Effects of predeposit and intentional perioperative haemodilution on blood saving program in major orthopaedic surgery.

In this study we evaluated the effects of predeposit and intentional perioperative haemodilution on a blood saving program in major orthopaedic surgery. We demonstrated that autologous blood phlebotomy and maintenance of optimal levels of perioperative haemodilution by delaying blood transfusion, even autologous, are efficient techniques in reducing homologous, red blood cell (HRBC) transfusion. Patients who received autologous red blood cell (ARBC) or HRBC more than one day after surgery, while having Hb values <8 g/dl, are less at risk of needing the first or additional HRBCs. In conclusion, predeposit and intentional haemodilution obtained by delaying blood transfusions, even autotransfusional, is a correct way of conducting a blood saving program (BSP) in major orthopaedic surgery. These techniques are clinically effective in avoiding or reducing HRBC transfusion.     

Blood transfusion practices--a case study

Blood transfusion practices of the treating doctors in a district hospital in Haryana were studied through retrospective study of blood bank records for the years 1992 to 1994 and interview of the clinicians of various specialities in the hospital. It was found that utilization of the whole blood was 90%, 89% and 81% respectively of the total blood units utilized during this period. Single unit transfusions out of the total transfusions done were 87% in 1992 and 1993 while these were 89.9% in 1994. Blood was often requested for volume replacement in acute haemorrhage. Only homologous blood transfusions were done at the hospital. This study has highlighted that there is scope for improvement of blood transfusion practices by strictly following the indications for use of blood, promoting the preparation and use of blood components, use of plasma expanders for acute blood loss, avoiding single unit transfusions and promoting the use of autologous blood during routine surgery.     

Transfusion associated graft versus host disease in an immunocompetent individual following coronary artery bypass grafting

Transfusion associated graft versus host disease (TA-GVHD) is a rare but commonly fatal complication of transfusion of cellular blood products, which usually occurs in immunosuppressed individuals following transfusion and subsequent engraftment of viable T lymphocytes. Very rarely it may arise in apparently immunocompetent individuals. The clinical syndrome consists of fever, skin rash, diarrhoea, hepatic dysfunction, and bone marrow aplasia. The outcome is nearly always fatal. We present here a case report of fatal TA-GVHD in a “presumed” immunocompetent patient, post coronary artery bypass grafting surgery after transfusion of blood products. The patient died 24 days after transfusion.There is a perceived increased risk of TA-GVHD following bypass grafting and other surgical procedures where cardiopulmonary bypass is required. TA-GVHD is probably underreported and the incidence is felt to be too low to warrant routine irradiation of cellular products for this group of patients. Clinicians, pathologists, and transfusion centers should be aware of this rare but devastating complication of blood transfusion after cardiac surgery.     

非体外循环冠状动脉旁路移植治疗高危冠心病的评价

背景：非体外与体外循环冠状动脉旁路移植是治疗冠状动脉粥样硬化性心脏病的外科学方法,但目前尚无二者对高危冠心病患者疗效比较的系统评价。 目的：通过Meta分析评价非体外与体外循环冠状动脉旁路移植对高危冠心病患者围手术期的疗效和安全性差异。 方法：计算机检索PubMed、EMbase、中国期刊全文数据库、中国生物医学文献数据库、维普数据库、万方数据库和Cochrane Library(2012年第8期),并辅以检索相关文献的参考文献,语种限制为中文和英文,检索时间为1993年1月至2012年6月。严格按照纳入和排除标准进行筛选研究。由2位评价员独立对纳入的研究进行质量评价与提取资料并交叉核对,最后将提取的资料用RevMan 5.1软件进行数据处理与分析。 结果与结论：共纳入16个研究包括2个随机对照试验与14个观察性研究;共6 441例患者,其中非体外循环冠状动脉旁路移植组2 948例患者,常规体外循环下冠状动脉旁路移植组3 493例患者。Meta 分析结果显示：非体外循环冠状动脉旁路移植与常规体外循环下冠状动脉旁路移植比较,在围手术期脑卒中、主动脉内球囊反搏使用、再发心肌梗死、呼吸功能不全与死亡率,呼吸机辅助时间、ICU时间、住院时间,输血量及术后引流量方面的差异均有显著性意义,而在房颤、急性肾功能损伤、伤口感染及二次开胸率方面的差异均无显著性意义。结果提示,在围手术期方面与常规体外循环下冠状动脉旁路移植相比,对高危冠心病患者采用非体外循环冠状动脉旁路移植是安全有效的,且具有创伤少,手术死亡率低,术后恢复快,术后并发症少的优点,但是由于纳入文献数量有限且大多为非随机对照试验,因此非体外循环冠状动脉旁路移植并不能取代常规体外循环下冠状动脉旁路移植,其具体疗效与中远期疗效需要进一步通过更高质量、大样本量、多中心的随机双盲对照试验研究及长期的观察才能得出肯定的结论。     

Delayed autologous transfusion: about 70 surgical patients at the Saint-Jean-de-Dieu Hospital in Afagnan, Togo

This prospective study was conducted from 2000, September the 1st to October the 31st, at the Saint-Jean-de-Dieu Hospital in Afagnan (Togo). All the 75 patients who received indication of autologous blood transfusion (ABT) accepted the protocol; 70 out of them, among whom 63% were female, benefited an ABT The age of the patients varies between 13 and 80 years old (average 33.2). Initial rate of haemoglobin was on average of 11.7 g/dl; 14% of these patients had a haemoglobin diseases. The most frequent interventions were hysterectomies (21%), bone surgery (16%), prostatectomies (11). Only one blood unit was taken from 63 patients and two units from the 7 others inducing giddiness (5) and headaches (1). During intra and postoperative periods, 41 patients were given 45 units of blood (use rate: 58%). The percentage of patients who received transfusion was 56% in gynaecological surgery 79% in orthopaedics and 88% in urology. Only one patient received an additional homologous unit of blood. The rate of haemoglobin was on average 10.2 g/dl the day after surgery. No incident in connection with the ABT was recorded. The ABT is a feasible, effective and secure method in the context of a small African hospital. It may be a solution to the problems of shortage of blood products and transfusion safety. Training and motivation are necessary for its successful implementation.     

Minimal cardiopulmonary bypass attenuates neutrophil activation and cytokine release in coronary artery bypass grafting

The minimal cardiopulmonary bypass (mini-CPB) circuit, a closed system with neither cardiotomy suction nor an open venous reservoir and thus no air–blood interface, reportedly reduces blood loss and inflammatory reactions associated with coronary bypass surgery. We evaluated the inflammatory reactions in patients in whom coronary bypass operations were performed with conventional CPB or mini-CPB (n = 15 each). Interleukin (IL)-6, IL-8, and neutrophil elastase levels; the neutrophil count; and the C-reactive protein value were measured before and immediately after surgery and on postoperative days 1 and 2. In addition, intraoperative blood loss and the transfusion volume were evaluated in these groups. Neutrophil elastase levels were lower in the mini-CPB group than in the conventional group on postoperative days 1 (127 ± 52 vs. 240 ± 100 μg/l, P = 0.013) and 2 (107 ± 17 vs. 170 ± 45 μ/l, P = 0.0001), as was the IL-8 level on postoperative day 1 (8.3 ± 6.4 vs. 19 ± 11 pg/ml, P = 0.016). The intraoperative blood loss and transfusion volumes were significantly lower in the mini-CPB group than in the conventional group (510 ± 244 vs. 1046 ± 966 ml, P = 0.012, and 691 ± 427 vs. 1416 ± 918 ml, P = 0.0033). Thus, mini-CPB appears to attenuate neutrophil activation and cytokine release after coronary bypass surgery and, in addition, has some beneficial effects on blood conservation.     

Prevalence of HBV, HCV, HIV and HTLV in autologous blood donors in France between 1993 and 2000]

The epidemiological surveillance of autologous blood donors has been carried out in France since 1993. The number of autologous donors increased regularly from 1993 to 1997 but has decreased during the last three years to become less than 50,000 in 2000. The sex-ratio was stable over time (0.85 male for 1 female). The population of autologous donors grew older between 1993 and 2000: the proportion of those aged under 50 years old decreased from 29% in 1993 to 18% in 2000 while the proportion of those over 69 increased from 22 to 34%. Between 1993 and 2000, HbsAg prevalence decreased by a factor of 2.5 and HCV prevalence by a factor of 5. For HIV, a slight decrease was observed and the prevalence of HTLV was stable over time. In 2000, HCV prevalence (0.23%) was two times higher than HBsAg prevalence (0.12%), fifteen times higher than HTLV prevalence in Continental France (0.015%) and one hundred times higher than HIV prevalence (0.002%). The prevalence was similar in men and women for HCV, about two times higher in men than in women for HBsAg and three times higher for HIV. On the contrary, HTLV prevalence was about two times higher in women than in men. HBsAg and HCV prevalence rates were also calculated by age group. The prevalence rates for HBsAg increased up to the 30-39 age group among women and the 40-49 age group among men; then the rates decreased but were higher in men than in women. For HCV, while the prevalence increased continuously with age among women, a peak was reached for men in the 30-39 age group followed by a decrease up to the 50-59 age group and the prevalence was stable afterwards. The very low level of the current risk of transmitting viral infections by homologous transfusion and technical changes in autologous transfusion seem to be the two main factors that contributed to the recent decline in the number of autologous donors. The decrease in HBsAg and anti-HCV prevalence between 1993 and 2000 is multifactorial, but the drop observed for HCV is probably linked to a decrease in HCV prevalence of the general population over the last ten years.     

Exposure of procoagulant phospholipids on the surface of platelets in patients undergoing cardiopulmonary bypass using non-coated and heparin-coated extracorporeal circuits

Cardiopulmonary bypass (CPB) is associated with a generalized hemostatic defect, in which platelet dysfunction seems to play a central role. The present study was designed to elucidate whether the potential procoagulant activity of platelets, detected as annexin V binding, was altered during coronary bypass surgery, using non-coated and heparin-coated extracorporeal circuits. Thirty patients undergoing elective coronary artery bypass grafting were prospectively randomized using either a standard untreated extracorporeal circuit (n = 15) or a heparin-treated extracorporeal circuit (n=15). Besides measurement of the procoagulant phospholipid activity, the mediastinal blood loss after surgery, and the blood transfusion requirements were also monitored. CPB induced a decrease in the percentage of activated platelets in whole blood, manifest directly after start of CPB, which was significantly attenuated using a non-treated system. Postoperatively, the percentage of activated platelets recovered in both systems, reaching a point of significance 24 hours after the operation, compared to the values 2 hours after the operation. The differences among the groups for mediastinal blood loss during the first 2 and 24 postoperative hours coincided with the differences in procoagulant phospholipid activity. Furthermore, there was no statistical difference among the groups for blood transfusion requirements. The platelets in both groups showed a significantly lower ability to generate ionomycin-induced procoagulant activity after blood-material interaction when compared to the baseline values. These observations are compatible with the notion that during CPB, irrespective of the heparin coating, platelets become modestly activated.     

Atrial fibrillation, blood loss, and transfusion in patients with left ventricular dysfunction: what is the effect of cardiopulmonary bypass?

Despite advancements in surgical technique, intensive care methods and pharmaceutical prophylaxis atrial fibrillation (AF) after on-pump coronary artery bypass remains common. Transfusion, blood loss, and cardiopulmonary bypass (CPB) have been identified as risk factors for AF and adverse outcomes such as early mortality. This study examines outcomes in patients with left ventricular dysfunction after revascularization with and without CPB. A systematic literature review identified 22 studies including 7,454 patients. Meta-analysis through subgroup analysis of the highest-quality studies revealed that the off-pump coronary artery bypass (OPCAB) technique is associated with a significantly lower incidence of blood loss, transfusion requirement, reoperation for bleeding, and length of stay. There was also a reduction in the incidence of AF in the OPCAB group but this was not statistically significant (odds ratio = 0.77, 95% confidence interval 0.58-1.02, p = 0.07). The results strengthen research suggesting that CPB has a damaging effect on hemostasis and subsequent transfusion requirements in this patient group. More research is required to assess the association between OPCAB and AF in patients with ventricular dysfunction.     

A new technique for hemodilution, preparation of autologous platelet-rich plasma and intraoperative blood salvage in cardiac surgery

We have developed a new system for the production of autologous platelet-rich plasma and red blood cell concentrates to be used in autologous transfusion support of cardiac surgery patients. In 15 operations no homologous blood products were required. Costs were diminished since with the same harness it was possible to carry out the intraoperative blood salvage and concentrate the erythrocytes contained in the oxygenator and its lines. Indirect costs were also reduced since no infective complication was observed due to homologous blood products.     

Aspects périopératoires de la transfusion sanguine en pédiatrie

In pediatric elective surgery, the main indications of blood transfusion are cardiac surgery, neurosurgery and abdominal tumors. Blood saving techniques are also available. The transfusion threshold has to take into account the physiological age-related particularities. Underestimation of blood loss and delayed transfusion are associated with a severe morbidity. In the absence of specific literature, the management of hemorrhagic shock is based on extrapolation of the adult recommendations.     

Cardiopulmonary bypass techniques and clinical outcomes in Beijing Fuwai Hospital: a brief clinical review

The purpose of this study is to briefly summarize cardiopulmonary bypass (CPB) techniques and clinical outcomes in Beijing Fuwai Hospital. This article introduces routine CPB techniques in Fuwai Hospital, including CPB instruments, circuit setup, priming, conventional CPB management, myocardial protection, deep hypothermic circulatory arrest, ultrafiltration, autologous cell saver blood transfusion, and extracorporeal membrane oxygenation (ECMO). Clinical outcomes and further improvements of CPB management are also discussed. In 2008, 7,607 cases of cardiac surgery were performed in Fuwai Hospital, including congenital heart disease (48.33%), coronary artery disease (23.30%), rheumatic heart disease (19.45%), blood vessel disease (5.90%), reoperative surgery (1.70%), and other diseases (1.33%). The use of off-pump coronary artery bypass grafting (CABG) in isolated CABG was >50%. Thirty-eight cases of heart transplantation were also included. Total operative mortality in 2008 was 1.2%. Average postoperative stay was 9.5 days. CPB time was <120 minutes in >70% of the patients, and aortic cross-clamping time was <60 minutes in >50% of the cases. The self-recovery rate in the blood cardioplegia group (69.50%) was lower than the crystalloid cardioplegia group (97.40%). Thirty-five patients underwent cardiac surgery, and one patient from the cardiac internal medicine wards required ECMO support. Twenty-seven patients (75%, mean support time: 123.6 ± 54.1 hours) were weaned off ECMO successfully and discharged without severe complications. In conclusion, clinical CPB protocol used in Beijing Fuwai Hospital is a safe, simple, and conventional CPB management system that is suitable for practical clinical application in China. Further optimization is still needed to improve perfusion quality.     

Catheter dilatation of coronary artery stenosis. 2 years' experience

We report our experiences with the first 40 patients treated by percutaneous transluminal coronary angioplasty (PTCA) over the past two years. The technique was successful in 25 patients (63%) with 28 coronary stenoses, reducing the degree of stenosis from a mean of 81 to 25% (p less than 0.001) and the coronary pressure gradient from 70 to 26 mm Hg (p less than 0.001). Because of reduction of coronary blood flow with evolving myocardial infarction an emergency aortocoronary bypass surgery was necessary in two patients (5%). An additional patient suffered a myocardial infarction (2.5%). Within a follow-up observation of 6 months, restenoses occurred in 7 patients (33%); 5 of them were treated with bypass surgery and one was redilated successfully. Our first experiences with PTCA are similar to the results of other institutions.     

A comparison of autologous and homologous transfusions in spinal fusion

Autologous transfusion has been used to overcome adverse effects of homologous transfusion. Clinical studies evaluating general orthopaedic postoperative results have been designed to compare these transfusion methods. However, few studies have evaluated postoperative results in spinal fusion surgeries, which have larger blood loss volumes. The purpose of this study is to determine if there are differences in postoperative infection and clinical results of spinal fusion with autologous, as compared to homologous, blood transfusion. A total of 62 patients who underwent instrumented spinal fusion and received autologous (n = 30) or homologous (n = 32) transfusions were reviewed. Information on gender, age, preoperative and 3-day postoperative hematologic features, total transfused units, segmental estimated blood loss, transfused units, and surgery time were collected. In addition, postoperative infection data on wound infection, pneumonia, urinary tract infection, cellulitis, and viral disease, incidence and duration of fever, as well as clinical results, fusion rates, and patient feedback were collected. No differences in postoperative infection and clinical results were found between the two types of transfusions; however, homologous transfusion was associated with an increased number of total units transfused, longer duration of fever, and decreased patient satisfaction regarding the transfusion.     

Transfusion-associated graft-versus-host disease in an immunocompetent individual following cardiac surgery

A 65-year-old man underwent coronary artery bypass graft surgery at our tertiary care hospital. Perioperatively, he was transfused with four units of nonirradiated whole blood from first-degree relatives and discharged from the hospital at postoperative day seven. He presented six days later with fever, skin rash, elevated liver enzymes, and progressive pancytopenia. Elevated bilirubin levels and diarrhea were added to the clinical picture over the following days. Clinical findings and results of a skin biopsy specimen were consistent with transfusion-associated graft-versus-host disease. The patient died 20 days after transfusion.     

How do I/we forecast tomorrow’s transfusion? A focus on recipients’ profiles

Red blood cell (RBC) transfusion is a life-saving medical intervention and has an essential role in the management of surgical patients. However, blood donations and supply levels are decreasing, therefore there is an unmet need for the accurate prediction of the transfusion probability for surgical patients. Multiple methods have been established to predict the need for RBC transfusion. Maximum surgical blood order schedules are widely used in the clinical setting. However, these lists are not designed to accurately predict RBC utilization for an individual case as factors such as preoperative haemoglobin level, total body blood volume, comedications are not considered. Artificial intelligence and related technologies based on machine learning modelling are valuable alternatives to predict transfusion probability taking into account patient individual risk factors including among others comorbidities, laboratory parameters, use of oral anticoagulation, ASA score, surgeon’s ID or applied blood saving measures. Overall, forecasting the need for a RBC transfusion can facilitate personalized medicine, quality assurance, decrease blood wastage, decrease costs, and increase patient safety. Furthermore, transfusion prediction models could facilitate blood management strategies before surgery.     

The issues in autologous transfusion

Autologous transfusion should be recognized by patients and physicians as an important measure to provide safer transfusion therapy. This should be suggested to patients in general good health (who are not obviously frail) who have no significant medical problems and no likelihood of severe reaction, who can take iron supplements, and who have at least a 10% chance of using blood during surgery or are having surgery in which the average use is one or more units. Such patients should receive iron supplementation beginning 1 week before the first autologous donation, and should donate one to five units on a weekly basis, but no more frequently than every 72 hours, with their last unit donated 72 hours before surgery. Elderly individuals may donate if the risk of donor reaction seems low. In children and adults, the amount of blood removed should be reduced in proportion to the blood volume if the individual does not meet the standard weight of 50 kg for a 450-mL donation. "Fail-safe" identification systems should be used; these will insure that the correct donor/patient receives the transfusion. Processing of the units is preferred but still optional. Use of these units as homologous units should not be done unless the donor has a hematocrit level acceptable to an autologous donor, meets all the criteria for recipient safety, the unit is processed and negative for all viral markers, and the donor has recently (eg, within 3 years) participated in the volunteer donor program. The unit should be transfused to the patient in situations in which homologous blood would be indicated. Safeguards to prevent volume overload are needed when the unit is stored as whole blood. Future research objectives should include the use of recombinant erythropoietin to prevent donation-induced anemia, delineation of medical conditions which should contraindicate the donation, and determination of the real costs involved in autologous transfusion. Education of the general public, patients, and physicians about the desirability of autologous transfusion should proceed. Third-party carriers also need to be educated about the cost implications and the need to pay for this activity. However, such education should also stress that autologous units will only cover planned, elective surgery and that major blood needs for emergency surgery, trauma, and chronic transfusion will still need to be met by homologous blood from altruistic community blood donors.     

Required laboratory examination and blood transfusion therapy in massive hemorrhage during surgery

Massive hemorrhage during surgery often results from diluted coagulopathy due to loss of coagulation factors (e.g., fibrinogen), especially in cases of thoracic aortic aneurysm and liver transplantation. The most important issue in preventing massive hemorrhage during surgery is transfusion therapy for hemostasis. When massive hemorrhage occurred in cases of the above surgery, we measured the fibrinogen level in plasma, and administered cryoprecipitate or fibrinogen concentrate to the patient when the fibrinogen level was below 150 mg/dL. The hemostatic efficacy of this treatment was evaluated by counting volume of blood loss and number of transfusion units in comparison with cases of conventional treatment with fresh frozen plasma. We observed a rapid increase in plasma fibrinogen level and subsequent improvement in hemostasis after cryoprecipitate or fibrinogen concentrate was administered. The average blood loss decreased by 30% and the average number of transfusion units was reduced about 30 to 60% when those agents were given to patients with severe hypofibrinogenemia during surgery. The number of cases of early death due to massive hemorrhage during surgery decreased by 75% when cryoprecipitate or fibrinogen concentrate was used. Thus, in patients showing hypofibrinogenemia (i.e., <150 mg/dL) during surgery, administration of cryoprecipitate or fibrinogen concentrate should be effective in establishing hemostatsis, and therefore in reducing blood loss and number of transfusion units. This treatment should help to improve the prognosis of patients in surgery, and also to decrease the use of blood products.     

Usefulness of low prime perfusion pediatric circuit in decreasing blood transfusion

We tested the efficiency of small prime volume in decreasing the blood requirement during pediatric cardiac surgery. This is a retrospective analysis of transfusion in 259 consecutive patients weighing <15 kg. We downsized the bypass circuit and avoided noncritical components to obtain a cardiopulmonary bypass prime volume, including a cardioplegia circuit of 140 ml for patients up to 6 kg, and of 170 ml for those weighing 6-15 kg. For intra- and postoperative care, transfusions were limited to 1 unit of packed red blood cells and 1 unit of fresh frozen plasma in 129 of the 134 patients weighing <6 kg. Seventy-six of 125 (61%) patients who were between 6 kg and 15 kg had bloodless surgery. None of the 259 patients had platelets infusion. In transfused cases, only eight patients (3%) needed more than two different donor products. In bloodless cases, hemoglobin values were 11.5 +/- 1.8 g/dl before, 9.4 +/- 1.7 g/dl during, and 10.5 +/- 1.8 g/dl after surgery. No adverse effects of this procedure were encountered. Small prime volume is efficient and safe in decreasing blood use in pediatric surgery.     

Preoperative autologous blood donation in 612 hospitals. A College of American Pathologists' Q-Probes study of quality issues in transfusion practice.

We compared predeposit autologous blood utilization practices in 612 hospitals (where 107,559 autologous and 2,504,522 homologous units were transfused in all of 1989). Participating blood bankers prospectively followed up donors who presented for initial donation during an 11-week period in early 1990. They recorded the number of autologous donors whose blood was drawn (n = 22,276); units that were donated (n = 40,163), transfused (n = 23,988), crossed over (n = 937), and discarded (n = 15,443); and donors transfused with autologous blood only (n = 11,923) or donors who received homologous blood (n = 2002). Most donors (89.7%) avoided homologous blood, including donors (39.5%) who did not require transfusion. Units that were donated for low-risk surgery represented 23.1% of all units that were collected, and the rate of donation for these procedures was directly proportional to the percentage of donors who did not require transfusion and to the discard rate. We concluded that a major focus of quality improvement in autologous transfusion practice should be the reduction of donations for surgical procedures for which blood replacement is rarely needed.