However, any operators using this equipment must be well trained and remain alert to the potential risk for air embolization at all times while the patient is being treated. All such devices currently manufactured, however, contain air-in-line sensors. Air, however, still may be infused into patients by the roller pumps contained in various transfusion devices, especially apheresis machines and intraoperative salvage machines. Since the replacement of evacuated glass bottles by plastic blood bags, the risk for air embolism from phlebotomy or transfusion has virtually disappeared from transfusion practice. William Savage, in Hematology (Seventh Edition), 2018 Air Emboli Although there are potential replacement plasticizers, DEHP is most commonly used since the exposure to DEHP through transfusion is generally felt to be less than other environmental exposures. Shorter storage lessens the load of DEHP delivered to the recipient. DEHP leaches out from the plastic bag and intercalates and stabilizes the red cell membrane. One of the benefits of using DEHP for RBC storage is the prevention of hemolysis. The storage of RBCs in bags made of polyvinyl chloride plasticized with DEHP has caused more recent concern because of the reported association between DEHP exposure and impaired development of the male genital tract. The safety of DEHP has been questioned for years owing to its tendency to leach from the bag and to be present at levels of 50–70 mg/L in stored RBCs. Since their introduction in the 1960s, plastic blood bags used for storing RBCs have been made from polyvinylchloride containing the lipophilic plasticizer di(2-ethylhexyl)phthalate (DEHP), which confers pliability. Cushing, in Hematology (Seventh Edition), 2018 Di(2-ethylhexyl)phthalate Less BTHC than DEHP leaches into the bag contents, and excellent 24-hour posttransfusion RBC recovery occurs with minimal hemolysis. PVC plasticized with butyryl- n-trihexyl-citrate (BTHC) has been introduced in place of DEHP. When DEHP was added to EEA containers, blood stored in EEA containers without DEHP had greater RBC osmotic fragility than did blood in EEA with DEHP or PVC containers. A study comparing another plastic, poly(ethylene-co-ethyl acrylate) (EEA), with polyvinyl chloride (PVC) containing DEHP 44 found that blood stored in EEA containers had higher plasma hemoglobin and greater susceptibility to osmotic lysis than did blood stored in PVC containers. 43 With all of this information, however, no direct causal link has been established between DEHP and cancer in humans.īecause of the concerns about toxicity, alternative materials for blood-storage containers have been under investigation for some time. Peroxisomes are involved in the β-oxidation of fatty acids, producing hydrogen peroxide, which has been suggested to be the causative agent in the carcinogenicity of DEHP. Hepatomegaly has been shown to be caused by proliferation of cellular organelles called peroxisomes. 42īecause of an association with hepatomegaly, DEHP has also been linked to potential hepatocarcinogenicity. It caused a form of shock lung leading to death when administered to rats in intravenous form, 40 caused testicular atrophy in rats given dietary doses, 41 and led to lung injury in dogs and baboons transfused with stored blood. DEHP, identified as a carcinogen in rats and mice, 39 is ubiquitous in the environment. 38 Concern over the potential toxic effects of DEHP in humans has fueled a great deal of research and much debate. Whole blood products had the highest DEHP levels, compared with RBC concentrates, irradiated RBC concentrates, FFP, and platelet products. A more recent evaluation of the levels of DEHP in stored blood components found that as storage time increased, the amount of DEHP detected ranged from 6.8 to 36.5 μg/mL in RBC concentrates. In addition, two patients were found to have DEHP at levels ranging from 0.069 to 0.270 mg per gram dry weight of tissue. In 1970, Jaeger and Rubin 37 reported that 5 to 7 mg of DEHP could be isolated per 100 mL of blood. As a result, DEHP can leak into blood stored in the container and be transfused along with the blood. It is not bound to the plastic but is dissolved in it. DEHP is added in large quantities to the plastic, approximately 40% by weight. DEHP, the chemical that allows the vinyl plastic to be pliable, is referred to as a plasticizer. In the early 1970s, however, reports surfaced about the potential toxicity of blood stored in bags with di(2-ethylhexyl)phthalate (DEHP). The use of vinyl plastic blood bags and tubing in transfusion medicine is advantageous in the collection, processing, storage, and dispensing of blood components. Ness, in Blood Banking and Transfusion Medicine (Second Edition), 2007 Storage Containers
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