Hemodilution in clinical surgery: state of the art 1996

Acute normovolemic hemodilution entails removal of blood from a patient either immediately before or shortly after induction of anesthesia and simultaneous replacement with cell-free fluid. Nowadays, because of their predictable volume effects, the synthetic colloids (6% dextran 60/70, 6% hydroxyethyl starch 200,000) are preferred as volume substitutes; albumin should be avoided because of its high cost. Hemodilution has experienced a renaissance in recent years, mainly due to the evolving discussion of legal aspects, immunologic changes, viral infections, and a potentially higher cancer recurrence rate associated with the transfusion of homologous blood. Hemodilution should be considered for elective surgical patients free of contraindications and presenting with an initial hemoglobin concentration >/= 12 g/dl and an anticipated blood loss of >/= 1500 ml. The efficacy of this method (judged by the need to give homologous blood transfusion) depends on the preoperative (initial) hematocrit, the target hematocrit (to which hemodilution is performed), and the preset intra- and postoperative transfusion trigger. In the past, data from clinical trials showed that in healthy subjects a target hematocrit of 20% to 25% (hemoglobin 7.0-8. 0 g/dl) is feasible and safe for the patient. The lower the target hematocrit accepted, the more extensive is the monitoring required: Intraoperative target hemoglobin concentrations of 5.0 g/dl and less have been tolerated by surgical patients without adverse effects. The safety and efficacy of acute normovolemic hemodilution in terms of reducing homologous blood transfusion requirements has been demonstrated in various clinical studies. Hemodilution therefore is regarded an integral part of programs aimed at reducing the need for homologous blood and can thus be successfully combined with preoperative autologous blood deposition, intraoperative blood salvage, and carefully adjusted surgical techniques. Hemodilution is feasible and relatively cost-effective, and it minimizes adverse effects associated with transfusion of homologous blood, particularly transmission of viral diseases, immunosuppression, and infectious complications.     

Red blood cell transfusions for total hip replacement in a regional hospital. A six-year analysis

To evaluate changes in the need for homologous blood and to assess the impact of autologous blood transfusion, red cell transfusions in unilateral total hip replacement surgery, performed electively in the period 1986-1991, were studied in a regional hospital. Transfusion data, perioperative blood loss and post-operative haemoglobin concentration of 495 patients were analysed. From 1986 to 1991, the percentage of patients not transfused with homologous blood increased from 18.5 to 45.5%. After the introduction of an autologous blood transfusion programme in 1987, 116 of 430 patients (27.0%) donated autologous blood. No increase in the percentage of autologous donors was observed during the study. Most common reasons for nonparticipation were the patient's age, doctors' underordering and logistic limitations. 81.9% of autologous donors had total hip replacement surgery without homologous transfusions. Mean blood loss reduced significantly from 1,373 +/- 781 ml in 1986 to 958 +/- 582 ml in 1991 (p < 0.001). Transfusion requirement in the nonautologous patients fell from 2.6 +/- 1.8 units in 1986 to 1.4 +/- 1.4 units per patient in 1989 and increased thereafter to 2.2 +/- 2.1 units in 1991 (p < 0.01) and showed a strong correlation with blood loss (r = 0.58; p < 0.001). No changes in postoperative haemoglobin concentration were observed throughout the study. In conclusion, collection of autologous blood is effective, albeit still underutilized, to reduce homologous blood requirement. The close correlation between blood loss and transfusion requirement accentuates the role of surgical practice in the reduction of homologous transfusions.     

Lower homologous blood requirement in autologous blood donors after treatment with recombinant human erythropoietin

The risk of blood-borne diseases has substantially increased the use of autologous blood transfusion. Many autologous donors, however, still need homologous transfusions. To find out whether recombinant erythropoietin (rhEPO) reduces requirements for homologous blood transfusion, we carried out a randomised, controlled trial, in which patients were stratified according to blood volume. We studied 95 autologous blood donors undergoing elective hip surgery. 50 patients were randomly assigned 500 U/kg rhEPO subcutaneously twice a week for 3 weeks, and 45 patients received no treatment (control group). The patients each donated two units of blood before surgery. Only 5 (10%) rhEPO-treated patients received homologous transfusions compared with 16 (36%) controls (p < 0.01). rhEPO was most useful in patients with a blood volume below 4 L and an estimated blood loss below 2 L or with a blood volume of 4-5 L and blood loss of 1-2 L. Continued administration of rhEPO caused no further increase in reticulocyte counts after the fourth injection, which was accompanied by a pronounced depletion of storage iron. rhEPO treatment had no effect on renal function, platelet count, or blood pressure. Subcutaneous rhEPO is an effective and safe way to reduce exposure to homologous blood in autologous donors. Its use can be restricted to a subpopulation of autologous blood donors, which improves the cost-effectiveness of this expensive approach.     

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.     

Albumin-impregnated polyester vascular prosthesis for abdominal aortic surgery: an improvement?

AIM: To compare the peroperative blood loss and the postoperative systemic inflammatory reaction in patients receiving either a Vasculour II Albumin pre-impregnated prosthesis (VA group, n = 32) or a preclotted Vasculour II prosthesis (V group, n = 33) for elective surgery of the abdominal aorta. SETTING: University Hospital. DESIGN: Prospective, randomised study. METHODS: Peroperative blood loss was measured over two different periods: Phase I from the beginning of the operation to the completion of the proximal anastomosis, when blood loss cannot be related to the model of prosthesis implanted and phase II after the completion of the proximal anastomosis to the end of the operation. Postoperative blood loss was evaluated by the determination of the retroperitoneal drainage volume over a period of 2 days immediately following the operation. The presence of periprosthetic fluid was measured with echography at days 4, 9, 30 and 60. The postoperative systemic inflammatory reaction was evaluated by measuring the sedimentation rate and the C reactive protein levels daily from day 1 to day 9, and at days 14, 21, 28, 45, and 60, and by measuring the body temperature daily from day 1 to day 9. RESULTS: No significant differences of peroperative blood loss were observed. The same proportion of patients (35%) in both groups received homologous transfusion. The mean number of units of homologous blood transfused per patient was respectively 0.77 and 0.91 for the VA and the V group. The retroperitoneal drainage volume and the percentage of patients with periprosthetic fluid did not differ significantly. No significant differences in systemic postoperative inflammatory reaction were observed. CONCLUSION: There were no benefits in using albumin-impregnated prosthesis as opposed to preclotted prosthesis in terms of peroperative and postoperative blood loss, or by looking at the incidence of homologous blood transfusion. However, the glutaraldehyde cross-linked albumin did not induce any systemic inflammatory reaction.     

Recombinant human erythropoietin as adjuvant treatment for autologous blood donation in elective surgery with large blood needs (> or = 5 units): a randomized study

BACKGROUND: Autologous blood transfusion presents no infectious or immunologic side effects. The aim of this randomized study was to determine the impact of recombinant human erythropoietin (rHuEPO) on the donation of 5 units of autologous blood by nonanemic patients who were candidates for elective surgery with transfusion requirements of > or = 5 units. STUDY DESIGN AND METHODS: Starting on Day -35, 420 mL of blood was taken weekly. All patients received 200 mg of iron saccharose complex intravenously at each visit and six subcutaneous injections of rHuEPO (141 U/kg) or placebo between Days -21 and -7. RESULTS: Of 50 patients, 45 completed the study (placebo, 21; rHuEPO, 24). Total red cell production was higher in the rHuEPO group (p = 0.001). Donation of 5 units was possible for 67 percent (placebo group) and 79 percent (rHuEPO group) of patients (p = 0.5). The mean number of blood units donated was 4.6 (placebo group) and 4.7 (rHuEPO group). More patients in the placebo group received allogeneic blood (9/21 [43%] vs. 6/23 [26%]), although the difference did not reach significance (p = 0.34). CONCLUSION: In nonanemic patients donating 5 units of blood, rHuEPO associated with intravenous iron increased total red cell production. However, no difference was found between the rHuEPO and placebo groups with regard to the number of units of autologous blood donated of the number of patients receiving allogeneic blood transfusion.     

Genetic therapy for transplant vascular sclerosis

Red blood cells are still transfused inappropriately in spite of recent media attention and public awareness about the risks of blood products. A prospective audit was conducted to determine the avoidable blood transfusion rates in the elective perioperative setting utilising the guidelines issued by the American College of Physicians (ACP). Of 82 consecutive adult patients who were admitted for major elective surgery over a 3-month period, 28 were transfused a total of 94 units of homologous SAG-M blood, of which 50 (53%) were inappropriate as recommended by the ACP guidelines. Violations of the guidelines were perioperative transfusion in bleeding patients who were haemodynamically stable (31%) and transfusion in asymptomatic, stable patients solely to attain a haemoglobin level above 10 g% (22%). There is a need for objective, easily adaptable and widely disseminated consensus guidelines to the indications for red blood cell transfusion.     

Immunization with the N-terminal region of the nonstructural protein NS1 promotes survival after challenge with lethal influenza A virus dose

We investigated the utilization patterns of autologous blood donation for radical retropubic prostatectomy (RRP) during a 6-year period. A total of 225 patients electing RRP with blood donation were identified for analysis. Group 1 consisted of 113 men who had an RRP from 1990 to 1993. Group 2 consisted of 112 men who had an RRP from 1993 to 1995. Charts were reviewed for the number of units transfused, number of autologous units donated, and operative blood loss. More patients autodonated blood in the later group (84% vs. 75%). Technical improvements and experience have significantly decreased blood loss and the need for transfusions (69% vs. 96% in the early group). In the more current series, only 14% of patients who autodonated blood required homologous transfusion vs. 42% in the earlier group. An increase in the amount of wasted blood (42% vs. 16% in the early group) also was noted. The 4-unit donors had the lowest homologous transfusion rate in both series (group 1 = 21%, group 2 = 5%); the 2-unit donors had the lowest units wasted per person (0.74). In addition, the 2-unit donors maintained a low homologous transfusion rate of 16%. These data suggest that 2 units of autologous blood donation has a reduced risk of homologous blood transfusion while the amount of autologous blood wasted is minimized.     

Intraoperative and postoperative autologous transfusion in orthopedic surgery

Information was collected retrospectively on three comparable groups, 25 patients in each, who had been operated on for thoracic scoliosis. Group 1 received homologous transfusions only. Group 2 and group 3 were transfused postoperatively with drained whole blood (Solcotrans orthopaedics). Group 3 received in addition peroperatively washed packed red blood cells (Haemolite 2 Cell Saver) recirculated. The need for homologous transfusions was reduced from 119 units to 23 patients in group 1, to 36 units to 14 patients in group 2 and 34 units to 13 patients in group 3. Three of the first 15 patients in group 2 experienced chills and fever reactions in connection with the autologous transfusion. No reactions were seen after infusion when we scrapped the last 50 to 100 ml of drained blood.     

Aprotinin and recombinant human erythropoietin reduce the need for homologous blood transfusion in cardiac surgery

The effects of low dose aprotinin (Trasylol) and preoperative administration of recombinant human erythropoietin (EPO) were evaluated in 144 patients undergoing cardiopulmonary bypass divided into four groups. Group I (n = 43) received a subcutaneous administration of EPO (18,000 U) one week before operation and intraoperative administration of low-dose aprotinin (mean; 1.38 +/- 0.26 x 10(6) kallikrein inactivator units; KIU) from extracorporeal circulation, group II (n = 39) received only preoperative administration of EPO, group III (n = 28) received only intraoperative administration of low-dose aprotinin (mean; 1.46 +/- 0.25 x 10(6) KIU), and group IV (n = 34) were not administered either drug. Compared with group IV, the intraoperative blood loss was significantly lower in group I (p < 0.01), and in group II or III (p < 0.05). The postoperative drainage in 24 hours was significantly lower in groups I and III receiving aprotinin than in the other groups. The mean volume of total homologous blood transfusion and the percentage of cases not requiring a homologous blood transfusion in each group was, respectively, 74 +/- 235 ml and 88.4% in group I, 282 +/- 1289 ml and 87.2% in group II, 414 +/- 584 ml and 60.7% in group III, and 976 +/- 1931 ml and 44.1% in group IV. Significant differences were recognized between group I and group IV (p < 0.05). These findings indicate that when used in combination, both drugs reduce blood loss and the need for a homologous blood transfusion more effectively than either drug alone.     

Autotransfusion after coronary artery bypass grafting halves the number of patients needing blood transfusion

BACKGROUND: Several randomized studies about autotransfusion of shed mediastinal blood in patients undergoing coronary artery bypass grafting have resulted in divergent findings concerning reduction of the need for homologous blood transfusions. Most of these studies used less strict criteria for homologous blood transfusion than applied in daily clinical practice. METHODS: A prospective, randomized, controlled study involving 120 patients having elective, uncomplicated coronary artery bypass grafting was performed. The autotransfusion group received transfusion of shed mediastinal blood for 18 hours. Criteria for homologous blood transfusion were hemoglobin concentration less than 5.0 mmol/L in the intensive care unit and less than 5.5 mmol/L during the rest of the hospital stay. RESULTS: Twenty-eight percent of patients in the autotransfusion group received homologous blood transfusion versus 55% in the control group (p = 0.007). Ninety-five percent of the shed mediastinal blood was transfused. In the autotransfusion group, a total of 26 units of homologous blood was used versus 78 units in the control group (p < 0.001). CONCLUSIONS: Autotransfusion of shed mediastinal blood in patients undergoing elective, uncomplicated coronary artery bypass grafting halves the number of patients needing homologous blood and reduces the amount of homologous blood given.     

Blood transfusion and lung function in chronically anemic patients with severe chronic obstructive pulmonary disease

OBJECTIVE: To study in anemic patients with chronic obstructive pulmonary disease (COPD) whether blood transfusion reduces minute ventilation and work of breathing (WOB). DESIGN: We prospectively evaluated the minute ventilation and WOB in 20 anemic adults (hemoglobin of <11 g/dL). Ten patients had severe COPD and ten patients were without lung disease. Measurements were made before and after receiving red blood cell transfusion; post-transfusion measurements were made 24 to 36 hrs after the last transfusion. SETTING: The study was performed in the intensive care unit of a tertiary referral center for home mechanical ventilation and for patients considered difficult to wean from mechanical ventilation. PATIENTS: Twenty clinically stable patients (12 female, eight male) with chronic anemia were studied. Ten patients with COPD (mean forced expiratory volume in 1 sec: 0.55+/-0.1 [SD] L) were compared with ten patients without lung disease. All participants had adequate renal and left ventricular function. INTERVENTIONS: Patients received 1 unit of packed red blood cells for each g/dL that their hemoglobin value was less than an arbitrarily defined target value of 11.0 to 12.0 g/dL. Each unit was transfused over 2 hrs and < or =3 units in total was given. MEASUREMENTS AND MAIN RESULTS: Esophageal pressure was measured from a catheter which was positioned in the middle of the esophagus. Flow was measured using a pneumotachygraph connected to a mouthpiece while a nose clip closed the nostrils during the measurements. From these data, respiratory rate, minute ventilation, and inspiratory resistive WOB were computed. Arterial blood gas values, oxygen saturation, hemoglobin, and hematocrit were also measured, and oxygen content was calculated before and 24 to 36 hrs after transfusion. In patients with COPD, hemoglobin increased from 9.8+/-0.8 to 12.3+/-1.1 g/dL due to a mean transfusion of 2.2+/-0.4 (SD) units of red blood cells. There was a reduction in the mean minute ventilation from 9.9+/-1.0 to 8.2+/-1.2 L/min (p < .0001); correspondingly, WOB decreased from 1.03+/-0.24 to 0.85+/-0.21 WOB/L (p< .0001). The capillary P(CO2) increased from 38.1+/-6.0 to 40.7+/-6.8 torr (5.1+/-0.8 to 5.8+/-0.9 kPa) (p < .05). Similarly, capillary P(O2) changed from 56.9+/-8.9 to 52.8+/-7.0 torr (7.6+/-1.2 to 7.0+/-0.9 kPa) (p < .05). In anemic patients without lung disease, minute ventilation, WOB, and the capillary blood gas values did not change after increase of the hemoglobin by a similar degree. CONCLUSIONS: We conclude that red blood cell transfusion in anemic patients with COPD leads to a significant reduction of both the minute ventilation and the WOB. In these patients, transfusion may be associated with unloading of the respiratory muscles, but it may also result in mild hypoventilation.     

Perioperative specific management of blood volume loss in craniosynostosis surgery

Accurate assessment and replacement of blood loss and fluid-electrolyte deficit during craniosynostosis repair is difficult owing to patient size and the diversity of surgical technique. Forty-three patients undergoing primary craniosynostosis repair over a 10-year period were studied retrospectively to determine blood loss and fluid deficit and to assess blood transfusion practices during both intraoperative and postoperative periods. Blood loss was calculated on the basis of estimated red cell mass (ERCM) and fluid-electrolyte imbalance was investigated with blood samplings. Blood transfusion was considered appropriate if the postoperative or posttransfusion ERCM was within 12% of the preoperative value. Estimated fluid requirement (EFR) was used in 4 ml kg(-1) h(-1) except for neonates. Intraoperatively, 80% of all patients were appropriately managed with respect to blood transfusion and EFR. Postoperatively only 20% of the patients receiving transfusions were transfused appropriately. In 23.3% of these patients (10/43) unexpected respiratory distress developed immediately after their recovery from the anesthesia. With the measurement of estimated blood volume and allowable blood loss, appropriate transfusion could be achieved for the successful treatment of the primary craniosynostosis.     

A rapid method for DNA extraction from fine-needle aspiration biopsies of thyroid tumors, and subsequent RET mutation analysis

In 22 consecutive patients with tetralogy of Fallot (TF), a total correction was attempted without the use of a homologous blood transfusion from September 1995 to March 1997. The 22 patients were divided into two groups according to their surgical procedures; namely, either a simple correction (group I: n = 14) or a complex correction including the relief of peripheral pulmonary stenosis and/or the division of a previous systemic-pulmonary shunt (group II: n = 8). In 77% of all patients, surgery was performed without a homologous blood transfusion. No differences were found in the non-transfusion rate and the hematocrit (Ht) values between the two groups and, as a result, we thus confirm that this additional procedure is not a risk factor for surgery without a homologous blood transfusion. According to the correlation of the red blood cell volume before and after surgery, the preoperative Ht value corresponding to the postoperative Ht of 30% could be accurately predicted. The calculated Ht values were 41.0% in the patient weighing 15 kg, 42.5% in those weighing 10 kg, and 46.9% in those weighing 5 kg. These data suggest that a surgical correction without a homologous blood transfusion can therefore be safely performed in almost all patients with TF.     

Intraoperative autotransfusion is associated with modest reduction of allogeneic transfusion in prosthetic hip surgery

BACKGROUND: The efficacy of intraoperative salvage and washing of wound blood and the predictors of allogeneic red cell transfusions in prosthetic hip surgery are insufficiently known. METHODS: In 96 patients, undergoing primary or revision surgery, salvaged and washed red cells and, if necessary, allogeneic blood were used to keep haematocrit not lower than 33%. The bleeding of red cells during hospital stay was calculated from the red cell balance. The preoperative red cell reserve (mililitres of red cells in excess of a haematocrit of 33%) was estimated and the difference between this volume and the total bleeding of red cells was retrospectively used to classify patients with regard to the need for red cells. Stepwise regression analysis was used to define patient-related variables associated with allogeneic blood transfusion. RESULTS: Preoperative knowledge of the type of operation (primary, revision), the preoperative red cell reserve, and the body mass could predict roughly half of the need for banked blood (r2 = 0.45). Only one-third of the total bleeding of red cells was retransfused. For complete avoidance of allogeneic blood, autotransfusion was most effective in patients with a moderate need (0-4 u). However, 32% of such patients required allogeneic blood. CONCLUSIONS: Autotransfusion has a limited efficacy to decrease the need for allogeneic blood, and other blood-saving methods should be added for this purpose. It is difficult to predict the need for allogeneic blood preoperatively.     

Structural, material, and anatomic characteristics of the collateral ligaments of the canine cubital joint

Surgical resection remains the mainstay of treatment for patients with hepatic tumors, despite the associated morbidity including the need for blood transfusion. Acute isovolemic hemodilution (AIH) has been shown to decrease the transfusion requirement for cardiac, urologic, and orthopedic procedures. However, the reported experience with AIH during hepatic resections is limited. Seven patients underwent major hepatic resection from July 1992 to June 1994 with standard AIH. Their clinical parameters were compared with those of nine matched control patients during the same time period. AIH and control patients had similar preoperative laboratory values (hematocrit, bilirubin, and coagulation studies), extent of liver resection, and pathologic diagnoses. Mean tumor diameters were larger in the AIH group (9.3 cm vs. 5.8 cm). Most important, patients managed with AIH required homologous blood transfusions significantly less often than the control group (14% vs. 67%; P=0.05). Furthermore, if they did receive transfusions, AIH patients needed fewer units of red cells (0.1+/-0.1 units vs. 1.7+/-0.6 units). There was no morbidity associated with AIH. AIH can be safely performed in patients undergoing major hepatic resection for malignancy. AIH appears to reduce the number of patients requiring homologous blood transfusion as well as the number of units transfused per patient. This technique warrants further study in a larger prospective, randomized trial.     

Recombinant human erythropoietin reduces the need for erythrocyte and platelet transfusions in pediatric patients with sarcoma: a randomized, double-blind, placebo-controlled trial

OBJECTIVE: To evaluate the effect of recombinant human erythropoietin (EPO) and iron supplementation on transfusion requirements in pediatric patients with sarcoma who were receiving chemotherapy, we performed a double-blind, placebo-controlled, randomized trial. METHODS: Twenty-four pediatric patients with malignant solid tumors were randomly assigned to receive either placebo (saline solution) or EPO for a 16-week study period. The starting dose was 150 IU/kg per dose three times a week and was escalated by 50 IU/kg per dose increments monthly until packed red blood cell (PRBC) transfusion independence was achieved or a dosage of 300 IU/kg per dose was reached. Iron supplementation was prescribed at a dose of 6 mg of elemental iron per kilogram daily. The primary study end point was the comparison of PRBC transfusion requirements in the two groups. RESULTS: Of 24 patients, 20 were evaluable for response. The median PRBC transfusion requirement during the 16-week period was 23 ml/kg in EPO-treated patients versus 80 ml/kg in placebo patients (p = 0.02). The median number of single-donor platelet units transfused was zero in the EPO-treated patients compared with four in the placebo group (p = 0.005). No statistical difference in the intensity of bone marrow suppression was seen, as measured by the median number of complete blood cell counts with an absolute neutrophil count of < 1000 cells/microliter. CONCLUSIONS: Treatment with EPO and iron significantly reduces PRBC transfusions in pediatric patients receiving concomitant chemotherapy for malignant sarcomas. A decrease in the number of platelet transfusions was also seen and deserves further study.     

Allogeneic versus autologous blood during abdominal aortic aneurysm surgery

OBJECTIVES: To determine if cell-salvaged autologous blood can serve as an alternative to homologous blood, and to examine the incidence of infected complications and length of postoperative stay. DESIGN: A prospective randomised study comprising autologous and homologous blood transfusions in patients undergoing elective infrarenal abdominal aortic surgery. METHODS: Fifty patients undergoing AAA surgery were prospectively randomised to homologous blood (n = 27), or autologous blood transfusion (n = 23), using a cell salvage autotransfusion device. RESULTS: The haemoglobin at the time of hospital discharge was similar for both groups (11.0 vs. 10.8 g/dl) with no difference in perioperative mortality. The length of stay was reduced in those patients who received autologous blood (9 days vs. 12 days, p < 0.05 Mann-Whitney U test). There were four infected cases in the autologous group and 12 in the homologous group (p = n.s., Fisher's exact probability test). However, patients who received 3-4 units of homologous blood had an increased risk of infection compared to those who received a similar amount of autologous blood (50% vs. 0%). CONCLUSIONS: Cell salvage autologous blood can safely replace, or at least decrease, exposure to homologous blood transfusion, with a reduction in the mean hospital stay.     

The effects of perioperative blood salvage and autologous blood donation on transfusion requirements in scoliosis surgery

Fifty consecutive cases of surgical instrumentation and fusion for adolescent idiopathic scoliosis were prospectively studied to test the hypothesis that the use of predonated autologous blood combined with judicious perioperative blood salvage could decrease the amount of homologous blood needed. All cases had posterior instrumentation and fusion. Nineteen patients had their rib prominence resected with an average of 4.8 ribs per patient. Our protocol called for perioperative blood salvage with the cell saver and reinfusion of postoperative drained blood if more than 300 ml were drained in 4 hours. Two units of predonated autologous blood was made available. Hypotensive anesthesia and meticulous hemostasis kept the blood loss to a minimum. The average total blood loss was 1,055 ml. Blood loss per segment was 91 ml with an average of 11 segments fused per patient. Patients with rib resection had a blood loss of 1,105 ml, while those without had a blood loss of 955 ml. The cell saver blood returned per case was 391 ml with the hematocrit of the product averaging 46%. Twelve patients were reinfused an average of 300 ml of the postoperative drained blood. The predonated autologous blood was used as part of the intraoperative fluid management. In no patient was homologous blood needed. The average starting hematocrit was 35.6%, with the hematocrit at discharge (seventh day) being 32.4%. There were no complications or blood transfusion reactions. Our results suggest that judicious perioperative blood management may decrease the need for homologous blood transfusion in selected posterior idiopathic scoliosis surgery.     

Gabexate mesilate, a new synthetic serine protease inhibitor: a pilot clinical trial in valvular heart surgery

OBJECTIVE: To assess the effects of gabexate mesilate ([GM], Foy, ONO Pharmaceutical Co, Osaka, Japan) on blood loss in cardiac valve replacement surgery and to establish whether GM reduces blood loss or transfusion requirements after this surgery. DESIGN: Randomized single-blind trial in 30 patients receiving either GM (2 mg/kg/h in a central venous catheter), or no GM, after heparin. SETTING: Department of Anesthesia and Intensive Care, Cardiac Surgery, in a hospital in Italy. PARTICIPANTS: Consent patients. INTERVENTIONS: Cardiac valve replacement surgery. MEASUREMENT AND MAIN RESULTS: Intraoperative and postoperative bleeding, blood transfusion, hemoglobin, and hematocrit were compared. In the GM group bleeding was reduced and no transfusions were required. CONCLUSION: GM appears to play a useful role in reducing blood loss during extracorporeal circulation in cardiac surgery.