Autologous blood transfusion in elective heart surgery: prospective study of 189 consecutive patients

Blood autotransfusion has entered a new phase in blood transfusion technique, since it represents an important alternative in eliminating the risks connected with blood transfusion: viral hepatitis, AIDS, blood transfusion reactions, and alloimmunization. Transfusion requirements during cardiac surgical procedures have steadily decreased; nowadays most adult patients require no transfusion during surgery. Patients (pts) receiving bank-blood may develop infectious diseases (hepatitis, AIDS, etc.). We have studied how to avoid the risk of infections with homologous blood transfusions. We present our experience of day-hospital pre-operative autologous blood collection. One-hundred-eighty-nine patients undergoing primary myocardial revascularization or valvular replacement were submitted to the drainage of 350 ml of blood three times every four days before surgery. The blood was centrifuged at once, to separate red cells from plasma. Surgeries were performed 21 days after the first drainage; iron therapy was recommended. After surgery pts received blood only if haematocrit was lower than 28%. The following data were recorded: no. of pts who received homologous blood; blood loss and homologous total blood volume used for each pt. Average blood loss was 1230 cc for ischemic pts and 701 cc for valvular pts. Non-A non B hepatitis occurred in 3/189 pts (1.5%). All of them had received homologous blood transfusions. Our data show clearly that autotransfused pts had a better post-operative period; less bank-blood and fewer transfusions have been used. No pt had collateral effects such as angina or hypotension from blood drawing. Our data show that severe cardiac diseases do not represent an absolute contraindication to heavy blood drainage.(ABSTRACT TRUNCATED AT 250 WORDS)     

Advantages and limits of programmed autologous transfusion in cardiovascular surgery. Apropos of 524 patients]

Between October 1987 and July 1989, 544 patients, candidates for cardiovascular surgery, were included in a trial of programmed autologous autotransfusion. Five hundred and twenty four patients underwent one or several (maximum 4) blood donation sessions in the 3 weeks before surgery with no complications. Overall, 57% of patients benefited from homologous blood transfusion, thereby avoiding all risk of contamination. It was in the group of patients able to undergo 3 or 4 preoperative blood donations that we observed the smallest number of homologous transfusions (30%). Programmed autologous transfusion would seem to be a very useful technique for cardiac surgery, allowing a reduction in health care costs without additional patient risk. In order to improve on this method, it may be useful to associate a peroperative technique of blood recuperation in patients in whom the transfusion needs are likely to exceed the possibilities of preoperative blood donation alone.     

Perfusionist strategies for blood conservation in pediatric cardiac surgery

There is increasing concern about the safety of homologous blood transfusion during cardiac surgery, and a restrictive transfusion practice is associated with improved outcome. Transfusion-free pediatric cardiac surgery is unrealistic for the vast majority of procedures in neonates or small infants; however, considerable progress has been made by using techniques that decrease the need for homologous blood products or even allow bloodless surgery in older infants and children. These techniques involve a decrease in prime volume by downsizing the bypass circuit with the help of vacuum-assisted venous drainage, microplegia, autologous blood predonation with or without infusion of recombinant (erythropoietin), cell salvaging, ultrafiltration and retrograde autologous priming. The three major techniques which are simple, safe, efficient, and cost-effective are: a prime volume as small as possible, cardioplegia with negligible hydric balance and circuit residual blood salvaged without any alteration. Furthermore, these three techniques can be used for all the patients, including emergencies and small babies. In every pediatric surgical unit, a strategy to decrease or avoid blood bank transfusion must be implemented. A strategy to minimize transfusion requirement requires a combined effort involving the entire surgical team with pre-, peri-, and postoperative planning and management.     

Preliminary reports of autologous blood transfusion in a plastic surgery unit

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

Surgery and anesthesia in sickle cell disease. Cooperative Study of Sickle Cell Diseases

From 1978 to 1988, The Cooperative Study of Sickle Cell Disease observed 3,765 patients with a mean follow-up of 5.3 +/- 2.0 years. One thousand seventy-nine surgical procedures were conducted on 717 patients (77% sickle cell anemia [SS], 14% sickle hemoglobin C disease [SC], 5.7% S beta zero thalassemia, 3% S beta zero + thalassemia). Sixty-nine percent had a single procedure, 21% had two procedures, and the remaining 11% had more than two procedures during the study follow- up. The most frequent procedure was abdominal surgery for cholecystectomy or splenectomy (24% of all surgical procedures, N = 258). Of these, 93% received blood transfusion, and there was no association between preoperative hemoglobin A level and complication rates (except reduction in pain crisis). Overall mortality within 30 days of a surgical procedure was 1.1% (12 deaths after 1,079 surgical procedures). Three deaths were considered to be related to the surgical procedure and/or anesthesia (0.3%). No deaths were reported in patients younger than 14 years of age. Sickle cell diseases (SCD)-related complications after surgery were more frequent in SS patients who received regional compared with general anesthesia (adjusted for risk level of the surgical procedure, patient age, and preoperative transfusion status, P = .058). Non-SCD-related postoperative complications were higher in both SS and SC patients who received regional compared with those who received general anesthesia (P =.095). Perioperative transfusion was associated with a lower rate of SCD- related postoperative complications for SS patients undergoing low-risk procedures (P = .006, adjusted for age and type of anesthesia), with crude rated of 12.9% without transfusion compared with 4.8% with transfusion. In SC patients, preoperative transfusion was beneficial for all surgical risk levels (P = .009). Thus, surgical procedures can be performed safely in patients with SCD.     

Effect of erythropoietin therapy in cardiac surgery using autologous blood transfusion

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

Predictors of homologous blood transfusion for patients undergoing open heart surgery

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

Perioperative handling of patients on antiplatelet therapy with need for surgery

The widespread use of metal stents and drug-eluting stents has shown the extent to which patients with unstable coronary perfusion depend on antiplatelet drugs, and how their risk of late thrombosis depends on the long-term use of agents such as clopidogrel. It has also been shown that the risk of surgical bleeding, if antiplatelet drugs are continued, is lower than that of coronary thrombosis if they are withdrawn. Thus, except for low-risk settings, the practice of withdrawing antiplatelet drugs 5–10 days prior to surgical procedures should be changed. The following suggestions are meant to provide a guideline in this respect. Most of the current surgical procedures may be performed while on low-dose aspirin treatment. Except when bleeding may occur in closed spaces (e.g. intracranial surgery, spinal surgery in the medullary canal, surgery of the posterior chamber of the eye) or where excessive blood loss is expected, where only clopidogrel should be discontinued; in all other cases the surgical procedures should be carried out in the presence of dual antiplatelet agents (if prescribed). Aspirin may be discontinued only in subjects at low risk of thrombosis, and at high risk of intraoperative bleeding. Operations associated with an expected excessive blood loss should be postponed unless vital. When prescribed for acute coronary syndrome or during stent re-endothelialization, clopidogrel should not be discontinued before a noncardiac procedure. For elective procedures, surgery should be postponed until the end of the indication for clopidogrel. After the operation, clopidogrel should be resumed within the 12–24 h. Cardiac procedures should be postponed for at least 4 days after clopidogrel withdrawal. The thrombotic risk of preoperative withdrawal of antiplatelet drugs overwhelms the benefit of regional or neuraxial blockade. Antiplatelet treatment replacement by heparin or low-molecular weight heparin does not provide protection against the risk of coronary artery or stent thrombosis. Haemostasis requires that at least 20% of circulating platelets have a normal function. As the effects of antiplatelet agents are not reversible by other drugs, fresh platelets are the only manner to rapidly restore normal haemostasis. Aprotinin decreases postoperative bleeding and transfusion rates in patients undergoing CABG and on clopidogrel during the days preceding surgery.     

Peroperative blood autotransfusion in heart surgery]

A drastic reduction in homologous blood or plasma transfusion becomes necessary to prevent the risks of severe infections disease transmission. The authors studied the possibility of homologous blood save in cardiac surgery by peroperative autotransfusion. This procedure, although it diminished the average blood bank requirements, above all for an unexplained decrease in postoperative bleeding, did not obtain the good results that other authors had with the technique of 2 or 3 preoperative withdrawal, storage and postoperative reinfusion. In future our trend is to associate preoperative and intraoperative withdrawals to take advantage of both techniques.     

Feasibility of a Predeposit Autologous Blood Donation Program in Colorectal Cancer Patients: Results from a Randomized Clinical Study

The hematologic and transfusion data of a multicenter randomized trial investigating the effect of blood transfusions on the 5-year survival were used to study the feasibility of an autologous blood donation program in colorectal cancer patients. Three hundred and ten patients were randomized for autologous blood transfusions (predeposition of 2 units) or homologous blood transfusions, and transfusion rules were standardized. The Hb level in the patients who donated blood decreased by 20.1 +/- 1.3 g/l (mean +/- SEM) preoperatively and 4.5 +/- 1.8 g/l postoperatively, and in controls 3.7 +/- 1.1 g/l and 16.5 +/- 1.9 g/l (significantly different between the two groups, both pre- and postoperatively: p less than 0.01). Because blood loss and number of transfusions were similar in both groups, this indicated that either preoperative or postoperative erythropoiesis is stronger in patients who had donated blood. Twenty-three percent of the autologous patients and 61% of the homologous patients were exposed to homologous blood. The effectiveness of the procedure differed per tumor localization. In patients with a right-sided colon carcinoma, 22% of the control patients needed homologous blood, compared to 10% of the autologous patients. In patients with other colon carcinomas, this was 52 and 16%, respectively, and in patients with a rectal carcinoma 85 and 41%. We conclude that predeposition of 2 units of blood for colorectal cancer surgery is feasible and useful to prevent homologous blood usage in a significant number of patients with left colon carcinoma or rectal carcinoma.     

Blood loss,predictors of bleeding,transfusion practice and strategies of blood cell salvaging during liver transplantation

Blood loss during liver transplantation (OLTx) is a common consequence of pre-existing abnormalities of the hemostatic system,portal hypertension with multiple collateral vessels,portal vein thrombosis,previous abdominal surgery,splenomegaly,and poor "functional" recovery of the new liver.The intrinsic coagulopathic features of end stage cirrhosis along with surgical technical difficulties make transfusion-free liver transplantation a major challenge,and,despite the improvements in understanding of intraoperative coagulation profiles and strategies to control blood loss,the requirements for blood or blood products remains high.The impact of blood transfusion has been shown to be significant and independent of other well-known predictors of posttransplant-outcome.Negative effects on immunomodulation and an increased risk of postoperative complications and mortality have been repeatedly demonstrated.Isovolemic hemodilution,the extensive utilization of thromboelastogram and the use of autotransfusion devices are among the commonly adopted procedures to limit the amount of blood transfusion.The use of intraoperative blood salvage and autologous blood transfusion should still be considered an important method to reduce the need for allogenic blood and the associated complications.In this article we report on the common preoperative and intraoperative factors contributing to blood loss,intraoperative transfusion practices,anesthesiologic and surgical strategies to prevent blood loss,and on intraoperative blood salvaging techniques and autologous blood transfusion.Even though the advances in surgical technique and anesthetic management,as well as a better understanding of the risk factors,have resulted in a steady decrease in intraoperative bleeding,most patients still bleed extensively.Blood transfusion therapy is still a critical feature during OLTx and various studies have shown a large variability in the use of blood products among different centers and even among individual anesthesiologists within the same center.Unfortunately,despite the large number of OLTx performed each year,there is still paucity of large randomized,multicentre,and controlled studies which indicate how to prevent bleeding,the transfusion needs and thresholds,and the "evidence based" perioperative strategies to reduce the amount of transfusion.     

Reduction of homologous blood requirement in cardiac surgery by intraoperative aprotinin application--clinical experience in 152 cardiac surgical patients

The protease inhibitor aprotinin interacts with plasmin and kallikrein, which are generated in cardiac surgery during cardiopulmonary bypass (CPB). The influence of high-dose aprotinin application (2 million kallikrein inactivator units given i.v. at the beginning of anaesthesia followed by a 500,000 KIU/h infusion throughout the operation and additional 2 millions KIU added to the priming of the oxygenator) on perioperative blood loss and donor blood requirement was studied in 152 adult cardiac surgical patients. This group was compared to 317 patients having cardiac surgery without the application of aprotinin. Aprotinin reduced the homologous blood requirement by 43% (1783 +/- 100 vs 1015 +/- 131 ml, p less than 0.05), while the reduction of postoperative blood loss was 29% (1070 +/- 43 vs 761 +/- 51 ml, p less than 0.05). Fortytwo percent of the aprotinin treated patients completed their hospital stay without having any donor blood transfusion compared to 18% in the group without aprotinin. The blood saving effect was even more pronounced in operations with prolonged perfusion times. Intra- and postoperative complications were equally distributed in both groups. The blood-saving effect of aprotinin may be due to a platelet-preserving effect and/or kallikrein inhibition during CPB. There were no clinically relevant side effects related to aprotinin observed. It is concluded that high dose aprotinin therapy reduces both postoperative blood loss and homologous blood requirement, and therefore the routine application of aprotinin during cardiac surgical procedures is to be recommended.     

Relationship of serotonergic antidepressants and need for blood transfusion in orthopedic surgical patients

BACKGROUND: Several reports of various bleeding problems associated with the use of serotonergic antidepressants have been published. However, no information concerning the effect of these drugs on perioperative blood loss and blood transfusion requirements during orthopedic surgery is available. The objective of this study was to determine the association between use of serotonergic antidepressants and perioperative blood loss and transfusion in orthopedic surgical patients. METHODS: A retrospective follow-up study, using routinely collected hospital and pharmacy data, was conducted among all orthopedic patients undergoing surgery from January 1, 1999, through December 31, 2000. The actual blood transfusion requirements and blood loss during surgery were assessed. Patients were divided into 3 groups for comparison: users of serotonergic antidepressants, users of nonserotonergic antidepressants, and nonusers of antidepressants. The Medical Ethics Committee approved the study protocol, and informed consent was obtained from all patients or their legal relatives. RESULTS: A total of 520 subjects with evaluable data participated in the study. The risk of blood transfusion almost quadrupled for the serotonergic antidepressant group as compared with the nonusers (adjusted odds ratio, 3.71; 95% confidence interval, 1.35-10.18). Patients using nonserotonergic antidepressants had no increased risk (odds ratio, 0.74; 95% confidence interval, 0.10-5.95). CONCLUSIONS: Use of serotonergic antidepressants is associated with an increased risk of bleeding and subsequent need for blood transfusion during orthopedic surgery. The bleeding could be attributed to inhibition of serotonin-mediated platelet activation.     

Identification of predictive factors for perioperative blood transfusion in colorectal resection patients

Background Blood transfusion is associated with higher postoperative complication. With the availability of autologous blood and erythropoietin, it would be advantageous to identify patients who are at higher risk for requiring blood transfusion. Our aim is to identify possible predictive factors for perioperative blood transfusion in patients undergoing colorectal resection. We examined 206 patients who underwent colorectal resections. Materials and methods We analyzed factors including preoperative hematocrit, age, history of radiation, type of resection, operative blood loss, additional surgical procedure, surgery duration, and comorbidity. Results Forty-one patients (19.9%) received perioperative blood transfusion. Twenty patients (55.6%) with preoperative hematocrit less than 30 received transfusion (p < 0.0001). Twenty-one patients (12.4%) with preoperative hematocrit greater than 30 received perioperative blood transfusion. Thirty-three patients (17.9%) under 65 years received transfusion. Eight patients (36.4%) more than the age of 65 received transfusion (p = 0.05). Ten patients (16.1%) without any comorbidity received transfusion, whereas ten patients (15.1%) with one comorbidity, ten patients (22.2%) with two comorbidities, and 11 patients (33.3%) with greater than three comorbidities received blood transfusion (p = 0.07). In the multivariate analysis, relative risk of perioperative blood transfusion was 3.63 for patients with preoperative hematocrit less than 30 (p < 0.0001), 1.26 for patients more than the age of 65 (p = 0.49), and 1.07 for each comorbidity (p = 0.62). Patients with higher number of comorbidities and age greater than 65 tend to have lower preoperative hematocrit than other patients. Conclusion Hematocrit less than 30 is an independent risk factor for requiring perioperative blood transfusion, and patients with hematocrit less than 30 should be considered for autologous blood transfusion and erythropoietin. Presented at American Society of Colon and Rectum Surgeons Annual Meeting, Philadelphia, PA, May 3, 2005.     

Pericarditis in end-stage renal disease

Our approach to the clinical management of uremic and dialysis-associated pericarditis has been presented previously and is outlined in Figure 1. In hemodynamically stable patients with no effusion and in those with small to medium effusions, we recommend initial therapy with intensified dialysis. Close monitoring, perhaps every third day, with echocardiography should be carried out. If pericardial effusion progressively increases or if a large pericardial effusion fails to resolve after 7 to 10 days of intensive dialysis, the pericardial effusion may be drained by subxiphoid pericardiotomy or by pericardiectomy. Similarly, if hemodynamic evidence of cardiac pretamponade or tamponade appears, surgical drainage also should be carried out. If the echocardiogram is inadequate for interpretation but tamponade physiology is present, we recommend confirmation by cardiac catheterization before surgical drainage is attempted, recognizing that there may be circumstances such as left ventricular failure and pulmonary hypertension that may complicate the interpretation of the catheterization data. The type of invasive pericardial procedure chosen is determined by local experience. As stated, we prefer not to perform pericardiocentesis before surgery unless tamponade-induced hypotension is so severe that an adequate blood pressure cannot be maintained by means of plasma volume expansion. Under these circumstances, we prefer that pericardiocentesis be performed in the operating room immediately before the induction of anesthesia for the definitive surgical procedure. Although pericardiectomy is a definitive procedure for pericarditis with effusion in the uremic patient, the procedure has substantial morbidity. The results of subxiphoid pericardiotomy are encouraging, and it is clear that it can be carried out safely in patients who are debilitated or who are at increased risk from general anesthesia and major surgery.(ABSTRACT TRUNCATED AT 250 WORDS)     

Autologous Blood Donation in Nonorthopaedic Surgical Procedures as a Blood Conservation Strategy

Autologous blood donation in many nonorthopaedic procedures is controversial. Our study of 408 consecutive such procedures could be divided into two groups. In group I, the anticipated probability for homologous blood transfusion was very low (less than 5%): vaginal hysterectomy and miscellaneous gynecologic procedures, obstetrical delivery, mammoplasty and cholecystectomy. In group II, the anticipated probability for homologous blood transfusion was high (greater than 5%): open heart and vascular surgery, neurosurgery, mastectomy, abdominal and radical hysterectomy, and extensive urologic procedures. We conclude that for procedures in which the blood transfusion probability is very low, autologous blood donation should not be encouraged; this practice should be promoted in procedures in which the blood transfusion probability is 'high' (i.e. greater than 5%), with emphasis on maximizing autologous blood collection in order to minimize homologous blood transfusion.     

MitraClip implantation under sedation

The percutaneous MitraClip system is a catheter-based device designed to perform edge-to-edge mitral valve (MV) leaflet repair at the site of regurgitation. MitraClip implantation is an alternative procedure in patients at high surgical risk with symptomatic severe mitral regurgitation (MR) who are not candidates for MV repair/replacement due to their degree of comorbidity and associated high mortality risk. The procedure is guided by 3-dimensional (3D) transesophageal echocardiography (TEE) and fluoroscopy. A clip is positioned between the anterior and posterior leaflet to reduce valve regurgitation. Quantitatively, the reduction in MR is less than with surgical repair, but it significantly improves patients’ quality of life and functional capacity. Advantages are avoidance of sternotomy and cardiopulmonary bypass, beating-heart repair of the MV and reduction in post-operative duration of mechanical ventilation, intensive care unit (ICU) stay and need for blood transfusion.General anesthesia (GA) with orotracheal intubation is the most common approach in the literature because of the TEE probe and the need for the patient to be immobilized during the procedure. Since May 2014, of the 39 patients who have had MitraClip implantation in our hospital, only two were under deep sedation.We describe here the case of a MitraClip implantation performed under deep sedation with ketamine and propofol infusion in a patient unsuitable for surgical repair because of her comorbidities.     

Acute Normovolemic Hemodilution does not Reduce Antithrombin Concentration for Cardiac Surgery

BACKGROUND: Acute normovolemic hemodilution (ANH) is used to reduce allogeneic blood transfusion with cardiac surgery. This procedure involves pre-operatively removing and storing a volume of whole blood and replacing the volume with crystalloid. The stored blood is then available for transfusion, if required. Hemodilution associated with ANH may reduce the effectiveness of heparin anticoagulation due to dilution of antithrombin. The aim of this study was to determine if antithrombin concentrations are reduced in patients who undergo one unit of ANH during cardiac surgery. METHODS: Patients scheduled for cardiac surgery (n = 71) were grouped according to whether they did or did not undergo ANH pre-operatively. Antithrombin concentrations were measured before and after ANH. This study had 80% power to detect a difference in reduction of antithrombin concentration of 6% between groups following ANH with an alpha error of <0.05. The effect of one unit ANH was expected to cause a difference of 12% or greater. RESULTS: No significant difference in the concentration of antithrombin between ANH patients and those that did not have ANH, nor was there a difference in the decrease in antithrombin between groups. CONCLUSIONS: The results indicate that one unit of ANH does not significantly reduce the concentration of antithrombin prior to cardiac surgery. Thus patients who undergo one unit of ANH are not at increased risk due to dilution of antithrombin.     

Autologous blood salvage in the era of patient blood management

Almost 150 years after the first autologous blood transfusion was reported, intraoperative blood salvage has become an important method of blood conservation. The primary goal of autologous transfusion is to reduce or avoid allogeneic red blood cell transfusion and the associated risks and costs. Autologous salvaged blood does not result in immunological challenge and its consequences, provides a higher quality red blood cell that has not been subjected to the adverse effects of blood storage, and can be more cost‐effective than allogeneic blood when used for carefully selected surgical patients. Cardiac, orthopaedic and vascular surgery procedures with large anticipated blood loss can clearly benefit from the use of cell salvage. There are safety concerns in cases with gross bacterial contamination. There are theoretical safety concerns in obstetrical and cancer surgery; however, careful cell washing as well as leucoreduction filters makes for a safer autologous transfusion in these circumstances. Further studies are needed to determine whether oncologic outcomes are impacted by transfusing salvaged blood during cancer surgery. In this new era of patient blood management, where multimodal methods of reducing dependence on allogeneic blood are becoming commonplace, autologous blood salvage remains a valuable tool for perioperative blood conservation. Future studies will be needed to best determine how and when cell salvage should be utilized along with newer blood conservation measures.     

Complications and limitations of injection sclerotherapy in portal hypertension.

Injection sclerotherapy is now the accepted first line treatment for bleeding oesophageal varices, although it is associated with an impressive list of rare complications. The main problem concerns the strategy for uncontrollable or recurrent bleeding. Patients with uncontrolled bleeding may be referred for surgery after considerable blood loss and are then extremely difficult to assess. The effects of blood loss on liver function can lead to an unduly pessimistic assessment of liver status. An effective choice of emergency surgical procedure may require considerable surgical expertise. Oesophageal transection and devascularisation are satisfactory for many patients with oesophageal varices secondary to cirrhosis and should nearly always control bleeding. Difficulties arise in patients who are grossly obese and in those who have undergone extensive surgery in the upper abdomen. Problems may also be encountered in those treated by repeated sclerotherapy, which may have caused severe inflammatory change and thickening around the lower oesophagus and upper stomach. We believe that an emergency mesocaval shunt using either a vein graft or a synthetic material such as polytetrafluoroethylene is the procedure of choice for this difficult group of very sick patients. The surgical exposure is satisfactory and not unduly prolonged in even the largest patients and the technique does not interfere with any subsequent transplant operation. There is a greater choice in the management of the patient with less urgent bleeding from recurrent varices after sclerotherapy. Repeat sclerotherapy may be effective for small oesophageal varices while liver transplantation may be indicated in the patient with deteriorating liver function. A selective distal splenorenal shunt should be considered for patients with intact splenic and left renal veins and a mesocaval vein graft for the remainder. We would therefore suggest that surgery should still be considered for the management of portal hypertension, particularly in the following circumstances: (1) Uncontrollable bleeding during the initial course of sclerotherapy; (2) Life threatening haemorrhage from recurrent varices; (3) Bleeding from ectopic varices not accessible to sclerotherapy; (4) Uncontrollable bleeding from oesophageal ulceration secondary to injection sclerotherapy; (5) Severe, symptomatic hypersplenism; (6) For patients who live in communities remote from blood transfusion facilities and adequate medical care. The management of the complications of portal hypertension continues to pose problems. We believe that the best results should come from a combined management approach using injection sclerotherapy as primary treatment and surgery for complications and for haemorrhage from unusual anatomical sites.