Blood loss during repair of craniosynostosis

Surgical repair of craniosynostosis carries a high risk with large blood losses. Over a 2-yr period, we have managed 115 patients undergoing craniosynostosis repair with peroperative haemodilution to achieve a final PCV of 0.28-0.35. Measurements of PCV allowed calculation of estimated blood losses and transfused volumes in terms of red blood cell mass. Total estimated red cell volume lost was 91 +/- 66% of patient's estimated red blood cell volume during the peroperative period. The type of skull deformation and surgical procedure determined the extent of peroperative bleeding. Peroperative transfusion was satisfactory in 48% of patients and slight overtransfusion was noted in 32%. During the postoperative period, liberal administration of blood led to overtransfusion and possibly unnecessary transfusion in 74% of patients. Because of the well known risks of transmission of infectious disease, strict volume compensation with development of haemodilution and autotransfusion procedures should be used to limit these risks.     

Global blood management in orthopaedic surgery

Blood loss tends to be significant in many orthopaedic procedures because of the nature of the tissues and the inability to cauterize or coagulate bleeding bony surfaces. Regional hypotensive anesthesia has been useful in reducing blood loss particularly for joint replacement. A spectrum of measures is available to retrieve autologous blood and reinfuse it. The loop consists of predeposit autologous blood, preoperative hemodilution, intraoperative and postoperative red cell retrieval, and reinfusion. The safety of autologous blood has been accepted universally, but the measures to preserve it must be used judiciously to avoid excessive cost and, most importantly, ensure patient safety.     

Transfusion requirements for craniosynostosis surgery in infants

Retrospective review of the records of 73 consecutive young children who underwent craniosynostosis surgery between 1978 and 1992 in one center was conducted to determine transfusion requirements, to document morbidity, and to identify causative variables associated with transfusion. Operative age and weight, affected suture(s), craniofacial surgeon, neurosurgeon, anesthesiologist, preoperative and postoperative hematocrit, and transfusion volumes of blood and crystalline products were recoded. Transfusion volumes were converted to percent estimated red cell mass for analysis. Affected sutures were unicoronal (22), sagittal (17), bicoronal (11), multiple (11), metopic (10), and lambdoid (2). Mean operative age was 6.4 months. Mean preoperative hematocrit was 34 percent. Eighty percent of patients were discharged with hematocrit of 29 percent or greater. Discharge hematocrit was unrelated to year of surgery. Mean intraoperative transfusion was 72.1 +/- 56.6 percent estimated red cell mass. Transfusions differed statistically among suture(s), neurosurgeons, and anesthesiologists. Extensive cranio-orbital surgery for synostosis in young children does not produce excessive hemorrhage or transfusion morbidity. The anesthesiologist and neurosurgeon may be equally or more important than the affected suture(s) as causal variables in transfusion.     

Extreme hemodilution due to massive blood loss in tumor surgery

Reassociation kinetics and molecular structure of hepatocytes DNA of rabbits Shinshilla, Marder breeds and their hybrids have been measured. It is shown that hybrids genome is not the simple sum of donors genome. The hybrids genome has new specific feature of molecular organisation which different from donors genome.     

An algorithm to optimize perioperative blood management in surgery

Innovation in surgical blood management has been fueled by patients' perceptions of the risks associated with allogeneic blood transfusions and by surgeons' attitudes toward the use of allogeneic blood. The challenge is to determine the best blood management strategy to implement in the individual patient, particularly in patients with anemia who are at high risk of allogeneic blood transfusion. An algorithm to estimate safe blood loss based on individual patient parameters has been developed. The algorithm uses patient weight, gender, and preoperative hematocrit level to derive the volume of blood loss that can be tolerated while maintaining a target postoperative hematocrit level. Because the margin of safe blood loss can be anticipated, the most appropriate blood conservation option(s) can be implemented and perioperative blood management can be optimized.     

The influence of desmopressin on blood loss during spinal fusion surgery in neuromuscular patients

PURPOSE: Fatigue and impairment of physical performance are common and severe problems of cancer patients. We describe the effect of an aerobic exercise program designed for cancer patients suffering from these symptoms. METHODS: Five cancer patients (4 female, 1 male, age 18 to 55), participated in the training program. Fatigue had been present for a time ranging between 5 wk and 18 months and hindered the patients from carrying out normal daily activities. The training program consisted of walking daily on a treadmill with an intensity corresponding to a lactate concentration of 3 +/- 0.5 mmol.L-1 and was carried out for 6 wk. RESULTS: By the end of the exercise program we observed an improvement in maximal physical performance (from 6.4 +/- 0.4 km.h-1 to 7.5 +/- 0.9 km.h-1, P < 0.05) and maximal walked distance (from 1640 +/- 724 m to 3300 +/- 953 m, P < 0.05). Heart rate and lactate concentration by an equivalent submaximal workload (5 km.h-1) were significant reduced (from 138 +/- 21 beats.min-1 to 113 +/- 20 beats.min-1, P < 0.05, and from 2.6 +/- 1.4 mmol.L-1 to 1.3 +/- 0.6 mmol.L-1, P < 0.05); all patients experienced a clear reduction of fatigue and could carry out normal daily activities again without substantial limitations. CONCLUSION: We conclude that an aerobic exercise program of precisely defined intensity, duration, and frequency can be prescribed as therapy for primary fatigue in cancer patients.     

Perioperative management of the pediatric patient

Children are not just small adults. Perioperative nurses working with pediatric patients plan nursing interventions based on established principles of perioperative practice as well as incorporating concepts of growth and development relating to the child. A thorough assessment of the pediatric patient prior to surgery enables the perioperative nurse to plan for the surgical procedure, modifying as need be for the individual patient's specific needs. With adequate preparation, communication, and emotional support, the pediatric surgical experience can be positive for the child, parents, and perioperative team.     

A retrospective audit of blood loss in total hip joint replacement surgery at Middlemore Hospital

AIMS: To quantify the level of inappropriate red cell transfusion in primary and complex hip replacement surgery. METHODS: Data extraction was by retrospective review of patients records. Calculation of total red cell volume loss was by use of pre and postoperative (day 7) haematocrit levels, patient weight and number of units transfused. Transfusion was accepted as justified only if instituted for a 30% red cell volume loss or loss sufficient to drop the haematocrit below 0.28. RESULTS: Of 104 patients having primary hip joint replacement, 58 were transfused with a total of 157 units of red cells; 37 (24%) of these units were given inappropriately. Of 38 patients having complex hip replacement operations, 32 were transfused with a total of 139 units of red cells; 12 (9%) of these were given inappropriately. CONCLUSIONS: Inappropriate transfusion occurs in hip replacement surgery. A concurrent audit of red cell usage is required to better define the magnitude of the problem. Two unit transfusion is commonly given when one unit would have been sufficient.     

Transfusion management in pediatric and adolescent scoliosis surgery. Efficacy of autologous blood

STUDY DESIGN: A retrospective review of consecutive pediatric and adolescent patients who required posterior spinal fusion to correct scoliosis. OBJECTIVES: To 1) measure the participation of pediatric patients in predeposit programs for autologous and directed blood donation 2) to assess the success of autologous predonation in preventing allogeneic blood use, 3) to determine whether transfusion indications differed between patients who received allogeneic blood and those who received autologous blood, and 4) to assess factors that predict transfusion requirements during scoliosis surgery. SUMMARY OF BACKGROUND DATA: Authors of recent studies in adults have questioned whether transfusion of autologous blood is a cost-effective therapy when compared with the less-expensive alternative--transfusion of allogeneic blood. In children, the efficacy of autologous blood has not been assessed in a large population of surgical patients. In adults, the frequency of patient participation, the success of autologous donors in avoiding allogeneic transfusion, and the proportion of collected autologous units used during the perioperative period are measures used to establish the efficacy of autologous predonation programs. METHODS: Hospital and clinic records for each patient who underwent posterior spinal fusion from September 1, 1989 through September 1, 1994 were reviewed. Blood bank consultation, autologous donation records, anesthesia records, surgical reports, and hospital records were reviewed. Seventy percent of patients (164 of 243) participated in autologous donation. RESULTS: More than 90% of autologous donors successfully avoided receiving allogeneic blood. Patients with idiopathic scoliosis (n = 168) were more likely to participate in autologous donation (n = 144) and to avoid allogeneic blood (n = 135). Patients with neurologic causes of scoliosis more commonly used allogeneic or directed donation (56 of 75 patients). Nineteen patients with neuromuscular causes of scoliosis participated in autologous donation, but more than one half of this group (10 of 19 patients) required allogeneic blood in addition to autologous units. CONCLUSIONS: Using measures of efficacy similar to those reported in studies of adults, autologous blood was found to be more effective in meeting the transfusion needs of pediatric patients who required posterior spinal fusion than in meeting those needs in adult surgical patients in previous studies.     

Induced hypotension may influence blood loss in orthognathic surgery, but it is not crucial

Numerous investigators have attempted to isolate the Rh antigens in a stable, immunologically reactive form since the discovery of the Rh system over 56 years ago. We report here a successful and reproducible approach to solubilizing and adsorbing the human Rh antigen(s) to a solid-phase matrix in an antigenically active form. Similar results were obtained with rabbit A/D/F red blood cell antigens. The antigen preparation was made by dissolution of the red blood cell membrane lipid followed by fragmentation of the residual cytoskeleton in an EDTA solution at low ionic strength. The antigenic activity of the soluble preparations was labile in standard buffers but was stable in zwitterionic buffers for extended periods of time. Further studies showed that the antigenic activity of these preparations was enhanced, as was their affinity for plastic surfaces, in the presence of acidic zwitterionic buffers. Adherence to plastic surfaces at low pH maintained antigenic reactivity and specificity for antibody was retained. The data show that this approach yields a stable form of antigenically active human Rh D antigen that could be used in a red blood cell-free assay for quantitative analysis of Rh D antibody and for Rh D antibody immunoadsorption and purification.     

Measurement of extracellular fluid volume and blood volume in sheep

Methods are described for the simultaneous measurement of extracellular fluid volume (ECFV) and plasma volume (PV) in sheep using dilution of 82Br (as sodium bromide) and 131I-labelled ovine gamma globulin. Following injection of 82Br (100 micronCi), equilibrium in blood was reached after 3 h at which time only 4% of the injected dose was in rumen water. The ECFV was measured as the mean of the 2- and 3-h bromide space after correction for the relative water content of plasma, the Gibbs-Donnan factor and the loss of 82Br into red blood cells. 131I-labelled ovine gamma globulin (20 micronCi) was injected after the 3-h 82 Br space was obtained and blood samples were taken at 10, 20, 30 and 40 min. In 16 determinations in 11 sheep (25-47 kg body weight) the mean (+/- s.e.m.) ECFV was 9112 +/- 289 ml (or 245 +/- 9 ml/kg). The mean PV for 16 observations in 11 sheep measured together with ECFV was 1597 +/- 62 ml (or 42-8 +/- 1-8 ml/kg). Although there was no relationship between body weight and PV there was a significant correlation between ECFV and body weight and also significant negative correlations between body weight and ECFV or PV when these were expressed as a function of body weight. The variation in ECFV measured on four occasions over 7-10 days in four sheep was 3-5% (range 2-6-4-6%). For PV measured in two animals on two consecutive days at the same time as ECFV the coefficient of variation was 1-5 and 2-1%. Acute sodium depletion (250-670 mmol) by parotid duct cannulation in three sheep resulted in a fall in ECFV which would account for only 15-20% of the sodium deficit. The remainder is presumably derived from ruminal sodium stores.     

Evaluating blood loss in children''s orthopaedic surgery: a simplified method of photometric analysis of eluted swabs

People aged eighty-five years and over (the oldest old) will form an increasing proportion of the population of New Zealand and many other countries. Because of their smaller numbers and relative inaccessibility, their health status has sometimes been extrapolated from populations of people aged sixty-five to eighty-four years. For people aged sixty-five to eighty-four years an exponential relationship is seen between age and morbidity and mortality. We explore if this exponential relationship extends to people aged ninety years and over. We analyzed data from the New Zealand 1991 Census and 1992 hospital discharge records and, for people aged sixty to eighty-nine years, confirmed an exponential relationship between age and mortality, inactivity, hospital utilization, and occupation of residential institutions. This exponential trend did not continue for people aged ninety years and over for whom mortality rates and indicators of morbidity were considerably lower than expected, and conclude that the actual health status of people aged ninety years and over is better than the status extrapolated from that of people aged sixty to eighty-nine years.     

Regional blood redistribution following blood loss in unanesthetized rats

The authors describe relative changes in the blood filling of 46 vascular areas of the body in rats after a moderate and severe blood loss. Moderate blood loss caused redistribution of the blood from the skin of the chest and from the skin of the posterior limbs, the majority of the abdominal and pelvis minor organs, muscular and bone tissues of the abdomen, pelvis minor and extremities into the brain, heart, lungs, kidneys, stomach and into the muscles of the head and neck. In severe blood loss the changes were analogous, but the blood content in the kidneys and the stomach decreased, and there was also a relative elevation of the blood in the muscles and bones of the chest. The intensity of the redistributive reaction in severe blood loss was less than in moderate blood loss.     

Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction

Fish sperm head plasma membranes have been demonstrated to contain syndecan (transmembrane heparan sulfate proteoglycan) immunofluorohistochemically and using immunoblot analysis and transglutaminase (TGase) by histochemistry. In order to examine the involvement of syndecan in fertilization, mature eggs were inseminated by direct mixing with untreated sperm or with sperm pretreated with an antiheparan sulfate (HS) antibody monoclonal (mAb), bovine serum albumin, human transferrin, or a TGase inhibitor (monodansylcadaverine, cystamine, and iodoacetamide). The fertilization rates of eggs inseminated with untreated and albumin-pretreated sperm were approximately 99.3% and 94.7%, respectively. Those of eggs pretreated with the anti-HS antibody and transferrin were 0% and 5.4%, respectively, whereas use of sperm pretreated with TGase inhibitors resulted in fertilization rates of approximately 13.2-17.8%. These results indicate that sperm head syndecan play an important role in fish sperm-egg contact and/or binding and that TGase inhibitors may reduce the fertilization rate by inhibiting sperm motility.     

Perioperative management of pulmonary hypertension after heart transplantation in childhood

BACKGROUND: Pulmonary hypertension is responsible for a substantial part of perioperative and postoperative mortality and morbidity after cardiac transplantation. Treatment of right ventricular failure after increased pulmonary vascular resistance is difficult especially in infants and children. Therefore we started a preventive therapy of pulmonary hypertension after cardiac transplantation to avoid right ventricular failure and compared the results with a group of patients with conventional therapy. METHODS: Group 1 (n = 13), with transplantation from 1988 to 1991, was treated with vasodilators when symptoms of right ventricular failure developed. Group 2 (n = 19) had preventive treatment with prostaglandin E1 (PGE1), the phosphodiesterase-III inhibitor enoximone, and alkalinazation starting during weaning from cardiopulmonary bypass. RESULTS: Six patients in group 1 died; four of them as the result of right ventricular failure in the immediate postoperative course despite aggressive treatment. In group 2 there were three deaths as the results of rejection (2) and infection (1). None of these patients developed right ventricular failure (p = 0.02). Cold ischemic time, extracorporeal circulation time, and waiting time before transplantation were significantly longer in group 2. Side effects of this preventive therapy were not observed. CONCLUSIONS: We conclude that prophylactic therapy of pulmonary hypertension with vasodilators in infants and children after heart transplantation is safe and effective in preventing right ventricular failure in the postoperative course.     

Avoidance of homologous blood transfusion despite extreme blood loss

We report the case of a 22-year-old woman who underwent two-step scoliosis surgery without allogeneic transfusion, although the intraoperative blood loss (3500 ml) during the first procedure was higher than the calculated blood volume (3250 ml). Preoperatively the patient had donated four units of autologous blood. Intraoperatively blood-saving methods were combined. During the first operation acute normovolemic hemodilution (target hemoglobin 9.0 g/dl) was applied and during the second operation controlled hypotension (systolic blood pressure 80 mmHg). Intraoperative auto-transfusion was used in both procedures. During the first operation severe normovolemic anemia (minimal hemoglobin 3.5 g/dl) was accepted while the patient was ventilated with FiO2 1.0. The hemoglobin concentration was 8.6 g/dl after the first procedure and had increased to 11.6 g/dl 4 weeks after the second procedure. No severe complications occurred during the postoperative phase. This case report shows that also in surgical procedures with extreme blood loss any allogenic transfusion can be avoided by the combination of blood-saving methods, acceptance of low intraoperative transfusion trigger and ventilation with 100% oxygen.