Adverse effects of cell saver in patients undergoing ruptured abdominal aortic aneurysm repair

A retrospective analysis of 56 patients undergoing ruptured abdominal aortic aneurysm (AAA) repair was performed to find out if cell saver had any impact on postoperative morbidity and mortality. All patients but one were male. The mean age was 68 ± 8 years (35-85 years). Cell saver was used in 40 patients (CS group) and was not used in 16 patients (NCS group). We compared the incidences of respiratory, renal, and gastrointestinal complications; reoperation; transfusion requirement; length of hospital stay; and mortality between the groups. This study demonstrated that intraoperative cell saver usage significantly increased the incidence of respiratory complications and the need for blood and fresh frozen plasma transfusion, and prolonged the hospital stay in patients with ruptured AAA, but did not have any impact on mortality. Postoperative complications were more prominent in patients who received >3000 mL cell saver blood.     

Ranitidine prevents postoperative transfusion-induced depression of delayed hypersensitivity

The influence of perioperative blood transfusion on postoperative depression of cell-mediated immunity (CMI) and the effect of ranitidine on transfusion-induced changes in postoperative CMI were investigated. CMI was assessed preoperatively and postoperatively by skin testing with seven common delayed-type antigens in 83 consecutive patients undergoing major elective abdominal surgery. Sixty-six of these patients were randomly divided into ranitidine or no-ranitidine-treatment groups, and the remaining 17 patients were operated on without ranitidine. Thus, 50 patients were operated on without ranitidine therapy, and whole blood transfusion was given to 24 of these patients. Postoperative skin test response was more reduced in transfused vs nontransfused patients (-57% vs -38%, p less than 0.0001). Fourteen of the 24 patients receiving blood transfusion could be exactly matched to 14 patients not receiving transfusion (age, sex, B-hemoglobin, S-albumin, type and duration of surgery, etc.), which confirmed that a more pronounced reduction in postoperative skin test response was found in transfused patients (-55% vs -31%, p less than 0.0001). Seventeen of the 33 patients treated with perioperative ranitidine, 50 mg intravenously every 6 hours for 72 hours, received perioperative blood transfusion. Eleven of these patients could be matched to 11 transfused patients not receiving perioperative ranitidine. Ranitidine prevented postoperative reduction in skin test response (+6% vs -55%, p less than 0.0001). It is concluded that perioperative transfusion with whole blood amplifies the postoperative impairment in delayed hypersensitivity and that transfusion-induced postoperative impairment in delayed hypersensitivity may be prevented by perioperative ranitidine treatment.     

Effects of cell saver autologous blood transfusion on blood loss and homologous blood transfusion requirements in patients undergoing cardiac surgery on- versus off-cardiopulmonary bypass: a randomised trial.

OBJECTIVE: Off-pump CABG is potentially associated with reduced intraoperative blood loss and homologous blood transfusion in comparison to on-pump CABG. In this randomised controlled study we investigated the effects of autologous cell saver blood transfusion on blood loss and homologous blood transfusion requirements in patients undergoing CABG on- versus off-CPB. METHODS: Eighty patients were randomised into one of four groups: (A) on-CPB with cell saver blood transfusion (CSBT), (B) on-CPB without CSBT, (C) off-pump with CSBT and (D) off-pump without CSBT. Volume of intraoperative autologous blood transfusion, postoperative mediastinal blood loss and homologous blood transfusion requirements were measured. Homologous blood was transfused when haemoglobin concentration fell below 8 g/dl postoperatively. Pre- and postoperatively prothrombin time and partial thromboplastin time were measured. RESULTS: Preoperative patient characteristics were well matched among the four groups. The amount of salvaged mediastinal blood available for autologous transfusion was significantly higher in the on-pump group (A) compared to the off-CPB group (C) (433+/-155 ml vs 271+/-144 ml, P=0.001). Volume of homologous blood transfusion was significantly higher in group B vs groups A, C and D (595+/-438 ml vs 179+/-214, 141+/-183 and 230+/-240 ml, respectively, P<0.005). The cell saver groups (A and C) received significantly less homologous blood than the groups without cell saver (160+/-197 ml vs 413+/-394 ml, respectively, P<0.005). Patients undergoing off-CPB surgery received significantly less homologous blood than those undergoing on-CPB CABG irrespective of cell saver blood transfusion (184+/-214 ml vs 382+/-397 ml, P<0.05). Postoperative blood loss was similar in the four groups (842+/-276, 1023+/-291, 869+/-286 and 903+/-315 ml in groups A to D, respectively, P>0.05). Clotting test results revealed no significant difference between the groups. There was no significant difference in postoperative morbidity between groups. CONCLUSION: Off-pump CABG is associated with significant reduction in intraoperative mediastinal blood loss and homologous transfusion requirements. Autologous transfusion of salvaged washed mediastinal blood reduced homologous transfusion significantly in the on-CPB group. Cell saver caused no significant adverse impact on coagulation parameters in on- or off-CPB CABG. Postoperative morbidity and blood loss were not affected by the use of CPB or autologous blood transfusion. We recommend the use of autologous blood transfusion in both on- and off-pump CABG surgery.     

Intraoperative use of platelet-plasmapheresis in vascular surgery

STUDY OBJECTIVE: To determine, in a pilot study, whether pheresis of plasma and platelets before surgical blood loss, with reinfusion of the autologous plasma and platelets after completion of the aortic reconstruction, will result in decreased bleeding and decreased transfusion of allogenic blood components in patients undergoing elective aortic reconstruction. DESIGN: Randomized study. SETTING: University medical center. INTERVENTIONS: Patients were randomized to perioperative (acute) platelet plasmapheresis (APP group) versus conventional blood component therapy (control group). In the APP group, blood was withdrawn after induction of anesthesia, to sequester approximately 300 mL of platelet rich plasma (PRP); platelet poor plasma (PPP) and red blood cells (RBC) were sequestered as well. An autotransfusion device was used to collect and re-infuse autologous RBC during the course of the operation in both groups. After completion of the aortic reconstruction, autologous PRP and PPP were re-infused in the APP group. Blood loss, volume of blood component transfusions, and preoperative and postoperative hemoglobin (Hb), hematocrit (Hct), platelet, international normalized ratio (INR), and activated partial thromboplastin time (aPTT) were recorded. MEASUREMENTS AND MAIN RESULTS: There was no difference between groups in demographics, preoperative laboratory values, or surgical procedures, although more patients were treated for aneurysms (73% vs. 60%) and fewer for occlusive disease (20% vs. 40%) in the control versus APP group. Also, there were no differences between the control and APP groups in duration of operation, blood loss, volume of colloid infused, or volume of allogenic RBC and plasma transfused. Patients in the APP group received a greater volume of crystalloid solution (9.1 +/- 3.4 L vs. 6.8 +/- 3.0 L; p = 0.002), but fewer units of allogenic platelets than the control group (0.7 +/- 1.0 units vs. 0.2 +/- 0.4 units; p < 0.04). There were no differences in postoperative Hb, Hct, INR, aPTT, or fibrinogen. The platelet count was lower in the APP group than in the control group (123 +/- 40 x 10(3)/mm(3) vs. 182 +/- 51 x 10(3)/mm(3); p = 0.004). CONCLUSIONS: Perioperative platelet plasmapheresis led to fewer allogenic platelet transfusions in patients undergoing elective aortic reconstruction. However, there was no decrease in blood loss and no reduction in transfusion of allogenic RBC or plasma. Perioperative platelet plasmapheresis is not recommended for routine use in elective aortic reconstruction.     

Endovascular repair for abdominal aortic aneurysms: initial experience of an endograft programme

OBJECTIVE: To evaluate early clinical results of elective endovascular repair of abdominal aortic aneurysms during the initial phase of an aortic endograft programme and to compare them with conventional open surgery. METHODS: Between July 1999 and September 2001, all patients with infrarenal abdominal aortic aneurysms undergoing elective repair were studied. The results of endovascular repair were compared with those of conventional repair. RESULTS: Twenty-seven endovascular repairs (24 men and three women; mean age, 74 yr) and 25 conventional repairs (19 men and six women; mean age, 73 yr) for infrarenal abdominal aortic aneurysms were evaluated. The aneurysm diameters in the two groups were similar (mean, 6.1 cm in the endovascular repair group and 6.6 cm in the conventional repair group). The comorbidities of the two groups were also comparable. The duration of operation was longer in the endograft group (249 +/- 86 min vs. 206 +/- 56 min), while the blood loss was significantly less (600 +/- 486 mL vs. 1074 +/- 1220 mL). The length of stay in the Intensive Care Unit (ICU) and the overall duration of hospitalization was also significantly less in the endograft group (1 +/- 1 d vs. 3 +/- 2 d in ICU; 9 +/- 5 d vs. 13 +/- 6 d of hospitalization). There was one hospital death in each group (4%), and the complications were similar between the two groups. During a mean follow-up period of 11.6 +/- 7.5 months, there was no rupture or open conversion in the endograft group. CONCLUSIONS: In the initial phase of the aortic endograft programme, the mortality and morbidity were acceptable and comparable to that of open surgery.     

Abdominal aortic aneurysm surgery: retroperitoneal or transperitoneal approach?

AIM: Mortality and morbidity of abdominal aortic aneurysm surgery have decreased significantly in time and transperitoneal approach (TPA) still preserves its popularity although retroperitoneal approach (RPA) is known to cause lower incidence and shortened duration of ileus, shorter intensive care unit (ICU) and hospital stay, earlier oral intake and less patient discomfort or pain. METHODS: One hundred and fifty patients that underwent abdominal aortic aneurysm repair at our Cardiovascular Surgery Center between January, 1990 and March, 2000 were reviewed and analyzed based on the elective/emergent nature of the surgery and the type of the incision as either TPA or RPA. RESULTS: Significantly shorter mechanical ventilation (15.2+/-3.8 vs 10.1+/-2.3 hours) and nasogastric decompression periods (40.6+/-10.7 vs 9.1+/-2.2 hours), less need for intravenous fluid supplementation and shorter ICU stay (29.5+/-14.8 vs 18.6+/-1.9 hours) were observed with the retroperitoneal approach (P<0.001). Need for allogeneic blood transfusion was, similar (1.3+/-1.4 vs0.9+/-0.4, P>0.05). Analysis of mortality and morbidity revealed bleeding as the major cause of mortality for ruptured aneurysm. A similar comparison between TPA and RPA groups, however, revealed no significant difference (P>0.05). CONCLUSIONS:| Retroperitoneal approach is a reliable technique causing less fluid-electrolyte imbalance with rapid restoration of gastrointestinal physiology. It causes less discomfort to patients with reduced need for analgesia. A shorter weaning period from mechanical ventilation is among the benefits for patients with co-morbid states.     

Minimizing blood transfusions during abdominal aortic surgery: recent advances in rapid autotransfusion

The purpose of this study was to determine what percentage of patients could avoid the transfusion of any homologous bank blood products during elective abdominal aortic surgery with a recently developed semicontinuous, rapid autotransfusion device. Fifty patients (26 with abdominal aortic aneurysms and 24 with aortic occlusive disease) prospectively received intraoperative autologous transfusion (group 1) and were matched for comparison with 50 patients receiving homologous blood without use of any autotransfusion equipment (group 2). For the entire perioperative period, 34 group 1 patients (68%) received only their own autotransfused blood and no other homologous blood components compared with group 2 in which 48 patients (96%) required some bank blood (p less than 0.0001). Rapid autotransfusion reduced usage of homologous red cell transfusion by 75%. The mean postoperative hemoglobin was similar in both groups (group 1, 11.91 gm/dl vs. group 2, 11.90 gm/dl, p = 0.73). Rapid autotransfusion was not associated with significant hemolysis, air embolism, or coagulopathy and did not increase morbidity or death. By eliminating the need for any bank blood components in most patients, rapid autotransfusion minimizes the risk of blood-borne diseases and transfusion reactions. New rapid autotransfusion devices offer a distinct advantage over past equipment and allow significant changes in current transfusion practices during elective abdominal aortic reconstructions.     

Aortic and large artery compliance in end-stage renal failure

Pulse wave velocity (PWV) was measured in the aorta, right leg and arm of 90 control subjects (CS) and 92 hemodialysis patients (HD) of the same age and mean arterial pressure (MAP). Blood chemistry, including blood lipids, and echographic dimensions of the aorta, were measured in all subjects. Presence of aortic calcification was evaluated by abdominal X-ray and echography. Whereas femoral and brachial PWV were only slightly increased in HD (P less than 0.05), the aortic PWV was significantly elevated (1113 +/- 319 cm/sec) in comparison with CS (965 +/- 216 cm/sec; P = 0.0016). Aortic diameters were larger in HD, both at the root of aorta (32.7 +/- 4 vs. 28.2 +/- 2.8 mm; P less than 0.0001) and aortic bifurcation (16.9 +/- 3.1 vs. 14.6 +/- 2.2 mm; P less than 0.0001). Although the MAP was similar in HD (109.9 +/- 19.3 mm Hg) and CS (110.2 +/- 17.2 mm Hg), the pulse pressure was significantly increased in HD patients (76.6 +/- 23.7 vs. 63.9 +/- 22 mm Hg; P = 0.007). In the two populations, aortic PWV was found to increase with age (P less than 0.0001) and MAP (P less than 0.0001). The presence of aortic calcification showed only a borderline relationship with the increase in aortic PWV (P = 0.050 in CS and P = 0.069 in HD). As change in PWV is directly related to change in distensibility, and the aortic diameters were increased in HD, these results indicate that aortic wall compliance is decreased in HD, resulting in an increase in the pulsatile component of arterial pressure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of the effects of a cell saver and low-dose aprotinin on blood loss and homologous blood usage in patients undergoing valve surgery.

OBJECTIVE: To compare 2 important techniques of blood conservation, use of a cell saver and low-dose aprotinin, in terms of blood loss and homologous blood usage in patients undergoing cardiac valve surgery. DESIGN: Prospective, randomized. SETTING: Tertiary care hospital. PARTICIPANTS: Sixty adult patients undergoing elective valve surgery. INTERVENTIONS: The patients were divided into 3 groups of 20 each. In group 1, aprotinin in the dose of 30,000 KIU/kg was added to the pump prime, with a further dose of 15,000 KIU/kg added at the end of each hour of cardiopulmonary bypass. In group 2, a cell-saver system was used to collect all blood at the operation site for processing in preparation for subsequent reinfusion. Group 3 patients acted as a control group and underwent routine management, which included collection of autologous blood during the pre-cardiopulmonary bypass period. A hemoglobin of <8 g/dL was considered as an indication for bank blood transfusion in the postoperative period. MEASUREMENTS AND MAIN RESULTS: The chest tube drainage was significantly less in group 1 compared with groups 2 and 3, with total drainage (median [interquartile range]) amounting to 250 mL [105 to 325 mL] vs. 700 mL [525 to 910 mL] in group 2 and 800 mL [650 to 880 mL] in group 3 (p < 0.001). The patients in groups 1 and 2 required significantly less bank blood (median [interquartile range]) as compared with group 3 (350 mL [0 to 525 mL], 350 mL [0 to 350 mL], and 1050 mL [875 to 1050 mL]; p < 0.001), respectively. Cell saver provided 410 +/- 130 mL of hemoconcentrated blood in group 2. The average preoperative hemoglobin concentration was 11.3 g/dL, and it was around 9 g/dL on the 7th postoperative day. The hemoglobin concentration at various stages during hospitalization in all 3 groups was similar. CONCLUSIONS: Low-dose aprotinin and a cell saver are effective and comparable methods of blood conservation. Aprotinin helps by decreasing the postoperative drainage, and a cell saver helps by making the patient's own blood available for transfusion.     

Prospective randomised evaluation of a new cell saving device in elective aortic reconstruction

In order to evaluate the clinical and haematological implications of salvage autotransfusion using the Haemolite device (Haemonetics, Leeds, UK), 67 aortic reconstructions were studied. Bank blood transfused during the operation fell from a median of four units in the control group to zero using the cell saver (P less than 0.0001), and wound drainage decreased from 250 to 200 ml (P = 0.12). Evidence of fibrinolytic and platelet activation was found during salvage, but no bleeding diathesis was encountered. There was no morbidity or mortality related to the technique, and median hospital stay was reduced in autotransfused patients. The Haemolite is a safe effective device for autotransfusion in elective aortic surgery, and can substantially reduce exposure of both patients and staff to the dangers of homologous blood.     

Electrolyte and acid-base disturbances caused by blood transfusions

The effect of blood transfusions on the electrolyte, metabolic and hemodynamic status of 31 patients undergoing major laparotomies was studied. Two groups were compared: Group I, 11 patients receiving continuous intraoperative blood transfusions exceeding 5 units at a rate over 0.3 ml/kg/min, and Group II, 20 patients receiving transfusions of 1-5 units at a rate below the limit. Transiently increased potassium values (5.2 +/- 0.3 mmol/l) were found in Group I during the rapid transfusion phase. The difference was statistically significant (P less than 0.05) when compared to Group II (4.3 +/- 0.2 mmol/l). There was also a significant correlation (r = 0.64; P less than 0.05) between the increase in serum potassium concentrations and the respective potassium load caused by the blood transfused. Most of the hyperpotassemic patients had surgery of the abdominal aorta. During the rapid transfusion, the patients in Group I had significantly lower concentrations of serum ionized calcium (P less than 0.05) and higher central venous pressures (P less than 0.05), but more periods of hypotension when compared to Group II. After the transfusion the massively transfused patients had slight metabolic alcalosis, the BE and pH differing significantly (P less than 0.05) from the values of Group II. It is concluded that hyperpotassemia may occur during rapid transfusions (over 0.4 ml/kg/min) of stored blood, especially in patients undergoing surgery of the abdominal aorta, even without simultaneous shock, acidosis or hypothermia. Calcium administration may be of benefit especially in situations where combined hyperpotassemia and hypocalcemia reduce the myocardial performance.     

A prospective study of aspirin's effect on red blood cell loss in cardiac surgery

The effect of aspirin on red blood cell (RBC) loss and blood transfusions was evaluated prospectively in 100 consecutive patients, with normal bleeding times, undergoing elective coronary artery bypass (CABG) surgery. Patients taking 85-325 mgm of aspirin daily up to or within 48 hours of surgery (the "aspirin" group) were compared to patients not taking aspirin or those who had discontinued aspirin at least 4 days before surgery (the "no-aspirin" group). RBC loss was determined by measuring preoperative and postoperative RBC volume using RISA and 51Cr techniques. There were no significant differences, respectively, between the aspirin and no-aspirin groups for: RBC loss (1158 +/- 67 ml vs 1129 +/- 47 ml, p = 0.737), chest tube drainage (925 +/- 31 ml vs 844 +/- 70 ml, p = 0.553), and gm% discharge Hemoglobin (Hgb) (9.94 +/- 0.32 vs 9.49 +/- 1.4, p = 0.0148). Strict criteria for blood transfusions were employed: (1) intraoperative hematocrit of less than 21%, (2) postoperative Hgb of less than 7 gm% for patients less than 70 years old and (3) postoperative Hgb of less than 8 gm% for patients greater than 70 years old. There were no significant differences, respectively, between the aspirin and no-aspirin groups for units of blood transfused (1.32 +/- vs 1.21 +/- 0.20, p = 0.843) and patients not receiving transfusions during the entire hospitalization (44% vs 50%). Patients taking 85-325 mgm of aspirin with a normal bleeding time undergoing elective CABG did not have increased RBC loss or increased transfusion requirements. These results indicate it is not necessary to delay elective CABG surgery for the purpose of discontinuing aspirin.     

Use of sodium nitroprusside induced hypotensive anaesthesia for reducing blood loss in patients undergoing lienorenal shunts for portal hypertension

A randomized study was performed on 18 patients to determine whether hypotensive anaesthesia, induced by sodium nitroprusside (SNP), would reduce blood loss during elective proximal lienorenal shunt operations for portal hypertension which was due to extrahepatic obstruction or non-cirrhotic portal fibrosis. Eight patients received SNP intraoperatively to reduce the systolic blood pressure to below 95 mmHg, and there were 10 control patients. Blood loss, the number of units of blood transfused, and urine output during surgery were measured together with the postoperative drainage from the abdominal and chest tubes over the first 24 h. There was a significantly lower blood loss (mean +/- s.d. 517 +/- 220 versus 1286 +/- 523 ml; P less than 0.01) and number of units of blood transfused was less (0.9 +/- 0.9 versus 3.0 +/- 1.2; P less than 0.01) in the SNP patients than in the controls. The urine output was greater in the SNP group (606 +/- 211 versus 399 +/- 139 ml, n.s.). Postoperative drainages from the chest and abdomen were similar. Hypotensive anaesthesia with SNP reduces operative blood loss and transfusion requirement in patients with good liver function undergoing proximal lienorenal shunts for portal hypertension.     

Endovascular versus "fast-track'' abdominal aortic aneurysm repair

Recent studies have shown that endovascular abdominal aortic aneurysm repair (EVAR) has decreased costs, as well as decreased intensive care unit and total hospital length of stays when compared to abdominal aortic aneurysm (AAA) repair using a retroperitoneal exposure. The authors hypothesized that the fast-track AAA repair, which combines a retroperitoneal exposure with a patient care pathway that includes a gastric promotility agent and patient-controlled analgesia, would have no differences when compared to EVAR. Records of 58 patients who underwent AAA repair between April 14, 2000, and July 12, 2002, were reviewed retrospectively. Demographic information, length of stay, intraoperative and postoperative complications, mortality, and costs were evaluated. Fifty-eight AAA repairs were performed with the EVAR (n=28) and fast-track (n=30) techniques. The EVAR group was slightly older (72 vs 68 years, p=0.04), had slightly smaller average aneurysm size (5.5 +/-0.13 vs 6.1 +/-0.17 cm, p=0.008), and had more patients designated American Society of Anesthesia class 4 (p<0.0001). Both groups were predominantly male. Otherwise there were no statistically significant differences in risk factors. Patients who underwent fast-track repair tended to have a longer operation (216 +/-7.4 vs 158 +/-6.8 minutes, p<0.0001), with a greater volume of blood (1.8 +/-0.29 vs 0.32 +/-0.24 units, p=0.0005), colloid (565 +/-89 vs 32 +/-22 cc, p<0.0001), and crystalloid transfusions (4,625 +/-252 vs 2,627 +/-170 cc, p<0.0001). There were no statistically significant differences in the number of intraoperative or postoperative complications between the 2 groups. EVAR patients resumed a regular diet earlier (0.21 +/-0.08 vs 1.8 +/-0.11 days, p<0.0001). Intensive care unit stay was shorter for EVAR (0.50 +/-0.10 vs 0.87 +/-0.10 days, p=0.01), but floor (2.1 +/-0.23 vs 2.6 +/-0.21 days, p=0.17), and total hospital lengths of stay (2.8 +/-0.32 vs 3.4 +/-0.18 days, p=0.07) were similar between the 2 groups. Total hospital cost was lower in the fast-track (10,205 dollars +/-736 dollars vs 20,640 dollars +/- 1,206 dollars, p<0.0001) leading to greater overall hospital earnings (6,141 dollars +/- 1,280 dollars vs 107 dollars +/- 1,940 dollars, p=0.01). Fast-track AAA repair is a viable alternative for the treatment of abdominal aortic aneurysms. Compared to endovascular repair, the fast-track method had increased transfusions of blood and intravenous fluids and increased operating room times, but equivalent lengths of floor and total hospital stay and increased total hospital earnings.     

Aspartate and glutamate-enriched cardioplegia in left ventricular dysfunction

BACKGROUND: The effects of exogenous L-aspartate and L-glutamate-enriched cardioplegia on postoperative left ventricular functions after coronary artery bypass surgery in patients with moderate left ventricular dysfunction (left ventricular ejection fraction [LVEF]= 30-40%) were studied. METHODS: In this prospective randomized study, 22 patients with moderate left ventricular dysfunction (mean LVEF = 37.27%+/- 3.43%), who underwent elective coronary artery bypass surgery, were examined. Isothermic substrate-enriched [L-aspartate and L-glutamate (13 mmol/L)] blood cardioplegia was used in 11 patients (Group AG), and cardioplegia including only potassium and sodium bicarbonate was used in 11 patients (Group C). All hemodynamic parameters for left and right heart were studied in both groups. Total perfusion time was 126.63 +/- 44.91 minutes versus 114.81 +/- 43.66 minutes (p = 0.54). The aortic cross-clamp time was 77.09 +/- 28.02 minutes versus 67.81 +/- 22.77 minutes (p = 0.4), respectively. The amount of cardioplegic solutions were 7218.2 +/- 3043.6 mL versus 5454.5 +/- 3048.1 mL (p = 0.167). Mean number of distal anastomosis were 3 +/- 0.89 versus 2.9 +/- 0.7 (p = 0.793). RESULTS: There was no difference between both groups in intra- and postoperative periods. In coronary sinus blood gas measures, myocardial acidosis caused by the aortic cross-clamp was found to be more severe in the Group C, but delta pH (0.12 +/- 0.14 vs. 0.092 +/- 0.058; p = 0.613) and delta lactate (1.39 +/- 1.03 vs. 1.62 +/- 0.85; p = 0.579) were similar in both groups. Free oxygen radical production caused by aortic cross-clamp was significant in the Group C. Not all myocardial enzymes, but Troponin-T levels were found higher in control group than the study group (0.6 +/- 0.36 vs. 0.36 +/- 0.25; p = 0.1). CONCLUSIONS: Although L-aspartate and L-glutamate favor myocardial metabolic functions, they do not have any affect on myocardial functional recovery in patients with moderate left ventricular dysfunction.     

The Impact of Introducing an Autologous Intraoperative Transfusion Device to a Community Hospital

The purpose of this study was to determine the benefits and disadvantages of transfusing autologous blood during abdominal aortic aneurysm (AAA) surgery at a district general hospital with an intraoperative autologous transfusion device (Haemoccel ABT 350). In this retrospective study, 128 patients underwent abdominal aortic aneurysm repair between 1992 and 1999 by a single vascular surgeon. Ninety-three patients (60 autologous and 33 allogeneic) had elective AAA repair (group A) and 25 patients (4 autologous and 21 allogeneic) had emergency AAA repair (group B). Nine group A patients (7.6%) received their own salvaged blood and no other allogeneic blood. Although the mean estimated blood loss was higher in the autologous group of patients (NS), the intraoperative autologous transfusion device did not significantly reduce allogeneic blood usage in patients who had autologous transfusion in both elective and emergency groups. There was no difference in postoperative hemoglobin and hematocrit, ICU stay or hospital stay. In this study, red cell salvage was significantly more expensive than blood bank usage (p < 0.0001), yet it did not significantly reduce the needs of allogeneic blood. We concluded that the intraoperative autologous transfusion device is underused, not cost-effective and requires formulation of local guidelines.     

Continuous autotransfusion during liver transplantation

The advantages and disadvantages of continuous autotransfusion during liver transplantation are investigated in our study compared with blood saving and traditional cell saving techniques. Patients were divided into three groups in this retrospective study; Group 1 (n = 14): continuous autotransfusion was applied; in Group 2 (n = 14): no blood saving technique used; in Group 3 (n = 14): Haemonetics cell saver was used. In Group 1 the number of Child B patients was significantly higher than Child C patients (p < 0.05). The initial values of haemoglobin were significantly lower in Groups 1 and 3 (89 +/- 19 vs. 103 +/- 17 vs. 90 +/- 16.8 g/l; p < 0.03). During hepatectomy in Group 1 lower haemoglobin values were detected than in the other two groups (96 +/- 7 vs. 104 +/- 16 vs. 106 +/- 16.6 g/l; p < 0.05). The quantity of total blood utilisation (donor + autotransfusion) was significantly higher in Group 3 than Group 2 and in Group 1 than Group 2 (21.06 +/- 11.2 vs. 11.07 +/- 3.8 vs. 30.71 +/- 18 U; p < 0.001). Comparing the values of ACT in each group during operation periods no significant difference was found. Treatment time on the ICU of the patients in Group 3 was significantly longer than in the other two groups (11.08 +/- 7.8 vs. 9.17 +/- 3.5 vs. 26.62 +/- 14.6 days; p < 0.03). We found that applying CATS is advantageous during liver transplantation, as the device reduces donor blood requirement. No significant complication was observed.     

Anaesthesia for endoluminal repair of abdominal aortic aneurysms

An audit of 100 patients undergoing elective abdominal aortic surgery either by open aortic repair (OAR group 50 patients) or endovascular aortic repair (EAR group 50 patients) was undertaken to document changes in anaesthetic technique and perioperative outcome. The data for the OAR group was collected retrospectively and thatfor the EAR group prospectively. Combined general anaesthesia and thoracic epidural anaesthesia was used in 44 of the OAR group whereas lumbar central neural blockade alone was used in 47 of the EAR group. The major differences between the two groups were that intraoperative blood loss was significantly less in the EAR group (OAR 1,674 +/- 1,008 ml, EAR 459 +/- 350 ml, P<0.001) and that no patient in the EAR group required admission to the Intensive Care Unit (ICU), whereas ICU time for the OAR patients was 29 +/- 22 hours. Hospital stay was also significantly different between the two groups (OAR 13 +/- 6 days, EAR 5 +/- 3 days, P<0.001). Major complications occurred in 20patients in the OAR group but only 4patients in the EAR group (P<0.001). EAR reduces blood loss, the requirement for ICU admission, and hospital stay. Central neural blockade is a satisfactory anaesthetic technique for EAR.     

Tranexamic acid reduces the need for allogenic red blood cell transfusions in patients undergoing total hip replacement

PURPOSE: This prospective randomized double-blind trial evaluates the efficacy of tranexamic acid (TA) to decrease blood losses and red blood cell transfusions in patients undergoing primary unilateral total hip replacement (THR). METHODS: Forty ASA class I to III patients received either iv TA 10 mg.kg(-1) bolus before surgery plus a 1 mg.kg(-1).hr(-1) infusion until wound closure (Group TA) or a placebo (Group P). Red blood cell transfusions were administered according to a standardized protocol. RESULTS: One patient of Group P was excluded because of an erroneous diagnosis at enrollment. Total measured blood losses (Group TA: 1308 +/- 462 mL vs Group P: 1469 +/- 405 mL), preoperative hemoglobin levels (Group TA: 130.4 +/- 12.5 g.L(-1) vs Group P: 131.4 +/- 12.8 vs g.L(-1)), and seven-day postoperative hemoglobin values (Group TA: 97.8 +/- 11.8 g.L(-1) vs Group P: 102.9 +/- 12.2 g.L(-1)) were similar. Autologous whole blood was available in five patients of Group P and seven patients of Group TA. Fewer patients in Group TA required red blood cells (Group TA: 6/20 vs Group P: 13/19; P = 0.026) and allogenic red blood cell transfusions (Group TA: 0/20 vs Group P: 8/19; P = 0.0012). The median number of transfused unit per patient was also significantly less in patients of Group TA (0 unit) than in Group P (2 units; P = 0.03). CONCLUSION: TA did not change measured blood losses but reduced red blood cell transfusion requirements in patients undergoing primary unilateral THR.     

Postoperative effects of low-dose intrathecal morphine in coronary artery bypass surgery

BACKGROUND: Intrathecal morphine has been used in hopes of providing long-lasting postoperative analgesia in patients after cardiac surgery. The aim of this study was to evaluate the effects of 7 micro/kg intrathecal morphine administration in coronary bypass surgery in the postoperative period. METHODS: We conducted a prospective, randomized, blinded, and controlled study. Twenty-three patients, who underwent primary elective coronary bypass surgery, were randomly allocated to receive morphine 7 micro/kg intrathecally, before the induction of general anesthesia (Group M, n = 12) or no intrathecal injection (Group C, n = 11). Pain scores, determined by visual analogue scale (VAS), were recorded immediately after extubation upon admission to the intensive care unit (ICU), at the 2nd, 4th, 6th, and 18th hour after extubation. Pethidine was administered if the patient's VAS > or = 4 and consumption was recorded. Extubation time and ICU length of stay were also recorded. RESULTS: VAS scores were lower in the Group M at each measured time than the control group (p = 0.016, 0.023, 0.004, 0.0001, and 0.001, respectively). According to the VAS scores, pethidine requirement was lower in the Group M than the control (p = 0.001). Extubation time (3.58 +/- 1.57 vs. 4.86 +/- 1.38 hours, p = 0.045) and ICU length of stay (16.25 +/- 2.70 vs. 19.30 +/- 2.45 hours, p = 0.014) were also significantly shorter in the Group M than the control group. No significant complications were seen in this group of patients. CONCLUSIONS: Intrathecal morphine provided effective analgesia, earlier tracheal extubation and less ICU length stay after on-pump coronary bypass surgery. The influence on ICU length of stay requires further evaluations.