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 JOHNM. 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 towardgiving increasingly large amounts of blood throughout resuscitation. Itwas not unusual to administer to the critically injured soldier 15 to 30pints of blood on the day of injury. Much of the blood was given afterthe control of obvious hemorrhage. The desirability of this practice wasoften questioned, but was based on the belief that adequate resuscitation(i. e., stabilization of blood pressure and pulse rate at relatively normallevels, subsidence of clinical symptoms and signs of shock) was principallya function of restoration of blood volume. Likewise, during and after surgery,maintenance of blood volume seemed to be the most critical factor in therecovery or death of the wounded patient. The present studies of bloodvolume in battle casualties were therefore undertaken in an effort to evaluatethese clinical impressions by more objective, quantitative methods, particularlywith 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 woundinghave been carried out (1, 7, 10). In general, these investigationshave stressed primarily the clinical status of the patient as correlatedwith his blood volmne at the the time he entered the hospital. For severalreasons, we decided to place our emphasis principally on blood volume inthe postoperative rather than the resusitative phase of the patient'scourse. (1) It was felt that more could be learned about the adequacy oftransfusion and its effect in maintaining blood volume through resuscitationand surgery. In particular, determinations at this time would provide quantitativeanswers as to the necessity for large transfusions. (2) In most instancesadequate hemostasis was achieved at this time allowing for adequate mixingof 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.
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cells or dye without significant loss during mixing. (3) Likewise, therapid administration of blood or colloids was not necessary here, so thatmixing phenomena of labeled cells and dye could be observed without beingconfounded by concomitant mixing of other fluids rapidly infused for resuscitation.
Those patients, therefore, whose blood volumes were determined withlabeled 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 theday following surgery to avoid interfering effects due to elevated plasmahemoglobin.
Methods
Labeled Red Cell Method
Labeling of red cells was carried out using radioactive chromium asthe tagging material. Chromium51 was used in preference to p32because of the more lasting incorporation of Cr5l in the redcells as compared to p32. Since with the method used negligibleescape of Cr5l from the red cells occurs within the first 24hours, prolonged study of mixing could be carried out and serial volumesdetermined without the necessity of relabeling new cells. The followingis the method used for labeling the red cells and calculating the bloodvolume.
1. Preparation of labeled red blood cells.
(a) Ten cc. of sterile, physiologic saline and 150 to 200 microcuriesof radioactive chromium are placed in a sterile, glass-stoppered flask.
(b) Fifteen cc. of fresh heparinized "O" blood* is added tothe centrifuge flask.
(c) The flask is placed in an incubator at 38° C. and allowed toreact 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 storedat refrigerator temperature until ready for use.
(f) If the cells are to be stored for several hours before use, theyare 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 aspiratedinto a syringe of suitable volume.
(b) At least 2.5 cc. of labeled blood from the syringe is placed intoa tared volumetric flask as a standard, weighed, and made to volume withdistilled 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.
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(c) The syringe containing the material to be injected is weighed togetherwith the needle to be used for injection.
(d) The remaining labeled blood is injected intravenously and the syringeand needle are immediately weighed without rinsing.
(e) Blood samples are collected 20 and 40 minutes after injection andas indicated thereafter until mixing is complete. In most cases, multiplesamples were taken until the last 2 aliquots differed by less than 5 percent.
(f) The hematocrit of each sample is carefully determined. At least3 hematocrits were obtained on each patient.
(g) Exactly 5 cc. of each whole blood sample is pipetted into a countingtest tube. Likewise, duplicate 5 cc. samples of standard are pipetted intocounting tubes.
(h) All standards and samples are counted in a well-type scintillationcounter.*
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 towhich standard was diluted)/Weight of labeled blood used as standard
V1=Weight of syringe and needle before injections minus weightafter injection.
C2=cpm/cc. of patient's blood after adequate time for mixingof 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 whereinthree 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 correctfor dye loss during the mixing period. This value at zero time gave thetheoretical concentration of dye that would have occurred in the plasmaif uniform mixing had been effected at the instant of injection and noneof the dye had been
*Standard scintillationcounting technics were used.
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excreted. Where abnormal plasma hemoglobin levels or an interferingcloudiness were suspected the samples were discarded. Each reported determinationwas made on the basis of three valid samples with the exception of thoseso indicated where extrapolation was on the basis of only two. When onlyone plasma level was obtained or when a linear plot did not result theobservation was discarded. The total blood volume was calculated from theplasma volume and the hematocrit value. Where simultaneous blood volumeswere determined by using labeled cells and dye, the two were administeredseparately via different veins to avoid error through loss during changingof syringes.
In calculating the total blood volume from the plasma volume or redcell volume, no correction factors were used to effect the possible errorintroduced by differences between venous and total body hematocrit. Theestimated normal blood volume used for the dye method was 8 percent ofbody 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 in2 volumes of saline showed a transfer of 1.5 percent of the total radioactivityto the suspending medium in 36 hours. When bank blood plasma was used forresuspension less than 0.5 percent of the total radioactivity appearedin 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 determinedas indicated in table 6. Three duplicate determinations done several daysapart 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 hadbeen stored 6 hours after labeling with Cr51.
2. Evans Blue Dye
Nine patients who received no transfusions had multiple plasma volumedeterminations during their postoperative course. Using these volumes andthe hematocrit to compute the red blood cell volume it was found that theresults were constant within an estimated variation of S. D. = ±5percent.
Results
The results are tabulated in tables 1 through 3.
Careful evaluation of mixing was carried out during the first 60 to90 minutes in all patients to make sure that the volume was calculatedfrom completely mixed samples. Samples were taken until successive countsdiffered by less than 5 percent. Furthermore, because it was suspectedthat relatively sequestered areas of blood might exist in some
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of these patients (5, 13, 15), later samples were taken in nineindividuals. It was reasoned that if such areas existed and they were notcompletely sequestered, late samples might have mixed into larger volumeswhich were not apparent in earlier samples. The results of these studiesare seen in table 2. It can be seen that even though the early sampleshad reached a plateau and agreed with one another within less than 5 percent,later samples taken at varying intervals revealed slightly greater apparentvolumes in most instances. In all but Case No. 1, the later samples alsofell within less than 5 percent of one another. The interpretation of thesefindings is open to some question owing to the possibility of selectivedestruction of labeled cells. Two patients were given hexamethonium afterthe early mixing of labeled cells was complete. It was felt that if slowlymixing, stagnant areas of blood existed, the opening of arterioles andincreased flow caused by hexamethonium might improve the circulation throughsuch 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 therange of 120 to 130 down to 90 to 100. Neither individual showed any increasein volume at intervals of 30 to 60 minutes thereafter.
The postoperative blood volume measurements revealed one outstandingresult, namely, that large transfusions were a definite necessity in manyof these patients and very rarely resulted in overtransfusion. In fact,regardless of the amount of blood received, the vast majority of patientsemerged from surgery with some deficit of total blood volume. Of the 25patients studied with dye none revealed an initial postoperative bloodvolume greater than normal. In only 3 patients out of 28 studied with Cr51labeled red cells was overtransfusion present, and in none of these wasthere any evidence of cardiorespiratory difficulty. This was probably dueto the fact that the degree of overtransfusion was minimal. Two of thethree overtransfused patients were followed with successive blood volumemeasurements. In one instance, the red cell volume returned to normal in9 days and in the other in 7 days. The latter's course, however, was complicatedby jaundice and purpura apparently due to thrombocytopenia. Of the threeovertransfused patients, one had an abdominal wound and the other two hadthoraco-abdominal wounds. They received 7,000, 7,000 and 1,500 cc. of bloodrespectively.
Clinical State
In general, varying degrees of hypovolemia were tolerated very wellby the group during this postoperative period. Fourteen or 58 percent ofthe weighed patients studied with labeled cells showed
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deficiencies of 15 percent or more of the average normal for their weight.We would class this group as definitely undertransfused. The average deficiencyfor these patients was 32 percent. However, of the 14 patients only 3 werein shock, these patients showing deficiencies of 38, 43 and 52 percent,respectively. The others were doing well postoperatively with no clinicalevidence of shock. The average amount of blood which had been receivedprior to the blood volume determination in this hypovolemic group was 6,740cc. This figure is in contrast to the group whose deficit was less than15 percent. Their average replacement was 3,187 cc. or less than half thatof the hypovolemic patients. The results were even more striking in thepatients studied with dye. Fourteen of the 18 patients whose weights wereknown and whose normal blood volume could therefore be calculated revealeda deficit of greater than 15 percent. Their average deficit was 31 percent.All these patients were doing well postoperatively with no clinical evidenceof shock. Their blood requirement pattern was similar to that of thosestudied with labeled cells, the group with greater than 15 percent deficithaving received 7,785 cc. and the group with less than 15 percent deficitreceiving 4,160 cc. Thus those individuals who had required the most bloodremained the most hypovolemic following surgery. It was in this group thatthe most massive transfusions were required.
In only one patient did shock exist in the presence of a normal bloodvolume. This patient had received severe head injuries, with shell andbone fragments in the brain substance. In addition, there were severe facialinjuries and a compound comminuted fracture of the left humerus. This patienthad received 4,500 cc. of blood prior to the blood volume determination,which measured 96 percent of normal for his weight. The volume was done3 hours before his death at which time his pulse was 140 to 160, respiration40 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 undoubtedlyof paramount importance here and may well explain the shock picture inthe presence of a normal blood volume.
When the patients are placed in categories dependent upon the locationof their wounds, several trends relative to blood volume and blood requirementscome to light. In view of the relatively small numbers of patients, thesetrends must be considered tentative. They seem to be dependent primarilyon one fundamental factor, the presence or absence of large areas of muscleinjury. In the extremity wounds where a large amount of muscle injury wasalmost invariably present, large amounts of blood were necessary duringresuscitation and surgery. Yet when the blood volume was determined postoperativelyby either method, all members of the group fell in the hypovolemic class
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with deficits in volume of 15 percent or more and an average hematocritof 36.5.
On the other hand, those who had abdominal wounds, though they had receiveda similar amount of blood as compared to those with extremity wounds, revealedpostoperative blood volumes more closely approximating normal and an averagehematocrit of 45.8. The excess loss of blood from wound of muscle is easilyunderstood when one considers the local pathology involved in wounds causedby 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 isparticularly true in high-velocity missile wounds. Bleeding from the largemass of damaged muscle continues from the time of injury until operation.During this time, the blood loss is greater than the observer generallyrealizes. The importance of other factors, such as hemolysis and trappingof blood, as added mechanisms for the causation of these low blood volumesis not fully known at the present time.
Relation of Hematocrit
Table 3 illustrates 10 patients with extremity wounds on whom serialpostoperative hematocrits were done. They show a consistent fall in hematocrit.One factor which may contribute in part to this effect is the rise in plasmavolume observed in many hypovolemic convalescent patients. A rising plasmavolume and falling hematocrit were noted in the absence of any significantchange in the total red cell volume indicating a dilution effect as beingat least partially responsible for the falling hematocrit.
As has been previously reported, hemoconcentration characteristicallyfollows severe intra-abdominal injuries (1). This is probably dueto the loss of plasma in excess of red cells into the bowel wall, mesenteryand peritoneal cavity. Serial postoperative hematocrits in patients withabdominal injuries are compared with the postoperative changes followingwounds of the extremities in table 3. Because hemoconcentration and plasmaloss were so frequently quite marked, surgeons often administered dextranas an adjunct to blood transfusion therapy during and after repair of majorintra-abdominal injuries. This was true during much of the time when thesedata were collected.
Comparative Blood Volumes
In 15 patients, simultaneous blood volume determinations were carriedout using labeled red cells and T-1824. The results are recorded in table4. In general the methods agreed fairly well, the average difference being16.3 percent and falling in the range of difference found by previous investigatorsin normal individuals. In three patients, however, the discrepancy wasconsiderably larger (26 to 39 percent), the dye volume being larger inall instances. All of
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these individuals had severe abdominal wounds; two of the three hadlacerations involving the liver. This would suggest that the same factorcausing hemoconcentration in such patients allows for leakage of dye outof the vascular system with resultant falsely high plasma and blood volumedeterminations. Peters (12) has commented previously on the lossof 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 ofadded interest and significance. These data suggest that under certaincircumstances the dye method may not be a reliable one.
Discussion
The impression was originally gained by those in the North African-MediterraneanTheater (1) that blood loss rather than any other factor was responsiblefor shock in the wounded patient. Their findings indicated that the presenceor absence of shock as well as its degree upon admission to the hospitalwas directly correlated with the deficiency in blood volume present atthat time. The present studies lend support to those findings and extendthe concept to the surgical and postoperative period where it is seen thattremendous amounts of blood are often necessary to maintain the blood volumeclose to normal range. Of the 52 patients studied, 31 or 59.6 percent requiredover 10 pints of blood. In other words, over half of the patients studiedrequired complete replacement of their blood volume. Of these 31 patients,9 required 20 pints or roughly twice their blood volume. This group emphasizedwell the real necessity in some patients for massive transfusions. Theaverage deficiency of blood volume in these 31 individuals after receivingsuch massive transfusions was still 25.2 percent.
In addition to the problem of how large a circulating blood volume wasnecessary for these patients was that of how effectively the blood transfusedhad increased that volume. Possibly present in almost every patient observedbut becoming more apparent with the larger volumes of transfusion, wasan apparent discrepancy between the amount of blood transfused and thatactually measured after operation. This volume deficit appears to consistof both plasma and red blood cells. As examples the data of table 5 wereextracted from table 1 and arbitrary estimates of admission blood volumemade. Most of these patients were chosen as examples because the volumesinvolved were large enough to make errors in estimation of initial volumerelatively insignificant. They demonstrate an average deficit of 5,373cc. with a range from 1,600 to 7,900 cc. Likewise 10 patients requiringpostoperative transfusions were studied with one or more determinationsof their plasma volume with Evans Blue for up to 7 days after wounding.The results are tabulated in table 7. When a transfusion intervened betweentwo determinations, the change in
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circulatory red cells measured was significantly less than that expectedin 6 of 12 instances. None of these patients showed clinical reason tosuspect red cell loss.
It was because of these consistently low blood volumes after large transfusionand the discrepancy between the volume of blood infused and that measuredthereafter that such concern was shown over the possibility of incompletemixing of labeled cells in relatively sequestered areas of blood volume.If large amounts of blood were pooled in areas relatively inaccessibleto mixing, falsely low total blood volumes would be the result. Althoughthe blood volumes calculated from late samples were slightly greater thanthose calculated from early ones, in no instance did they result in a bloodvolume of 5,000 cc. or over. One of the nine patients (table 2) showedan 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. Sevenof 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 theblood volume increase when calculated from the late samples as comparedwith the early samples was 600 cc. or less in every instance.
Likewise in the two patients given hexamethonium no increase in bloodvolume occurred concomitant with the fall in blood pressure. Furthermore,in those patients who had received massive transfusion and survived, nonedeveloped clinical or laboratory evidence of overtransfusion during theirpostoperative course. If such a pooling mechanism as has been postulatedexisted early, one would expect a reversal of this process during clinicalrecovery with mobilization of substantial amounts of trapped blood andsome resultant evidence of overtransfusion. In no instance did such occur.Although these data are not sufficient for positive conclusions, they donot support the concept that a significant amount of pooling existed inthese 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 determinethe blood volume. Where such large volumes of infused blood are involved,one should see significant gains in weight if most of the blood has beenretained; little or no change if it is being lost externally as fast asit is being infused. Correlating the postoperative blood volume with changein weight would thus help clarify the question of loss versus pooling.Obviously if most of the bleeding was into the tissues little would belearned by this procedure. (2) Determine the blood volume postoperativelywith chromium-labeled cells. Determine the hemoglobin to Cr51 ratioin blood and in tissue biopsies such as muscle. If large amounts of bloodare sequestered in the tissues and inaccessible to the labeled cells, thehemo-
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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 theUnited 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 largeamounts of O blood there will be a destruction of the patient's own cellsextending over several days but this is relatively infrequent and usuallyinvolves volume changes much smaller than those reported here.
The relative importance of hemolysis of recipient and donor cells asa contributing cause for the large requirement of blood replacement inthese patients is not fully known at the present time. These patients donot show overt clinical manifestations of rapid blood destruction suchas chills, fever and jaundice. Moreover, the average plasma hemoglobindone immediately after surgery in 22 patients who had received an averageof 12 pints of blood each day was only 18 mg. per 100 cc. (3), (normal5 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 individualswill induce plasma Hg. levels of greater than 300 mg./100 cc. (6, 11),the levels found in these postoperative patients would be indicative ofminimal intravascular hemolysis. The rate of plasma Hg. clearance is ofcourse a factor here. The most rapid clearance rate found in the groupstudied was 5 mg. per 100 cc. per hour which would be insufficient to lowera significantly high concentration of Hg. to the levels found even overa 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 criticalfactor here and the necessary data for such evaluation in these patientsare not at hand. The infusion of 16.4 gm. of Hg. (6) (equivalentto hemolysis of approximately 100 cc. blood) in a normal individual resultedin 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-injectionlevel 24 hours later. Clearance of bilirubin in the wounded patient, whereimpaired hepatic function has been shown by others (1, 14) wouldbe expected to be slower than in normals. Therefore the 6-hour postoperativeaverage level of 2.5 mg. per 100 cc., which is the highest level reachedin any of the preoperative and postoperative specimens, would imply relativelysmall amounts of hemolysis.
The postoperative hematocrit afforded a relatively poor index to therequirements for transfusion. Because of rapid changes in
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plasma volume which take place independently from changes in red cellvolume after extensive blood loss, the hematocrit gives little informationabout the actual red cell volume at any given time. By the same token anyconclusions concerning the status of total blood volume drawn from hematocritdata alone are likely to be in error.
Conclusions
Blood volume determinations have been carried out postoperatively in52 wounded patients. These patients required large amounts of blood tomaintain them through the phases of resuscitation and surgery. Generallypatients with extremity wounds, where large amounts of muscle destructionhad taken place, required the largest amounts of blood and still remainedthe most hypovolemic following surgery. However, no matter where the injurywas located, if considerable areas of muscle were involved, large amountsof blood were usually required.
Overtransfusion occurred in only three instances and in no case wasit of sufficient degree to cause cardiorespiratory symptoms. The errorin most cases was undertransfusion rather than overtransfusion.
Hematocrit determinations in the postoperative period are not a reliableindex to the requirement for blood.
Where simultaneous blood volumes were determined with labeled cellsand dye, the difference between the two was 16 percent, the dye volumebeing greater in all but four instances. However, in severe abdominal wounds,especially with liver involvement, the discrepancy was much larger. Herethe dye volumes were greater by 26.8, 33 and 39 percent. This probablyrepresents increased capillary permeability and gross vascular damage inthe involved area with resultant leakage of dye.
The discrepancies between the large amounts of blood given and the smallblood volumes determined thereafter are explainable on three possible bases:(1) Trapping of large amounts of blood in a sequestered state which mixesslowly or not at all; (2) hemolysis of large amounts of donor and/or recipienterythrocytes; (3) continued loss of blood either externally or into thetissues during the preoperative, operative and postoperative periods. Thelatter is believed, at the present time, to be the most important of thesefactors.
Acknowledgment
We wish to express our sincere appreciation to Colonel William S. Stone,Commandant, Army Medical Service Graduate School, Walter Reed Army MedicalCenter, Washington, D. C., and to Colonel Richard P. Mason, Commandant,Far East Medical Research Unit, for their continued encouragement and supportof the project.
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Table 1A. Blood Volume Determined With Radioactive Chromium
176-177
Table 1A. Blood Volume Determined With Radioactive Chromium-Continued
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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
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Table 2. Blood Volume as Related to Time of Sampling
| 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 | 1¾ | 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.
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Table 4. Comparison of Simultaneous Blood VolumesDetermined 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 includedin table 1.
Table 5. Showing Discrepancy Between BloodReceived 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 | (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 dayafter 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 traumaticamputations and underwent uneventful amputations with minimal blood lossand had thereafter only the clean amputation wounds.
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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 takenfor Cr51 determination.
2Red blood cell volume expected on the basis of 30 cc./Kg. bodyweight.
3Red blood cell volume measured.
4Female.
Table 7. Red Blood Cell Volume Response toTransfusion, Measured with Evans Blue
(a) Case No. | (b) RBC received (cc.)1 | (c)
| (d)
| (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 |
RBCobserved (cc.)21Red cells received by transfusions betweenmeasurements of the plasma volume.
2The change in red cell volume as measured by plasma volumeand hematocrit determinations before and after transfusion.
3The difference between columns (a) and (c).
4Column (d) expressed as percent of the total measured red cellvolume.
5Column (d) expressed as percent of the transfused red cellvolume.
189
References
1. Beecher, H. R., Editor: The Physiologic Effects ofWounds, p. 45. U. S. Government Printing Office, Washington, D.C., 1952.
2. Berlin, N. I., Lawrence. J. H., and Cartland, J.: TheBlood Volume in Chronic Leukemia as Determined by P32 LabeledRed Blood Cells. J. Lab. and Clin. Med. 36: 435, 1950.
3. Crosby, W. H.: A Study of Blood Transfusion as Usedin the Treatment of Battle Casualties in Korea. A preliminary report fromthe Surgical Research Team, U. S. Army.
4. Nachman, H., James, G. W., III, Moore, J. W., and Evans,E. L.: A Comparative Study of Red Cell Volumes in Human Subjects with RadioactivePhosphorus Tagged Red Cells and T-1824 Dye. J. Clin. Invest. 29:258, 1950.
5. Gibson, J. G., 2d., Seligman, A. M., Peacock, W. C.,Fine, J., Aub, J. C., and Evans. R. D.: The Circulating Red Cell and PlasmaVolume and the Distribution of Blood in Large and Minute Vessels in ExperimentalShock in Dogs, Measured by Radioactive Isotopes of Iron and Iodine. J.Clin. Invest. 20: 177, 1941.
6. Gilligan, R. D., Altschule, M. D., and Ratersky, E.K.: Studies o. Hemoglobinema and Hemoglobinuria Produced in Men by IntravenousInjection of Hemoglobin Solution. J. Clin. Invest. 20: 177, 1941.
7. Grant, R. T., and Reeve, E. B.: Observations on theGeneral Effects of Injury in Man, p. 228. Medical Research Council SpecialReport, Ser. No. 277, H. M. Stationery Off., London, 1951.
8. Gregerson, M. I., Gibson, J. G., and Stead, E. A.:Plasma Volume Determinations with Dyes: Errors in Colorimetry; Use of theBlue Dye T-1824. Amer. J. Physiol. 113: 54-55, 1935.
9. Gregerson, M. I.: A Practical Method for the Determinationof Blood Volume with the Dye, T-1824; Survey of the Present Basis of theDye Method and its Clinical Applications. J. Lab. and Clin. Med. 29:1266-1286, 1944.
10. Noble, R. F., and Gregerson, M. I.: Blood Volume inClinical Shock. II. The Extent and Cause of Blood Volume Reduction in TraumaticHemorrhagic and Burn Shock. J. Clin. Invest. 25: 172, 1946.
11. Ottenberg, R., and Fox, C. I., Jr.: The Rate of Removalof Hemoglobin from the Circulation and its Renal Threshold in Human Beings.Amer. J. Physiol. 123: 516, 1938.
12. Peters, J. P.: Role of Sodium in Production of Edema.New Eng. J. Med. 239: 353, 1948.
13. Root, G. T., and Mann, F. C.: An Experimental Studyof Shock with Special Reference to its Effect on the Capillary Bed. Surgery12: 861, 1942.
14. Scott, R., Jr., Olney, J. M., Jr., and Howard, J.M.: Hepatic Function in the Battle Casualty (A preliminary report). NationalResearch Council Bulletin on Shock, App. A., p. 2, Dec. 1952.
15. Zweifach, B. W., Hershey, S. G., Rovenstine, E. A.,Lee, R. E., Hyman, C., and Chambers, R.: Omental Circulation in MorphinizedDogs Subjected to Graded Hemorrhage. Ann. Surg. 120: 232-250, 1944.
