Shed blood autotransfusion influences ischemia-sensitive laboratory parameters after coronary operations

The diagnostic significance of ischemia-sensitive laboratory parameters in respect to possible interference with shed blood autotransfusion was assessed in a prospective study with 100 patients undergoing elective coronary artery bypass grafting. Serum levels of creatine kinase, creatine kinase MB activity, creatine kinase MB mass concentration, 2-hydroxybutyrate dehydrogenase, lactate dehydrogenase-1, troponin-T, myoglobin, and glutamicoxaloacetic transaminase were repeatedly assessed up to the sixth postoperative day. Thirty-seven patients were excluded from the study due to postoperative development of myocardial infarction (n = 4), transient ischemic events (n = 25), and left bundle-branch blocks (n = 8). In the remaining group of 63, 37 patients were retransfused with 580 +/- 370 mL shed blood up to the twelfth postoperative hour, and 26 patients did not receive autotransfusion due to minimal mediastinal blood loss. The results of our study show that the ischemia-sensitive laboratory parameters were significantly influenced by shed blood autotransfusion: 8 hours postoperatively, creatine kinase (272%), creatine kinase MB fraction (151%), 2-hydroxybutyrate dehydrogenase (130%), lactate dehydrogenase-1 (133%), troponin-T (200%), myoglobin (159%) and glutamic-oxaloacetic transaminase levels (153%) were significantly elevated (p < 0.05) in patients with postoperative autotransfusion, although there were no electrocardiographic signs of myocardial ischemia in this group of patients. Our study shows that postoperative autotransfusion of mediastinal shed blood may interfere with the diagnosis of perioperative myocardial ischemia by laboratory parameters in coronary bypass patients.     

Costs of blood transfusion: a process-flow analysis

PURPOSE: To determine the cost of transfusing 2 units (U) of packed RBCs at a comprehensive cancer center. METHODS: We performed a process-flow analysis to identify all costs of transfusing 2 U of allogeneic packed RBCs on an outpatient basis to patients with either (1) solid tumor who did not undergo bone marrow transplantation (BMT), (2) solid tumor who underwent BMT, (3) hematologic malignancy who did not undergo BMT, (4) hematologic malignancy who underwent allogeneic BMT, or (5) hematologic malignancy who underwent autologous BMT. We conducted structured interviews to determine the personnel time used and physical resources necessary at all steps of the transfusion process. RESULTS: The mean cost of a 2-U transfusion of allogeneic packed RBCs was $548, $565, $569, $569, and $566 for patients with non-BMT solid tumor, BMT solid tumor, non-BMT hematologic malignancy, allogeneic BMT hematologic malignancy, and autologous BMT hematologic malignancy, respectively. Sensitivity analysis showed that total transfusion costs were sensitive to variations in the amount of clinician compensation and overhead costs, but were relatively insensitive to reasonable variations in the direct costs of blood tests and the blood itself, or the probability or extent of transfusion reaction. CONCLUSION: The costs of the transfusion of packed RBCs are greater than previously analyzed, particularly in the cancer care setting.     

History of autologous blood transfusion in neurosurgical operations]

Two Caucasian patients are described who had destructive postpartum thyroiditis (PPT) before the subsequent onset of Graves' hyperthyroidism (GH). HLA class II DQ typing in these two subjects identified putative susceptibility alleles previously detected in GH and PPT. Although PPT destructive thyroiditis preceding the development of GH is relatively uncommon, the occurrence of both these syndromes in the same patient suggests the possibility of an etiological role for thyroid antigen release and genetic susceptibility as pathogenic factors in the development of Graves' disease.     

Hemorrhage and the use of blood products after adult cardiac operations: myths and realities

BACKGROUND: Several patient-, procedure-, and prescriber-related factors are thought to influence the decision to administer allogeneic blood products. We reexamine a number of assertions applied commonly to the practice of transfusion in cardiac operations. METHODS: More than 50 original articles including a total of more than 10,000 patients from 70 centers were reviewed. Data from 5,426 patients operated on between 1990 and 1994 at the Montreal Heart Institute are presented. RESULTS: From our review of the literature, we conclude that postoperative mediastinal fluid drainage averages 917 mL and that aspirin therapy increases drainage by less than 300 mL in most studies, which should not increase use of blood products, insofar as a strict transfusional protocol is adhered to. Across centers, transfusions can vary eightfold for the same postoperative drainage. Data from our institution show that postoperative mediastinal drainage per se is not influenced by reoperation or by the type of operation. However, total blood losses and transfusion requirements remain increased in reoperative and complex procedures. Excessive mediastinal drainage resulting in increased transfusions occurs in 29% of patients. CONCLUSIONS: Exposure to allogeneic transfusions remains institution dependent. Constant reevaluation of local practice is essential to implement efficient blood conservation strategies.     

Infectious mediastinitis after cardiac operations: computed tomographic findings

BACKGROUND: Infectious mediastinitis after cardiac operations is of great concern to cardiac surgeons because of its poor prognosis. Prompt surgical interventions such as debridement and irrigation are the key to treatment of infectious mediastinitis. METHODS: We surveyed retrospectively the cases of 722 consecutive cardiac surgery patients at our hospital. Mediastinitis developed in 21 patients after the cardiac operation. We performed computed tomography in 11 of these patients before resternotomy and in 10 patients as the control 2 to 3 weeks after the cardiac operation. RESULTS: Mediastinal soft tissue swelling was seen in 7 patients, bilateral pleural effusion was found in 9 patients, sternal dehiscence or sternal erosion was observed in 8 patients, and subcutaneous fluid accumulation was found in 7 of the mediastinitis group. Unilateral pleural effusion was seen in 6 and bilateral effusion in 1, and mediastinal soft tissue swelling was seen in 1 patient of the control group. CONCLUSIONS: Our study showed that mediastinal soft tissue mass combined with bilateral pleural effusion can be a characteristic computed tomography finding in poststernotomy infectious mediastinitis, and that chest computed tomography is more sensitive to detecting sternal dehiscence, sternal erosion, and subcutaneous fluid accumulation.     

The benefits of active rewarming after cardiac operations: a randomized prospective trial

Studies were carried out to observe the species composition of mosquitos and to determine the vectors responsible for the transmission of filariasis in Grik, Perak, Malaysia. A total of 2,155 mosquitos belonging to 7 genera and 30 species were collected. Anopheles donaldi comprised 24.1% of the collection. Twelve out of 519 An. donaldi were infected with L3 larvae of Brugia malayi. The peak biting time was around 23.00-24.00 hours. The infective bites per month ranged from 0 to 6.3.     

Addition of a thiazide: an effective remedy for furosemide resistance after cardiac operations

BACKGROUND: The frequent use of diuretic drugs in cardiac surgical practice contrasts with the lack of documentation regarding diuretic treatment in this setting. The aims of this study were to delineate the need for diuretic drugs in adult cardiac surgical practice and to evaluate the impact of adding a combination of 50 mg hydrochlorothiazide and 5 mg amiloride orally to patients responding poorly to furosemide. METHODS: Two hundred ten consecutive patients, 159 undergoing coronary artery bypass grafting procedures and 51 having valve operations, were studied. RESULTS: Seventy-seven patients received large doses of furosemide (> or = 80 mg/24 h) at some time during the postoperative course, and of these 20 responded poorly to furosemide (weight loss 0.3 +/- 0.2 kg) despite considerable fluid retention. The addition of hydrochlorothiazide and amiloride provided a prompt and effective remedy to relative furosemide resistance. Average weight loss was 2.3 +/- 0.2 kg (p < 0.01 compared with response to furosemide) and average diuresis was 2,949 +/- 156 mL in the following 24 hours. CONCLUSIONS: Relative furosemide resistance is common after cardiac operations. Thiazides, although they are mild diuretic agents, may serve as useful adjuncts in this setting.     

Autotransfusion of shed mediastinal blood after open heart operation

This prospective study was designed to determine whether the autotransfusion of shed mediastinal blood (ATS) after open heart surgery is safe and effective. Forty-two patients undergoing cardiac operation were randomized to receive either nonwashed shed mediastinal blood (group 1; n = 22) or banked blood (group 2: n = 20). No difference in mean age (group 1: 49 +/- 11 years; group 2: 45 +/- 12 years), coronary artery bypass grafting (group 1: n = 5, 23%; group 2: n = 6, 30%), valve replacement (group 1: n = 17, 77%, group 2: n = 14, 70%), and mean preoperative hemoglobin level (group 1: 13.7 +/- 2.3, group 2: 14.4 +/- 1.6) was noted between non-ATS and ATS groups (p = not significant). The mean hemoglobin levels after operation were similar in the two groups (group 1: 11.89 +/- 1.52; group 2: 12.03 +/- 1.34). No difference in the mean blood loss 4, 6 and 24 hours after operation (group 1: 33 +/- 190, 420 +/- 340 and 550 +/- 300; group 2: 340 +/- 230, 420 +/- 280 and 670 +/- 380) was observed between the two groups. The mean volume autotransfused in group I was 380 +/- 230 ml (200 approximately 1300 ml). In group I, the patients required bank blood 1080 +/- 720, compared with 1780 +/- 1045 in group II. The bank blood requirement in group I reducted by 40%. These data demonstrate that ATS after open heart surgery is safe and effective.     

Intravenous diltiazem and acute renal failure after cardiac operations

BACKGROUND: Perioperative administration of intravenous diltiazem to patients undergoing cardiac procedures has been shown to decrease the incidence of ischemia and arrhythmias. However, after adopting this practice in our cardiac surgery program, we perceived an increased incidence of postoperative renal dysfunction. METHODS: A directed record review of postoperative renal function was conducted for consecutive patients undergoing cardiac operation for the time periods before and after adoption of prophylactic intravenous diltiazem (0.1 mg.kg-1.h-1 for 24 hours). The two groups were compared using chi 2 and two-sample t tests. The risk of development of postoperative renal failure was modeled with logistic regression. RESULTS: Diltiazem-treated patients (n = 271) were similar to the control patients (n = 143) in terms of age (64 versus 61 years; p = 0.14), ejection fraction (0.46 versus 0.47; p = 0.61), baseline serum creatinine level (1.2 versus 1.1 mg/dL; p = 0.27), prevalence of comorbid conditions, and surgical characteristics. The prevalence of left main coronary artery disease was lower in the diltiazem group than the control group (39% versus 52%; p = 0.01). During the 7-day postoperative period, the average peak serum creatinine level was higher in the diltiazem group (1.7 +/- 0.9 mg/dL; mean +/- 1 standard deviation) than the control group (1.5 +/- 0.5 mg/dL; p = 0.003). The incidence of acute renal failure requiring dialysis was 4.4% in the diltiazem group versus 0.7% in the control group (p = 0.04). There was no difference in length of hospitalization or mortality. The risk of acute renal failure was strongly associated with intravenous diltiazem (adjusted odds ratio [AOR] 6.3; p = 0.08), age (AOR 2.5 per 10 years; p = 0.07), baseline serum creatinine (AOR 4.8 per 1 mg/dL; p = 0.02), the presence of left main coronary disease (AOR 5.3; p = 0.02), and the presence of cerebrovascular disease (AOR 4.5; p = 0.05). CONCLUSIONS: Our retrospective analysis suggests that prophylactic use of intravenous diltiazem in patients undergoing cardiac operations was associated with increased renal dysfunction. Further studies of the risk and benefits of intravenous diltiazem in this setting should be undertaken.     

DNA typing of recipient blood after massive transfusion

BACKGROUND: Transfusion is known to alter the recipient's blood group, protein allotype, and alloenzyme phenotype by the introduction of donor material and the dilution of his or her own cells and proteins. There is little information about typing the DNA of blood after transfusion. STUDY DESIGN AND METHODS: Ten adult patients who had undergone massive transfusion with white cell-containing blood components were studied. Pretransfusion and posttransfusion blood specimen DNA types were compared by using Southern blot and polymerase chain reaction (PCR) analyses. RESULTS: DNA types were identical in all 90 paired observations. CONCLUSION: These preliminary findings, in a limited number of patients, suggest that certain DNA methods may provide reliable typing of adult recipients after massive transfusion.     

Red blood cell transfusion practices in patients undergoing orthopedic surgery: a multi-institutional analysis

This retrospective review analyzed and compared transfusion practices in patients undergoing orthopedic surgery in five Massachusetts hospitals with current practice guidelines; opportunities for improvement were identified. Patient-specific clinical information and data about transfusion practices were obtained from the medical records of 384 Medicare patients undergoing orthopedic surgery between January 1992 and December 1993. The number of patients who donated autologous blood preoperatively differed significantly among hospitals as did the number of autologous units that were unused. The number of blood units transfused at each transfusion event also differed significantly; some surgeons transfused > or =2 units in the majority of their patients, while others transfused 1 unit at a time. This variation in practice was not explained by differences in patients' clinical status. The mean pretransfusion hematocrit was higher for autologous versus allogeneic blood, suggesting more liberal criteria to transfuse autologous blood. Nearly half of all transfusion events were determined to have been potentially avoidable. Avoidable transfusions were also three to seven times more likely with autologous than with allogeneic blood. Significant inter-hospital differences existed in the number of elective surgery patients exposed to allogeneic blood. The major determinant of allogeneic blood use in these patients was the availability of autologous blood. Each additional autologous blood unit available decreased the odds of allogeneic blood exposure twofold. Differences in intraoperative and postoperative blood salvage use also were noted. These findings indicate that significant variations in practice exist. Comparative data enabled hospitals to identify and target specific areas for improvement.     

Reexploration for bleeding is a risk factor for adverse outcomes after cardiac operations

OBJECTIVE: Although previous studies have included early reexploration for bleeding as a risk factor in analyzing adverse outcomes after cardiac operations, reexploration for bleeding has not been systematically examined as a multivariate risk factor for increased morbidity and mortality after cardiac surgery. Furthermore, multivariate predictors of the need for reexploration have not been identified. Accordingly, we performed a retrospective analysis of 6100 patients requiring cardiopulmonary bypass from January 1, 1986, to December 31, 1993. METHODS: Eighty-five patients who had ventricular assist devices were excluded from further analysis because of the prevalence of bleeding and the significant morbidity and mortality associated with placement of a ventricular assist device, unrelated to reexploration. In the remaining 6015 patients, potential adverse outcomes analyzed included operative mortality, mediastinitis, stroke, renal failure, adult respiratory distress syndrome, prolonged mechanical ventilation, sepsis, atrial arrhythmias, and ventricular arrhythmias. To control for the confounding effects of other risk factors, we performed a multivariate logistic regression analysis. Potential covariates considered in the logistic model included age, sex, race, history of reoperation, urgency of the operation, congestive heart failure, prior myocardial infarction, renal failure, diabetes, hypertension, chronic obstructive pulmonary disease or stroke, and the bypass and crossclamp time. RESULTS: The overall incidence of reexploration was 4.2% (253/6015). Four independent risk factors--increased patient age (p < 0.001), preoperative renal insufficiency (p = 0.02), operation other than coronary bypass (p < 0.001), and prolonged bypass time (p = 0.0.3)--were identified as predictors of the need for reexploration. The preoperative use of aspirin, heparin, or thrombolytic agents and the bleeding time were not identified as predictors. Reexploration for bleeding was identified as a strong independent risk factor for operative mortality (p = 0.005), renal failure (p < 0.0001), prolonged mechanical ventilation (p < 0.0001), adult respiratory distress syndrome (p = 0.03), sepsis (p < 0.0001), and atrial arrhythmias (p = 0.006). CONCLUSION: These data indicate that meticulous attention to surgical hemostasis and possibly application of recently developed modalities designed to facilitate perioperative correction of coagulopathy could improve outcomes after cardiac operations.     

Long-term detection of microchimaerism in peripheral blood after pretransplantation blood transfusion

Renal allograft survival is prolonged after pretransplantation blood transfusion. The aim of this study was to test retrospectively the development and persistence of microchimaerism after pretransplantation blood transfusion and to assess whether the type of blood transfusion (partially matched [= sharing of at least one HLA-B and one HLA-DR antigen between blood donor and recipient] versus mismatched) influences the (continued) presence of donor-type cells. A sensitive nested PCR technique based on HLA-DRB1 allele-specific amplification using sequence-specific primers (detection level: one donor cell among 10(5) recipient cells) for detection of donor cells was implemented in our laboratory. We studied 21 patients for microchimaerism in the peripheral blood compartment, following blood transfusion. Our preliminary data show that microchimaerism was detectable up to 8 weeks after blood transfusion. In all patients receiving a partially matched blood transfusion, donor-type cells were detected in the first week after transfusion, in 7/8 patients 2-4 weeks after transfusion, and in some patients up to 8 weeks after transfusion. After mismatched transfusion a tendency to shorter duration of microchimaerism was observed.     

Postoperative inflammatory response after autologous and allogeneic blood transfusion

BACKGROUND: Allogeneic blood transfusions cause immunosuppression. The aim of this study was to determine whether complement anaphylatoxins, cytokines, or both are released in the recipient, after blood transfusions in general, and after autologous blood transfusions in particular. METHODS: Thirty-one patients having total hip joint replacement surgery were randomized to receive either allogeneic red blood cells (n = 15) or predeposited autologous whole blood transfusion (n = 16). Plasma concentrations of the anaphylatoxins C3a and C5a, the terminal C5b-9 complement complex, and cytokines IL-6 and IL-8 in the recipients were repeatedly analyzed before, during, and after surgery. RESULTS: Significantly increased concentrations of IL-6 and IL-8 appeared in both groups, with a significantly greater increase in the autologous blood group. Patients in both groups developed a moderate but significant increase of C3a without a significant difference between them. C5a and terminal C5b-9 complement complex were not greatly changed. CONCLUSIONS: The study showed a greater increase in cytokine concentration after autologous blood transfusion than after allogeneic blood transfusion. The lower response in the latter may result from transfusion-induced suppression of cellular immunity.     

CT analysis of the anterior mediastinal fat: before and after lobectomy

CT analysis was performed to evaluate change in the anterior mediastinal fat (AMF) after lobectomy and differences in AMF in the lobectomized region. In 67 carcinoma patients who underwent lobectomy, the area and volume of AMF were measured on CT before and after surgery. Mediastinal deviation after lobectomy was also correlated to the altered fat tissue. The postoperative AMF distribution was distinctly changed in the left upper lobectomy (LUL) group, showing a marked increase from the infra-aortic arch to the carina level, with converse decreases in upper and lower slices. No significant post-operative change was noted in total AMF volume. There was a close correlation between changes in AMF area and mediastinal deviation after lobectomy, and postoperative mediastinal deviation was also greater the in the LUL group than in any other group. In conclusion, postoperative change in the AMF area was distinctly different in the LUL group. Redistribution of displaced AMF is considered to be the main cause of seemingly increased fat tissue.     

Early markers of major adverse events in children after cardiac operations

OBJECTIVES: The purpose of this study was to determine the physiologic variables that predict major adverse events in children in the intensive care unit after cardiac operations. METHODS: A cohort observational study was conducted. At the time of admission to the intensive care unit and 4, 8, 12, and 24 hours later the following variables were recorded: mean arterial pressure, heart rate, cardiac index, oxygen delivery, mixed venous oxygen saturation, base deficit, blood lactate, gastric intramucosal pH, carbon dioxide difference (the difference between arterial carbon dioxide tension and gastric intraluminal carbon dioxide tension), and toe-core temperature gradient. Major adverse events were prospectively identified as cardiac arrest, need for emergency chest opening, development of multiple organ failure, and death. RESULTS: Ninety children were included in the study; 12 had major adverse events and there were 4 deaths. Blood lactate level, mean arterial pressure, and duration of cardiopulmonary bypass were the only significant, independent predictors of major adverse events when measured at the time of admission to the intensive care unit. The odds ratio (95% confidence intervals) for major adverse events if a lactate level was greater than 4.5 mmol/L was 5.1 (1.2 to 21.1), for admission hypotension 2.3 (0.5 to 9.8), and for a cardiopulmonary bypass time greater than 150 minutes 13.7 (3.3 to 57.2). Four hours after admission lactate and carbon dioxide difference, and 8 hours after admission lactate and base deficit, were independently significant predictors. The odds ratios for major adverse events if the blood lactate level was greater than 4 mmol/L at 4 and 8 hours were 8.3 (1.8 to 38.4) and 9.3 (1.9 to 44.3), respectively. At no time in the first 24 hours were cardiac output, oxygen delivery, mixed venous oxygen saturation, toe-core temperature gradient, or heart rate significant predictors of major adverse events. CONCLUSIONS: In the context of our current treatment strategies, the duration of cardiopulmonary bypass and blood lactate level, measured in the early postoperative period, were the best predictors of impending major adverse events.