BUFFERED CITRATE SOLUTION IN BLOOD TRANSFUSION

1431 the day of admission. He had been in good health and not subject to abdominal pain, until six months before admission, when he lost his job. Since then his livelihood had been precarious, with consequent anxiety and irregularity of meals. Bouts of epigastric pain had started soon after this misfortune. The pain came on 1 hours after heavy meals, and was relieved by alkalis. Five weeks before admission it had become rapidly worse. It was more intense and now came on regularly after every meal, sometimes accompanied by vomiting, which On the fourth day before admission the gave relief. patient felt faint and weak, sweated and then collapsed, and vomited a quantity of dark blood. He was put to bed at home and later passed a large loose black motion. Next morning he felt weak and was pale, but because there was no pain he went to work, as also on the following two days. On the day before admission, after half a day’s work, he felt extremely weak and faint, and went straight home to bed. Next day he vomited a small .amount of dark blood. On admission the patient was pale, restless, cold and sweating, and frequently complained of thirst ; his speech was rambling and hardly intelligible. The pulse-rate was 102, the blood pressure 90/70, and the haemoglobin 34 per ,cent. (Sahli). A continuous-drip blood transfusion was started at once, and 1800 c.cm. from three donors was given in twenty hours. Three hours after the end of the transfusion the patient was troubled with cough, which lasted for several hours. Apart from this the result was satisfactory. There was a striking improvement in the general condition, and the haemoglobin rose to over 70 per ,cent., at which level it remained for the next 10 days. During this time there was a steady improvement, and the pulse-rate fell gradually to normal. On the eleventh day, however, there was a recurrence of bleeding as - evidenced by a rise of pulse-rate associated with faintness and sweating. The haemoglobin fell to 40 per cent. On the twelfth day he became restless and vomited 30 c.cm. of dark blood. A transfusion of 600 c.em. of blood was given slowly by drip. Next morning the man .again became gravely ill, and the haemoglobin was found to have fallen to 28 per cent. A litre of blood, given by the same method, produced great improvement .and return of the pulse-rate to normal. The haemoglobin reached 48 per cent., and remained constant at about this figure for several days. On the seventeenth day there was again evidence of severe hemorrhage, and again the haemoglobin fell abruptly, reaching 29 per cent. Another drip transfusion was given, only 600 c.cm. being used with the idea of minimising the risk of starting the bleeding again. This was followed by a rigor and pyrexia, which passed off ,quickly, leaving the patient very much better. Next morning his condition was still satisfactory, until quite auddenly he collapsed, became dyspnceic and stuporose, and rapidly lost consciousness. His skin was cold and moist, his pulse of poor volume and too rapid to count. A Red ’Cross donor was obtained, and 300 c.cm. of blood was given rapidly as a life-saving measure. The result was - striking : improvement soon began to show itself, consciousness returning, and the mentality approaching normal. A further 500 c.cm. of blood was then given slowly at the ordinary drip rate, raising the haemoglobin to 48 per cent. Thirty-six hours later there was a similar event, which was treated by giving 1050 c.cm. .of blood. During the next ten days there was no evidence of gross blood loss, and the patient seemed to be gaining ground. The haemoglobin remained at or about 45 per cent. On the twenty-ninth day he became restless again, and - estimations of the haemoglobin showed that this had fallen to 35 per cent. A transfusion of 550 c.cm. was given, after which, though blood could be detected in the stools by the benzidine test, for a further three weeks, - there was no recurrence of the severe haemorrhage. From - this time he made a slow but uninterrupted recovery, .and he was discharged, after 12 weeks in hospital, gaining weight, with a haemoglobin of 69 per cent. and with no blood detectable in the stools by chemical methods for the past 5 weeks. A barium meal showed an area of ’Spasm in the prepyloric segment, but no ulcer crater was The duodenum appeared normal. aeen. on

In a previous case of haematemesis in 1933, in which the outlook seemed hopeless owing to repeated severe blood loss, a series of transfusions each of 400 c.cm. was given. Six of these were required, after which the patient made a good recovery. This case came before the days of the continuous-drip method, but like the present one it was instructive in showing the value of persisting with transfusion, even when it may seem that the patient is beyond hope, and that to keep on transfusing will be to waste blood. I should like to thank Dr. George Graham for permission publish these notes and for much valuable advice in their preparation. to

REFERENCES

Cubitt, A. W. (1937) Lancet, 1, 864. Marriott, H. L., and Kekwick, A. (1935) Ibid, (1936) Proc. R. Soc. Med. 29, 337. Wood, I. J. (1936) Brit. med. J. 2, 115. —

1, 977.

—

BUFFERED CITRATE SOLUTION IN BLOOD TRANSFUSION BY TEMPLE

GREY, M.A. Oxon., M.B., Ch.M. Sydney

PATHOLOGIST TO THE EAST LONDON HOSPITAL FOR CHILDREN HON. PATHOLOGIST, EAST END MATERNITY HOSPITAL

;

MANY reasons have been advanced for the reactions from time to time after blood transfusion. Chilling of the blood is one, and this I have overcome by taking the donor’s blood into a Dewar flask.l Some however who take other precautions against chilling assure me they came across reactions nevertheless. It occurred to me in August, 1934, that the alkalinity of the citrate used might be a cause, and considering that on general principles anything offered to the circulation ought to have, if not the actual salt constituents of the blood, at least an approximation to these and especially the proper pH (7-3), I prepared a modified citrate solution which has been used by myself and others with satisfactory results ever since. seen

Stock solution.-Dissolve 0-6 g. KH2P04> 0-9 g. CaCl2, and 3.0 g. glucose in 100 c.cm. distilled water. This keeps many months. Buffered solution for use.-Take 30 c.cm. physiological saline and 30 c.cm. distilled water into a clean flask, add 2-0 g. sodium citrate. (It is useful to keep in the screwtopped bottle of pure sodium citrate a glass scoop, consisting of the filed-off bottom of a hard glass tube calibrated to contain 1-0 g.; pick out with a pair of forceps kept for the purpose.) Add 2 c.cm. stock solution. Boil for ten minutes. As the solution cools, add a few drops of phenol red solution. The reaction will be alkaline. Filter while hot into another flask. When cool, two or three drops of normal HC1 will give the copper colour of pH 7-3. Cover with a suitable rubber cap. This solution

keeps indefinitely. For use, take one volume of the solution for nine volumes of blood-for example, 30 c.cm. (1oz.) of solution and 270 c.cm. blood make up 300 c.cm. 1

Lancet, 1932, 2, 127.

B

DERBYSHIRE ROYAL INFIRMARY.-A contributory

scheme is to be introduced at this hospital to help to provide funds for its development. The scheme will also benefit other voluntary hospitals in the area. A 48-hour week for nurses is to be started, which means that 64 members must be added to the staff, and difficulty is being experienced in obtaining suitable candidates.