自体血液回输在心脏瓣膜替换手术中的应用

目的 探讨术中血液回输技术的安全性和效果,评价其在心脏瓣膜替换手术中的应用价值.方法 本研究共选人单个心脏瓣膜替换手术32例,随机分为2组.所有患者均于全身麻醉和体外循环下行心脏瓣膜替换手术.对两组患者术中出血量.术中自体血液回输量,异体血输入量,手术前、输血前、输血后血常规和动脉血气分析结果进行观测,记录输血并发症的情况.结果 两组术中出血量差异无统计学意义;两组患者术前、输血前、术后血红蛋白（HGB）、红细胞比积（HCT）比较,差异均无统计学意义;两组血气分析的pH值、血钾、乳酸比较差异无统计学意义（P〉0.05）;而两组库血输入量差异有统计学意义（P〈0.01）.两组均未观察到有输血并发症发生.结论 在体外循环下心脏瓣膜置换术中自体血液回输可有效地减少围术期自体血的丢失,补充血容量,维持有效循环,同时明显减少异体血的用量及并发症发生,是安全、有效的,有很高的临床应用价值.     

Comparison of the hemostatic effects of fresh whole blood, stored whole blood, and components after open heart surgery in children

In a double-blind study, we compared the postoperative (post-op) blood loss in 161 children undergoing open heart surgery with cardiopulmonary bypass whose immediate post-op transfusion requirements were met with either very fresh whole blood (VFWB), 24- to 48-hour-old whole blood or reconstituted whole blood (packed red blood cells, fresh frozen plasma [FFP], and platelets). Assignment to treatment groups was not strictly random but dependent, in part, on the ability of families to provide directed donors for fresh blood. The three patient groups were comparable with respect to patient age, pre-op coagulation profiles (bleeding time, prothrombin time, activated partial thromboplastin time, platelet count, fibrin split products, fibrinogen, and platelet aggregation tests) difficulty of operative procedures and time spent on CPB. Mean 24-hour post-op blood loss in milliliters per kilogram was 50.9 +/- 9.3 in the VFWB group, 44.8 +/- 6.0 in the 24- to 48-hour-old group, and 74.2 +/- 8.9 in the reconstituted group (p = .03). When blood loss was compared in the 93 children less than 2 years of age, mean blood loss was 52.3 +/- 10.8 in the VFWB group, 51.7 +/- 7.4 in the 24- to 48-hour-old group, and 96.2 +/- 10.7 in the reconstituted group (P = .001). For subjects who had received reconstituted blood, 30-minute and 3-hour post-op platelet aggregation responses to adenosine diphosphate (10 mumol/L) and 30-minute aggregation response to epinephrine (2.5 mumol/L) were more depressed than in the VFWB and 24- to 48-hour groups (P less than .001, P = .005, and P = .02). Comparison of other post-op coagulation tests could not explain the increased blood loss in the reconstituted group. We conclude that the transfusion of less than 48 hours old whole blood is associated with significantly less post-op blood loss than the transfusion of packed red blood cells, FFP, and platelets in children under 2 years old who underwent complex cardiac surgery. The blood losses associated with the transfusion of VFWB and 24- to 48-hour-old blood are comparable and may be, in part, due to better functioning platelets.     

Predictors of homologous blood transfusion for patients undergoing open heart surgery

OBJECTIVE: It has become very important to avoid homologous blood transfusions in today's cardiac surgery. We performed a retrospective analysis to find out preoperative factors to predict the risk for transfusion of red-cell concentrate in cardiac surgery. METHODS: This study included 400 consecutive patients undergoing coronary artery bypass grafting. We also included emergency (4 %) and re-operations (8 %). We tried to find out predictive factors for the need of transfusion of red-cell concentrate on the base of logistic regression coefficient and the odds ratio. We looked at the following factors as predictors of transfusion risk: left ventricular ejection fraction < 0.35, age over 70 years, preoperative hemoglobin < 11 g/dl, insulin-dependent diabetes (IDDM), emergency operation, female sex, impaired renal function (creatinine > 1.6 mg/dl), and re-operation. RESULTS: In our group, 132 (33 %) patients received transfusion during hospitalization, while 268 (67 %) did not. On average, 2.2 +/- 0.68 units of red-cell concentrate were transfused per patient. In addition, we found a predictive value for transfusion for the following parameters: age > 70 years, preoperative hemoglobin < 11 g/dl, re-operation and ejection fraction < 0.35. We could not find any significantly increased blood transfusion risk in female cases, insulin dependent diabetes mellitus, or impaired renal function. CONCLUSIONS: We could show that there is normally no need for blood transfusion in (2/3) of the patients in cardiac surgery according to this study's results. Furthermore, it was obvious that some patient variables can be used predict the risk for perioperative transfusion. Based on these results, the prophylactic administration of aprotinin or the use of a cell saver could be useful in selected patients.     

Humoral immune response to autologous blood transfusion in hip surgery: whole blood versus packed red cells and plasma.

BACKGROUND AND OBJECTIVES: The immune response to the transfused autologous buffy coat content in whole blood has, to date, not been studied in detail. SUBJECTS AND METHODS: Patients undergoing hip arthroplasty were studied according to whether they received autologous whole blood (WB) (n = 30), autologous fresh-frozen plasma and buffy coat-poor red cells (RC) (n = 40), or no transfusion (NT) (n = 27). Plasma levels of tumour necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6) and complement SC5b-9 were analysed by enzyme-linked immunosorbent assay (ELISA) 7 days after surgery. RESULTS: There were no significant between-group differences regarding the time course of TNF-alpha, IL-6 and complement SC5b-9 plasma level changes, the infection rate, or the length of hospital stay. CONCLUSION: In comparison to the impact of surgery on cytokine and complement levels, the transfusion of autologous buffy coat is not relevant.     

The effects of mild normovolemic hemodilution on regional flow, oxygenation, and small vessel blood content in the rabbit heart subjected to acute coronary occlusion.

The effect of mild hemodilution (hematocrit, 19%) on ischemic and nonischemic regions of myocardium during acute coronary occlusion was studied in 41 pentobarbital-anesthetized, open-chest New Zealand white rabbits. Blood flow in the control area determined with radioactive microspheres was unaffected by occlusion and increased 61.8% following hemodilution. The endo/epi ratio remained at about 1.0. Occlusion decreased flow in the affected region to 41% of the control myocardium, and endo/epi ratio decreased significantly to 0.76. Hemodilution raised flow in this area 84.3%. Occlusion increased small vessel blood content (a measure of open capillary density) in the ischemic region significantly. Hemodilution further significantly increased this volume in the occluded area, although the increase in the control region was not significant. Relative tissue pO2, measured polarographically, declined significantly following occlusion in the affected area. Isovolemic hemodilution did not affect relative O2 tension in either area. The data indicate that during mild hemodilution, the O2 supply-demand status of both the occluded and nonoccluded myocardial regions is maintained.     

Advantage of autologous blood transfusion in surgery for hepatocellular carcinoma

AIM: To evaluate the significance of autologous blood transfusion (AT) in reducing homologous blood transfusion (HT) in surgery for hepatocellular carcinoma (HCC). METHODS: The proportion of patients who received HT was compared between two groups determined by the time of AT introduction; period A (1991-1994, n = 93) and period B (1995-2000, n = 201). Multivariate logistic regression analysis was performed in order to identify independent significant predictors of the need for HT. We also investigated the ...     

贮存式自体输血在肝癌择期手术中的应用

［摘要］　目的　探讨贮存式自体输血在肝癌择期手术中应用的可行性。方法　34例肝癌择期手术的患者采用自体血贮存备血,对采血前后Hb、BP变化结果进行分析。结果　最大采血量1 200 ml,平均726 ml,采血前后Hb变化差异有统计学意义（P<0.05）,但仍在正常范围内,采血前后BP变化差异无统计学意义（P>0.05）,均能按预期手术治疗,无围手术期肝性脑病。结论　贮存式自体输血简单、安全,值得在肝癌手术患者中推广应用。     

Determinants of costs and resource utilization associated with open heart surgery.

AIMS: This study sought to determine the patient- and the therapy-related determinants of in-hospital costs for patients undergoing heart surgery at the University Hospital in Zurich. METHODS AND RESULTS: We performed a retrospective analysis of all adult cardiac surgical patients from the canton St. Gallen who were covered by a fixed fee arrangement (29,500 Swiss francs (19,470 Euro)) and referred to our institution during 1998. A total of 201 patients (143 (71%) male) with basic insurance were hospitalized in 1998 under the fixed fee arrangement. The mean age of the patients was 61.4 years (95% confidence intervals (CI): 60; 63). With the help of univariate analysis, the following pre-operative characteristics were found to be significantly associated with cost: age (P<0.001), pre-operative cardiac diagnosis (coronary vs valvular heart disease) (P<0.001) and EuroSCORE (P<0.0001). A significant correlation was also found between intra-operative variables and costs (P<0.0001) as well as between postoperative variables and costs (P<0.0001). A linear regression model based on EuroSCORE, operation time and postoperative infection status is able to predict costs for patients (all P -values <0.0001, except for P<0.05 for operation time, R(2)=0.565). CONCLUSIONS: These results suggest that both pre-operative (patient related) and intra-operative (therapy- and patient-related) variables are predictors of costs in cardiac surgical patients.     

The safety and efficacy of hypovolemic phlebotomy on blood loss and transfusion in liver surgery: a systematic review and meta-analysis

BackgroundHypovolemic phlebotomy (HP) is a novel intervention that involves intraoperative removal of whole blood (7–10 mL/kg) without volume replacement. The subsequent central venous pressure (CVP) reduction is hypothesized to decrease blood loss and the need for blood transfusion. The objective was to conduct a systematic assessment of the safety and efficacy of HP on blood loss and transfusion in the liver surgery literature.MethodsMEDLINE, EMBASE, and Cochrane Library databases were searched. Outcomes of interest included blood loss, allogenic red blood cell transfusion, postoperative adverse events, and CVP change. A qualitative synthesis and meta-analysis were performed as appropriate.ResultsFour cohort studies, one case series, and three randomized controlled trials involving 2255 patients were included. Meta-analysis of studies involving liver resections for any indication (n = 6) found no difference in transfusion (OR 0.38, p = 0.12) or incidence of adverse events with HP compared to non-use. Pooling of studies involving liver resections for an underlying pathology (n = 4) revealed HP was associated with significant reduction in transfusion (OR 0.25, p = 0.03) but no differences in blood loss (−173 mL, p = 0.17).ConclusionThis review suggests HP is safe and associated with decreased transfusion in patients undergoing liver surgery. It supports further investigation.     

Effect of erythropoietin therapy in cardiac surgery using autologous blood transfusion

Autologous blood transfusion in cardiac surgery is currently widely practiced to avoid homologous blood transfusion. To assess the benefit of recombinant human erythropoietin (rhEPO), the authors studied 72 patients (53 men, 19 women) who underwent elective cardiac surgery over a 15-month period and agreed to this protocol. Of these, 47 had coronary artery bypass grafting, 19 had valve replacement, and 6 had other procedures. Each patient was scheduled to preserve more than 800 mL of autologous blood preoperatively. They received rhEPO (100 to 40 U/kg) IV 3 times weekly during a 2 to 3-week preoperative period. During surgery, an autotransfusion system was also applied. During the preoperative period, 49 patients (68.1%) increased their hemoglobin by more than 1.0 g/dL, and 66 patients (91.7%) had their operation without homologous blood transfusion. This is a significantly high incidence compared with the group who had neither preoperative preservation nor rhEPO (55 of 109 patients; 50.5%). The authors conclude that rhEPO is effective in preserving autologous blood safely before elective surgery, and most elective cardiac surgery can be done without homologous blood transfusion by preoperatively preserving autologous blood with the aid of rhEPO and employing intraoperative autotransfusion.     

Preliminary reports of autologous blood transfusion in a plastic surgery unit

We commenced autologous blood transfusion at the plastic surgery unit of the National Orthopaedic Hospital, Enugu, Nigeria in January 2001. Forty-three patients who have so far had autologous blood transfusion up to June 2004 are reviewed. Autologous blood was found to be cheaper than homologous blood with no untoward reactions. We conclude that autologous blood is safe, cheap and should be considered in elective surgical cases.     

The organ effects of systemic inflammation response activated during open heart surgery and current treatment methods]

Multi-organ failure may occur due to activation of systemic inflammatory process with many other factors in open-heart procedures when cardiopulmonary bypass is used. Activation of systemic inflammatory process may cause postoperative complications. Surgical trauma, contact of blood with foreign surface, endotoxemia and ischemia-reperfusion injury are major factors that contribute to activation of inflammatory response. In this review we purposed to investigate the factors which contribute to the systemic inflammatory process, multiorgan dysfunction and the therapeutic modalities during open heart surgery.     

Effectiveness of preoperatively obtained autologous platelet concentrates in open heart surgery

BACKGROUND: Autologous blood components have been widely introduced in open heart surgery. However, the effectiveness of autologous platelet products remains controversial. METHODS: Autologous platelet concentrates (PC) were collected from patients (n = 35) scheduled for primary valvular heart surgery 1 to 3 days before the operation and were transfused immediately after cardiopulmonary bypass. Blood loss and platelet-related factors were compared with the control patients who had no PC (n=35). RESULTS: There were no serious complications in harvesting, preservation, and transfusion of autologous PC. The maximal platelet aggregation response significantly improved after its transfusion and tended to be higher with autologous PC stored 1 day than with ones stored 2-3 days. Activation of coagulation and fibrinolytic factors did not significantly differ between the groups. Postoperative blood loss was significantly less in autologous PC group, and seemed to have a negative correlation with platelet aggregation response. CONCLUSIONS: Autologous PC can be safely prepared and are clinically effective in reduction of postoperative blood loss in open heart surgery.     

Reduction of blood transfusion requirement in open heart surgery by administration of high doses of aprotinin--preliminary results

Reduction of homologous blood requirement in cardiac surgery is of increasing interest and may be achieved by various technical and pharmacological means. High-dose aprotinin (about 840 mg, equivalent to 6 million Kallikrein inactivator units), a serine proteinase inhibitor, was administered during open heart surgery to 60 patients refusing homologous blood transfusions or suspected to have an increased risk of bleeding. As a significant decrease in donor blood requirement could be observed, a prospective, randomised double blind study in 80 male patients undergoing primary coronary surgery with high-dose aprotinin administration was performed. Mean blood loss was reduced by 45.9% (652 ml in the treated vs 1204 ml in the untreated group, p less than 0.01) and the mean amount transfused was decreased by 74.2% (242 ml vs 937 ml, p less than 0.01). No homologous blood was needed in 57.9% of the aprotinin-treated patients and in 31.6% of patients not treated with aprotinin.     

Comparison of results of autologous versus homologous blood transfusion in open-heart surgery

Background

The aim of this study was to determine a method to decrease the use of homologous blood during openheart surgery using a simple blood-conservation protocol. We removed autologous blood from the patient before bypass and used isovolumetric substitution. We present the results of this protocol on morbidity and mortality of surgery patients from two distinct time periods.

Methods

Patients from the two surgical phases were enrolled in this retrospective study in order to compare the outcomes using autologous or homologous blood in open-heart surgery. A total of 323 patients were included in the study. The autologous transfusion group (group 1) comprised 163 patients and the homologous transfusion group (group 2) 160 patients. In group 1, autologous bloods were prepared via a central venous catheter that was inserted into the right internal jugular vein in all patients, using the isovolumetric replacement technique. The primary outcome was postoperative in-hospital mortality and mortality at 30 days. Secondary outcomes included the length of stay in hospital and in intensive care unit (ICU), time for extubation, re-intubations, pulmonary infections, pneumothorax, pleural effusions, atrial fibrillation, other arrhythmias, renal disease, allergic reactions, mediastinitis and sternal dehiscence, need for inotropic support, and low cardiac-output syndrome (LCOS).

Results

The mean ages of patients in groups 1 and 2 were 64.2 ± 10.3 and 61.5 ± 11.6 years, respectively. Thirty-eight of the patients in group 1 and 30 in group 2 were female. There was no in-hospital or 30-day mortality in either group. The mean extubation time, and ICU and hospital stays were significantly shorter in group 1. Furthermore, postoperative drainage amounts were less in group 1. There were significantly fewer patients with postoperative pulmonary complications, pneumonia, atrial fibrillation and renal disease. The number of patients who needed postoperative inotropic support and those with low cardiac output was also significantly less in group 1.

Conclusion

Autologous blood transfusion is a safe and effective method in carefully selected patients undergoing cardiac surgery. It not only prevents transfusion-related co-morbidities and complications but also enables early extubation time and shorter ICU and hospital stay. Furthermore, it reduces the cost of surgery.     

Comparative effects of red blood cell transfusion and increasing blood flow on tissue oxygenation in oxygen supply-dependent conditions

Red blood cell (RBC) transfusion is usually administered to improve oxygen delivery (DO(2)) in order to sustain tissue oxygen demand. However, this practice is not supported by firm clinical or experimental data. Using a randomized two-period crossover design, this study compared the efficacy of "fresh" RBC transfusion and increased blood flow to restore tissue oxygenation in oxygen supply-dependent conditions. In 12 ketamine-anesthetized mongrel dogs submitted to nonpulsatile normothermic cardiopulmonary bypass, DO(2) was reduced by a progressive decrease in pump flow. DO(2) dependency was defined as an O(2) uptake (V O(2)) decrease by more than 15% from baseline value. Then, intervention consisted of a 40% increase in DO(2) obtained either by transfusion of "fresh" dog's RBC (stored < 3 d) or by increase in pump flow. Animals received both interventions sequentially in a random order, while O(2) saturation was maintained constant. In O(2) supply-dependent conditions, rising pump flow from 1.6 +/- 0.4 to 2.7 +/- 0.7 L/ min increased DO(2) from 5.4 +/- 1.1 to 9.0 +/- 1.3 ml/kg/min (p < 0.01) and V O(2) from 3.5 +/- 0.4 to 4.1 +/- 0.5 ml/kg/min (p = 0.02). "Fresh" RBC transfusion, which increased the hemoglobin concentration from 6.4 +/- 0.9 to 11.1 +/- 1.3 g/dl, increased DO(2) from 5.4 +/- 1.2 to 9.0 +/- 1.4 ml/kg/min (p < 0.01) and V O(2) from 3.6 +/- 0.4 to 4.1 +/- 0.5 ml/kg/min (p = 0.02). There was no difference in V O(2) resulting from both interventions. In oxygen supply-dependent conditions, "fresh" RBC transfusion and increased blood flow are equally effective in restoring tissue oxygenation.     

自体血小板分离与急性等容性血液稀释对体外循环下心脏手术血液保护效果的对比研究

目的:对比自体血小板分离技术(APP)与急性等容性血液稀释(ANH)技术对体外循环下心脏外科手术患者的血液保护作用.方法:选取择期预计体外循环时间＜2h的心脏手术患者90例,随机分为两组,每组45例.APP组在麻醉诱导后采集自体血进行血液分离,分离后的红细胞和贫血小板血浆按需回输,富血小板血浆于体外循环结束、鱼精蛋白中...