

Hct. Percent1

(e)

RBCV, predicted normal (cc.)2

(f)

RBCV measured (cc.)3

2 Dec

A

51

42

1600

4 1780

6 Dec

-----

-----

40

-----

1750

4 Dec

B

89

45

2750

1900

11 Dec

-----

-----

40

-----

1820

7 Dec

C

65

44

2000

2560

9 Dec

D

71

44

2200

1860

13 Dec

-----

-----

45

-----

1870

11 Dec

E

-----

46

-----

2180

1Hematocrit determined on the specimens taken for Cr51 determination.
2Red blood cell volume expected on the basis of 30 cc./Kg. body weight.
3Red blood cell volume measured.
4Female.

Table 7. Red Blood Cell Volume Response to Transfusion, Measured with Evans Blue

(a)

Case No.

(b)

RBC received (cc.)1

(c)

 RBC observed (cc.)2

(d)

 RBC-RBC received (cc.)3

(e)

Percent of RBCV4

(f)

Percent of RBC received5

Fresh Blood Received

47

450

225

+390

+240

-60

+15

4. 0

. 8

-13

+6

30

450

+480

+30

1. 7

+6

37

675

+290

-385

28. 0

-58

38

450

675

+300

+660

-150

+15

10. 8

. 8

-33

-2

40

2,250

+1,710

-540

36. 0

-23

41

675

+350

-325

16. 0

-48

Bank Blood Received

31

450

+210

-240

3. 9

-53

40

225

+230

+5

. 5

+2

53

675

+260

-415

37. 0

-62

43

675

+1,065

+390

35. 0

+58

1Red cells received by transfusions between measurements of the plasma volume.
2The change in red cell volume as measured by plasma volume and hematocrit determinations before and after transfusion.
3The difference between columns (a) and (c).
4Column (d) expressed as percent of the total measured red cell volume.
5Column (d) expressed as percent of the transfused red cell volume.


189

References

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