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Sertic F, Crespo M, Habertheuer A, Diagne D, Chavez L, Richards T, Molina M, Suzuki Y, Rame E, Wald J, Cantu E, Bermudez C. Early Outcomes with the Use of ExtraCorporeal Membrane Oxygenation as a Bridge to Combined Heart and Lung Transplant. J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Habertheuer A, Richards T, Sertic F, Crespo M, Molina M, Vallabhajosyula P, Cantu E, Suzuki Y, Diagne D, Bermudez C. Stratification Risk Analysis in Bridging Patients to Lung Transplant on ECMO: The STABLE Recipient Risk Score. J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Otto JM, Plumb JOM, Wakeham D, Clissold E, Loughney L, Schmidt W, Montgomery HE, Grocott MPW, Richards T. Total haemoglobin mass, but not haemoglobin concentration, is associated with preoperative cardiopulmonary exercise testing-derived oxygen-consumption variables. Br J Anaesth 2018; 118:747-754. [PMID: 28510737 DOI: 10.1093/bja/aew445] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2016] [Indexed: 01/22/2023] Open
Abstract
Background Cardiopulmonary exercise testing (CPET) measures peak exertional oxygen consumption ( V˙O2peak ) and that at the anaerobic threshold ( V˙O2 at AT, i.e. the point at which anaerobic metabolism contributes substantially to overall metabolism). Lower values are associated with excess postoperative morbidity and mortality. A reduced haemoglobin concentration ([Hb]) results from a reduction in total haemoglobin mass (tHb-mass) or an increase in plasma volume. Thus, tHb-mass might be a more useful measure of oxygen-carrying capacity and might correlate better with CPET-derived fitness measures in preoperative patients than does circulating [Hb]. Methods Before major elective surgery, CPET was performed, and both tHb-mass (optimized carbon monoxide rebreathing method) and circulating [Hb] were determined. Results In 42 patients (83% male), [Hb] was unrelated to V˙O2 at AT and V˙O2peak ( r =0.02, P =0.89 and r =0.04, P =0.80, respectively) and explained none of the variance in either measure. In contrast, tHb-mass was related to both ( r =0.661, P <0.0001 and r =0.483, P =0.001 for V˙O2 at AT and V˙O2peak , respectively). The tHb-mass explained 44% of variance in V˙O2 at AT ( P <0.0001) and 23% in V˙O2peak ( P =0.001). Conclusions In contrast to [Hb], tHb-mass is an important determinant of physical fitness before major elective surgery. Further studies should determine whether low tHb-mass is predictive of poor outcome and whether targeted increases in tHb-mass might thus improve outcome.
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Richards T, Glendenning A, Benson D, Alexander S, Thati S. The independent patient factors that affect length of stay following hip fractures. Ann R Coll Surg Engl 2018; 100:556-562. [PMID: 29692191 PMCID: PMC6214067 DOI: 10.1308/rcsann.2018.0068] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2018] [Indexed: 11/22/2022] Open
Abstract
Introduction Management of hip fractures has evolved over recent years to drive better outcomes including length of hospital stay. We aimed to identify and quantify the effect that patient factors influence acute hospital and total health service length of stay. Methods A retrospective observational study based on National Hip Fracture Database data was conducted from 1 January 2014 to 31 December 2015. A multiple regression analysis of 330 patients was carried out to determine independent factors that affect acute hospital and total hospital length of stay. Results American Society of Anesthesiologists (ASA) grade 3 or above, Abbreviated Mental Test Score (AMTS) less than 8 and poor mobility status were independent factors, significantly increasing length of hospital stay in our population. Acute hospital length of stay can be predicted as 8.9 days longer when AMTS less than 8, 4.2 days longer when ASA grade was 3 or above and 20.4 days longer when unable to mobilise unaided (compared with independently mobile individuals). Other factors including total hip replacement compared with hemiarthroplasty did not independently affect length of stay. Conclusions Our analysis in a representative and generalisable population illustrates the importance of identifying these three patient characteristics in hip fracture patients. When recognised and targeted with orthogeriatric support, the length of hospital stay for these patients can be reduced and overall hip fracture care improved. Screening on admission for ASA grade, AMTS and mobility status allows prediction of length of stay and tailoring of care to match needs.
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Abbott T, Fowler A, Pelosi P, Gama de Abreu M, Møller A, Canet J, Creagh-Brown B, Mythen M, Gin T, Lalu M, Futier E, Grocott M, Schultz M, Pearse R, Myles P, Gan T, Kurz A, Peyton P, Sessler D, Tramèr M, Cyna A, De Oliveira G, Wu C, Jensen M, Kehlet H, Botti M, Boney O, Haller G, Grocott M, Cook T, Fleisher L, Neuman M, Story D, Gruen R, Bampoe S, Evered L, Scott D, Silbert B, van Dijk D, Kalkman C, Chan M, Grocott H, Eckenhoff R, Rasmussen L, Eriksson L, Beattie S, Wijeysundera D, Landoni G, Leslie K, Biccard B, Howell S, Nagele P, Richards T, Lamy A, Gabreu M, Klein A, Corcoran T, Jamie Cooper D, Dieleman S, Diouf E, McIlroy D, Bellomo R, Shaw A, Prowle J, Karkouti K, Billings J, Mazer D, Jayarajah M, Murphy M, Bartoszko J, Sneyd R, Morris S, George R, Moonesinghe R, Shulman M, Lane-Fall M, Nilsson U, Stevenson N, van Klei W, Cabrini L, Miller T, Pace N, Jackson S, Buggy D, Short T, Riedel B, Gottumukkala V, Alkhaffaf B, Johnson M. A systematic review and consensus definitions for standardised end-points in perioperative medicine: pulmonary complications. Br J Anaesth 2018; 120:1066-1079. [DOI: 10.1016/j.bja.2018.02.007] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/01/2018] [Accepted: 02/12/2018] [Indexed: 02/02/2023] Open
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Abdullah HR, Sim YE, Sim YT, Ang AL, Chan YH, Richards T, Ong BC. Preoperative Red Cell Distribution Width and 30-day mortality in older patients undergoing non-cardiac surgery: a retrospective cohort observational study. Sci Rep 2018; 8:6226. [PMID: 29670189 PMCID: PMC5906451 DOI: 10.1038/s41598-018-24556-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 04/06/2018] [Indexed: 12/20/2022] Open
Abstract
Increased red cell distribution width (RDW) is associated with poorer outcomes in various patient populations. We investigated the association between preoperative RDW and anaemia on 30-day postoperative mortality among elderly patients undergoing non-cardiac surgery. Medical records of 24,579 patients aged 65 and older who underwent surgery under anaesthesia between 1 January 2012 and 31 October 2016 were retrospectively analysed. Patients who died within 30 days had higher median RDW (15.0%) than those who were alive (13.4%). Based on multivariate logistic regression, in our cohort of elderly patients undergoing non-cardiac surgery, moderate/severe preoperative anaemia (aOR 1.61, p = 0.04) and high preoperative RDW levels in the 3rd quartile (>13.4% and ≤14.3%) and 4th quartile (>14.3%) were significantly associated with increased odds of 30-day mortality - (aOR 2.12, p = 0.02) and (aOR 2.85, p = 0.001) respectively, after adjusting for the effects of transfusion, surgical severity, priority of surgery, and comorbidities. Patients with high RDW, defined as >15.7% (90th centile), and preoperative anaemia have higher odds of 30-day mortality compared to patients with anaemia and normal RDW. Thus, preoperative RDW independently increases risk of 30-day postoperative mortality, and future risk stratification strategies should include RDW as a factor.
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Ampil F, Caldito G, Ghali G, Nathan C, Mills G, Kim D, Richards T, Vora M, Lian T, Milligan E. Do Subgroups (T3-T4 Versus Nodal Metastases) of Intermediate-Risk Head and Neck Cancer Matter in Empirical Treatment With Postoperative Radiation Therapy? Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2017.12.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Richards T, Clement R, Russell I, Newington D. Acute hand injury splinting - the good, the bad and the ugly. Ann R Coll Surg Engl 2018; 100:92-96. [PMID: 29182002 PMCID: PMC5838697 DOI: 10.1308/rcsann.2017.0195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2017] [Indexed: 11/22/2022] Open
Abstract
Injuries to the hand comprise 20% of all emergency department attendances, with an estimated annual treatment cost of over £100 million in the UK. The initial assessment and management of hand injuries is usually undertaken by junior staff, many of whom have little or no training or experience in splinting hand fractures. In the Department of Orthopaedic Hand Surgery, Morriston Hospital, we regularly observe patients presenting to the specialist hand fracture clinics having had initial management that shows no appreciation for the treatment objectives or the safe positions for splinting. This article aims to provide guidance for frontline staff on the management of hand fractures, with particular emphasis on the appropriate nonoperative care to avoid any unnecessary morbidity.
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Kanapathy M, Simpson R, Madden L, Thrasivoulou C, Mosahebi A, Becker DL, Richards T. Upregulation of epidermal gap junctional proteins in patients with venous disease. Br J Surg 2017; 105:59-67. [DOI: 10.1002/bjs.10653] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/05/2017] [Accepted: 06/23/2017] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Leg ulceration is a feared complication of venous insufficiency. It is not known whether varicose veins predispose skin to poor wound healing. The expression pattern of gap junctional protein connexin, a known marker of poor wound healing, was investigated across various stages of venous disease.
Methods
Patients undergoing intervention for varicose veins were assessed according to the Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification of varicose veins. Paired 4-mm punch biopsies were taken from above the ankle (pathological) and above the knee (control). Tissues were stained with haematoxylin and eosin, and for connexin 43, connexin 30 and connexin 26.
Results
Forty-eight paired biopsies were taken (12 each for CEAP class C0, C2, C4 and C6). The pathological skin showed progressive epithelial hyperthickening, an increase in the number and depth of rete ridges, increased inflammation and loss of dermal architecture with disease progression from C4 onwards. The overall absolute connexin expression and mean connexin expression per cell in the pathological skin similarly increased across the CEAP classes from as early as C2. Increasing levels of connexin in control skin were also noted, indicating progression of the disease proximally. Connexin 43 expression showed the strongest positive correlation between pathological and control skin.
Conclusion
Connexins were overexpressed in patients with simple varicose veins, with a stepwise increased expression through venous eczema to ulceration. Connexin 43 is a potential biomarker for venous disease. This finding suggests that varicose veins predispose skin to poor wound healing. Surgical relevanceThe overexpression of connexins, a family of gap junctional proteins, is known to cause poor healing in venous leg ulceration. It is not known whether there is any association with superficial venous disease. Here, connexin proteins were overexpressed in patients with uncomplicated varicose veins, before histological skin changes. Connexin could be a biomarker of venous disease progression.
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Benson D, Richards T, Glendenning A, Alexander S, Thati S. The Independent Patient Factors That Affect Length of Stay Following Hip Fractures. Int J Surg 2017. [DOI: 10.1016/j.ijsu.2017.08.427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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37
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Butcher A, Richards T. Cornerstones of patient blood management in surgery. Transfus Med 2017; 28:150-157. [PMID: 28940786 DOI: 10.1111/tme.12476] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 08/11/2017] [Accepted: 08/28/2017] [Indexed: 12/22/2022]
Abstract
Pre-operative anaemia and perioperative red blood cell transfusion carry significant consequence when it comes to surgical outcomes. The establishment of patient-centred clinical pathways has been designed to harness and endorse good transfusion practice, termed the three pillars of patient blood management (PBM). These focus on the timely and appropriate management of anaemia, prevention of blood loss and restrictive transfusion where appropriate. This article reviews the current evidence and ongoing research in the field of PBM in surgery. Strategies to implement PBM have shown significant benefits in appropriate transfusion practice, reduced costs and improved length of hospital stay. Recently published national quality standards have recognised the features of the PBM blueprint such as the consideration of alternatives to red blood cell transfusion, the active measures to reduce perioperative blood loss and the appropriate management of post-operative anaemia. Adopting PBM in surgical patients should be paramount to reduce the risks posed by perioperative anaemia and blood transfusions. The principles of PBM help structure the interventions and decisions relating to anaemia and blood transfusion, but, more importantly, represent a paradigm shift towards a more considered approach to blood transfusion, acknowledging its risks, preventatives and alternatives.
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Klein A, Collier T, Yeates J, Miles L, Fletcher S, Evans C, Richards T. The ACTA PORT-score for predicting perioperative risk of blood transfusion for adult cardiac surgery. Br J Anaesth 2017; 119:394-401. [DOI: 10.1093/bja/aex205] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2017] [Indexed: 01/09/2023] Open
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Shah N, Abeysundara L, Dutta P, Christodoulidou M, Wylie S, Richards T, Schofield N. The association of abdominal muscle with outcomes after scheduled abdominal aortic aneurysm repair. Anaesthesia 2017; 72:1107-1111. [DOI: 10.1111/anae.13980] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2017] [Indexed: 01/01/2023]
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Butcher A, Richards T, Stanworth SJ, Klein AA. Diagnostic criteria for pre-operative anaemia-time to end sex discrimination. Anaesthesia 2017; 72:811-814. [DOI: 10.1111/anae.13877] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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41
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Muñoz M, Acheson AG, Auerbach M, Besser M, Habler O, Kehlet H, Liumbruno GM, Lasocki S, Meybohm P, Rao Baikady R, Richards T, Shander A, So-Osman C, Spahn DR, Klein AA. International consensus statement on the peri-operative management of anaemia and iron deficiency. Anaesthesia 2016; 72:233-247. [PMID: 27996086 DOI: 10.1111/anae.13773] [Citation(s) in RCA: 438] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2016] [Indexed: 12/13/2022]
Abstract
Despite current recommendations on the management of pre-operative anaemia, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in surgical patients. A number of experienced researchers and clinicians took part in an expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the peri-operative period. These statements include: a diagnostic approach for anaemia and iron deficiency in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up. We urge anaesthetists and peri-operative physicians to embrace these recommendations, and hospital administrators to enable implementation of these concepts by allocating adequate resources.
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Best L, Webb A, Gurusamy K, Cheng S, Richards T. Transcranial Doppler Ultrasound Detection of Microemboli as a Predictor of Cerebral Events in Patients with Symptomatic and Asymptomatic Carotid Disease: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2016; 52:565-580. [DOI: 10.1016/j.ejvs.2016.05.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 05/19/2016] [Indexed: 10/21/2022]
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44
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Kanapathy M, Smith O, Hachach-Haram N, Bystrzonowski N, Richards T, Mosahebi A. Systematic review and meta-analysis of the efficacy of epidermal grafting for wound healing. Int J Surg 2016. [DOI: 10.1016/j.ijsu.2016.08.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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45
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Ampil F, Caldito G, Vora M, Richards T, Nathan C, Mills G, Devarakonda S, Cruz ND, Assercq M. Advanced-Stage “Horseshoe” Anterior Commissure Laryngeal Cancers, Contemporary Management, and Long-Term (10-year) Outcomes. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.1553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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46
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Best LMJ, Richards T. Response to commentary on 'Transcranial Doppler Microemboli for Case Selection in Asymptomatic Carotid Stenosis'. Eur J Vasc Endovasc Surg 2016; 52:705. [PMID: 27601218 DOI: 10.1016/j.ejvs.2016.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 08/01/2016] [Indexed: 10/21/2022]
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47
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Bruinvels G, Burden RJ, McGregor AJ, Ackerman KE, Dooley M, Richards T, Pedlar C. Sport, exercise and the menstrual cycle: where is the research? Br J Sports Med 2016; 51:487-488. [DOI: 10.1136/bjsports-2016-096279] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2016] [Indexed: 11/04/2022]
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48
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Richards T, Mann S, Samei E. TU-FG-209-06: Quantitative Evaluation of the Temporal Performance of Clinical Fluoroscopic Imaging Systems: The Temporal Modulation Transfer Function (TMTF). Med Phys 2016. [DOI: 10.1118/1.4957576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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49
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Muñoz M, Shander A, Kehlet H, Evans C, Richards T, Auerbach M. Reply from the authors. Br J Anaesth 2016; 116:723-4. [PMID: 27106985 DOI: 10.1093/bja/aew086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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50
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Klein AA, Arnold P, Bingham RM, Brohi K, Clark R, Collis R, Gill R, McSporran W, Moor P, Rao Baikady R, Richards T, Shinde S, Stanworth S, Walsh TS. AAGBI guidelines: the use of blood components and their alternatives 2016. Anaesthesia 2016; 71:829-42. [PMID: 27062274 DOI: 10.1111/anae.13489] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2016] [Indexed: 12/13/2022]
Abstract
Blood transfusion can be life-saving. Anaesthetists regularly request and administer blood components to their patients. All anaesthetists must be familiar with indications and appropriate use of blood and blood components and their alternatives, but close liaison with haematology specialists and their local blood sciences laboratory is encouraged. Considerable changes in approaches to optimal use of blood components, together with the use of alternative products, have become apparent over the past decade, leading to a need to update previous guidelines and adapt them for the use of anaesthetists working throughout the hospital system.
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