Blood conservation techniques and platelet function in cardiac surgery.

Postoperative alterations in platelet function induced by cardiopulmonary bypass (CPB) are of importance. The effect on platelet aggregation of three different techniques for reducing blood consumption was studied in 30 patients undergoing elective aortocoronary bypass grafting from the beginning of anesthesia until the 1st postoperative day. The patients were randomly divided into three groups, in which 1) a cell separator was used during and after CPB; 2) a hemofiltration device was used; and 3) high-dose aprotinin was used in order to reduce the need of homologous blood. A fourth group undergoing neurosurgery procedures served as a control. Platelet aggregation induced by adenosine diphosphate (concentration 0.25, 0.50, 1.0, and 2.0 microM), collagen (4 microliters/ml), and epinephrine (25 microM) was determined by the turbidimetric method. Platelet aggregation was not significantly changed in the control group, indicating that the operation itself did not impair platelet function. At the end of the operation (after retransfusion of the salvaged pump blood), the maximum aggregation and maximum gradient of aggregation induced by all three inductors were most reduced (significantly) in the cell-separator patients. On the 1st postoperative day, platelet aggregation in the hemofiltration patients and the patients treated with aprotinin had normalized. Aggregation of patients pretreated with high-dose aprotinin was not different from that of the hemofiltration patients throughout the investigation. Blood loss was significantly highest in the cell-separator group (770 +/- 400 ml on the 1st postoperative day) but was not different between the hemofiltration (390 +/- 230 ml) and the aprotinin-treated patients (260 +/- 160 ml).(ABSTRACT TRUNCATED AT 250 WORDS)     

Blood conservation in surgery: current concepts and practice

Blood conservation is based on the principle of avoiding allogeneic blood transfusion with the aim of improving outcome and protecting patients' rights. Surgical patients receive a significant proportion of the allogeneic blood transfused in the hospital. Blood conservation in surgery greatly reduces overall allogeneic blood use, thereby reducing costs, hazards, and adverse outcomes. Blood conservation techniques aim to lower the "transfusion trigger," optimize the hematocrit, minimize blood loss, and optimize tissue oxygenation. Successful blood conservation involves a combination of techniques tailored to the individual patient. It requires planning and a multidisciplinary team approach but usually little technology. Bloodless medicine and surgery programs represent the gold standard in blood conservation. Blood conservation is evidence based, and it results in faster recovery, lower morbidity, lower mortality, shorter hospital stay, lower cost, and better patient (and physician) satisfaction while avoiding the hazards of allogeneic blood transfusion. Blood conservation is thus the current standard of care.     

Blood conservation in cardiac surgery

Blood tranfusion practice varies between institutions. It has been suggested that many blood transfusions are inappropriate. Blood transfusion can be life-saving but can also be hazardous and new techniques to improve its safety have markedly increased the cost of a unit of blood. As the safest transfusion is to use the patient's own blood simply to establish more rigorous transfusion guidelines, particularly with respect to the conservation of red cells, can only be to the advantage of all.     

Blood conservation in cardiac surgery

We reviewed current blood conservation techniques and their use in cardiac surgery. Avoidance of aspirin preoperatively is an important blood conservation measure. Patients scheduled for an elective operation should participate in autologous predonation programs. With careful monitoring, patients with major coronary artery disease can safely donate blood preoperatively. Intraoperative processing of blood withdrawn before cardiopulmonary bypass provides autologous platelet-rich plasma for infusion after reversal of heparin sodium. Blood collected from the field during operation and blood remaining in the oxygenator after bypass can also be processed to yield washed and concentrated red blood cells for reinfusion. Randomized, prospective studies document that postoperative autotransfusion is both safe and effective in reducing homologous blood use. Aprotinin reduces plasma protein activation and platelet damage during bypass. The integration of available blood conservation techniques into a comprehensive program combined with careful consideration of the indications for transfusion may allow more patients to avoid transfusion entirely.     

Blood conservation in elective surgery

Blood conservation for elective surgery involves both the reduction of blood loss and the reduction of homologous blood transfusion. Methods of reducing blood loss such as the use of tourniquets, vasoconstrictor drugs, regional anaesthetic supplements and hypotensive anaesthesia are considered briefly. Preoperative and intraoperative techniques of autotransfusion and haemodilution are considered in detail, including a technique of scavenging and reinfusing blood aspirated from the surgical site.     

Blood loss minimization and blood salvage techniques for complex spinal surgery

Several techniques to limit blood loss and salvage lost blood are available to surgeons, physicians, and personnel who treat complex spinal disorders. These techniques include red blood cell augmentation, intraoperative antifibrinolytic administration, use of topical hemostatic agents, and intraoperative blood salvage and postoperative blood salvage. A substantial amount of research has been directed toward reducing perioperative blood loss in spinal surgery. More efforts need to be directed toward effective perioperative blood management in complex spinal surgery.     

Blood conservation in major orthopedic surgery

During an eight-year period, intraoperative autotransfusion was performed in 1922 operations. There were 476 primary hip arthroplasties, 1017 revision hip arthroplasties, 339 spinal procedures, and 90 vascular cases. There were no known complications related to autotransfusion in any of the cases. With proper technique, red cell salvage is approximately 58% effective, and intraoperative blood loss can be reduced by that amount. The first four years' experience with the preoperative autogeneic blood program is as follows. Using a combined program of predonation and primary hip arthroplasty, 72% of the revision hip arthroplasties and 81% of the spinal instrumentations required only autologous blood. A combined program of autologous donation and intraoperative autotransfusion is an excellent alternative to allogeneic blood replacement and a means of eliminating transfusion-related disease.     

Blood conservation in patients undergoing non-cardiac surgery

Concerns about the safety, inventory, and cost of allogeneic blood have led to a renewed interest in blood conservation. Autologous blood collection techniques, including preoperative autologous donation, acute normovolemic hemodilution, and perioperative blood recovery are routinely used as alternatives to allogeneic transfusion. In the future, these techniques may be combined with pharmacological strategies, such as presurgical erythropoietin therapy or red cell substitutes, to reduce further the need for allogeneic blood.     

Blood conservation techniques in obstetrics: a UK perspective

In the UK, maternal mortality due to haemorrhage appears to be rising, with obstetric haemorrhage accounting for 3-4% of the red cells transfused. Allogeneic blood transfusion carries risks such as administration errors, transmitted infections and immunological reactions. The supply of blood is decreasing, partly due to the exclusion of donors who have themselves received a blood transfusion since 1980, in order to stop transmission of variant-Creutzfeldt-Jakob disease. The cost of blood is significantly increasing, partly because it is now leucocyte-depleted to minimize viral transmission. Various blood conservation techniques can reduce exposure to allogeneic blood thereby reducing risk and conserving the blood supply. These include preoperative autologous donation, acute normovolaemic haemodilution and intra-operative cell salvage. Preoperative autologous donation may produce anaemia, does not eliminate transfusion risk, cannot be used in an emergency and is not acceptable to Jehovah's Witnesses. It should be reserved for exceptional circumstances (rare blood type or unusual antibodies). Acute normovolaemic haemodilution may induce anaemia and cardiac failure and cannot be used in an emergency. It may have a limited role in combination with other techniques. Intra-operative cell salvage is more effective and useful in obstetrics than the other techniques, overcomes their shortcomings and is endorsed by CEMACH, OAA/AAGBI Guidelines, the National Blood Service and NICE.     

Blood conservation in cardiac surgery. Preliminary results with an institutional commitment.

To evaluate the effect of blood conservation in cardiac surgery, use of blood products was analyzed in patients undergoing CABG before and after implementation of blood conservation techniques. Age, sex, coronary anatomy, ejection fraction, cardiopulmonary bypass time, and the preoperative hematocrit, platelet count, and clotting studies were similar in both groups. Methods of blood conservation included autologous transfusion of blood withdrawn before bypass, autotransfusion of shed mediastinal blood, strict protocols for transfusion, and acceptance of normovolemic anemia. With blood conservation, 25.5% of patients received no transfusions and 54.9% received blood only. Significant reductions (p less than 0.001) were achieved in the transfusion of blood from 6.8 +/- 2.4 to 2.3 +/- 2.6 units per patient and of plasma from 2.5 +/- 2.2 to 0.6 +/- 2.0 units per patient. Reductions in the use of platelets and cryoprecipitate were substantial, although not significant. Total donor exposure was reduced significantly from 13.1 +/- 7.3 to 4.3 +/- 6.7 donors per patient. The postoperative hematocrit was significantly lower and remained so at discharge. However, 30 days later there was no difference. This reduction in transfusion requirements decreased costs and donor exposure.     

Image-guided laparoscopic surgery. Review and current status

The main drawback with laparoscopic surgery is that the surgeon is unable to palpate vessels, tumours and organs during surgery. Further-more, the laparoscope only provides a surface view of organs. There is a need for more advanced visualizations techniques that can enhance the display presented to the surgeon so that important information below the surface of the organs is included when planning the procedure as well as for guidance and control during treatment. In this paper, we present a review of the literature and the state of art within image-guided laparoscopic surgery. We describe our own experience using a prototype navigation system for advanced visualizations and guidance during laparoscopic procedures in the retroperitoneum. Furthermore, we show sample images from the Future Operating Room for laparoscopic surgery in Trondheim, where this technology is being further developed and tested in clinical studies. Our system is based on three-dimensional navigation technology, i.e. preoperatively acquired magnetic resonance or computed tomography data used in combination with tracked instruments, allowing the surgeon to interactively control the display of images prior to and during surgery with normal use of the instruments. In summary, we believe that abdominal image navigation using tracked instruments and advanced visualizations has a large potential for improving future laparoscopic surgery, especially in cases where vessels and anatomical relations beyond surfaces is difficult to identify using only a laparoscope. The technology helps the surgeon to better understand the anatomy and locate blood vessels. Accordingly, we believe that this new technology could increase safety and make it easier for the surgeon to perform successful laparoscopic surgery.     

脊柱微创手术技术发展现状

近几十年,随着脊柱外科理念和科学技术的巨大进步,脊柱微创手术的普及程度大为提高。脊柱微创技术旨在最大限度降低手术并发症风险,同时获得与传统开放手术相同的效果。脊柱微创手术提倡尽可能地避免或减少与手术入路相关的组织损伤,尽可能保留手术范围内正常的解剖结构,同时术后可快速康复并获得更好的生活质量。从腰椎椎间盘显微切除技术开始,各种革命性的微创技术不断涌现,并逐步代替开放术式。内窥镜、导航和机器人等现代手术辅助设备的发展进一步扩大了脊柱微创手术的适应证范围,使其适用于许多复杂的脊柱病变。例如,使用显微镜或内窥镜不仅能更安全地进行常规的神经减压/融合操作,也可显著提高脊柱转移性病变、复杂脊柱感染和复杂脊柱创伤相关手术的可行性、安全性。     

Blood conservation in cardiac surgery: let's get restrictive

Despite increasing evidence suggesting harmful effects of blood transfusions, physician practices are slow to change. A systematic approach is required to successfully minimize the need for red cell transfusions in the perioperative cardiac surgical patient. This involves preoperative, intraoperative, and postoperative strategies to minimize blood loss and maximize blood conservation. In addition it requires physician education regarding the potential deleterious effects of blood and the more recent evidence that restrictive transfusion strategies are safe and possibly beneficial to postoperative surgical outcomes. In this article, we review the data with respect to blood transfusions in cardiac surgery patients as well as management strategies to minimize the need for blood transfusions in the perioperative period.     

脊柱外科的回顾与展望

脊柱外科己经历了一百多年历史。粗略划分有如下一些里程碑。就我所知,有文字记载是十九世纪1895年,英国伦敦泰晤士报报告一例颈椎损伤采用钢丝固定,     

Digital surgery: current trends and techniques

Digital deformities continue to be a common ailment among many patients who present to foot and ankle specialists. When conservative treatment fails to eliminate patient complaints, surgical correction remains a viable treatment option. Proximal interphalangeal joint arthrodesis remains the standard procedure among most foot and ankle surgeons. With continued advances in fixation technology and techniques, surgeons continue to have better options for the achievement of excellent digital surgery outcomes. This article reviews current trends in fixation of digital deformities while highlighting pertinent aspects of the physical examination, radiographic examination, and surgical technique.     

Blood conservation in thoracic aortic surgery with total cardiopulmonary bypass

BACKGROUND: In thoracic aortic surgery, a large number of homologous transfusions sometimes cause systemic inflammatory response, which may lead to pulmonary dysfunction, renal dysfunction and brain edema. To predict the need for homologous blood transfusion in aortic surgery, we use blood transfusion index (preoperative Ht x body weight) to predict the magnitude of homologous transfusion. PATIENTS AND METHODS: From Dec 1997 to May 2000, 59 consecutive patients were underwent thoracic aortic graft replacement with total cardiopulmonary bypass. These patients were divided in 2 groups, who were underwent graft replacement without blood transfusions, and who needed blood transfusions. Each group was compared in age, sex, emergency, Ht, CPB time, blood transfusion index and operative mortality. RESULTS: Forty patients (67.7%) did not required blood transfusion. In elective cases (32 cases), 84.3% were underwent operation without blood transfusion. There was no significant difference between 2 groups in terms of age and mean bypass duration. Blood transfusion index was significantly higher in transfusion group (2,320 +/- 784) compared with that in not transfusion group (1,445 +/- 706). CONCLUSION: Blood transfusion index was useful preoperative parameter to predict the need for homologous transfusion.     

Complications associated with cement augmentation techniques in spinal surgery

Metabolic conditions can compromise the integrity of the spine, placing patients at risk of pain, progressive spinal deformity, and failure of instrumentation used in treatment of spinal pathology. Vertebroplasty, kyphoplasty, sacroplasty, and augmented pedicle screws are frequently performed procedures developed to help combat these issues. These procedures are infrequently associated with significant issues, but serious complications from these surgeries can occur. Consequently, it is critical that treating surgeons be aware of the most common complications associated with cement augmentation procedures, as well as understand how to minimize their occurrence, diagnose them swiftly, and manage them appropriately when needed.     

Review of current varicocelectomy techniques and their outcomes

What’s known on the subject? and What does the study add? The relationship between varicocele and infertility is well established, and several surgical and radiological techniques for varicocelectomy are currently used in practice. The postoperative benefits of the surgery is also well established. The AUA has set forth guidelines on the evaluation and indications for treatment of varicocele; however, to date, there is no consensus as to which surgical technique should be considered the gold standard. This paper evaluates the current methods in practice and evaluates them based on specific and stringent criteria. All surgical and radiological methods that are frequently used were included. We suggest that by using either of the two microsurgical techniques, inguinal or subinguinal, that there would be better outcomes across all parameters postoperatively with better long term outcomes. We also investigated several new techniques and made recommendations for further research.

OBJECTIVES

• ? To review all the various techniques and their results and efficiencies to provide practicing urologists with some guidance for choice of technique
• ? To discuss improvements of varicocelectomy techniques in the last 15 years and their impact on results of surgery.

PATIENTS AND METHODS

• ? A PubMed English literature review of literature from 1995 to present.

RESULTS

• ? Pregnancy rates were highest with microsurgical subinguinal technique
• ? Varicocele recurrence rates were lowest with microsurgical subinguinal technique
• ? Hydrocele formation rates were lowest with microsurgical inguinal technique
• ? Surgical complications were highest in the laparoscopic technique
• ? Varicocelectomy by itself or in conjunction with IVF is cost effective

CONCLUSIONS

• ? Microsurgical subinguinal or microsurgical inguinal techniques offer best outcomes
• ? Varicocelectomy is a cost effective treatment modality for infertility
• ? Further research is needed to explore new developments in varicocelectomy