A simple mathematical approach to calculate blood loss in radical prostatectomy

INTRODUCTION: The aim of this study was to apply a simple mathematical approach to calculate blood loss in 126 patients undergoing radical retropubic prostatectomy (RRP). MATERIALS AND METHODS: Perioperative red blood cell loss (RBCL) was estimated by adding the difference in circulating red blood cells from before to after surgery to the allogeneic red blood cells transfused in the same period. RESULTS: Mean preoperative hematocrit was 45 +/- 4% and mean perioperative RBCL was 574 +/- 297 ml, corresponding to a mean equivalent whole blood loss (WBL) of 1,479 +/- 831 ml. Twenty of 126 patients (15.9%) received 42 units of allogeneic packed red blood cells (PRBC), for a mean of 2.1 +/- 1.2 U/patient. The transfusion rate was higher in patients with a preoperative hematocrit of 40% or less (45 vs. 13%, p = 0.014). CONCLUSIONS: Anatomical RRP is still associated with appreciable operative blood loss. Owing to the high preoperative hematocrit values, the allogeneic blood transfusion rate is low and the transfusion requirement of the majority of patients is limited to about 2 units of PRBC. Preoperative autologous blood augmentation strategies may not be routinely needed for patients with a basal hematocrit of >40%.     

Analysis of a protocol for an autologous blood transfusion program for total joint replacement surgery

This retrospective study analysed an autologous blood transfusion program for total joint replacement surgery. A group of 99 patients receiving autologous blood transfusion was compared with a control group of 55 patients. One-unit phlebotomies were done 14 and 7 days before surgery. The whole blood was transfused intraoperatively. Preoperative hemoglobin values were within the normal range for all patient groups except the female autologous blood group for which the mean value was 122 +/- 11.3 g/L. Due to perioperative hemodilution, the postoperative hemoglobin values were substantially lower than preoperative values for all groups. Mean intraoperative blood loss was similar for the autologous and control groups (650 to 750 ml). No adverse reactions were associated with the autologous transfusions and 74% of the autologous group received autologous blood only. From this analysis a 3-week, three-unit preoperative collection was proposed for future use. A standardized protocol will allow logistical ease and implementation of the program for various surgical procedures.     

Blood usage in an Australian intensive care unit: have we met best practice goals?

The transfusion of blood products, especially red cell concentrates, in critically ill patients is controversial and benefits of red cell concentrate transfusion in these patients have not been clearly demonstrated. We performed a prospective observational study to compare best evidence to actual practice of red cell concentrate and other blood product administration in an intensive care unit (ICU) in a university-associated tertiary hospital. All primary admissions during a 28-day period were included in the study and data collected included transfusion of red cells and blood products, patient demographics and ICU and hospital outcome. One hundred and seventy-five admissions were studied; 44% followed cardiac surgery. Forty-one patients (23%) received red cell concentrates in ICU, with 120 units transfused in 61 separate episodes. Other blood product usage was minimal. One third (20/61) of red cell concentrate transfusion episodes were of a single unit. The mean (+/- SD) pre-transfusion haemoglobin was 7.9 +/- 1.1 g/dl. Despite transfusion, such patients left ICU with a lower haemoglobin concentration compared with untransfused ICU patients (9.5 +/- 1.0 versus 10.5 +/- 2.1 g/dl; P < 0.001). Cardiac surgical patients received similar red cell transfusion to general ICU patients. Univariate analysis showed no significant difference in mortality between patients who did or did not receive red cell concentrate transfusion (P = 0.17). However, red cell concentrate transfusion was associated with a reduced adjusted mortality both in ICU (OR 0.13, 95% CI 0.02-0.73) and in hospital at 28 days (OR 0.10, 95% CI 0.02-0.58). The low red cell concentrate and blood product usage in our ICU were consistent with restrictive transfusion practice and selective red cell concentrate transfusion was associated with reduced mortality.     

Anticoagulation, bleeding and blood transfusion practices in Australasian cardiac surgical practice

We surveyed contemporary Australasian cardiac surgical and anaesthetic practice, focusing on antiplatelet and antifibrinolytic therapies and blood transfusion practices. The cohort included 499 sequential adult cardiac surgical patients in 12 Australasian teaching hospitals. A total of 282 (57%) patients received red cell or component transfusion. The median (IQR) red cell transfusion threshold haemogloblin levels were 66 (61-73) g/l intraoperatively and 79 (74-85) g/l postoperatively. Many (40%) patients had aspirin within five days of surgery but this was not associated with blood loss or transfusion; 15% had clopidogrel within seven days of surgery. In all, 30 patients (6%) required surgical re-exploration for bleeding. Factors associated with transfusion and excessive bleeding include pre-existing renal impairment, preoperative clopidogrel therapy, and complex or emergency surgery. Despite frequent (67%) use of antifibrinolytic therapy, there was a marked variability in red cell transfusion rates between centres (range 17 to 79%, P < 0.001). This suggests opportunities for improvement in implementation of guidelines and effective blood-sparing interventions. Many patients presenting for surgery receive antiplatelet and/or antifibrinolytic therapy, yet the subsequent benefits and risks remain unclear.     

Gender is an essential determinant of blood transfusion in patients undergoing coronary artery bypass graft procedure

STUDY OBJECTIVE: To determine factors that account for gender difference in the need for blood transfusion in coronary artery bypass graft (CABG) patients. DESIGN: Retrospective study of consecutive patients. SETTING: Anesthesiology department of a teaching hospital. PATIENTS: 253 CABG patients (163 males and 90 females). INTERVENTIONS: Packed red blood cells (PRBCs), platelets, and fresh frozen plasma (FFP) were transfused depending on the need of each patient. MEASUREMENTS AND MAIN RESULTS: For each patient, we recorded the gender, age, weight, height, body surface area (BSA), and duration of surgery. Hematocrit (Hct) levels prior to surgery, end of surgery, and at discharge from the hospital were recorded. PRBC administration and use of FFP and platelets were noted. Differences between the data for female and male patients were evaluated using Student's t-test, Chi-square test, and regression analysis. Approximately 60% female and only 20% male patients received PRBCs intraoperatively, whereas 78% females and only 43% males received PRBCs during their entire hospital stay. On average, females received 1.20 units of PRBCs intraoperatively and 2.38 units during the entire hospital stay, while the males received 0.31 units and 1.36 units for similar periods. Gender differences in PRBC transfusion persisted even when females and males were compared within the same subgroups for age, weight, duration of surgery, and preoperative Hct. PRBC units given intraoperatively had a significant correlation with age and preoperative Hct in females, but they had a significant correlation with age, preoperative Hct, and duration of surgery in males. PRBCs given during the entire hospital stay, however, had significant correlation with age, preoperative Hct, and duration of surgery in both females and males. Multiple logistic regression analysis showed that the probability of a patient receiving or not receiving PRBC transfusion is significantly influenced by age, preoperative PRBC mass, duration of surgery, and gender. CONCLUSION: Gender is an independent essential determinant of blood transfusion in CABG patients, and it may interact with age, weight, preoperative Hct, duration of surgery, and other factors in determining the probability of transfusion.     

Red blood cell transfusions in patients undergoing lower extremity artery bypass surgery.

BACKGROUND AND AIMS: The purpose of this study was to search predictors of red blood cell transfusions in peripheral vascular surgical patients. MATERIAL AND METHODS: All the patients who undergone infrainguinal bypass surgery at Helsinki University Hospital in the year 2000 were included. Of 266 records 261 (98%) were available for data review. Multiple stepwise regression model was created to identify independent predictors of blood use. RESULTS AND CONCLUSIONS: 174 (67%) of the patients received red blood cell transfusion. The lowest measured mean (SD) haemoglobin was 94 (11) g/l intraoperatively and 92 (+/- 10) g/l on the first two postoperative days. The median (range) number of units was 3 (1-19). Multivariate analysis showed that high age (p = 0.019), small body surface area (p = 0.017), low preoperative haemoglobin (p < 0.001), blood loss (p < 0.001), long lasting surgery (p<0.001), reoperation (p=0.018), femoro-distal reconstruction (p=0.048) and chronic obstructive pulmonary disease (p = 0.023) increased the risk to receive red blood cell transfusion. The frequent use of antithrombotic medication (72% of the patients) did not significantly increase red blood cell administration. The generous use of red blood cells despite relative safe haemoglobin levels indicates a need for a standardized multidisciplinary transfusion strategy in this patient population. Otherwise, most of the predictors for red blood cell administration were nonmodifiable.     

Elective coronary artery bypass surgery without homologous blood transfusion. Early results with an inexpensive blood conservation program

Restriction of donor blood transfusions in cardiac surgery should reduce risks of infective contamination and antigenicity. We report a systemic, simple and inexpensive blood conservation program used for 121 consecutive patients who underwent elective coronary artery bypass surgery without need for homologous blood transfusion. The left internal mammary artery was grafted in all cases, in addition to saphenous vein grafts. Autologous, heparinized blood was removed intraoperatively, pre-bypass, and returned to the patient at conclusion of the extracorporeal circulation. The volume remaining in the oxygenator and the tubing set was returned without cell processing or hemofiltration. Using the hard-shell cardiotomy reservoir from the heart-lung machine, autotransfusion of the shed mediastinal blood was continued hourly up to 18 hours after surgery. The mean postoperative mediastinal bleeding was 551 +/- 206 ml, of which 505 +/- 218 ml was autotransfused. No re-exploration for bleeding was required and no homologous red-cell transfusions were given. Five patients each received 1-2 units of fresh frozen plasma because of prolonged bleeding time. Morbidity was low and mortality nil. At discharge the mean hemoglobin was 12.0 +/- 1.4 g/dl and the hematocrit 36.0 +/- 4.2%.     

Identification of risk factors for allogenic transfusion in cardiac surgery from an observational study

OBJECTIVE: To determine perioperative variables for predicting allogenic transfusion in adult cardiac surgery. STUDY DESIGN: Prospective study. PATIENTS: We included 335 consecutive patients undergoing cardiac surgery between February and April 2001. METHODS: Perioperative variables were prospectively collected in a database. For each patient who received transfusion, hemoglobin threshold for transfusion and total number of units of red cell concentrates were collected. Univariate and multivariate analysis were performed. RESULTS: The two strategies for blood conservation which were predominantly used were aprotinin therapy (78%) and blood salvage from the extracorporeal circuit (68%). During perioperative period, 42% of patients [95% CI: 37-47%] received allogenic transfusion. The haemoglobin threshold for transfusion was 7.4 +/- 1.1 and 8.0 +/- 0.7 g x dl(-1) in operating room and in intensive care unit, respectively. On average, 3.4 +/- 2.7 units of red cell concentrates were transfused perioperatively per patient. Using multivariate analysis, perioperative allogenic transfusion was significantly associated with the following variables: preoperative haemoglobin level < 12 g x dl(-1) (odds ratio 8.9; p = 0.001), emergency procedure (odds = 3.7, p = 0.01), reoperation (odds ratio = 3.3; p = 0.002), chronic obstructive pulmonary disease (odds ratio = 2.5; p = 0.03) and complex surgery (odds ratio = 2.4; p = 0.01). The age, the gender, and body mass index were only independent risk factors by univariate analysis. CONCLUSION: In despite of techniques to limit requirement of allogenic transfusion, a large proportion of cardiac surgical patients remains transfused. Independent risk factors of perioperative transfusion are haemoglobin level < 12 g x dl(-1), emergency procedure, reoperation, chronic obstructive pulmonary disease and complex surgery.     

Blood transfusion during aneurysm surgery

INTRODUCTION: Increasing costs and concerns about blood supply safety have led to a reevaluation of blood transfusion practices. This study was undertaken to examine blood use during aneurysm surgery. METHODS: We performed a retrospective analysis of hospital records including operative, anesthetic, and nursing notes, computed tomographic scans, and four-vessel angiographic films of 547 patients undergoing surgery for ruptured and unruptured cerebral aneurysms at Harborview Medical Center in Seattle. During the review period, the transfusion threshold was not altered. RESULTS: A total of 134 patients (24.5%) received an intraoperative blood transfusion (median number of units, 2; range, 1-17). Preoperative factors associated with intraoperative blood use included older patient age (P < 0.001), lower hematocrit level on admission (P = 0.007), ruptured rather than unruptured aneurysm (P = 0.004), severe intraventricular hemorrhage (P = 0.03), and larger aneurysm size (P = 0.004). Factors not associated with intraoperative blood transfusion included past medical history (including cardiac or pulmonary disease), admission clinical grade after aneurysm rupture, findings such as hydrocephalus on computed tomographic scanning, and aneurysm location and aneurysm neck-to-fundus ratio. Also associated with blood transfusion during surgery were intraoperative aneurysm rupture (P < 0.0001), intracerebral hematoma evacuation (P = 0.02), and obliteration of multiple aneurysms (P = 0.002). Among patients who received an intraoperative transfusion, those who experienced an aneurysm rupture required an average of 3.6 +/- 0.35 units, whereas patients who did not have a rupture required 1.9 +/- 0.12 units (P = 0.001). Postoperatively, a total of 244 patients (44.6%), including 77 who received blood intraoperatively, required a blood transfusion (median number of units, 2; range, 1-31). Postoperative blood transfusion was associated with the treatment of patients with subarachnoid hemorrhage (P < 0.0001), particularly among poor-grade patients who developed medical complications. CONCLUSION: Blood transfusion can be expected in one in five patients undergoing aneurysm surgery. Reducing intraoperative rupture may reduce the need for blood products.     

Aprotinin reduces blood loss in off-pump coronary artery bypass (OPCAB) surgery.

OBJECTIVE: Effects of aprotinin in off-pump coronary artery bypass (OPCAB) surgery have not yet been described. This study analyses hemostasiologic changes and potential benefit in OPCAB patients treated with aprotinin. METHODS: In a prospective, double-blind, randomized study 47 patients undergoing OPCAB surgery were investigated. Patients received either aprotinin (2 x 10(6) KIU loading dose and 0.5 x 10(6) KIU/h during surgery, n=22) or saline solution (control, n=25). Activated clotting time was adjusted to a target of 250 s intraoperatively. Blood samples were taken up to 18h postoperatively: complete hematologic and hemostasiologic parameters including fibrinopeptide A (FPA) and D-dimer in a subgroup of 31 patients were analyzed. Blood loss, blood transfusion and other clinical data were collected. RESULTS: Both groups showed comparable demographic and intraoperative variables. Forty-one (87%) patients of the whole study group received aspirin within 7 days prior to surgery. Number of grafts per patient were comparable (2.9+/-1.0 [mean+/-SD] in the aprotinin group and 2.8+/-1.2 in control, P=0.83). Blood loss during the first 18 h in intensive care unit was significantly reduced in patients treated with aprotinin (median [25th-75th percentiles]: 500 [395-755] ml vs. 930 [800-1170] ml, P<0.001). Postoperatively only two patients (10%) in the aprotinin group received packed red blood cells, whereas eight (35%) in the control group (P=0.07). Perioperatively FPA levels reflecting thrombin generation were elevated in both groups. The increase in D-dimer levels after surgery was significantly inhibited in the aprotinin group (P<0.001). Early clinical outcome was similar in both groups. CONCLUSIONS: Aprotinin significantly reduces blood loss in patients undergoing OPCAB surgery. Inhibition of enhanced fibrinolysis can be observed. FPA generation during and after OPCAB surgery seems not to be influenced by aprotinin.     

Coronary artery bypass grafting surgery without the routine application of blood products: Is it feasible?

OBJECTIVE: Fresh frozen plasma (FFP) substitution is currently standard practise in cardiac surgery. In this study we investigate whether elective coronary artery bypass grafting (CABG) surgery is feasible without the administration of blood products compared to the substitution of fresh frozen plasma. PATIENTS AND METHODS: From September 1997 to April 1998, 120 consecutive patients underwent CABG surgery at our institution. In the FFP group patients (n=60; men, n=43; women, n=17; mean age: 64+/-8.5 years) received 4 units of fresh frozen plasma (FFP) intraoperatively. In comparison, patients in the control group (n=60; men, n=44; women, n=16; mean age: 65+/-7.5 years) did not receive FFP. Main endpoints included perioperative hematologic parameters, blood loss, and the amount of blood products that were administered. RESULTS: Intraoperatively, the substitution of packed red blood cells (pRBC) in the FFP group was significantly higher compared with the control group (0.63+/-0.94 units/patient vs. 0.12+/-0.38 units/patient, P=0.001). Postoperatively, patients in the FFP group required significantly more pRBC products than patients in the control group (0.78+/-1.09 vs. 0.42+/-0.77, P=0.024). There were no significant differences in hemoglobin (FFP group: 99+/-11.1 g/dl; control group: 105+/-13.5 g/dl) and hematocrit levels (FFP group: 30+/-3.39%; control group: 32+/-4%). Also, no significant differences regarding the postoperative blood loss was observed between groups (FFP group: 588+/-224 vs. control group: 576+/-272 ml/24 h). CONCLUSIONS: This study clearly demonstrates that the avoidance of routine intraoperative FFP administration does not lead to an increase in blood loss postoperatively compared to patients that received FFPs. Furthermore, we did not observe increased requirements for postoperative FFP infusion in patients that did not receive FFPs intraoperatively.     

Surgical management of multi-organ visceral tumors in patients with von Hippel-Lindau disease: a single stage approach

PURPOSE: We assessed surgical feasibility of a 1-stage multi-organ approach for multiple visceral tumors in patients with von Hippel-Lindau disease. MATERIALS AND METHODS: A total of 14 men and 15 women with von Hippel-Lindau disease underwent simultaneous multi-organ surgery for multiple adrenal, renal and pancreatic tumors at the National Cancer Institute between 1988 and 2001. Perioperative and followup data were analyzed retrospectively. The Mann-Whitney U test was used for statistical analysis. RESULTS: Surgery involving 2 or more organs (mean 2.4 procedures per patient, range 2 to 4) was performed in all patients and concurrent pancreatic operations were performed in 12 (41%). Overall a combined 71 procedures, were performed including 4 cases (13%) treated laparoscopically. Mean +/- SD operative time and estimated blood loss were 464 +/- 142 minutes (range 206 to 830) and 2,798 +/- 4,285 cc (300 to 20,000), respectively. In 16 patients (55%) blood transfusion was administered intraoperatively. At a median followup of 21 months (range 5 to 151) renal tumors recurred in 8 patients (28%), requiring further kidney operations, but no patient had pancreatic or adrenal recurrence. The overall complication rate was 38%, and there was no operative mortality. CONCLUSIONS: A single stage surgical approach for multi-organ visceral tumors is a viable option for patients with von Hippel-Lindau disease. With careful patient selection and surgical planning combined procedures can be safely performed in 1 operative setting.     

Craniosynostosis: an assessment of blood loss and transfusion practices

Assessment and accurate replacement of blood loss during primary craniosynostosis repair is difficult due to patient size and surgical technique. Eighty-five charts of all patients undergoing primary craniosynostosis repair over a 15-year period were reviewed to determine blood loss and to assess blood transfusion practices both intraoperatively and postoperatively. Blood loss was calculated on the basis of estimated red cell mass (ERCM). Blood transfusion management was considered appropriate if the postoperative or posttransfusion ERCM was within 15 per cent of the preoperative value. Isolated sagittal craniectomy was the most common operation performed (60 per cent). Mean blood loss for sagittal craniectomies was 24 per cent of estimated blood volume (EBV) or approximately 20 ml.kg-1 and for metopic craniectomies 42 per cent of EBV (P less than 0.05). Intraoperatively, 70 per cent of all patients were appropriately managed with respect to blood transfusion. Postoperatively only 29 per cent of patients receiving transfusions were transfused appropriately. At our institution, intraoperative blood transfusion practices are appropriate, but postoperative transfusions are frequently unnecessary.     

Anemia and blood transfusion in trauma patients admitted to the intensive care unit

BACKGROUND: Anemia is a common occurrence in the intensive care unit (ICU). Although resuscitation, including the use of blood, is a mainstay of early treatment of trauma victims, the safety and efficacy of red blood cell (RBC) transfusion has come under scrutiny recently. The issue of blood use in critically injured patients requires evaluation. METHODS: This was a post hoc analysis of a subset of trauma patients (> or =18 years in age) from a prospective, multicenter, observational, cohort study in the United States. Patients were enrolled within 48 hours after ICU admission and followed for up to 30 days, or until hospital discharge or death. RESULTS: Five hundred seventy-six patients from 111 ICUs in 100 hospitals were enrolled between August 2000 and April 2001. At baseline, mean age was 44.1 +/- 20.2 years, 73.6% were men, and mean APACHE II score was 16.9 +/- 8.2. Mean baseline hemoglobin was 11.1 +/- 2.4 g/dL and patients remained anemic throughout the study either with or without transfusion; 55.4% of patients were transfused (mean, 5.8 +/- 5.5 units) during the ICU stay and 43.8% of patients had an ICU length of stay > or = 7 days. Mean pretransfusion hemoglobin was 8.9 +/- 1.8 g/dL. Mean age of RBCs transfused was 20.1 +/- 11.4 days. As compared with the full study population, patients in the trauma subset were more likely to be transfused and received an average of 1 additional unit of blood. CONCLUSION: Anemia is common in critically injured trauma patients and persists throughout the duration of critical illness. These patients receive a large number of RBC transfusions during their ICU course with aged blood.     

Preoperative blood test results and type of fracture as transfusional risk factors in patients older than 65 years with trochanteric hip fracture

OBJECTIVE: To determine the effect of risk factors for allogenic blood transfusion in surgery for trochanteric hip fractures. PATIENTS AND METHODS: A retrospective study of all the trochanteric hip fracture patients older than 65 years who underwent surgery to repair trochanteric hip fracture related to osteoporosis in 2000 and 2001 in a regional hospital. Data recorded were age; gender; type of fracture (international AO classification); level of anesthetic risk (ASA classification); hemoglobin concentration and hematocrit upon admission, on the day of surgery and 2 days later; time elapsing between admission and surgery; blood transfusion and blood product use. RESULTS: One hundred two patients (29 men and 73 women) with trochanteric hip fractures were studied. Mean (+/- SD) patient age was 82.9 +/- 8.8 years (range, 65-99 years). Upon admission, mean hemoglobin was 123 +/- 18.1 g/L (range, 56-154 g/L), hematocrit was 37% +/- 5% (range, 10%-40%). Time elapsing until surgery was 3.5 +/- 1.6 days (range, 0-8 days). Admission hemoglobin concentration was lower in patients who required transfusion (116 g/L) than in patients who did not (133 g/L) (P < 0.001). Logistical regression analysis identified only AO classification of fracture type (P < 0.05) and admission hemoglobin concentration (P < 0.001) as independent risk factors for transfusion. CONCLUSIONS: The hemoglobin level at admission and the trochanteric fracture type bear a relation to transfusion needs. These results suggest that in elderly patients we should improve hemoglobin levels and initiate blood salvage measures in order to reduce the need for allogenic blood transfusion, with its inherent risks.     

Polymerized bovine hemoglobin solution as a replacement for allogeneic red blood cell transfusion after cardiac surgery: results of a randomized,double-blind trial

BACKGROUND: Blood loss leading to reduced oxygen-carrying capacity is usually treated with red blood cell transfusions. This study examined the hypothesis that a hemoglobin-based oxygen-carrying solution can serve as an initial alternative to red blood cell transfusion. METHODS: In a randomized, double-blind efficacy trial of HBOC-201, a total of 98 patients undergoing cardiac surgery and requiring transfusion were randomly assigned to receive either red blood cell units or HBOC-201 (Hemopure; Biopure Corporation, Cambridge, Mass) for the first three postoperative transfusions. Patients were monitored before and after transfusion, at discharge, and at 3 to 4 weeks after the operation for subsequent red blood cell use, hemodynamics, and clinical laboratory parameters. RESULTS: The use of HBOC-201 eliminated the need for red blood cell transfusions in 34% of cases (95% confidence interval 21%-49%). Patients in the HBOC group received a mean of 1.72 subsequent units of red blood cells; those who received red blood cells only received a mean of 2.19 subsequent units (P =.05). Hematocrit values were transiently lower in the HBOC group but were similar in the two groups at discharge and follow-up. Oxygen extraction was greater in the HBOC group (P =.05). Mean increases in blood pressure were greater in the HBOC group, but not significantly so. CONCLUSION: HBOC-201 may be an initial alternative to red blood cell transfusions for patients with moderate anemia after cardiac surgery. In a third of cases, HBOC-201 eliminated the need for red blood cell transfusion, although substantial doses were needed to produce this modest degree of blood conservation.     

Albumin-impregnated prosthetic graft for infrarenal aortic replacement: Effects on the incidence and volume of perioperative blood transfusion

We retrospectively reviewed 290 cases in which an albumin-impregnated polyester prosthetic graft was used for surgical management of aortic bifurcation disease between November 1987 and December 1990. The purpose of this review was to determine the incidence and volume of blood transfusion and to evaluate the rate of patency and the incidence of infection achieved using this type of prosthesis. The indication for surgery was abdominal aortic aneurysm (AAA) in 218 cases (190 elective procedures and 28 emergency procedures) and occlusive disease of the aortic bifurcation (ODAB) in 72 cases. Mean follow-up was 25.5 ± 13.4 months (range: 1 and 50 months). The incidence of blood transfusion for elective AAA and ODAB surgery was 30.2% and 32.3% intraoperatively, 21.3% and 12.9% postoperatively, and 40.4% and 42.6% overall. The mean number of red cell packs transfused for elective AAA and ODAB surgery was respectively 1 and 0.8 intraoperatively, 0.4 and 0.6 postoperatively, and 1.4 and 1 overall. No immediate or late graft infection prosthesis was observed in any patient in this series. Primary and secondary patency was 95.5% and 97.5% at 6 months with no graft thrombosis during further follow-up. The fact that use of an impregnated graft in management of aortic bifurcation disease was accompanied by a high incidence and volume of blood transfusion suggests that these grafts do not reduce perioperative blood loss. Use of an impregnated prosthesis had no effect on the rate of patency and the incidence infection. (Ann Vasc Surg 1997; 11:588-595.)     

Transfusion-associated graft-versus-host disease with transfusion practice in cardiac surgery

BACKGROUND: Transfusion-associated graft-versus-host disease (TA-GVHD) in immunocompetent patients has still been underdiagnosed and underreported. Risk of TA-GVHD caused by transfusion practice in cardiac surgery should be appropriately recognized. METHODS: The correlation of TA-GVHD with transfusion practice in cardiac surgery was analyzed from our 17-year clinical experience. We retrospectively reviewed 2,686 consecutive adult patients who underwent cardiac surgery between 1980 and 1996. Classified according to transfusion practice, 847 patients (32%) received nonirradiated fresh homologous whole blood (mean per patient, 5+/-2 units) with or without other blood components; 592 patients (22%) nonirradiated stored RBCs older than 7 days (4+/-2), and 551 patients (21%) received irradiated homologous blood including, fresh whole blood (2+/-1), RBCs (4+/-1), and PCs (8+/-3), respectively. The remaining 696 patients (25%), did not require homologous transfusion. RESULTS: Four of 847 patients who received nonirradiated fresh homologous whole blood (< or =48 hours after donation) developed TA-GVHD. TA-GVHD did not occur in other patients. CONCLUSIONS: Our local experience demonstrates the incidence of TA-GVHD in patients who received fresh homologous whole blood in cardiac surgery was much higher, compared with previous reports. This result suggests that the frequency of TA-GVHD is nearly similar to the value calculated from the proportion of HLA haplotypes in the population.     

Peri-operative administration of tranexamic acid in lower limb arthroplasty: a multicentre,prospective cohort study

In the UK, tranexamic acid is recommended for all surgical procedures where expected blood loss exceeds 500 ml. However, the optimal dose, route and timing of administration are not known. This study aimed to evaluate current practice of peri-operative tranexamic acid administration. Patients undergoing primary total hip arthroplasty, total knee arthroplasty or unicompartmental knee arthroplasty during a 2-week period were eligible for inclusion in this prospective study. The primary outcome was the proportion of patients receiving tranexamic acid in the peri-operative period. Secondary outcomes included: dose, route and timing of tranexamic acid administration; prevalence of pre- and postoperative anaemia; estimated blood loss; and red blood cell transfusion rates. In total, we recruited 1701 patients from 56 NHS hospitals. Out of these, 1523 (89.5%) patients received tranexamic acid and of those, 1052 (69.1%) received a single dose of 1000 mg intravenously either pre- or intra-operatively. Out of the 1701 patients, 571 (33.6%) and 1386 (81.5%) patients were anaemic (haemoglobin < 130 g.l⁻¹) in the pre- and postoperative period, respectively. Mean (SD) estimated blood loss for all included patients was 792 (453) ml and 54 patients (3.1%) received a red blood cell transfusion postoperatively. The transfusion rate for patients with pre-operative anaemia was 6.5%, compared with 1.5% in patients without anaemia. Current standard of care in the UK is to administer 1000 mg of tranexamic intravenously either pre- or intra-operatively. Approximately one-third of patients present for surgery with anaemia, although the overall red blood cell transfusion rate is low. These data provide useful comparators when assessing the efficacy of tranexamic acid and other patient blood management interventions in future studies.     

Efficacy of preoperative autologous blood donation: analysis of blood loss and transfusion practice in total hip replacement

STUDY OBJECTIVE: To determine the frequency of allogeneic transfusion for total hip replacement (THR) surgery and to examine the efficacy of preoperative autologous blood donation (PABD) under specified, standardized blood transfusion guidelines. DESIGN: Prospective, nonrandomized study. SETTING: University medical center. PATIENTS: All ASA physical status I, II, III, and IV patients undergoing single, primary, THR surgery from April 1998 to March 1999. INTERVENTIONS: All patients received standardized transfusion and anticoagulation therapy. Demographic, blood loss, and transfusion data were collected and compared between all patients participating in PABD (donors) and patients not participating in PABD (nondonors). Overall allogeneic blood exposure was established. Since most anemic patients could not participate in PABD, allogeneic transfusion frequency was also examined in a subset of nonanemic patients (hemoglobin > or =12 g/dL) who were potentially able to participate in PABD. MEASUREMENTS AND MAIN RESULTS: n = 231 patients, 142 donors and 89 nondonors. Mean estimated blood volume (EBV) of donors was 4991 +/- 1042 mL versus nondonors 4631 +/- 1108 mL (p < 0. 01). ASA physical status I-II/III-IV among donors was 118/24 versus nondonors 61/28 (p < 0.01). Overall allogeneic blood exposure was 22% (51/231). Allogeneic transfusion frequency for all donors was 15% (22/142) versus nondonors 33% (29/89) (p < 0.05). Among nonanemic patients, donor versus nondonor EBV and ASA physical status I-II/III-IV were 5074 +/- 1019 mL versus 4743 +/- 1172 mL and 107/20 versus 48/15 (p = NS); allogeneic transfusion frequency reduced to 13% (16/127) versus 17% (11/63) (p = NS), respectively. CONCLUSIONS: Allogeneic blood exposure was >10% despite the use of PABD. The efficacy of PABD has been obscured by the fact that donors of autologous blood tend to be larger and healthier than nondonors. After exclusion of anemic patients, autologous donors and nondonors were clinically comparable and the difference in allogeneic blood exposure was not statistically significant. PABD offers only a modest, if any, benefit for THR surgery.