Effect of substituting allogenic blood transfusion with autologous blood transfusion on outcomes after radical oesophagectomy for cancer.

BACKGROUND: The oncologic benefit of avoiding allogenic blood transfusion in oesophageal cancer resection has not been studied. METHODS: The medical records of 68 patients (Auto group) who underwent a potentially curative oesophageal cancer resection without allogenic blood transfusion from 1996 to 1999 receiving 800 g of autologous blood donated preoperatively, and 97 patients (Allo group) who underwent the same operation with allogenic blood transfusion from 1990 to 1995 were compared. RESULTS: There were no differences in age, gender, stage of disease, number of retrieved nodes, or perioperative hemoglobin concentration between the two groups. The survival of the 45 patients with nodal involvement in the Auto group was better than that of the 59 patients in the Allo group (p=0.0435), and the survival of the 35 patients with T3 or T4 lesions in the Auto group was better than that of the 61 patients in the Allo group (p=0.0408). According to logistic regression analysis, allogenic blood transfusion correlated with tumour recurrence in patients with either nodal involvement or a T3-4 lesion. The natural killer cell activity remained higher in the Auto group than in the Allo group (p<0.05). CONCLUSION: Avoidance of allogenic blood transfusion favorably effected the survival of patients with oesophageal cancer at risk for recurrence.     

Perioperative blood transfusion and gastric cancer: adverse effects or unfavourable conditions of pretreatment?

The use of perioperative blood transfusion (PBT), the immunological status pre-operatively and at discharge from hospital, and the clinical course were examined retrospectively in 124 patients who underwent 'curative' resection for gastric cancer at Shinkokura Hospital, Japan from 1979 to 1988. The general condition of patients with PBT was worse than that of those without PBT and the pre-operative immunological status of patients with PBT was less favourable than that of those without PBT. At the time of discharge from hospital the immunological condition remained worse for patients who had been given PBT. The clinical course of patients with PBT was significantly worse. A dose-response relationship was evident but the types of blood products did not influence the outcome. Cox regression analysis adjusting for potentially confounding prognostic factors revealed that the clinical course was not altered by perioperative blood transfusion itself. These observations do not support the idea of adverse effects of perioperative blood transfusion on outcome of patients undergoing 'curative' resection for gastric cancer.     

Predicting blood usage in cardiac surgery--the transfusion predictor product

Blood cross-matched for patients undergoing cardiac surgery is used infrequently and represents a significant cost. We investigated the ability to predict the need for intraoperative transfusion. We hypothesized that red blood cell volume is a predictor because dilution is the primary cause for transfusion requirement intraoperatively. A total of 401 consecutive patients having cardiothoracic surgery requiring the use of cardiopulmonary bypass were retrospectively analyzed by revision of their perfusion record. This sample included 82% elective, 17% urgent, and 1% emergency procedures. The product of body surface area and preoperative hemoglobin gave us gHb/l/m2, which are the units of the Transfusion Predictor Product (TPPU). Mean patient age was 66.9 +/- 10.7 years, and 112 (28%) were women. Mean TPP was 257.2 +/- 45.5u. 52 patients (13%) received red blood cells intraoperatively. At less than TPP 211.7u, one standard deviation below the mean value, 32 patients of 69 (46%) received blood transfusion intraoperatively (p < 0.001). At a TPP greater than 211.7u, 20 patients of 322 (6%) had blood transfusion intraoperatively. Patients with a TPP > 211.7u do not require routine cross-matching of blood. Cross-matching for these patients should be individualized on the basis of predicted duration of CPB and/or other types of patient comorbidity.     

Blood use in urgent operations for patients with fractures of the femoral neck

Unnecessary preoperative cross-matching of blood wastes time and money and may increase morbidity and mortality by delaying a necessary operation. One hundred and ninety-three consecutive patients who underwent semi-urgent operative treatment for fractures of the neck of the femur at a large district general hospital were evaluated. Of the patients with haemoglobin values of 11 g/dl or more, only 12 per cent required transfusion for the operation. None of the patients with fractures treated by 'pinning' required a transfusion. It is our opinion that patients with normal preoperative haemoglobin levels can undergo operative treatment for fractures of the neck of femur after typing but without the necessity of cross-matching blood.     

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.     

Survival advantage of using autologous blood transfusion during surgery for esophageal cancer

Purpose: There is evidence that blood transfusion is associated with an increased rate of tumor recurrence. This study was conducted to assess the survival advantage of giving autologous blood instead of allogeneic blood during surgery for esophageal cancer. Methods: We retrospectively analyzed 62 patients who underwent esophagectomy for thoracic esophageal cancer between January 1991 and February 1995 and received allogeneic blood transfusion, and 61 patients operated on between March 1995 and February 1998, who received autologous blood transfusion. The clinicopathological factors and survival rates were compared between the two groups. Results: The clinicopathological factors that influenced prognosis were similar in the two groups; however, a definite survival advantage was evident in the autologous blood transfusion group. According to multivariate analyses, the transfusion of allogeneic blood was an independent prognostic factor (P = 0.0222), as was the presence of metastatic lymph nodes. Patients who received allogeneic blood transfusions perioperatively had more than a twofold greater risk (Hazard ration 2.406) of death over patients who received autologous blood transfusions. Conclusion: Autologous blood transfusion appears to be an independent prognostic factor for the survival of patients with esophageal cancer. Received: August 20, 2001 / Accepted: May 7, 2002 Reprint requests to: S. Motoyama     

Autologous blood transfusion in total hip arthroplasty

PURPOSE: To determine the possibility of avoiding homologous blood transfusion during total hip arthroplasty, and to clarify the problems associated with autologous blood transfusion. METHODS: A total of 253 patients received autologous blood transfusion during total hip arthroplasty between April 1990 and December 2000. Patients were assessed for the volume of haemorrhage during surgery, possibility of avoidance of homologous blood transfusion, and the disposal of autologous blood. RESULTS: There were no significant differences in the mean volume of haemorrhage among different underlying diseases. The mean total volume of haemorrhage was 2039 (standard deviation, 992) ml in revision surgery and 1673 (717.3) ml in primary surgery (p<0.05). The rate of avoidance of homologous blood transfusion was 75% among patients who underwent primary surgery, and 61% among those who underwent revision surgery. The rate was 95% in cases in which a combination of preoperative blood pooling and intra-operative recovery was used, 49% in cases where the preoperative blood pooling system alone was used, and 42% in those in which the intra-operative recovery system alone was employed. The autologous blood had to be disposed of in 3 (1%) cases, all of which were revision procedures with replacement of the polyethylene liner alone. CONCLUSION: Combined use of the preoperative blood pooling and intra-operative recovery systems is effective for avoiding homologous blood transfusion.     

Impact of radiofrequency assisted hepatectomy for reduction of transfusion requirements

BACKGROUND: Liver parenchyma transection technique using heat coagulative necrosis induced by radiofrequency (RF) energy is evaluated in this series. METHODS: Between January 2000 and October 2004, 156 consecutive patients underwent liver resection with the RF-assisted technique. Data were collected prospectively to assess the outcome, including intraoperative blood loss, blood transfusion requirement, and morbidity and mortality rates. RESULTS: There were 30 major hepatectomies and 126 minor resections. While total operative time was 241 +/- 89 minutes, the actual resection time was 75 +/- 51 minutes. Intraoperative blood loss was 139 +/- 222 mL. Nine patients (5%) received blood transfusion, predominantly those receiving major hepatectomy (P = .006). Thirty-six patients (23%) developed postoperative complications, and the mortality rate was 3.2%. Mean hospital stay was 12 +/- 12 days. CONCLUSION: The RF-assisted technique is associated with minimal blood loss, a low blood transfusion requirement, and reduced mortality and morbidity rates and can be used for both minor and major liver resections.     

Adverse effects of perioperative transfusion on patients with stage III and IV gastric cancer

BACKGROUND: The degree of immunomodulation by perioperative blood transfusion and its resultant effects on cancer surgery are a subject of controversy. We evaluated the prognostic effects of perioperative blood transfusion on gastric cancer surgery. METHODS: A total of 1710 patients who underwent curative gastrectomy for gastric cancer from 1991 to 1995 were retrospectively reviewed. Uni- and multivariate analyses of the incidence, amount, and timing of perioperative blood transfusions and a comparison of the clinicopathological features were performed. RESULTS: A higher incidence of blood transfusions was associated with female sex, large tumors, upper-body location, Borrmann type III or IV lesions, longer operations, total gastrectomies, splenectomies, and D3 or more extended lymphadenectomy. The tumors in the transfused group were more advanced in depth of invasion and nodal classification. More frequent tumor recurrences were found in the transfused group. A dose-response relationship between the amount of transfused blood and prognosis was evident. Subgroup analyses of prognosis according to stage showed significant differences in stages III and IV between the transfused and nontransfused groups. On multivariate analysis, transfusion was shown to be an independent risk factor for recurrence and poor prognosis. CONCLUSIONS: These results suggest that perioperative transfusion is an unfavorable prognostic factor. It is thus better to refrain from unnecessary blood transfusion and to give the least amount of blood to patients with gastric cancer when transfusion is inevitable, especially for those with stage III and IV gastric cancers.     

An analysis on blood transfusion for hepatic resection

BACKGROUND: Hepatic resection is prone to significant blood loss. Adverse effects of blood loss and transfusion mandate improvements in surgical techniques to reduce blood loss and transfusion. METHODS: We retrospectively analyzed the present status of intraoperative blood transfusion practice of 42 hepatic resections in National Kure Medical Center for the year of 2000. RESULTS: Median values for blood loss were 1355, 1708, 1415, and 2298 ml for nonanatomic, subsegmental, segmental and extended right resections, respectively. Crossmatched to transfused blood (C/T) ratios were 1.76, 1.19, 2.31, and 0.90 for nonanatomic, subsegmental, segmental and extended right resections, respectively. CONCLUSION: In general, C/T ratio of 1.5 to 2.5 has been recommended but own C/T ratios are 1.19 and 0.9 for subsegmental and extended right hepatic resection, which are lower than recommended values. It was estimated that inappropriate prediction of blood loss by several surgeons and unused maximum surgical blood order schedule (MSBOS) or type and screen (T&S) decreased these values of C/T ratio in the present analysis. We therefore conclude that MSBOS and T&S could be improved by avoiding such in appropriate prediction.     

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.     

Perioperative effects of hepatic resection surgery on hemodynamics, pulmonary fluid balance, and indocyanine green clearance

BACKGROUND: Major liver resection is a routine surgical treatment, but hemodynamic and pulmonary complications are common. We investigated the effects of hepatic resection on hemodynamics and pulmonary and liver function. PATIENTS AND MEASUREMENTS: Twelve patients who underwent major liver resection due to primary liver tumor, liver metastasis, or hemangioma were investigated prospectively and consecutively. Six patients who underwent gastrectomy due to gastric cancer served as a control group. Hemodynamic parameters (cardiac index, intrathoracic blood volume, mean arterial blood pressure), extravascular lung water, and indocyanine green clearance were measured after the induction of general anesthesia, during the preparation period, during total hilar clamping ("Pringle's maneuver"), at the end of surgery, and 24 and 72 h after surgery. RESULTS: In contrast to gastrectomy, patients who underwent liver resection developed a hyperdynamic circulatory state (cardiac index 72 h postoperatively: 4.6+/-1.2 l/m(2) vs. 3.6+/-0.6 l/m(2)). Simultaneously we observed a significant increase in extravascular lung water in the liver resection group, indicating a moderate pulmonary edema. Indocyanine green clearance did not deteriorate following liver resection. CONCLUSIONS: After liver resection the physiological response resulted in elevated cardiac output and moderate pulmonary edema. Dynamic liver function was elevated within 24 h due to an increase in perfusion and regeneration activity of the remaining parenchyma.     

One hundred consecutive hepatobiliary resections for biliary hilar malignancy: preoperative blood donation, blood loss, transfusion, and outcome

BACKGROUND: Many reports on blood loss and transfusion requirements during hepatectomy for metastatic liver cancer or hepatocellular carcinoma have been published; however, there are no reports on these issues in hepatectomy for biliary hilar malignancy. The aim of this study was to review our experience with blood loss and perioperative blood requirements in 100 consecutive hepatectomies for biliary hilar malignancy. METHODS: One hundred consecutive hepatectomies with en bloc resection of the caudate lobe and extrahepatic bile duct for hilar malignancies were performed, including 81 perihilar cholangiocarcinomas and 19 advanced gallbladder carcinomas involving the hepatic hilus. Fifty-eight hilar resections were combined with other organ and/or vascular resection. Data on preoperative blood donation, intraoperative blood loss, and perioperative transfusion were collected and analyzed. RESULTS: Preoperative autologous blood donation was possible in 73 patients (3.4 +/- 1.2 U). Intraoperative blood loss was 1850 +/- 1000 mL (range, 677-5900 mL), and it was < 2000 mL in 62 patients. Intraoperatively, only 7 of the 73 patients (10%) who donated blood received transfusion of unheated, homologous blood products (packed red blood cells or fresh frozen plasma), whereas 18 the 23 patients (67%) without donation received homologous transfusions. Only 16 patients received transfusion postoperatively, and overall, 35 patients received unheated homologous blood products. Total serum bilirubin concentrations after hepatectomy in patients receiving autologous blood transfusion only was similar to those in patients who did not receive transfusion. The incidence of postoperative complications was higher in the 35 patients who received perioperative homologous transfusion than in 65 patients who did not (94% vs 52%; P <.0001). The mortality rate (including all deaths) was 3% (myocardial infarction, intra-abdominal bleeding, and liver failure, 1 patient each). CONCLUSIONS: Despite the technical difficulties arising from hepatectomy for biliary hilar malignancy, approximately two thirds of hepatectomies can be performed in an experienced center without perioperative homologous blood transfusion using preoperative blood donation.     

Usefulness of autologous blood transfusion for avoiding allogenic transfusion and infectious complications after esophageal cancer resection

BACKGROUND: A retrospective investigation was conducted to determine whether autologous blood collection could reduce allogenic transfusion after resection of esophageal cancer and whether allogenic transfusion influenced postoperative infection. METHODS: Patients (n = 100) who met the criteria for hemoglobin, age, body weight, and serum protein donated 800 mL of autologous blood from May 1994 to December 1997. The control group (n = 248) was selected from patients who met the same criteria and did not donate autologous blood over the 10 years before the start of autologous blood collection. RESULTS: Only three patients (3%) from the autologous group required allogenic transfusion versus 84 patients (33.7%) from the control group. Sixteen of the 26 patients who received more than 4 units of allogenic blood contracted postoperative infections compared with 25 of 165 patients who did not (P < .0001). Autologous blood transfusion significantly increased the probability of avoiding allogenic transfusion (odds ratio, 27.58), and allogenic transfusion was significantly related to postoperative infection (odds ratio, 1.19), according to logistic regression analysis. CONCLUSIONS: Autologous blood collection reduces the need for allogenic transfusion in patients undergoing resection of esophageal cancer, and avoidance of allogenic transfusion may reduce the risk of postoperative infection.     

The surgical treatment of chronic gastric atony following Roux-Y diversion for alkaline reflux gastritis.

Symptoms of severe nausea, vomiting, abdominal pain, and frequent bezoars, as well as objective gastric retention, can occur following Roux-Y biliary diversion for alkaline reflux gastritis. Medical therapy and prokinetic drugs have proven ineffective. This review evaluates 37 patients who underwent further gastric resection from 1979 to 1987 to improve gastric emptying and resolve symptoms. Fifteen patients underwent perioperative radionuclide solid-food gastric emptying studies. Seventy-three per cent (27 of 37 patients) of the patients who underwent further gastric resection (70% to 95%) had a satisfactory postoperative response. Twenty patients were graded Visick 1 or 2 and 7 Visick-3 patients, although much improved, still had some symptoms of gastroparesis. Twenty-seven per cent (10 of 37 patients) failed to improve and underwent completion total gastrectomy. Overall, 70% of this group had almost complete resolution of their symptoms. Three of 10 patients were considered "failures" due to postprandial pain in 1 and early vasomotor dumping in 2. Of the 10 patients who failed initial revisional surgery, 7 underwent a 70% to 80% subtotal gastric resection (STG) and 3 patients underwent 85% to 95% extensive resection (EXT.G.). Of the 15 patients who underwent perioperative radionuclide evaluation, a mean two-hour gastric retention of 61.4% +/- 4% (SEM) decreased to 25% +/- 4% following further gastric resection. Eight patients were in the STG group and seven patients were in the EXT.G group. Following STG, mean two-hour gastric retention of 58.2% +/- 3.5% decreased to 38% +/- 3% (p less than 0.05). In seven patients who underwent EXT.G, mean two-hour retention of 65% +/- 4% decreased to 10% +/- 2.5% (p less than 0.005). EXT.G resulted in normal gastric emptying and few late failures. In post-Roux-Y patients with symptoms of gastroparesis and documented gastric retention, EXT.G normalizes gastric emptying and restores a better quality of life. Total gastrectomy should be reserved for those patients who are failed by more extensive resection.     

Spine tumor resection among patients who refuse blood product transfusion: a retrospective case series

Study objectiveTo describe the perioperative blood conservation strategies and postoperative outcomes in patients who undergo complex spinal surgery for tumor resection and who also refuse blood product transfusion.DesignA retrospective case series.SettingA single-center, tertiary care and academic teaching hospital in Canada.PatientsAll adult patients undergoing elective major spine tumor resection and refusing blood product transfusion who were referred to our institutional Blood Utilization Program between June 1, 2004, and May 9, 2014.MeasurementsData on the use of iron, erythropoietin, preoperative autologous blood donation, acute normovolemic hemodilution, antifibrinolytic therapy, cell salvage, intraoperative hypotension, and active warming techniques were collected. Data on perioperative hemoglobin nadir, adverse outcomes, and hospital length of stay were also collected.Main resultsFour patients who refused blood transfusion (self-identified as Jehovah's Witnesses) underwent non-emergent complex spine surgery for recurrent chondrosarcoma, meningioma, metastatic adenocarcinoma, and metastatic malignant melanoma. All patients received 1 or more perioperative blood conservation strategy including preoperative iron and/or erythropoietin, intraoperative antifibrinolytic therapy, and cell salvage. No patients experienced severe perioperative anemia (average hemoglobin nadir, 124 g/L) or anemia-related postoperative complications.ConclusionsPatients who decline blood product transfusion can successfully undergo major spine tumor resection. Careful patient selection and timely referral for perioperative optimization such that the risk of severe anemia is minimized are important for success.     

Preoperative Type and Screen Before General Thoracic Surgery: A Nomogram to Reduce Unnecessary Tests

BackgroundA preoperative type and screen (T&S) is traditionally routinely obtained before noncardiac thoracic surgery; however an intraoperative blood transfusion is rare. This practice is overly cautious and expensive.MethodsWe included adult patients undergoing major thoracic surgery at the Mayo Clinic from 2007 to 2016. Patients receiving a T&S blood test ≤72 hours of surgery was the main exposure. We randomly split the cohort into derivation and validation datasets. We used multiple logistic regression to create a parsimonious nomogram predicting the need for a T&S in relation to the likelihood of intraoperative blood transfusion. We validated the nomogram in terms of discrimination, calibration, and negative predictive value.ResultsOf 6280 patients 46.1% had a preoperative T&S, but only 7.1% received intraoperative transfusions. The derivation dataset had 4196 patients. Patients who had a T&S were more likely to have baseline hemoglobin level <10 g/dL (7.9% vs 3.6%, P < .001) and less likely to have minimally invasive operations (36.1% vs 43.5%, P < .001) but were otherwise similar in baseline age and comorbidities. A transfusion threshold of 5% was selected a priori. The nomogram included age, planned operation, approach, body mass index, and preoperative hemoglobin. The nomogram was validated with a c-statistic of 86% and a negative predictive value of 97.9%. Patients who needed a blood transfusion but who did not have a preoperative T&S did not have a higher rate of mortality (P = .121).ConclusionsAn intraoperative blood transfusion during major thoracic surgery is a rare event. Patient who required transfusion but did not have a T&S did not have worse outcomes. A simple nomogram can aid in the selective use of T&S orders preoperatively.     

Laparoscopic liver resection assisted with radiofrequency

BACKGROUND: Radiofrequency-assisted laparoscopic liver resection is reported. METHODS: Patients suitable for liver resection were carefully assessed for laparoscopic resection. Patient and intraoperative and postoperative data were prospectively collected and analyzed. RESULTS: Eighteen patients underwent laparoscopic liver resection. All operations were performed without vascular clamping and consisting of tumorectomy (n = 9), multiple tumoretcomies (n = 2), segmentectomy (n = 2), and bisegmentectomies (n = 2). Mean blood loss was 121 +/- 68 mL, and mean resection was time 167 +/- 45 minutes. There was no need for perioperative or postoperative transfusion of blood or blood products. One patient developed pneumothorax during surgery as a result of direct puncture of pleura with the radiofrequency probe, and 1 patient had transient liver failure and required supportive care after surgery. The mean length of hospital stay was 6.0 +/-1.5 days. At follow-up, those with liver cancer had no recurrence. CONCLUSIONS: Radiofrequency-assist laparoscopic liver resection can decrease the risk of intraoperative bleeding and blood transfusion.     

Usefulness of vacuum-assisted cardiopulmonary bypass circuit for pediatric open-heart surgery in reducing homologous blood transfusion.

OBJECTIVE: Open-heart surgery without homologous blood transfusion is still difficult in children because priming volume in cardiopulmonary bypass circuit results in extreme hemodilution. Vacuum-assisted cardiopulmonary bypass circuit has the benefit of improving venous return and results in lowering priming volume. We introduced vacuum-assisted cardiopulmonary bypass circuit in order to reduce priming volume for pediatric patients in March 1995. A retrospective study was made on the efficacy of vacuum-assisted circuit for pediatric open-heart surgery in reducing homologous blood transfusion. METHODS: Patients weighing from 5 to 20 kg who underwent surgery between January 1991 and June 1996 were divided into two groups, group A comprised 128 patients before introduction of this circuit and group B comprised 49 patients after introduction, and their clinical course was compared. Vacuum-assisted circuit was used in 27 patients of group B. RESULTS: The percentage of transfusion-free operations was significantly higher in group B than in group A (33.6% in group A vs. 53.1% in group B, P = 0.014), and particularly this percentage in patients weighing less than 10 kg significantly increased (0% in group A vs. 42.9% in group B, P < 0.01). The amount of homologous blood transfusion was significantly lower in group B than in group A (374 +/- 362 ml in group A and 212 +/- 287 ml in group B, P < 0.01). The rate of complications and the duration of respiratory support did not differ between the two groups. The duration of hospital stay was lower in group B than in group A. CONCLUSIONS: The findings of this study indicate that vacuum-assisted circuit is useful for pediatric open-heart surgery in reducing homologous blood transfusion.     

Evaluating variation in perioperative red blood cell transfusion for patients undergoing elective gastrointestinal cancer surgery

BackgroundPatients undergoing gastrointestinal cancer surgery often receive packed red blood cell transfusions. Understanding practice variation is critical to support efforts working toward responsible transfusion use. We measured the extent and importance of variation in perioperative packed red blood cell transfusion use across physicians and hospitals among gastrointestinal cancer surgery patients.MethodsWe identified patients who underwent elective gastrointestinal cancer resection between 2007 and 2019 using linked administrative health data sets in Ontario, Canada. We used funnel plots to describe variation in transfusion use, adjusted for patient case mix. Hierarchical regression models quantified patient-level, between-physician, and between-hospital variation in transfusion use with R² measures, variance partition coefficients, and median odds ratios.ResultsOf 59,964 included patients (median age 69 years; 43.2% female; 75.8% colorectal resections), 18.0% received perioperative packed red blood cell transfusions. Funnel plots showed variation in transfusion use among physicians and hospitals. Patient characteristics, such as age, comorbidity, and procedure type, combined to explain 12.8% of the variation. After adjusting for case mix, systematic between-physician and between-hospital differences were responsible for 2.8% and 2.1% of the variation, respectively. This translated to an approximately 30% difference in the odds of transfusion for 2 similar patients treated by distinct physicians (median odds ratio: 1.35, 95% confidence interval 1.30–1.40) and hospitals (median odds ratio: 1.30, 95% confidence interval 1.23–1.42). We observed comparable effects across procedure-type subgroups.ConclusionTransfusion provision is highly driven by patient factors. Yet the impact of the treating physician and hospital on variation relative to other factors is important and reflects opportunities to target modifiable processes of care to standardize perioperative packed red blood cell transfusion practice.