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Jin X, Han H, Liang Q. Effects of surgical trauma and intraoperative blood loss on tumour progression. Front Oncol 2024; 14:1412367. [PMID: 38912060 PMCID: PMC11190163 DOI: 10.3389/fonc.2024.1412367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 05/22/2024] [Indexed: 06/25/2024] Open
Abstract
Surgery is the primary treatment of choice for tumours, and improves prognosis, prolongs survival and is potentially curative. Previous studies have described the effects of anaesthesia and changes in the neuroendocrine, circulatory and sympathetic nervous systems on postoperative cancer progression. There is growing evidence that intraoperative blood loss is an independent prognostic factor for tumour recurrence, postoperative inflammation is a predictor of cancer prognosis, and immunosuppressive status correlates with the degree of surgical damage. This paper outlines the potential mechanisms by which blood loss, surgical trauma and postoperative immunosuppressive status contribute to tumour growth and recurrence by reducing intraoperative haemorrhage and perioperative immunotherapy, thereby reducing tumour growth and recurrence, and improving long-term prognosis.
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Affiliation(s)
| | | | - Qilian Liang
- Oncology Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
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2
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Pabón-Carrasco M, Cáceres-Matos R, Martínez-Flores S, Luque-Oliveros M. The effectiveness of cell salvage in extracorporeal circulation surgeries in relation to use of health resources after use: A systematic review and meta-analysis. Heliyon 2024; 10:e30459. [PMID: 38720744 PMCID: PMC11077044 DOI: 10.1016/j.heliyon.2024.e30459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 04/19/2024] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
Background Alternatives to allogeneic blood transfusions are sought for resource management reasons and it is necessary to investigate the efficiency and efficacy on Cell Salvage use. The objective of this study is to analyze the effectiveness of the Cell Salvage system in addressing factors related to healthcare service utilization that may lead to increased healthcare expenditure. Methods A systematic review with meta-analysis was conducted through literature search in Medline, CINAHL, Scopus, Web of Science, and Cochrane Library. Inclusion criteria were studies in English/Spanish, without year restriction and Randomized Controlled Trials design, conducted in adults. Results Twenty-six studies were included in the systematic review, involving a total of 4781 patients (nexperimental group = 2365; ncontrol group = 2416). Significant differences favored the Cell Salvage system in units of transfused Red Blood Cells, in terms of units (p = 0.04; SMD = -0.42 95 % CI = -0.83 to -0.02) and individuals (p = 0.001; RR = 0.71, 95 % CI = 0.60 to 0.84) transfused. No significant differences were found in ICU (p = 0.93) and hospital stay duration (p = 0.21), number of reoperations (p = 0.68), and number of units and individuals transfused in terms of platelets (p > 0.05). Conclusions Cell Salvage use holds high potential for reducing healthcare costs and indirectly contributing to improving blood and blood product reserves within blood banks. Results obtained thus far do not provide definitive evidence regarding the duration of hospital stay, ICU stay, need for reoperation, or the quantity of transfused platelets. Therefore, it is recommended to increase the number of studies to assess the impact on the economic models of the Cell Salvage system.
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Affiliation(s)
- Manuel Pabón-Carrasco
- Faculty of Nursing, Physiotherapy and Podiatry, University of Sevilla, 41009, Sevilla, Spain
- “CTS-1054: Interventions and Health Care, Red Cross (ICSCRE)”, Spain
| | - Rocío Cáceres-Matos
- Faculty of Nursing, Physiotherapy and Podiatry, University of Sevilla, 41009, Sevilla, Spain
- Research Group CTS-1050: “Complex Care, Chronicity and Health Outcomes”, 6 Avenzoar ST, RI, 41009, Seville, Spain
| | - Salvador Martínez-Flores
- Cardiovascular and Thoracic Surgery Operating Theatre Unit of the Virgen Macarena University Hospital, Seville, Spain
| | - Manuel Luque-Oliveros
- Cardiovascular and Thoracic Surgery Operating Theatre Unit of the Virgen Macarena University Hospital, Seville, Spain
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3
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Liu DS, Farid AR, Linden GS, Cook D, Birch CM, Hresko MT, Hedequist DJ, Hogue GD. Utility of postoperative laboratory testing after posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform 2024; 12:375-381. [PMID: 37884756 DOI: 10.1007/s43390-023-00771-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/23/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE With advancements to blood management strategies, risk of perioperative transfusion following surgical treatment of adolescent idiopathic scoliosis (AIS) has diminished. We hypothesize that routine laboratory testing on postoperative-day 1 (POD1) and beyond is unnecessary. The purpose of this study is to determine necessity of POD1 labs, particularly hematocrit and hemoglobin levels, following surgical management of AIS. METHODS We performed a retrospective cohort study of consecutive AIS patients aged 11-19 who underwent posterior spinal fusion (PSF) at a single institution. Univariable logistic regression was utilized to determine factors associated with hematocrit ≤ 22% on POD1 or a postoperative transfusion. Firth's penalized logistic regression was used for any separation in data. Youden's index was utilized to determine the optimal point on the ROC curve that maximizes both sensitivity and specificity. RESULTS 527 patients qualified for this study. Among the eight total patients with POD1 hematocrit ≤ 22, none underwent transfusion. These patients had lower last intraoperative hematocrit levels compared to patients with POD1 hematocrit > 22% (24.1% vs 31.5%, p < 0.001), and these groups showed no difference in preoperative hematocrit levels (38.2% vs 39.8%, p = 0.11). Four patients underwent postoperative transfusion. Both preoperative hematocrit levels (34.0% vs 39.9%, p = 0.001) and last intraoperative hematocrit levels (25.1% vs 31.4%, p = 0.002) were lower compared to patients without transfusion. Intraoperative hematocrit < 26.2%, operative time of more than 35.8 min per level fused, or cell salvage > 241 cc were significant risk factors for postoperative transfusion. CONCLUSION Transfusion after PSF for AIS is exceedingly rare. POD1 labs should be considered when last intraoperative hematocrit < 26%, operative time per level fused > 35 min, or cell salvage amount > 241 cc. Otherwise, unless symptomatic, patients do not benefit from postoperative laboratory screening.
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Affiliation(s)
- David S Liu
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Gabriel S Linden
- Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Danielle Cook
- Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Craig M Birch
- Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - M Timothy Hresko
- Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Daniel J Hedequist
- Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Grant D Hogue
- Harvard Medical School, Boston, MA, USA.
- Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
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Gammon R, Becker J, Cameron T, Eichbaum Q, Jindal A, Lamba DS, Nalezinski S, Rios J, Shaikh S, Shepherd J, Tanhehco YC. How do I manage a blood product shortage? Transfusion 2023; 63:2205-2213. [PMID: 37840217 DOI: 10.1111/trf.17572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/14/2023] [Accepted: 09/21/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND The demand for blood products sometimes exceeds the available inventory. Blood product inventories are dependent upon the availability of donors, supplies and reagents, and collection staff. During prolonged extreme shortages, blood centers and transfusion services must alter practices to meet the needs of patients. STUDY DESIGN AND METHODS The Association for the Advancement of Blood and Biotherapies Donor and Blood Component Management Subsection compiled some strategies from its blood center and hospital transfusion service members that could be implemented during blood product shortages. RESULTS Some strategies that blood centers could use to increase their available inventories include increasing donor recruitment efforts, using alternate types of collection kits, manufacturing low-yield apheresis-derived platelets and/or whole blood-derived platelets, using cold-stored platelets, transferring inventory internally among centers of the same enterprise, using frozen inventory, decreasing standing order quantities, prioritizing allocation to certain patient populations, filling partial orders, and educating customers and blood center staff. Transfusion service strategies that could be implemented to maximize the use of the limited available inventory include increasing patient blood management efforts, using split units, finding alternate blood suppliers, trading blood products with other hospital transfusion services, developing a patient priority list, assembling a hospital committee to decide on triaging priorities, using expired products in extreme situations, and accepting nonconforming products after performing safety checks. DISCUSSION Blood centers and transfusion services must choose the appropriate strategies to implement based on their needs.
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Affiliation(s)
- Richard Gammon
- OneBlood, Scientific, Medical, Technical Direction, Orlando, Florida, USA
| | - Joanne Becker
- Department of Pathology and Laboratory Medicine; Blood Bank and Therapeutic Apheresis Unit, Roswell Park Comprehensive Cancer Center, and Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Tracy Cameron
- Ontario Regional Blood Coordinating Network, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Quentin Eichbaum
- Vanderbilt University Medical Center (VUMC), Nashville, Tennessee, USA
| | - Aikaj Jindal
- Department of Transfusion Medicine, Mohandai Oswal Hospital, Ludhiana, India
| | - Divjot Singh Lamba
- Department of Transfusion Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shaughn Nalezinski
- Department of Laboratory Medicine Transfusion Services, Concord Hospital, Concord, New Hampshire, USA
| | - Jorge Rios
- American Red Cross Blood Services, Dedham, Massachusetts, USA
| | - Salima Shaikh
- Vitalant, Northeast Division, Montvale, New Jersey, USA
| | - Janine Shepherd
- Transfusion Services Laboratory, Denver Health Hospital, Denver, Colorado, USA
| | - Yvette C Tanhehco
- Department of Pathology and Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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Shi Y, Zhu B, Zhang Y, Huang Y. Anesthetic management of a huge retroperitoneal leiomyoma: a case report. Perioper Med (Lond) 2023; 12:64. [PMID: 38017529 PMCID: PMC10683212 DOI: 10.1186/s13741-023-00352-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/12/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Retroperitoneal leiomyomas are rare, with just over 100 cases reported in the literature. Perioperative management of retroperitoneal leiomyomas can be challenging due to the large tumor size and the risk of hemorrhage. CASE PRESENTATION We report a case of a 40-year-old Han woman with a 40-cm retroperitoneal leiomyoma. General anesthesia was performed for the surgical resection. Key flow parameters like cardiac output and stroke volume variation, as shown by the Vigileo™-FloTrac™ system, enabled the anesthesiologist to implement goal-directed fluid optimization. Acute normovolemic hemodilution and cell salvage technique were used resulting in a successful en bloc tumor resection with a 6000-mL estimated blood loss. Although the patient experienced postoperative bowel obstruction, no other significant complications were observed. CONCLUSION Advanced hemodynamic monitoring and modern patient blood management strategies are particularly helpful for anesthetic management of huge retroperitoneal leiomyomas.
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Affiliation(s)
- Yue Shi
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Bo Zhu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Yu Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
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Beeton G, Zagales I, Ngatuvai M, Atoa A, Wajeeh H, Hoops H, Smith CP, Elkbuli A. Cost-Effectiveness of Cell Salvage in Trauma Blood Transfusions. Am Surg 2023; 89:4842-4852. [PMID: 37167954 DOI: 10.1177/00031348231175124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
INTRODUCTION Despite the increasing amount of evidence supporting its use, cell salvage (CS) remains an underutilized resource in operative trauma care in many hospitals. We aim to evaluate the utilization of CS in adult trauma patients and associated outcomes to provide evidence-based recommendations. METHODS A systematic review was conducted using PubMed, Google Scholar, and CINAHL. Articles evaluating clinical outcomes and the cost-effectiveness of trauma patients utilizing CS were included. The primary study outcome was mortality rates. The secondary outcomes included complication rates (sepsis and infection) and ICU-LOS. The tertiary outcome was the cost-effectiveness of CS. RESULTS This systematic review included 9 studies that accounted for a total of 1119 patients that received both CS and allogeneic transfusion (n = 519), vs allogeneic blood transfusions only (n = 601). In-hospital mortality rates ranged from 13% to 67% in patients where CS was used vs 6%-65% in those receiving allogeneic transfusions only; however, these findings were not significantly different (P = .21-.56). Similarly, no significant differences were found between sepsis and infection rates or ICU-LOS in those patients where CS usage was compared to allogeneic transfusions alone. Of the 4 studies that provided comparisons on cost, 3 found the use of CS to be significantly more cost-effective. CONCLUSIONS Cell salvage can be used as an effective method of blood transfusion for trauma patients without compromising patient outcomes, in addition to its possible cost advantages. Future studies are needed to further investigate the long-term effects of cell salvage utilization in trauma patients.
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Affiliation(s)
- George Beeton
- University of North Texas Health Science Center, Fort Worth, TX, USA
| | | | - Micah Ngatuvai
- NSU NOVA Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Andrew Atoa
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Hassaan Wajeeh
- NSU NOVA Southeastern University, Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Heather Hoops
- Department of Surgery, Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health & Sciences University, Portland, OR, USA
| | - Chadwick P Smith
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
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Lloyd TD, Geneen LJ, Bernhardt K, McClune W, Fernquest SJ, Brown T, Dorée C, Brunskill SJ, Murphy MF, Palmer AJ. Cell salvage for minimising perioperative allogeneic blood transfusion in adults undergoing elective surgery. Cochrane Database Syst Rev 2023; 9:CD001888. [PMID: 37681564 PMCID: PMC10486190 DOI: 10.1002/14651858.cd001888.pub5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Concerns regarding the safety and availability of transfused donor blood have prompted research into a range of techniques to minimise allogeneic transfusion requirements. Cell salvage (CS) describes the recovery of blood from the surgical field, either during or after surgery, for reinfusion back to the patient. OBJECTIVES To examine the effectiveness of CS in minimising perioperative allogeneic red blood cell transfusion and on other clinical outcomes in adults undergoing elective or non-urgent surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two clinical trials registers for randomised controlled trials (RCTs) and systematic reviews from 2009 (date of previous search) to 19 January 2023, without restrictions on language or publication status. SELECTION CRITERIA We included RCTs assessing the use of CS compared to no CS in adults (participants aged 18 or over, or using the study's definition of adult) undergoing elective (non-urgent) surgery only. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 106 RCTs, incorporating data from 14,528 participants, reported in studies conducted in 24 countries. Results were published between 1978 and 2021. We analysed all data according to a single comparison: CS versus no CS. We separated analyses by type of surgery. The certainty of the evidence varied from very low certainty to high certainty. Reasons for downgrading the certainty included imprecision (small sample sizes below the optimal information size required to detect a difference, and wide confidence intervals), inconsistency (high statistical heterogeneity), and risk of bias (high risk from domains including sequence generation, blinding, and baseline imbalances). Aggregate analysis (all surgeries combined: primary outcome only) Very low-certainty evidence means we are uncertain if there is a reduction in the risk of allogeneic transfusion with CS (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.59 to 0.72; 82 RCTs, 12,520 participants). Cancer: 2 RCTs (79 participants) Very low-certainty evidence means we are uncertain whether there is a difference for mortality, blood loss, infection, or deep vein thrombosis (DVT). There were no analysable data reported for the remaining outcomes. Cardiovascular (vascular): 6 RCTs (384 participants) Very low- to low-certainty evidence means we are uncertain whether there is a difference for most outcomes. No data were reported for major adverse cardiovascular events (MACE). Cardiovascular (no bypass): 6 RCTs (372 participants) Moderate-certainty evidence suggests there is probably a reduction in risk of allogeneic transfusion with CS (RR 0.82, 95% CI 0.69 to 0.97; 3 RCTs, 169 participants). Very low- to low-certainty evidence means we are uncertain whether there is a difference for volume transfused, blood loss, mortality, re-operation for bleeding, infection, wound complication, myocardial infarction (MI), stroke, and hospital length of stay (LOS). There were no analysable data reported for thrombosis, DVT, pulmonary embolism (PE), and MACE. Cardiovascular (with bypass): 29 RCTs (2936 participants) Low-certainty evidence suggests there may be a reduction in the risk of allogeneic transfusion with CS, and suggests there may be no difference in risk of infection and hospital LOS. Very low- to moderate-certainty evidence means we are uncertain whether there is a reduction in volume transfused because of CS, or if there is any difference for mortality, blood loss, re-operation for bleeding, wound complication, thrombosis, DVT, PE, MACE, and MI, and probably no difference in risk of stroke. Obstetrics: 1 RCT (1356 participants) High-certainty evidence shows there is no difference between groups for mean volume of allogeneic blood transfused (mean difference (MD) -0.02 units, 95% CI -0.08 to 0.04; 1 RCT, 1349 participants). Low-certainty evidence suggests there may be no difference for risk of allogeneic transfusion. There were no analysable data reported for the remaining outcomes. Orthopaedic (hip only): 17 RCTs (2055 participants) Very low-certainty evidence means we are uncertain if CS reduces the risk of allogeneic transfusion, and the volume transfused, or if there is any difference between groups for mortality, blood loss, re-operation for bleeding, infection, wound complication, prosthetic joint infection (PJI), thrombosis, DVT, PE, stroke, and hospital LOS. There were no analysable data reported for MACE and MI. Orthopaedic (knee only): 26 RCTs (2568 participants) Very low- to low-certainty evidence means we are uncertain if CS reduces the risk of allogeneic transfusion, and the volume transfused, and whether there is a difference for blood loss, re-operation for bleeding, infection, wound complication, PJI, DVT, PE, MI, MACE, stroke, and hospital LOS. There were no analysable data reported for mortality and thrombosis. Orthopaedic (spine only): 6 RCTs (404 participants) Moderate-certainty evidence suggests there is probably a reduction in the need for allogeneic transfusion with CS (RR 0.44, 95% CI 0.31 to 0.63; 3 RCTs, 194 participants). Very low- to moderate-certainty evidence suggests there may be no difference for volume transfused, blood loss, infection, wound complication, and PE. There were no analysable data reported for mortality, re-operation for bleeding, PJI, thrombosis, DVT, MACE, MI, stroke, and hospital LOS. Orthopaedic (mixed): 14 RCTs (4374 participants) Very low- to low-certainty evidence means we are uncertain if there is a reduction in the need for allogeneic transfusion with CS, or if there is any difference between groups for volume transfused, mortality, blood loss, infection, wound complication, PJI, thrombosis, DVT, MI, and hospital LOS. There were no analysable data reported for re-operation for bleeding, MACE, and stroke. AUTHORS' CONCLUSIONS In some types of elective surgery, cell salvage may reduce the need for and volume of allogeneic transfusion, alongside evidence of no difference in adverse events, when compared to no cell salvage. Further research is required to establish why other surgeries show no benefit from CS, through further analysis of the current evidence. More large RCTs in under-reported specialities are needed to expand the evidence base for exploring the impact of CS.
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Affiliation(s)
- Thomas D Lloyd
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Louise J Geneen
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | | | | | - Scott J Fernquest
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Tamara Brown
- School of Health, Leeds Beckett University, Leeds, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Susan J Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
- Nuffield Department of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Michael F Murphy
- NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust and University of Oxford, Oxford, UK
- Blood and Transplant Research Unit in Data Driven Transfusion, NIHR, Oxford, UK
| | - Antony Jr Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Blood and Transplant Research Unit in Data Driven Transfusion, NIHR, Oxford, UK
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Kumar N, Tan JYH, Chen Z, Ravikumar N, Milavec H, Tan JH. Intraoperative cell-salvaged autologous blood transfusion is safe in metastatic spine tumour surgery: early outcomes of prospective clinical study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:2493-2502. [PMID: 37191676 DOI: 10.1007/s00586-023-07768-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 03/30/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE Allogeneic blood transfusion (ABT) is current standard of blood replenishment despite known complications. Salvaged blood transfusion (SBT) addresses majority of such complications. Surgeons remain reluctant to employ SBT in metastatic spine tumour surgery (MSTS), despite ample laboratory evidence. This prompted us to conduct a prospective clinical study to ascertain safety of intraoperative cell salvage (IOCS), in MSTS. METHODS Our prospective study included 73 patients who underwent MSTS from 2014 to 2017. Demographics, tumour histology and burden, clinical findings, modified Tokuhashi score, operative and blood transfusion (BT) details were recorded. Patients were divided based on BT type: no blood transfusion (NBT) and SBT/ABT. Primary outcomes assessed were overall survival (OS), and tumour progression was evaluated using RECIST (v1.1) employing follow-up radiological investigations at 6, 12 and 24 months, classifying patients with non-progressive and progressive disease. RESULTS Seventy-three patients [39:34(M/F)] had mean age of 61 years. Overall median follow-up and survival were 26 and 12 months, respectively. All three groups were comparable for demographics and tumour characteristics. Overall median blood loss was 500 mL, and BT was 1000 mL. Twenty-six (35.6%) patients received SBT, 27 (37.0%) ABT and 20 (27.4%) NBT. Females had lower OS and higher risk of tumour progression. SBT had better OS and reduced risk of tumour progression than ABT group. Total blood loss was not associated with tumour progression. Infective complications other than SSI were significantly (p = 0.027) higher in ABT than NBT/SBT groups. CONCLUSIONS Patients of SBT had OS and tumour progression better than ABT/NBT groups. This is the first prospective study to report of SBT in comparison with control groups in MSTS.
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Affiliation(s)
- Naresh Kumar
- Department of Orthopaedic Surgery, Hand & Reconstructive Microsurgery Cluster, University Orthopaedics, National University Health System (NUHS) - Tower Block, Level 11, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Joel Yong Hao Tan
- Department of Orthopaedic Surgery, Hand & Reconstructive Microsurgery Cluster, University Orthopaedics, National University Health System (NUHS) - Tower Block, Level 11, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Zhaojin Chen
- Investigational Medicine Unit, Center for Translational Medicine, 14 Medical Drive, #07-01, Singapore, 117599, Singapore
| | - Nivetha Ravikumar
- Department of Orthopaedic Surgery, Hand & Reconstructive Microsurgery Cluster, University Orthopaedics, National University Health System (NUHS) - Tower Block, Level 11, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Helena Milavec
- Department of Orthopaedic Surgery, Hand & Reconstructive Microsurgery Cluster, University Orthopaedics, National University Health System (NUHS) - Tower Block, Level 11, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Jiong Hao Tan
- Department of Orthopaedic Surgery, Hand & Reconstructive Microsurgery Cluster, University Orthopaedics, National University Health System (NUHS) - Tower Block, Level 11, 1E Kent Ridge Road, Singapore, 119228, Singapore
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9
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Itano H, Akiyama T, Yoshihara M. Clinical efficacy of intraoperative Cell Saver autologous blood salvage in emergency surgery for massive hemothorax. Indian J Thorac Cardiovasc Surg 2023; 39:359-366. [PMID: 37346430 PMCID: PMC10279592 DOI: 10.1007/s12055-023-01489-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 03/18/2023] Open
Abstract
The objective of this study was to investigate the efficacy of intraoperative Cell Saver blood salvage during emergency surgery for massive hemothorax on minimizing perioperative allogeneic red blood cell (RBC) transfusion. Fourteen consecutive patients of massive hemothorax with more than 800 cc of intrathoracic bleeding estimated by chest X-ray and/or chest computed tomography (CT) scan at presentation between 2009 and 2021 were retrospectively reviewed. Intraoperative Cell Saver blood salvage was performed in 11 patients (Cell Saver group) with a median volume of 820 cc (range, 421-1700 cc). The amount of perioperative allogeneic RBC transfusion in the Cell Saver group (median, 4 units) was significantly smaller than that in the non-Cell Saver group (median, 10 units) (P = 0.009). The volume of Cell Saver autologous transfusion in 6 patients without preoperative chest tube drainage (median, 1114 cc) was significantly larger than that in 5 patients who had preoperative drainage (median, 660 cc) (P = 0.0173). In conclusion, the utilization of intraoperative blood salvage in emergency surgery for massive hemothorax along with limiting the amount of preoperative chest tube drainage is an efficient strategy to minimize perioperative allogeneic RBC transfusion.
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Affiliation(s)
- Hideki Itano
- Department of Thoracic Surgery, Daiyu-kai General Hospital, Ichinomiya-shi, Aichi, Japan
- Department of Thoracic Surgery, Uji Tokushu-kai Hospital, Uji-shi, Kyoto, Japan
| | - Takashi Akiyama
- Department of Thoracic Surgery, Daiyu-kai General Hospital, Ichinomiya-shi, Aichi, Japan
| | - Masashi Yoshihara
- Department of Thoracic Surgery, Daiyu-kai General Hospital, Ichinomiya-shi, Aichi, Japan
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10
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Perioperative transfusion and long-term mortality after cardiac surgery: a meta-analysis. Gen Thorac Cardiovasc Surg 2023; 71:323-330. [PMID: 36884106 DOI: 10.1007/s11748-023-01923-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 02/21/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVES Cardiac surgical procedures are associated with a high incidence of periprocedural blood loss and blood transfusion. Although both may be associated with a range of postoperative complications there is disagreement on the impact of blood transfusion on long-term mortality. This study aims to provide a comprehensive review of the published outcomes of perioperative blood transfusion, examined as a whole and by index procedure. METHODS A systematic review of perioperative blood transfusion cardiac surgical patients was conducted. Outcomes related to blood transfusion were analysed in a meta-analysis and aggregate survival data were derived to examine long-term survival. RESULTS Thirty-nine studies with 180,074 patients were identified, the majority (61.2%) undergoing coronary artery bypass surgery. Perioperative blood transfusions were noted in 42.2% of patients and was associated with significantly higher early mortality (OR 3.87, p < 0.001). After a median of 6.4 years (range 1-15), mortality remained significantly higher for those who received a perioperative transfusion (OR 2.01, p < 0.001). Pooled hazard ratio for long-term mortality similar for patients who underwent coronary surgery compared to isolated valve surgery. Differences in long-term mortality for all comers remained true when corrected for early mortality and when only including propensity matched studies. CONCLUSIONS Perioperative red blood transfusion appears to be associated with a significant reduction in long-term survival for patients after cardiac surgery. Strategies such as preoperative optimisation, intraoperative blood conservation, judicious use of postoperative transfusions, and professional development into minimally invasive techniques should be utilised where appropriate to minimise the need for perioperative transfusions.
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11
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Wu H, Singh B, Yen TT, Maher J, Datta S, Chaves K, Lau BD, Frank S, Simpson K, Patzkowsky K, Wang K. Utilization and cost of cell salvage in minimally invasive myomectomy. Eur J Obstet Gynecol Reprod Biol 2023; 280:179-183. [PMID: 36512958 DOI: 10.1016/j.ejogrb.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/29/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the utilization and cost of intraoperative cell salvage (ICS) in minimally invasive myomectomy. STUDY DESIGN Retrospective cohort study of patients who underwent minimally invasive myomectomy at a quaternary care academic hospital. Patients were classified into: ICS setup vs no ICS setup, ICS setup with reinfusion vs ICS setup without reinfusion. RESULTS Of 382 patients who underwent minimally invasive myomectomy, 67 (17.5 %) had ICS setup, 30 (44.8 %) of those patients reinfused. Median volume of reinfusion per patient was 300 mL (range 125-1000 mL). Patients who ultimately underwent ICS reinfusion, compared to those with ICS setup only, had significantly larger mean maximum fibroid size (9.8 cm vs 8.0 cm, p = 0.02), higher median total specimen weight (367 vs 304 g, p = 0.03), higher median estimated blood loss (575 vs 300 mL, p < 0.0001), longer mean operative time (261 vs 215 min, p = 0.04). No perioperative complications were associated with ICS. Higher costs are associated with universal use or complete lack of ICS; lowest cost is associated with ICS setup only for those ultimately reinfused. CONCLUSION ICS might reduce requirements for allogeneic blood transfusions in patients undergoing minimally invasive myomectomy, and may contribute to cost savings. Uterine and maximum fibroid sizes are possible preoperative indicators for patients who require cell salvage reinfusion.
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Affiliation(s)
- Harold Wu
- Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Bhuchitra Singh
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.
| | - Ting-Tai Yen
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Jacqueline Maher
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Shreetoma Datta
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Katherine Chaves
- Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Brandyn D Lau
- Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore MD, United States of America
| | - Steven Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Khara Simpson
- Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Kristin Patzkowsky
- Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Karen Wang
- Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
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Tripković B, Jakovina Blažeković S, Bratić V, Tripković M. CONTEMPORARY RECOMMENDATIONS ON PATIENT BLOOD MANAGEMENT IN JOINT ARTHROPLASTY. Acta Clin Croat 2022; 61:78-83. [PMID: 36824646 PMCID: PMC9942475 DOI: 10.20471/acc.2022.61.s2.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Hip and knee replacement surgery are a common and effective procedure for the relief of pain and loss of function. The number of procedures is increasing and great interest is given how to improve outcome following hip and knee replacement surgery. Last two decades have been characterized by many innovations in hip and knee replacement surgery including minimally invasive technique but also by improvements in anesthetic technique and blood management. The patients undergoing hip and knee replacement surgery are commonly elderly and have cos-existing organ dysfunctions. These procedures are characterized by great perioperative disturbances including cardiovascular complications, high incidence of thromboembolic complications, possible significant perioperative blood loss, possible bone cement effect and high level of postoperative pain. Anesthetic assessment of patients include preoperative preparations, intraoperative and postoperative care. In this article, all problems of perioperative blood management are discussed. The recent data of advantages of blood management for every patient are outlined. Blood management include preoperative preparation, use of autologous blood in perioperative period and administration of drugs for minimizing intraoperative blood loss. The final result of improvements in blood management is reducing in blood loss and need for allogeneic blood and significant reduction in perioperative morbidity.
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Affiliation(s)
- Branko Tripković
- Department of Anesthesiology, Reanimatology and Intensive care, University Hospital Zagreb, University of Zagreb School of Medicine.
| | - Sanja Jakovina Blažeković
- Department of Anesthesiology, Reanimatology and Intensive care, University Hospital Zagreb, University of Zagreb School of Medicine.
| | - Vesna Bratić
- Department of Anesthesiology, Reanimatology and Intensive care, University Hospital Zagreb, University of Zagreb School of Medicine.
| | - Marko Tripković
- Department of Anesthesiology, Reanimatology and Intensive care, University Hospital Zagreb, University of Zagreb School of Medicine.
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13
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Shaw AD, Guinn NR, Brown JK, Arora RC, Lobdell KW, Grant MC, Gan TJ, Engelman DT. Controversies in enhanced recovery after cardiac surgery. Perioper Med (Lond) 2022; 11:19. [PMID: 35477446 PMCID: PMC9047268 DOI: 10.1186/s13741-022-00250-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 02/17/2022] [Indexed: 11/30/2022] Open
Abstract
Advances in cardiac surgical operative techniques and myocardial protection have dramatically improved outcomes in the past two decades. An unfortunate and unintended consequence is that 80% of the preventable morbidity and mortality following cardiac surgery now originates outside of the operating room. Our hope is that a renewed emphasis on evidence-based best practice and standardized perioperative care will reduce overall morbidity and mortality and improve patient-centric care. The Perioperative Quality Initiative (POQI) and Enhanced Recovery After Surgery–Cardiac Society (ERAS® Cardiac) have identified significant evidence gaps in perioperative medicine related to cardiac surgery, defined as areas in which there is significant controversy about how best to manage patients. These five areas of focus include patient blood management, goal-directed therapy, acute kidney injury, opioid analgesic reduction, and delirium.
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Affiliation(s)
- Andrew D Shaw
- Department of Intensive Care and Resuscitation, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Nicole R Guinn
- Department of Anesthesiology, Duke University Medical Center, Box 3094, 2301 Erwin Road, Durham, NC, USA
| | - Jessica K Brown
- Department of Anesthesiology and Perioperative Medicine, Division of Anesthesiology and Critical Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rakesh C Arora
- Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Michael C Grant
- Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Baltimore, MD, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Daniel T Engelman
- University of Massachusetts Medical School-Baystate, Baystate Medical Center, 759 Chestnut St, Springfield, MA, USA
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14
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Li Y, Zhang Y, Fang X. Acute normovolemic hemodilution in combination with tranexamic acid is an effective strategy for blood management in lumbar spinal fusion surgery. J Orthop Surg Res 2022; 17:71. [PMID: 35123513 PMCID: PMC8817589 DOI: 10.1186/s13018-022-02950-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/21/2022] [Indexed: 11/11/2022] Open
Abstract
Background The retrospective study was designed to compare the effectiveness and safety of acute normovolemic hemodilution (ANH), tranexamic Acid (TXA), and a combination of ANH and TXA in lumbar spinal fusion surgery. Methods Data of 120 patients underwent multi-level posterior spinal fusion for treating degenerative lumbar disease between June 2013 and December 2017 was collected, retrospectively. Four treatment strategies were enrolled, including ANH, TXA, a combination of ANH and TXA, and without any patient blood management. Intraoperative blood loss, hemoglobin and PCV at the end of surgery and at the postoperative first day, and postoperative drain collection, and intraoperative and postoperative transfusion and rate of transfusion were also collected. Results Intraoperative blood loss and postoperative drain collection of the TXA group, ANH combined with TXA group were statistically lower than those in the control group and ANH group (P < 0.05). Intraoperative and postoperative transfusion amount and rate of intra-operative allogenic transfusion of the ANH group, TXA group, and ANH combined with TXA group were statistically lower than those of the control group (P < 0.05). Hemoglobin and PCV at postoperative the first day in the ANH group, TXA group, and ANH combined with TXA group were significant higher than those in the control group (P < 0.05). The combination of TXA and ANH group achieved the lowest intraoperative blood loss, postoperative drain collection and allogenic transfusion rate. Conclusion A combination of TXA and ANH might be an effective strategy for reducing the rate of transfusion and blood loss in patients underwent lumbar spinal fusion surgery.
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15
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Yousuf MS, Samad K, Ahmed SS, Siddiqui KM, Ullah H. Cardiac Surgery and Blood-Saving Techniques: An Update. Cureus 2022; 14:e21222. [PMID: 35186524 PMCID: PMC8844256 DOI: 10.7759/cureus.21222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 11/12/2022] Open
Abstract
Cardiac surgery is typically attributed with a significant risk of intraoperative blood loss and allogeneic blood transfusions. Intraoperative blood loss, allogenic blood transfusions, high dose anticoagulation requirement, and interactions with cardiopulmonary bypass (CPB) have all been linked to cardiac surgeries. To reduce unnecessary transfusions and their negative effects, it is recommended to follow evidence-based multidisciplinary strategies, which are collectively termed patient blood management (PBM). This review highlights the most recent blood conservation strategies in adult cardiac surgery, which can be employed pre-operatively, intra-operatively, and postoperatively, to enhance red cell mass and attenuate the utilization of packed red blood cells (PRBCs) and other blood products.
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16
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Carson JL, Stanworth SJ, Dennis JA, Trivella M, Roubinian N, Fergusson DA, Triulzi D, Dorée C, Hébert PC. Transfusion thresholds for guiding red blood cell transfusion. Cochrane Database Syst Rev 2021; 12:CD002042. [PMID: 34932836 PMCID: PMC8691808 DOI: 10.1002/14651858.cd002042.pub5] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The optimal haemoglobin threshold for use of red blood cell (RBC) transfusions in anaemic patients remains an active field of research. Blood is a scarce resource, and in some countries, transfusions are less safe than in others because of inadequate testing for viral pathogens. If a liberal transfusion policy does not improve clinical outcomes, or if it is equivalent, then adopting a more restrictive approach could be recognised as the standard of care. OBJECTIVES: The aim of this review update was to compare 30-day mortality and other clinical outcomes for participants randomised to restrictive versus liberal red blood cell (RBC) transfusion thresholds (triggers) for all clinical conditions. The restrictive transfusion threshold uses a lower haemoglobin concentration as a threshold for transfusion (most commonly, 7.0 g/dL to 8.0 g/dL), and the liberal transfusion threshold uses a higher haemoglobin concentration as a threshold for transfusion (most commonly, 9.0 g/dL to 10.0 g/dL). SEARCH METHODS We identified trials through updated searches: CENTRAL (2020, Issue 11), MEDLINE (1946 to November 2020), Embase (1974 to November 2020), Transfusion Evidence Library (1950 to November 2020), Web of Science Conference Proceedings Citation Index (1990 to November 2020), and trial registries (November 2020). We checked the reference lists of other published reviews and relevant papers to identify additional trials. We were aware of one trial identified in earlier searching that was in the process of being published (in February 2021), and we were able to include it before this review was finalised. SELECTION CRITERIA We included randomised trials of surgical or medical participants that recruited adults or children, or both. We excluded studies that focused on neonates. Eligible trials assigned intervention groups on the basis of different transfusion schedules or thresholds or 'triggers'. These thresholds would be defined by a haemoglobin (Hb) or haematocrit (Hct) concentration below which an RBC transfusion would be administered; the haemoglobin concentration remains the most commonly applied marker of the need for RBC transfusion in clinical practice. We included trials in which investigators had allocated participants to higher thresholds or more liberal transfusion strategies compared to more restrictive ones, which might include no transfusion. As in previous versions of this review, we did not exclude unregistered trials published after 2010 (as per the policy of the Cochrane Injuries Group, 2015), however, we did conduct analyses to consider the differential impact of results of trials for which prospective registration could not be confirmed. DATA COLLECTION AND ANALYSIS: We identified trials for inclusion and extracted data using Cochrane methods. We pooled risk ratios of clinical outcomes across trials using a random-effects model. Two review authors independently extracted data and assessed risk of bias. We conducted predefined analyses by clinical subgroups. We defined participants randomly allocated to the lower transfusion threshold as being in the 'restrictive transfusion' group and those randomly allocated to the higher transfusion threshold as being in the 'liberal transfusion' group. MAIN RESULTS A total of 48 trials, involving data from 21,433 participants (at baseline), across a range of clinical contexts (e.g. orthopaedic, cardiac, or vascular surgery; critical care; acute blood loss (including gastrointestinal bleeding); acute coronary syndrome; cancer; leukaemia; haematological malignancies), met the eligibility criteria. The haemoglobin concentration used to define the restrictive transfusion group in most trials (36) was between 7.0 g/dL and 8.0 g/dL. Most trials included only adults; three trials focused on children. The included studies were generally at low risk of bias for key domains including allocation concealment and incomplete outcome data. Restrictive transfusion strategies reduced the risk of receiving at least one RBC transfusion by 41% across a broad range of clinical contexts (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.53 to 0.66; 42 studies, 20,057 participants; high-quality evidence), with a large amount of heterogeneity between trials (I² = 96%). Overall, restrictive transfusion strategies did not increase or decrease the risk of 30-day mortality compared with liberal transfusion strategies (RR 0.99, 95% CI 0.86 to 1.15; 31 studies, 16,729 participants; I² = 30%; moderate-quality evidence) or any of the other outcomes assessed (i.e. cardiac events (low-quality evidence), myocardial infarction, stroke, thromboembolism (all high-quality evidence)). High-quality evidence shows that the liberal transfusion threshold did not affect the risk of infection (pneumonia, wound infection, or bacteraemia). Transfusion-specific reactions are uncommon and were inconsistently reported within trials. We noted less certainty in the strength of evidence to support the safety of restrictive transfusion thresholds for the following predefined clinical subgroups: myocardial infarction, vascular surgery, haematological malignancies, and chronic bone-marrow disorders. AUTHORS' CONCLUSIONS Transfusion at a restrictive haemoglobin concentration decreased the proportion of people exposed to RBC transfusion by 41% across a broad range of clinical contexts. Across all trials, no evidence suggests that a restrictive transfusion strategy impacted 30-day mortality, mortality at other time points, or morbidity (i.e. cardiac events, myocardial infarction, stroke, pneumonia, thromboembolism, infection) compared with a liberal transfusion strategy. Despite including 17 more randomised trials (and 8846 participants), data remain insufficient to inform the safety of transfusion policies in important and selected clinical contexts, such as myocardial infarction, chronic cardiovascular disease, neurological injury or traumatic brain injury, stroke, thrombocytopenia, and cancer or haematological malignancies, including chronic bone marrow failure. Further work is needed to improve our understanding of outcomes other than mortality. Most trials compared only two separate thresholds for haemoglobin concentration, which may not identify the actual optimal threshold for transfusion in a particular patient. Haemoglobin concentration may not be the most informative marker of the need for transfusion in individual patients with different degrees of physiological adaptation to anaemia. Notwithstanding these issues, overall findings provide good evidence that transfusions with allogeneic RBCs can be avoided in most patients with haemoglobin thresholds between the range of 7.0 g/dL and 8.0 g/dL. Some patient subgroups might benefit from RBCs to maintain higher haemoglobin concentrations; research efforts should focus on these clinical contexts.
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Affiliation(s)
- Jeffrey L Carson
- Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Simon J Stanworth
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Jane A Dennis
- Cochrane Injuries Group, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Nareg Roubinian
- Kaiser Permanente Division of Research Northern California, Oakland, California, USA
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Darrell Triulzi
- The Institute for Transfusion Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Paul C Hébert
- Centre for Research, University of Montreal Hospital Research Centre, Montreal, Canada
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Efficacy of Intraoperative Blood Salvage in Cerebral Aneurysm Surgery. J Clin Med 2021; 10:jcm10245734. [PMID: 34945029 PMCID: PMC8708740 DOI: 10.3390/jcm10245734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 11/11/2021] [Accepted: 12/03/2021] [Indexed: 11/29/2022] Open
Abstract
Background. The use and effectiveness of intraoperative cell salvage has been analyzed in many surgical specialties. Until now, no data exist evaluating the efficacy of intraoperative cell salvage in cerebral aneurysm surgery. Aim. To evaluate the efficacy and cost effectiveness of intraoperative cell salvage in cerebral aneurysm surgery. Methods. Data were collected retrospectively for all the patients who underwent cerebral aneurysm surgery at our institution between 2013 and 2019. Routinely, we apply blood salvage through autotransfusion. The cases were divided into a ruptured cerebral aneurysm group and a unruptured cerebral aneurysm group. Results. A total of 241 patients underwent cerebral aneurysm clipping. Of all the cerebral aneurysms, 116 were ruptured and 125 were unruptured and clipped electively. Age, location of the aneurysm, postoperative red blood cell count, intraoperative blood loss, and number of allogenic blood cell transfusions were statistically significantly different between the groups. The autotransfusion of salvaged blood could only be facilitated in eight cases with ruptured cerebral aneurysms and in none with unruptured cerebral aneurysms clipped electively (p < 0.01). Additionally, 35 patients with ruptured cerebral aneurysms and one patient with unruptured cerebral aneurysm required allogenic red blood cell transfusion after surgery, and 71 vs. 2 units of blood were transfused (p < 0.0001). In terms of cost effectiveness, a total of EUR 45,189 in 241 patients was spent to run the autotransfusion system, while EUR 13,797 was spent for allogenic blood transfusion. Conclusions. The use of cell salvage in patients with unruptured cerebral aneurysm, undergoing elective surgery, is not effective.
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18
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Kupryashov AA, Kuksina EV, Kchycheva GA, Haydarov GA. Impact of anemia on outcomes in on-pump coronary artery bypass surgery patients. KARDIOLOGIIA 2021; 61:42-48. [PMID: 34882077 DOI: 10.18087/cardio.2021.11.n1802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/03/2021] [Indexed: 06/13/2023]
Abstract
Aim To study the contribution of preoperative anemia to the prognosis of adverse clinical events (mortality, complications, transfusion) in patients with ischemic heart disease (IHD) after myocardial revascularization in the conditions of artificial circulation.Material and methods This retrospective cohort study included 1 133 patients with IHD who had undergone isolated myocardial revascularization in the conditions of artificial circulation in 2019. The primary endpoints were mortality and a composite endpoint that included, in addition to mortality, cases of acute coronary syndrome, heart, respiratory and renal failure, neurological deficit, and infectious complications. The secondary endpoints were duration of artificial ventilation of more than 12 h, duration of stay in the resuscitation and intensive care unit (RICU) of more than one day, and duration of postoperative inpatient treatment of more than 7 days. Results Preoperative anemia was found in 196 (17.3 %) patients. The anemia was not associated with mortality but increased the risk of the composite endpoint, prolonged artificial ventilation, stay in RICU for more than one day, and red blood cell transfusion. Despite the absence of a relationship between red blood cell transfusion and mortality, the use of transfusion was associated with increased risks of the composite endpoint and prolonged stay in the RICU and hospital.Conclusion Preoperative anemia is a risk factor for adverse outcomes of myocardial revascularization in the conditions of artificial circulation. Timely treatment of preoperative anemia may improve outcomes of the treatment.
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Affiliation(s)
- A A Kupryashov
- Bakoulev`s Center for Cardiovascular Surgery, Moscow, Russia
| | - E V Kuksina
- Bakoulev`s Center for Cardiovascular Surgery, Moscow, Russia
| | - G A Kchycheva
- Bakoulev`s Center for Cardiovascular Surgery, Moscow, Russia
| | - G A Haydarov
- Bakoulev`s Center for Cardiovascular Surgery, Moscow, Russia
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Gowers B, Greenhalgh MS, McCabe-Robinson OJ, Ong CT, McKay JE, Dyson K, Iyengar KP. Using Fracture Patterns and Planned Operative Modality to Identify Fractured Neck of Femur Patients at High Risk of Blood Transfusion. Cureus 2021; 13:e18220. [PMID: 34703706 PMCID: PMC8541702 DOI: 10.7759/cureus.18220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2021] [Indexed: 12/02/2022] Open
Abstract
Background Fractured neck of femurs is common, serious injuries usually requiring operative management. Red blood cell transfusions are often required to treat perioperative anaemia, but these are not without adverse effects. Aims and objectives The aim of this study is to identify subgroups of fractured neck of femur patients more likely to require red blood cell transfusions. We try to identify targeted strategies to reduce blood transfusion-associated adverse effects and thus improve outcomes. Design and methods A retrospective cohort study of 324 patients. Patients were divided into cohorts based on radiological fracture patterns and operations performed. Data were collected from patient records, picture archiving and communication systems, the local transfusion laboratory, and the national hip fracture database. The primary outcome was blood transfusion rates in different fracture patterns in fractured necks of femur patients. The secondary outcome was blood transfusion rates in different operation types for fractured neck of femur patients. Chi-squared tests for independence were performed. Results 14.9%, 34.7% and 33.3% of patients with intracapsular, intertrochanteric and subtrochanteric fractures, respectively, received blood transfusions. There was a significant relationship between fracture pattern and blood transfusion (X2 (2, N = 324) = 17.1687, p = 0.000187). 47% of patients receiving long intramedullary nails, 45% of short intramedullary nails, 27% of open reduction internal fixations, 18% of hemiarthroplasties and 9% of total hip arthroplasties resulted in blood transfusions. There was a significant relationship between operative modality and blood transfusion (X2 (4, N = 302) = 22.0184, p = 0.000199). Conclusion In patients who have sustained a fractured neck of the femur, the fracture pattern and operative modality are both independently associated with the rates of red blood cell transfusion. In these identified groups, we propose that increased vigilance and awareness regarding transfusion avoiding strategies are utilised with the goal of improving patient outcomes.
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Affiliation(s)
- Benjamin Gowers
- Trauma and Orthopaedics, Kettering General Hospital, Kettering, GBR
| | | | | | - Chea Tze Ong
- Orthopaedics, Health Education England North West, Manchester, GBR
| | - Joseph E McKay
- Trauma and Orthopaedics, National Health Service (NHS) Education for Scotland, Edinburgh, GBR
| | - Kathryn Dyson
- Trauma and Orthopaedics, Health Education England North West, Manchester, GBR
| | - Karthikeyan P Iyengar
- Trauma and Orthopaedics, Southport and Ormskirk Hospital National Health Service (NHS) Trust, Southport, GBR
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20
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Tamura T, Waters JH, Nishiwaki K. Heparin concentration in cell salvage during heparinization: a pilot study. NAGOYA JOURNAL OF MEDICAL SCIENCE 2021; 82:449-455. [PMID: 33132429 PMCID: PMC7548247 DOI: 10.18999/nagjms.82.3.449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cell salvage is frequently used to avoid unnecessary allogeneic blood transfusions, which results in a reduction in blood transfusion volume and cost. The aspirated blood is washed with normal saline and centrifuged to recover only blood cells, salvaged blood is then made. In cardiovascular surgery, heparin is used to maintain activated clotting time over 400 seconds. Some practitioners believe that heparin remains in the salvaged blood. Therefore, we hypothesized that salvaged blood during cardiovascular surgery includes heparin. A pilot study was conducted to evaluate our hypothesis using three different salvage systems. This study was a prospective, observational, pilot study, with patients aged 20-85 years old who were scheduled for cardiovascular surgery from May 2018 to October 2018. The intent of this study was to evaluate whether salvaged blood with three different devices includes large enough quantities of heparin to influence activated clotting time in cardiovascular surgery. Between May and October 2018, 12 samples during heparinization were collected, and 12 samples of salvaged blood from 3 devices were collected after administrating protamine. The heparin concentration of the 24 samples was measured. All heparin concentrations in salvage blood sample from two devices was below the limit of measurement (0.10 IU/mL). Slightly measurable heparin was detected in salvaged blood sample from one device (mean 0.15 IU/mL). Salvaged blood during cardiovascular surgery intervention does not contain enough heparin to influence activated clotting time.
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Affiliation(s)
- Takahiro Tamura
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, PA, USA
| | - Jonathan H Waters
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, PA, USA
| | - Kimitosi Nishiwaki
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Roets M, Sturgess DJ, Obeysekera MP, Tran TV, Wyssusek KH, Punnasseril JEJ, da Silva D, van Zundert A, Perros AJ, Tung JP, Flower RLP, Dean MM. Intraoperative Cell Salvage as an Alternative to Allogeneic (Donated) Blood Transfusion: A Prospective Observational Evaluation of the Immune Response Profile. Cell Transplant 2021; 29:963689720966265. [PMID: 33076681 PMCID: PMC7784599 DOI: 10.1177/0963689720966265] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Allogeneic blood transfusion (ABT) is associated with transfusion-related immune modulation (TRIM) and subsequent poorer patient outcomes including perioperative infection, multiple organ failure, and mortality. The precise mechanism(s) underlying TRIM remain largely unknown. During intraoperative cell salvage (ICS) a patient's own (autologous) blood is collected, anticoagulated, processed, and reinfused. One impediment to understanding the influence of the immune system on transfusion-related adverse outcomes has been the inability to characterize immune profile changes induced by blood transfusion, including ICS. Dendritic cells and monocytes play a central role in regulation of immune responses, and dysfunction may contribute to adverse outcomes. During a prospective observational study (n = 19), an in vitro model was used to assess dendritic cell and monocyte immune responses and the overall immune response following ABT or ICS exposure. Exposure to both ABT and ICS suppressed dendritic cell and monocyte function. This suppression was, however, significantly less marked following ICS. ICS presented an improved immune competence. This assessment of immune competence through the study of intracellular cytokine production, co-stimulatory and adhesion molecules expressed on dendritic cells and monocytes, and modulation of the overall leukocyte response may predict a reduction of adverse outcomes ( i.e., infection) following ICS.
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Affiliation(s)
- Michelle Roets
- Department of Anaesthesia, the Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, the University of Queensland, Queensland, Australia
| | - David John Sturgess
- Faculty of Medicine, the University of Queensland, Queensland, Australia.,Department of Anaesthesia, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | | | - Thu Vinh Tran
- Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
| | - Kerstin Hildegard Wyssusek
- Department of Anaesthesia, the Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, the University of Queensland, Queensland, Australia
| | | | - Diana da Silva
- Department of Anaesthesia, the Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, the University of Queensland, Queensland, Australia
| | - Andre van Zundert
- Department of Anaesthesia, the Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, the University of Queensland, Queensland, Australia
| | | | - John Paul Tung
- Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
| | | | - Melinda Margaret Dean
- Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia.,School of Health and Sport Sciences, University of the Sunshine Coast, Petrie, Queensland, Australia
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22
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Vieira SD, da Cunha Vieira Perini F, de Sousa LCB, Buffolo E, Chaccur P, Arrais M, Jatene FB. Autologous blood salvage in cardiac surgery: clinical evaluation, efficacy and levels of residual heparin. Hematol Transfus Cell Ther 2021; 43:1-8. [PMID: 31791879 PMCID: PMC7910157 DOI: 10.1016/j.htct.2019.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/21/2019] [Accepted: 08/20/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Intraoperative blood salvage (cell saver technique) in cardiac surgery is universally used in surgical procedures with a marked risk of blood loss. The primary objectives of this study were to determine the concentration of residual heparin in the final product that is reinfused into the patient in the operating room and to evaluate the efficacy and safety of the cell saver technique. METHOD Twelve patients undergoing elective cardiac surgery were enrolled in this study. Using the XTRA Autotransfusion System, blood samples were collected from the cardiotomy reservoir, both prior to blood processing (pre-sample) and after it, directly from the bag with processed product (post-sample). Hematocrit and hemoglobin levels, the protein, albumin and residual heparin concentrations, hemolysis index, and the platelet, erythrocyte and leukocyte counts were measured. RESULTS Hematocrit and hemoglobin levels and red blood cell counts were higher in post-processing samples, with a mean variation of 54.78%, 19.81g/dl and 6.84×106/mm3, respectively (p<0.001). The mean hematocrit of the processed bag was 63.49 g/dl (range: 57.2-67.5). The residual heparin levels were ≤0.1IU/ml in all post-treatment analyses (p=0.003). No related adverse events were observed. CONCLUSION The reduced residual heparin values (≤0.1IU/ml) in processed blood found in this study are extremely important, as they are consistent with the American Association of Blood Banks guidelines, which establish target values below 0.5IU/ml. The procedure was effective, safe and compliant with legal requirements and the available international literature.
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Affiliation(s)
- Sérgio Domingos Vieira
- Banco de Sangue de São Paulo, São Paulo, SP, Brazil; Hospital do Coração da Assoc. Sanatório Sírio, São Paulo, Brazil.
| | | | | | - Enio Buffolo
- Hospital do Coração da Assoc. Sanatório Sírio, São Paulo, Brazil
| | - Paulo Chaccur
- Hospital do Coração da Assoc. Sanatório Sírio, São Paulo, Brazil
| | - Magaly Arrais
- Hospital do Coração da Assoc. Sanatório Sírio, São Paulo, Brazil
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23
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Lasko MJ, Conelius AM, Serrano OK, Nicolau DP, Kuti JL. Impact of Intraoperative Cell Salvage on Concentrations of Antibiotics Used for Surgical Prophylaxis. Antimicrob Agents Chemother 2020; 64:e01725-20. [PMID: 33139277 PMCID: PMC7674051 DOI: 10.1128/aac.01725-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/18/2020] [Indexed: 12/12/2022] Open
Abstract
Intraoperative cell salvage (IOCS) is used to administer autologous blood lost during surgery. We studied antibiotic disposition through an ex vivo IOCS system for vancomycin, piperacillin, ampicillin, and cefazolin. Only 2% ± 1% of antibiotic inoculated in whole blood was recovered in the IOCS reinfusion bag, whereas 97% ± 17% was found in the waste. These observations were confirmed for ampicillin in two patients undergoing liver transplantation. Studies measuring the impact of IOCS on perioperative antibiotic concentrations are warranted.
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Affiliation(s)
- Maxwell J Lasko
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Allison M Conelius
- Hartford Healthcare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut, USA
| | - Oscar K Serrano
- Transplant and Comprehensive Liver Center, Hartford Hospital, Hartford, Connecticut, USA
- University of Connecticut School of Medicine, Department of Surgery, Farmington, Connecticut, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
- Division of Infectious Diseases, Hartford Hospital, Hartford, Connecticut, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
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24
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Goel R, Petersen MR, Patel EU, Packman Z, Bloch EM, Gehrie EA, Lokhandwala PM, Ness PM, Shaz B, Katz LM, Frank SM, Tobian AAR. Comparative changes of pre-operative autologous transfusions and peri-operative cell salvage in the United States. Transfusion 2020; 60:2260-2271. [PMID: 32869327 DOI: 10.1111/trf.15949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/16/2020] [Accepted: 06/16/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND With improved safety of allogeneic blood supply, the use of preoperative autologous donations (PADs) and perioperative autologous cell salvage (PACS) has evolved. This study evaluated temporal trends in PAD and PACS use in the United States. METHODS The National Inpatient Sample database, a stratified probability sample of 20% of hospitalizations in the United States, was used to compare temporal trends in hospitalizations reporting use of PADs and PACS from 1995 to 2015. Factors associated with their use were examined between 2012 and 2015 with use of multivariable Poisson regression. Sampling weights were applied to generate nationally representative estimates. RESULTS There was a steady decrease in hospitalizations reporting PAD transfusions from 27.90 per 100 000 in 1995 to 1.48 per 100 000 hospitalizations in 2015 (P-trend <.001). In contrast, PACS increased from a rate of 1.16 per 100 000 in 1995 to peak of 20.51 per 100 000 hospitalizations in 2008 and then steadily declined (P-trend<.001). Higher odds of PACS and PADs were observed in older patients, elective procedures (vs urgent), and urban teaching/nonteaching hospitals (vs rural hospitals) (P < .001). PACS was more common in hospitalizations in patients with higher levels of severity of illness as compared to those with minor severity (adjusted prevalence ratio [adjPR], 2.39; 95% confidence interval [CI], 2.08-2.73; P<.001), while PADs were performed less often in patients with higher underlying severity of illness (All Patient Refined Diagnosis Related Groups, 4 vs 1, adjPR, 0.61; 95% CI, [0.39-0.95]; P = .028). CONCLUSIONS There was a significant decrease in PAD red blood cell transfusions, while PACS has increased and subsequently decreased; PACS plays an important role in surgical blood conservation. The subsequent decline in PACS likely reflects further optimization of transfusion practice through patient blood management programs and improvement of surgical interventions.
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Affiliation(s)
- Ruchika Goel
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Mississippi Valley Regional Blood Center, Davenport, Iowa, USA.,Simmons Cancer Institute, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Molly R Petersen
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Eshan U Patel
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Zoe Packman
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Evan M Bloch
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Eric A Gehrie
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | | - Paul M Ness
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Beth Shaz
- New York Blood Center, New York, New York, USA
| | - Louis M Katz
- Mississippi Valley Regional Blood Center, Davenport, Iowa, USA
| | - Steven M Frank
- Department of Anesthesiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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25
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Shander A, Goobie SM, Warner MA, Aapro M, Bisbe E, Perez-Calatayud AA, Callum J, Cushing MM, Dyer WB, Erhard J, Faraoni D, Farmer S, Fedorova T, Frank SM, Froessler B, Gombotz H, Gross I, Guinn NR, Haas T, Hamdorf J, Isbister JP, Javidroozi M, Ji H, Kim YW, Kor DJ, Kurz J, Lasocki S, Leahy MF, Lee CK, Lee JJ, Louw V, Meier J, Mezzacasa A, Munoz M, Ozawa S, Pavesi M, Shander N, Spahn DR, Spiess BD, Thomson J, Trentino K, Zenger C, Hofmann A. Essential Role of Patient Blood Management in a Pandemic: A Call for Action. Anesth Analg 2020; 131:74-85. [PMID: 32243296 PMCID: PMC7173035 DOI: 10.1213/ane.0000000000004844] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2020] [Indexed: 01/01/2023]
Abstract
The World Health Organization (WHO) has declared coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemic. Global health care now faces unprecedented challenges with widespread and rapid human-to-human transmission of SARS-CoV-2 and high morbidity and mortality with COVID-19 worldwide. Across the world, medical care is hampered by a critical shortage of not only hand sanitizers, personal protective equipment, ventilators, and hospital beds, but also impediments to the blood supply. Blood donation centers in many areas around the globe have mostly closed. Donors, practicing social distancing, some either with illness or undergoing self-quarantine, are quickly diminishing. Drastic public health initiatives have focused on containment and "flattening the curve" while invaluable resources are being depleted. In some countries, the point has been reached at which the demand for such resources, including donor blood, outstrips the supply. Questions as to the safety of blood persist. Although it does not appear very likely that the virus can be transmitted through allogeneic blood transfusion, this still remains to be fully determined. As options dwindle, we must enact regional and national shortage plans worldwide and more vitally disseminate the knowledge of and immediately implement patient blood management (PBM). PBM is an evidence-based bundle of care to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This multinational and diverse group of authors issue this "Call to Action" underscoring "The Essential Role of Patient Blood Management in the Management of Pandemics" and urging all stakeholders and providers to implement the practical and commonsense principles of PBM and its multiprofessional and multimodality approaches.
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Affiliation(s)
- Aryeh Shander
- From the Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood, New Jersey
| | - Susan M. Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthew A. Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matti Aapro
- Cancer Center Clinique Genolier, Genolier, Switzerland
| | - Elvira Bisbe
- Department of Anesthesiology, Perioperative Medicine Research Group, Hospital del Mar Medical Research Institute (IMIM), IMIM, Barcelona, Spain
| | | | - Jeannie Callum
- Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Melissa M. Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
| | - Wayne B. Dyer
- Australian Red Cross Lifeblood and Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jochen Erhard
- Department of Surgery, Evangelisches Klinikum Niederrhein, Duisburg, Germany
| | - David Faraoni
- Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Shannon Farmer
- Medical School, Division of Surgery, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
- School of Health Sciences and Graduate Studies, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Tatyana Fedorova
- Institute of Anesthesiology, Resuscitation and Transfusiology of the National Medical Research Center of Obstetrics, Gynecology and Perinatology named after Acad. V. I. Kulakov, Ministry of Health of the Russian Federation, Moscow, Russia
| | - Steven M. Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Bernd Froessler
- Department of Anesthesia, Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Hans Gombotz
- Department of Anesthesiology and Intensive Care, General Hospital Linz, Linz, Austria
| | - Irwin Gross
- Northern Light Health, Brewer, Maine
- Accumen, Inc, San Diego, California
| | - Nicole R. Guinn
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Thorsten Haas
- Department of Anesthesiology, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Jeffrey Hamdorf
- Medical School, The University of Western Australia, Western Australia Patient Blood Management Group, Perth, Western Australia, Australia
| | - James P. Isbister
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mazyar Javidroozi
- From the Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood, New Jersey
| | - Hongwen Ji
- Department of Anesthesiology and Transfusion Medicine, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Young-Woo Kim
- Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy and Center for Gastric Cancer, National Cancer Center, Ilsandong-gu, Goyang, Korea
| | - Daryl J. Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Johann Kurz
- Austrian Federal Ministry of Health, Vienna, Austria
- Department Applied Sciences, University of Applied Sciences, Vienna, Austria
| | - Sigismond Lasocki
- Département Anesthésie-Réanimation, Anesthésie Samu Urgences Réanimation, CHU Angers, Angers, France
| | - Michael F. Leahy
- Department of Haematology, PathWest Laboratory Medicine, University of Western Australia, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Cheuk-Kwong Lee
- Hong Kong Red Cross Blood Transfusion Service, Hong Kong Special Administrative Region, China
| | - Jeong Jae Lee
- Department of Obstetrics and Gynecology, Soonchunhyang University Hospital, Seoul, Korea
| | - Vernon Louw
- Division Clinical Haematology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jens Meier
- Clinic of Anesthesiology and Intensive Care Medicine, Johannes Kepler University Linz, Linz, Austria
| | | | - Manuel Munoz
- Department of Surgical Sciences, Biochemistry and Immunology, School of Medicine, University of Málaga, Málaga, Spain
| | - Sherri Ozawa
- Patient Blood Management, Englewood Health, Englewood, New Jersey
| | - Marco Pavesi
- Department of Anesthesiology and Intensive Care, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Nina Shander
- Jerry M. Wallace School of Osteopathic Medicine, Campbell University, Buies Creek, North Carolina
| | - Donat R. Spahn
- Institute of Anesthesiology, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
| | - Bruce D. Spiess
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Jackie Thomson
- South African National Blood Service, Johannesburg, South Africa
| | - Kevin Trentino
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Data and Digital Innovation, East Metropolitan Health Service, Perth, Western Australia, Australia
| | - Christoph Zenger
- Center for Health Law and Management, University of Bern, Bern, Switzerland
| | - Axel Hofmann
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
- Medical School, The University of Western Australia, Crawley, Western Australia, Australia
- School of Health Sciences and Graduate Studies, Curtin University, Perth, Western Australia, Australia
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26
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Roman MA, Abbasciano RG, Pathak S, Oo S, Yusoff S, Wozniak M, Qureshi S, Lai FY, Kumar T, Richards T, Yao G, Estcourt L, Murphy GJ. Patient blood management interventions do not lead to important clinical benefits or cost-effectiveness for major surgery: a network meta-analysis. Br J Anaesth 2020; 126:149-156. [PMID: 32620259 PMCID: PMC7844348 DOI: 10.1016/j.bja.2020.04.087] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/22/2020] [Accepted: 04/25/2020] [Indexed: 01/28/2023] Open
Abstract
Background Patient blood management (PBM) interventions aim to improve clinical outcomes by reducing bleeding and transfusion. We assessed whether existing evidence supports the routine use of combinations of these interventions during and after major surgery. Methods Five systematic reviews and a National Institute of Health and Care Excellence health economic review of trials of common PBM interventions enrolling participants of any age undergoing surgery were updated. The last search was on June 1, 2019. Studies in trauma, burns, gastrointestinal haemorrhage, gynaecology, dentistry, or critical care were excluded. The co-primary outcomes were: risk of receiving red cell transfusion and 30-day or hospital all-cause mortality. Treatment effects were estimated using random-effects models and risk ratios (RR) with 95% confidence intervals (CIs). Heterogeneity assessments used I2. Network meta-analyses used a frequentist approach. The protocol was registered prospectively (PROSPERO CRD42018085730). Results Searches identified 393 eligible randomised controlled trials enrolling 54 917 participants. PBM interventions resulted in a reduction in exposure to red cell transfusion (RR=0.60; 95% CI 0.57, 0.63; I2=77%), but had no statistically significant treatment effect on 30-day or hospital mortality (RR=0.93; 95% CI 0.81, 1.07; I2=0%). Treatment effects were consistent across multiple secondary outcomes, sub-groups and sensitivity analyses that considered clinical setting, type of intervention, and trial quality. Network meta-analysis did not demonstrate additive benefits from the use of multiple interventions. No trial demonstrated that PBM was cost-effective. Conclusions In randomised trials, PBM interventions do not have important clinical benefits beyond reducing bleeding and transfusion in people undergoing major surgery.
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Affiliation(s)
- Marius A Roman
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK.
| | - Riccardo G Abbasciano
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
| | - Suraj Pathak
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
| | - Shwe Oo
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Syabira Yusoff
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
| | - Marcin Wozniak
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
| | - Saqib Qureshi
- Department of Cardiothoracic Surgery, University Hospitals of Nottingham, Nottingham, UK
| | - Florence Y Lai
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
| | - Toby Richards
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Guiqing Yao
- Biostatistics Research Group, Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Lise Estcourt
- Haematology/Transfusion Medicine, NHS Blood, and Transplant, John Radcliffe Hospital, Headington, Oxford, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
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27
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Recommendations for Preoperative Assessment and Shared Decision-Making in Cardiac Surgery. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:185-195. [PMID: 32431570 DOI: 10.1007/s40140-020-00377-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose of review Recommendations about shared decision-making and guidelines on preoperative evaluation of patients undergoing non-cardiac surgery are abundant, but respective recommendations for cardiac surgery are sparse. We provide an overview of available evidence. Recent findings While there currently is no consensus statement on the preoperative anesthetic evaluation and shared decision-making for the adult patient undergoing cardiac surgery, evidence pertaining to specific organ systems is available. Summary We provide a comprehensive review of available evidence pertaining to preoperative assessment and shared decision-making for patients undergoing cardiac surgery and recommend a thorough preoperative workup in this vulnerable population.
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28
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Pearse BL, Keogh S, Rickard CM, Faulke DJ, Smith I, Wall D, McDonald C, Fung YL. Bleeding Management Practices of Australian Cardiac Surgeons, Anesthesiologists and Perfusionists: A Cross-Sectional National Survey Incorporating the Theoretical Domains Framework (TDF) and COM-B Model. J Multidiscip Healthc 2020; 13:27-41. [PMID: 32021232 PMCID: PMC6970603 DOI: 10.2147/jmdh.s232888] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/11/2019] [Indexed: 12/18/2022] Open
Abstract
Purpose Excessive bleeding is an acknowledged consequence of cardiac surgery, occurring in up to 10% of adult patients. This clinically important complication leads to poorer patient outcomes. Clinical practice guidelines are available to support best practice however variability in bleeding management practice and related adverse outcomes still exist. This study had two objectives: 1) to gain insight into current bleeding management practice for adult cardiac surgery in Australia and how that compared to guidelines and literature; and 2) to understand perceived difficulties clinicians face implementing improvements in bleeding management. Methods A national cross-sectional questionnaire survey was utilized. Perspectives were sought from cardiac surgeons, cardiac anesthesiologists and perfusionists. Thirty-nine closed-ended questions focused on routine bleeding management practices to address pre and intra-operative care. One open-ended question was asked; “What would assist you to improve bleeding management with cardiac surgery patients?” Quantitative data were analysed with SPSS. Qualitative data were categorized into the domains of the Theoretical Domains Framework; the domains were then mapped to the COM-B model. Results Survey responses from 159 Anesthesiologists, 39 cardiac surgeons and 86 perfusionists were included (response rate 37%). Four of the recommendations queried in this survey were reported as routinely adhered to < 50% of the time, 9 queried recommendations were adhered to 51–75% of the time and 4 recommendations were routinely followed >76% of the time. Conclusion There is a wide variation in peri-operative bleeding management practice among cardiac anaesthesiologists, surgeons and perfusionists in Australian cardiac surgery units. Conceptualizing factors believed necessary to improve practice with the TDF and COM-B model found that bleeding management could be improved with a standardized approach including; point of care diagnostic assays, a bleeding management algorithm, access to concentrated coagulation factors, cardiac surgery specific bleeding management education, multidisciplinary team agreement and support, and an overarching national approach.
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Affiliation(s)
- Bronwyn L Pearse
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia.,Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia.,Department of Cardiac Surgery, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Samantha Keogh
- School of Nursing and Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
| | - Claire M Rickard
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
| | - Daniel J Faulke
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Ian Smith
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Douglas Wall
- Department of Cardiac Surgery, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Charles McDonald
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Yoke L Fung
- School of Health and Sports Sciences, University of Sunshine Coast, Sunshine Coast, QLD, Australia
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29
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Pennestrì F, Maffulli N, Sirtori P, Perazzo P, Negrini F, Banfi G, Peretti GM. Blood management in fast-track orthopedic surgery: an evidence-based narrative review. J Orthop Surg Res 2019; 14:263. [PMID: 31429775 PMCID: PMC6701001 DOI: 10.1186/s13018-019-1296-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 07/25/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research. METHODS AND MATERIALS We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital. RESULTS Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction. CONCLUSION The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens.
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Affiliation(s)
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Fisciano, Italy. .,San Giovanni di Dio e Ruggi D'Aragona Hospital "Clinica Orthopedica" Department, Hospital of Salerno, Salerno, Italy. .,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, London, England.
| | - Paolo Sirtori
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Paolo Perazzo
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Francesco Negrini
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy
| | - Giuseppe Banfi
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy.,Vita-Salute San Raffaele University, Scientific Direction, Milan, Italy
| | - Giuseppe M Peretti
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, Milan, Italy.,University of Milan, Department of Biomedical Sciences for Health, Milan, Italy
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Wedel C, Møller CM, Budtz-Lilly J, Eldrup N. Red blood cell transfusion associated with increased morbidity and mortality in patients undergoing elective open abdominal aortic aneurysm repair. PLoS One 2019; 14:e0219263. [PMID: 31295273 PMCID: PMC6623955 DOI: 10.1371/journal.pone.0219263] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 06/19/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Red blood cell (RBC) transfusions are associated with increased mortality and morbidity. The aim of this analysis was to examine the association between RBC transfusions and long-term survival for patients undergoing elective open infrarenal abdominal aortic aneurysm (AAA) repair with up to 15 years of follow-up. METHODS Prospective cohort study using data from The Danish Vascular Registry from 2000-2015. Primary endpoint was all-cause mortality. Secondary endpoints were in-hospital complications. Transfused patients were divided into subgroups based on received RBC transfusions (1, 2-3, 4-5 or > 5). Using Cox regression multi-adjusted analysis, non-transfused patients were compared to transfused patients (1, 2-3, 4-5, >5 transfusions) for both primary and secondary endpoints. RESULTS There were 3 876 patients included with a mean survival of 9.1 years. There were 801 patients who did not receive transfusions. Overall 30-day mortality was 3.1% (121 patients) and 3.6% (112) for all transfused patients. For the five subgroups 30-day mortality was: No transfusions 1.1% (9 patients), 1 RBC 1.2% (4 patients), 2-3 RBC 2.2% (26 patients), 4-5 RBC 1.9% (14 patients) and > 5 RBC 7.9% (68 patients). After receiving RBCs, the hazard ratio for death was 1.54 (95% CI 1.27-1.85) compared to non-transfused patients. There was a significant increase in mortality when receiving 2-3 RBC: HR 1.32 (95% CI 1.07-1.62), 4-5 RBC: 1.64 (1.32-2.03) and >5 RBC: 1.96 (1.27-1.85) in a multi-adjusted model. CONCLUSION There is a dose-dependent association between RBC transfusions received during elective AAA repair and an increase in short- and long-term mortality. Approximately 25% of included patients had preoperative anemia. These findings should raise awareness regarding potentially unnecessary and harmful RBC transfusions.
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Affiliation(s)
- Charlotte Wedel
- Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Cecilie M. Møller
- Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Jacob Budtz-Lilly
- Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Nikolaj Eldrup
- Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Danish Vascular Registry, Aarhus University Hospital, Aarhus, Denmark
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Miao Y, Guo W, An L, Fang W, Liu Y, Wang X, An L. Postoperative shed autologous blood reinfusion does not decrease the need for allogeneic blood transfusion in unilateral and bilateral total knee arthroplasty. PLoS One 2019; 14:e0219406. [PMID: 31283774 PMCID: PMC6613835 DOI: 10.1371/journal.pone.0219406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/21/2019] [Indexed: 01/28/2023] Open
Abstract
Postoperative shed autologous blood reinfusion techniques have been used for decades in total knee arthroplasty (TKA), but the effectiveness of this procedure is still a matter of debate. This multicenter retrospective study investigated the medical records of patients who underwent unilateral and bilateral TKA from January 1, 2015 to December 31, 2017 in three hospitals. According to whether postoperative shed autologous blood reinfusion was used, the patients were divided into the control group and the shed autologous blood reinfusion group. The volume of perioperative infusion of red blood cells and plasma, the blood transfusion-related costs, and the postoperative hospital stay were compared between the two groups of patients. A total of 200 unilateral and 74 bilateral TKA were included after successful matching. Among the patients who underwent unilateral TKA, the control group and the shed autologous blood reinfusion group had 95 and 91 patients, respectively, who received allogeneic blood infusion (P = 0.268). There was no significant difference in the number of units of allogeneic red blood cells infused (P = 0.154), while the transfusion-related cost was increased (P<0.001). The same phenomena were observed over the patients underwent bilateral TKA. Shed autologous blood reinfusion does not reduce the need for infusing allogeneic red blood cells. In addition, the procedure increases patient expense and may also lead to an extended postoperative hospital stay.
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Affiliation(s)
- YuLiang Miao
- Department of Anesthesiology, Chinese PLA No. 306 Hospital, Beijing, China
| | - WenZhi Guo
- Department of Anesthesiology, the seventh center of PLA general hospital, Beijing, China
| | - LiNa An
- Department of Anesthesiology, the third center of PLA general hospital, Beijing, China
| | - WeiWu Fang
- Department of Anesthesiology, Chinese PLA No. 306 Hospital, Beijing, China
| | - Yan Liu
- Department of Anesthesiology, Chinese PLA No. 306 Hospital, Beijing, China
| | - XiaoPing Wang
- Department of Orthopaedics, Chinese PLA No. 306 Hospital, Beijing, China
| | - LiKun An
- Department of Orthopaedics, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
- * E-mail:
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Akbaş T. Long length of stay in the ICU associates with a high erythrocyte transfusion rate in critically ill patients. J Int Med Res 2019; 47:1948-1957. [PMID: 30859888 PMCID: PMC6567790 DOI: 10.1177/0300060519832458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE This study aimed to evaluate epidemiology and outcome among critically ill patients under a restrictive transfusion practice. METHODS One hundred sixty-nine patients who were admitted to the intensive care unit (ICU) between March 2016 to December 2017 and remained in the ICU > 24 hours were retrospectively included. RESULTS Hemoglobin levels on admission were <12 g/dL in 85% and <9 g/dL in 37.9% of patients. The median admission hemoglobin level was decreased on the last day of the ICU stay. Erythrocyte transfusion was required for 34% of patients. Transfused patients had high Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, more requirement for invasive mechanical ventilation, vasopressors, and dialysis, long ICU and hospital stays, low hemoglobin levels, and high hospital and ICU mortality rates. Multivariate analysis showed that the likelihood of transfusion increased from 6.6 to 25.8 fold when the ICU stay extended from ≥7 to ≥15 days. Age, vasopressor use, dialysis, and erythrocyte transfusion ≥5 units were predictors of mortality. CONCLUSION Patients receiving transfusion are severely ill and have more life support therapies. The number of erythrocyte units transfused, age, and organ support therapies are independent predictors of mortality.
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Affiliation(s)
- Türkay Akbaş
- Düzce University, Faculty of Medicine, Department of Internal Medicine, Division of Intensive Care Medicine, Düzce, Turkey
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Latchana N, Hirpara DH, Hallet J, Karanicolas PJ. Red blood cell transfusion in liver resection. Langenbecks Arch Surg 2019; 404:1-9. [PMID: 30607533 DOI: 10.1007/s00423-018-1746-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 12/17/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several modalities exist for the management of hepatic neoplasms. Resection, the most effective approach, carries significant risk of hemorrhage. Blood loss may be corrected with red blood cell transfusion (RBCT) in the short term, but may ultimately contribute to negative outcomes. PURPOSE Using available literature, we seek to define the frequency and risk factors of blood loss and transfusion following hepatectomy. The impact of blood loss and RBCT on short- and long-term outcomes is explored with an emphasis on peri-operative methods to reduce hemorrhage and transfusion. RESULTS Following hepatic surgery, 25.2-56.8% of patients receive RBCT. Patients who receive RBCT are at increased risk of surgical morbidity in a dose-dependent manner. The relationship between blood transfusion and surgical mortality is less apparent. RBCT might also impact long-term oncologic outcomes including disease recurrence and overall survival. Risk factors for bleeding and blood transfusion include hemoglobin concentration < 12.5 g/dL, thrombocytopenia, pre-operative biliary drainage, presence of background liver disease (such as cirrhosis), coronary artery disease, male gender, tumor characteristics (type, size, location, presence of vascular involvement), extent of hepatectomy, concomitant extrahepatic organ resection, and operative time. Strategies to mitigate blood loss or transfusion include pre-operative (iron, erythropoietin), intra-operative (vascular occlusion, parenchymal transection techniques, hemostatic agents, antifibrinolytics, low central pressure, hemodilution, autologous blood recycling), and post-operative (normothermia, correction of coagulopathy, optimization of nutrition, restrictive transfusion strategy) methods. CONCLUSION Blood loss during hepatectomy is common and several risk factors can be identified pre-operatively. Blood loss and RBCT during hepatectomy is associated with post-operative morbidity and mortality. Disease-free recurrence, disease-specific survival, and overall survival may be associated with blood loss and RBCT during hepatectomy. Attention to pre-operative, intra-operative, and post-operative strategies to reduce blood loss and RBCT is necessary.
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Affiliation(s)
- Nicholas Latchana
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dhruvin H Hirpara
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Paul J Karanicolas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
- Department of Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
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Lindau S, Kohlhaas M, Nosch M, Choorapoikayil S, Zacharowski K, Meybohm P. Cell salvage using the continuous autotransfusion device CATSmart - an observational bicenter technical evaluation. BMC Anesthesiol 2018; 18:189. [PMID: 30541447 PMCID: PMC6292025 DOI: 10.1186/s12871-018-0651-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/23/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The use of cell salvage and autologous blood transfusion has become an important method of blood conservation. So far, there are no clinical data about the performance of the continuous autotransfusion device CATSmart. METHODS In total, 74 patients undergoing either cardiac or orthopedic surgery were included in this prospective, bicenter and observational technical evaluation to validate red cell separation process and washout quality of CATSmart. The target of red cell separation process was defined as a hematocrit value in the packed red cell unit of 55-75% and of washout quality of 80-100% removal ratio. RESULTS Hematocrit values measured by CATSmart and laboratory analysis were 78.5% [71.3%; 84.0%] and 73.7% [67.5%; 75.5%], respectively. Removal ratios for platelets 94.7% [88.2%; 96.7%], free hemoglobin 89.3% [85.2%; 94.9%], albumin 97.9% [96.6%; 98.5%], heparin 99.9% [99.9%; 100.0%], and potassium 92.5% [90.8%; 95.0%] were within the target range while removal of white blood cells was slightly worse 72.4% [57.9%; 87.3%]. CONCLUSION The new autotransfusion device enables sufficient red cell separation and washout quality.
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Affiliation(s)
- Simone Lindau
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Madeline Kohlhaas
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Michael Nosch
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Marienhospital Bottrop gGmbH, Bottrop, Germany
| | - Suma Choorapoikayil
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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Xie T, Ma B, Li Y, Zou J, Qiu X, Chen H, Wang C, Rui Y. [Research status of the enhanced recovery after surgery in the geriatric hip fractures]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:1038-1046. [PMID: 30238732 DOI: 10.7507/1002-1892.201712083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To summarize the latest developments in the enhanced recovery after surgery (ERAS) in the geriatric hip fractures and its perioperative therapy management. Methods The recent original literature on the ERAS in the geriatric hip fractures were extensively reviewed, illustrating the concepts and properties of the ERAS in the geriatric hip fractures. Results It has been considered to be associated with the decreased postoperative morbidity, reduced hospital length of stay, and cost savings to implement ERAS protocols, including multimodal analgesia, inflammation control, intravenous fluid therapy, early mobilization, psychological counseling, and so on, in the perioperative (emergency, preoperative, intraoperative, postoperative) management of the geriatric hip fractures. The application of ERAS in the geriatric hip fractures guarantees the health benefits of patients and saves medical expenses, which also provides basis and guidance for the further development and improvement of the entire process perioperative management in the geriatric hip fractures. Conclusion Significant progress has been made in the application of ERAS in the geriatric hip fractures. ERAS protocols should be a priority for perioperative therapy management in the geriatric hip fractures.
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Affiliation(s)
- Tian Xie
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopaedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Binbin Ma
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopaedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Yingjuan Li
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Jihong Zou
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Geriatrics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Xiaodong Qiu
- Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Department of Anesthesiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopaedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Chen Wang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopaedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P.R.China
| | - Yunfeng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Institute of Traumatic Orthopaedics, School of Medicine, Southeast University, Nanjing Jiangsu, 210009, P.R.China;Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009,
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Stasko AJ, Stammers AH, Mongero LB, Tesdahl EA, Weinstein S. Response to Letter "The Influence of Intraoperative Autotransfusion on Postoperative Hematocrit after Cardiac Surgery: A Cross-Sectional Study" by Robert S. Kramer and Robert C. Groom. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2018; 50:127-128. [PMID: 29921996 PMCID: PMC6002647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Kinnear N, Heijkoop B, Hua L, Hennessey DB, Spernat D. The impact of intra-operative cell salvage during open radical prostatectomy. Transl Androl Urol 2018; 7:S179-S187. [PMID: 29928615 PMCID: PMC5989116 DOI: 10.21037/tau.2018.04.19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background To examine the effect of intra-operative cell salvage (ICS) in open radical prostatectomy. Methods In this retrospective cohort study, all patients undergoing open radical prostatectomy for malignancy at our institution between 10/04/2013 and 10/04/2017 were enrolled. Patients were grouped and compared based on whether they received ICS. Primary outcomes were allogeneic transfusion rates, and disease recurrence. Secondary outcomes were complications and transfusion-related cost. Results Fifty-nine men were enrolled; 30 used no blood conservation technique, while 29 employed ICS. There were no significant differences between groups in age, pre- or post-operative haemoglobin, Charlson comorbidity index, operation duration or length of stay. Tumour characteristics were also similar between groups, including pre-operative prostate specific antigen, post-operative Gleason score, T-stage, nodal status and rates of margin positivity. Compared with controls, the ICS group had longer follow up (945 vs. 989 days; P=0.0016). The control and ICS groups were not significantly different in rates of tumour recurrence (6 vs. 3 patients; P=0.30) or complications (10 vs. 5 patients; P=0.16). While the proportion of patients receiving allogenic transfusion was similar (9 vs. 6 patients; P=0.41), fewer red blood products transfused (40 vs. 12 units) meant transfusion related costs were lower in ICS patients (AUD $47,666 vs. $37,429). Conclusions ICS reduced transfusion related costs, without affecting allogeneic transfusion rates, tumour recurrence or complication rates. These findings extend the literature supporting ICS in oncological surgery. Prospective randomised studies are needed to confirm the existing level III evidence.
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Affiliation(s)
- Ned Kinnear
- Department of Urology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Bridget Heijkoop
- Department of Urology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Lina Hua
- Department of Urology, The Queen Elizabeth Hospital, Adelaide, Australia
| | | | - Daniel Spernat
- Department of Urology, The Queen Elizabeth Hospital, Adelaide, Australia
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Autologous and Nonautologous Blood Transfusion in Patients with Ruptured Ectopic Pregnancy and Severe Blood Loss. BIOMED RESEARCH INTERNATIONAL 2017; 2017:7501807. [PMID: 28695130 PMCID: PMC5488227 DOI: 10.1155/2017/7501807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 05/22/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND There are some theoretical concerns for the use of intraoperative cell salvage (ICS) in patients with ectopic pregnancy. This study aimed to observe the impact of ICS on the coagulation function and clinical outcomes of patients with ruptured ectopic pregnancy and severe blood loss. METHODS This was a retrospective study of 225 patients with ruptured ectopic pregnancy and severe blood loss treated at the Third Affiliated Hospital of Guangxi Medical University between January 2012 and May 2016. Patients were grouped according to ICS (n = 116) and controls (n = 109, allogenic transfusion and no transfusion). RESULTS Compared with controls, patients with ICS had shorter hospitalization (P = 0.007), lower requirement for allogenic blood products (P < 0.001), and higher hemoglobin levels at discharge (P < 0.001). There were no complications/ adverse reactions. In the ICS group, hemoglobin at discharge (-6.5%, P = 0.002) and thrombin time (-3.7%, P = 0.002) were decreased 24 h after surgery, while 24 h APTT was increased (+4.6%, P < 0.001). In the control group, hemoglobin at discharge (-16.8%, P < 0.001) was decreased after surgery and 24 h APTT was increased (+2.4%, P = 0.045). At discharge, hemoglobin levels were higher in the ICS group (P < 0.001). CONCLUSION ICS was associated with good clinical outcomes in patients with ruptured ectopic pregnancy and severe blood loss.
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Côté CL, Yip AM, MacLeod JB, O'Reilly B, Murray J, Ouzounian M, Brown CD, Forgie R, Pelletier MP, Hassan A. Efficacy of intraoperative cell salvage in decreasing perioperative blood transfusion rates in first-time cardiac surgery patients: a retrospective study. Can J Surg 2017; 59:330-6. [PMID: 27668331 DOI: 10.1503/cjs.002216] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Evidence regarding the safety and efficacy of intraoperative cell salvage (ICS) in transfusion reduction during cardiac surgery remains conflicting. We sought to evaluate the impact of routine ICS on outcomes following cardiac surgery. METHODS We conducted a retrospective analysis of patients who underwent nonemergent, first-time cardiac surgery 18 months before and 18 months after the implementation of routine ICS. Perioperative transfusion rates, postoperative bleeding, clinical and hematological outcomes, and overall cost were examined. We used multivariable logistic regression modelling to determine the risk-adjusted effect of ICS on likelihood of perioperative transfusion. RESULTS A total of 389 patients formed the final study population (186 undergoing ICS and 203 controls). Patients undergoing ICS had significantly lower perioperative transfusion rates of packed red blood cells (pRBCs; 33.9% v. 45.3% p = 0.021), coagulation products (16.7% v. 32.5% p < 0.001) and any blood product (38.2% v. 52.7%, p = 0.004). Patients receiving ICS had decreased mediastinal drainage at 12 h (mean 320 [range 230-550] mL v. mean 400 [range 260-690] mL, p = 0.011) and increased postoperative hemoglobin (mean 104.7 ± 13.2 g/L v. 95.0 ± 11.9 g/L, p < 0.001). Following adjustment for other baseline and intraoperative covariates, ICS emerged as an independent predictor of lower perioperative transfusion rates of pRBCs (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.31-0.87), coagulation products (OR 0.41, 95% CI 0.24-0.71) and any blood product (OR 0.47, 95% CI 0.29-0.77). Additionally, ICS was associated with a cost benefit of $116 per patient. CONCLUSION Intraoperative cell salvage could represent a clinically cost-effective way of reducing transfusion rates in patients undergoing cardiac surgery. Further research on systematic ICS is required before recommending it for routine use.
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Affiliation(s)
- Claudia L Côté
- From Dalhousie Medicine, New Brunswick, Saint John, NB (Côté); Cardiovascular Research, New Brunswick Heart Center, Saint John Regional Hospital, Saint John, NB (Yip, MacLeod, Forgie, Pelletier, Hassan); Clinical Perfusion Services, Saint John Regional Hospital, Saint John, NB (O'Reilly); the Cardiovascular Data Management Centre, Hospital for Sick Children, University of Toronto, Toronto, Ont. (Murray); and the Toronto General Hospital, Toronto, Ont. (Ouzounian)
| | - Alexandra M Yip
- From Dalhousie Medicine, New Brunswick, Saint John, NB (Côté); Cardiovascular Research, New Brunswick Heart Center, Saint John Regional Hospital, Saint John, NB (Yip, MacLeod, Forgie, Pelletier, Hassan); Clinical Perfusion Services, Saint John Regional Hospital, Saint John, NB (O'Reilly); the Cardiovascular Data Management Centre, Hospital for Sick Children, University of Toronto, Toronto, Ont. (Murray); and the Toronto General Hospital, Toronto, Ont. (Ouzounian)
| | - Jeffrey B MacLeod
- From Dalhousie Medicine, New Brunswick, Saint John, NB (Côté); Cardiovascular Research, New Brunswick Heart Center, Saint John Regional Hospital, Saint John, NB (Yip, MacLeod, Forgie, Pelletier, Hassan); Clinical Perfusion Services, Saint John Regional Hospital, Saint John, NB (O'Reilly); the Cardiovascular Data Management Centre, Hospital for Sick Children, University of Toronto, Toronto, Ont. (Murray); and the Toronto General Hospital, Toronto, Ont. (Ouzounian)
| | - Bill O'Reilly
- From Dalhousie Medicine, New Brunswick, Saint John, NB (Côté); Cardiovascular Research, New Brunswick Heart Center, Saint John Regional Hospital, Saint John, NB (Yip, MacLeod, Forgie, Pelletier, Hassan); Clinical Perfusion Services, Saint John Regional Hospital, Saint John, NB (O'Reilly); the Cardiovascular Data Management Centre, Hospital for Sick Children, University of Toronto, Toronto, Ont. (Murray); and the Toronto General Hospital, Toronto, Ont. (Ouzounian)
| | - Joshua Murray
- From Dalhousie Medicine, New Brunswick, Saint John, NB (Côté); Cardiovascular Research, New Brunswick Heart Center, Saint John Regional Hospital, Saint John, NB (Yip, MacLeod, Forgie, Pelletier, Hassan); Clinical Perfusion Services, Saint John Regional Hospital, Saint John, NB (O'Reilly); the Cardiovascular Data Management Centre, Hospital for Sick Children, University of Toronto, Toronto, Ont. (Murray); and the Toronto General Hospital, Toronto, Ont. (Ouzounian)
| | - Maral Ouzounian
- From Dalhousie Medicine, New Brunswick, Saint John, NB (Côté); Cardiovascular Research, New Brunswick Heart Center, Saint John Regional Hospital, Saint John, NB (Yip, MacLeod, Forgie, Pelletier, Hassan); Clinical Perfusion Services, Saint John Regional Hospital, Saint John, NB (O'Reilly); the Cardiovascular Data Management Centre, Hospital for Sick Children, University of Toronto, Toronto, Ont. (Murray); and the Toronto General Hospital, Toronto, Ont. (Ouzounian)
| | - Craig D Brown
- From Dalhousie Medicine, New Brunswick, Saint John, NB (Côté); Cardiovascular Research, New Brunswick Heart Center, Saint John Regional Hospital, Saint John, NB (Yip, MacLeod, Forgie, Pelletier, Hassan); Clinical Perfusion Services, Saint John Regional Hospital, Saint John, NB (O'Reilly); the Cardiovascular Data Management Centre, Hospital for Sick Children, University of Toronto, Toronto, Ont. (Murray); and the Toronto General Hospital, Toronto, Ont. (Ouzounian)
| | - Rand Forgie
- From Dalhousie Medicine, New Brunswick, Saint John, NB (Côté); Cardiovascular Research, New Brunswick Heart Center, Saint John Regional Hospital, Saint John, NB (Yip, MacLeod, Forgie, Pelletier, Hassan); Clinical Perfusion Services, Saint John Regional Hospital, Saint John, NB (O'Reilly); the Cardiovascular Data Management Centre, Hospital for Sick Children, University of Toronto, Toronto, Ont. (Murray); and the Toronto General Hospital, Toronto, Ont. (Ouzounian)
| | - Marc P Pelletier
- From Dalhousie Medicine, New Brunswick, Saint John, NB (Côté); Cardiovascular Research, New Brunswick Heart Center, Saint John Regional Hospital, Saint John, NB (Yip, MacLeod, Forgie, Pelletier, Hassan); Clinical Perfusion Services, Saint John Regional Hospital, Saint John, NB (O'Reilly); the Cardiovascular Data Management Centre, Hospital for Sick Children, University of Toronto, Toronto, Ont. (Murray); and the Toronto General Hospital, Toronto, Ont. (Ouzounian)
| | - Ansar Hassan
- From Dalhousie Medicine, New Brunswick, Saint John, NB (Côté); Cardiovascular Research, New Brunswick Heart Center, Saint John Regional Hospital, Saint John, NB (Yip, MacLeod, Forgie, Pelletier, Hassan); Clinical Perfusion Services, Saint John Regional Hospital, Saint John, NB (O'Reilly); the Cardiovascular Data Management Centre, Hospital for Sick Children, University of Toronto, Toronto, Ont. (Murray); and the Toronto General Hospital, Toronto, Ont. (Ouzounian)
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Abstract
BACKGROUND Preoperative anemia has a prevalence of approximately 30% and is one of the strongest predictors of perioperative red blood cell (RBC) transfusion. It is rarely treated although it is an independent risk factor for the occurrence of postoperative complications. Additionally, the high variability in the worldwide usage of RBC transfusions is alarming. Due to these serious deficits in patient care, in 2011 the World Health Organization recommended the implementation of a patient blood management (PBM). OBJECTIVES This article provides information about PBM as a multidimensional and interdisciplinary approach. MATERIAL AND METHODS A selective literature search was carried out in the Medline and Cochrane library databases including consideration of national and international guidelines. RESULTS A PBM promotes the medically and ethically appropriate use of all available resources, techniques and materials in favor of an optimized perioperative patient care. Patients' own resources should be specifically protected, strengthened and used and include (i) diagnosis and therapy of preoperative anemia, (ii) minimizing perioperative blood loss, (iii) blood-conserving surgical techniques, (iv) restriction of diagnostic blood sampling, (v) utilization of individual anemia tolerance, (vi) optimal coagulation and hemotherapy concepts and (vii) guideline-based, rational indications for the use of RBC transfusions. CONCLUSION A PBM should be advocated as an incentive to evaluate and critically optimize local conditions. An individual, interdisciplinarily structured bundle of different PBM measures has great potential to optimize the quality of patient care and to make it safer.
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New HV, Berryman J, Bolton-Maggs PHB, Cantwell C, Chalmers EA, Davies T, Gottstein R, Kelleher A, Kumar S, Morley SL, Stanworth SJ. Guidelines on transfusion for fetuses, neonates and older children. Br J Haematol 2016; 175:784-828. [DOI: 10.1111/bjh.14233] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Helen V. New
- NHS Blood and Transplant; London UK
- Imperial College Healthcare NHS Trust; London UK
| | | | | | | | | | | | - Ruth Gottstein
- St. Mary's Hospital; Manchester/University of Manchester; Manchester UK
| | | | - Sailesh Kumar
- Mater Research Institute; University of Queensland; Brisbane Australia
| | - Sarah L. Morley
- Addenbrookes Hospital/NHS Blood and Transplant; Cambridge UK
| | - Simon J. Stanworth
- Oxford University Hospitals NHS Trust/NHS Blood and Transplant; Oxford UK
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Carson JL, Stanworth SJ, Roubinian N, Fergusson DA, Triulzi D, Doree C, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev 2016; 10:CD002042. [PMID: 27731885 PMCID: PMC6457993 DOI: 10.1002/14651858.cd002042.pub4] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND There is considerable uncertainty regarding the optimal haemoglobin threshold for the use of red blood cell (RBC) transfusions in anaemic patients. Blood is a scarce resource, and in some countries, transfusions are less safe than others because of a lack of testing for viral pathogens. Therefore, reducing the number and volume of transfusions would benefit patients. OBJECTIVES The aim of this review was to compare 30-day mortality and other clinical outcomes in participants randomized to restrictive versus liberal red blood cell (RBC) transfusion thresholds (triggers) for all conditions. The restrictive transfusion threshold uses a lower haemoglobin level to trigger transfusion (most commonly 7 g/dL or 8 g/dL), and the liberal transfusion threshold uses a higher haemoglobin level to trigger transfusion (most commonly 9 g/dL to 10 g/dL). SEARCH METHODS We identified trials by searching CENTRAL (2016, Issue 4), MEDLINE (1946 to May 2016), Embase (1974 to May 2016), the Transfusion Evidence Library (1950 to May 2016), the Web of Science Conference Proceedings Citation Index (1990 to May 2016), and ongoing trial registries (27 May 2016). We also checked reference lists of other published reviews and relevant papers to identify any additional trials. SELECTION CRITERIA We included randomized trials where intervention groups were assigned on the basis of a clear transfusion 'trigger', described as a haemoglobin (Hb) or haematocrit (Hct) level below which a red blood cell (RBC) transfusion was to be administered. DATA COLLECTION AND ANALYSIS We pooled risk ratios of clinical outcomes across trials using a random-effects model. Two people extracted the data and assessed the risk of bias. We conducted predefined analyses by clinical subgroups. We defined participants randomly allocated to the lower transfusion threshold as 'restrictive transfusion' and to the higher transfusion threshold as 'liberal transfusion'. MAIN RESULTS A total of 31 trials, involving 12,587 participants, across a range of clinical specialities (e.g. surgery, critical care) met the eligibility criteria. The trial interventions were split fairly equally with regard to the haemoglobin concentration used to define the restrictive transfusion group. About half of them used a 7 g/dL threshold, and the other half used a restrictive transfusion threshold of 8 g/dL to 9 g/dL. The trials were generally at low risk of bias .Some items of methodological quality were unclear, including definitions and blinding for secondary outcomes.Restrictive transfusion strategies reduced the risk of receiving a RBC transfusion by 43% across a broad range of clinical specialties (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.49 to 0.65; 12,587 participants, 31 trials; high-quality evidence), with a large amount of heterogeneity between trials (I² = 97%). Overall, restrictive transfusion strategies did not increase or decrease the risk of 30-day mortality compared with liberal transfusion strategies (RR 0.97, 95% CI 0.81 to 1.16, I² = 37%; N = 10,537; 23 trials; moderate-quality evidence) or any of the other outcomes assessed (i.e. cardiac events (low-quality evidence), myocardial infarction, stroke, thromboembolism (high-quality evidence)). Liberal transfusion did not affect the risk of infection (pneumonia, wound, or bacteraemia). AUTHORS' CONCLUSIONS Transfusing at a restrictive haemoglobin concentration of between 7 g/dL to 8 g/dL decreased the proportion of participants exposed to RBC transfusion by 43% across a broad range of clinical specialities. There was no evidence that a restrictive transfusion strategy impacts 30-day mortality or morbidity (i.e. mortality at other points, cardiac events, myocardial infarction, stroke, pneumonia, thromboembolism, infection) compared with a liberal transfusion strategy. There were insufficient data to inform the safety of transfusion policies in certain clinical subgroups, including acute coronary syndrome, myocardial infarction, neurological injury/traumatic brain injury, acute neurological disorders, stroke, thrombocytopenia, cancer, haematological malignancies, and bone marrow failure. The findings provide good evidence that transfusions with allogeneic RBCs can be avoided in most patients with haemoglobin thresholds above 7 g/dL to 8 g/dL.
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Affiliation(s)
- Jeffrey L Carson
- Rutgers Robert Wood Johnson Medical SchoolDivision of General Internal Medicine125 Paterson StreetNew BrunswickNew JerseyUSA08903
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust and University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe Hospital, Headley WayHeadingtonOxfordUKOX3 9BQ
| | - Nareg Roubinian
- Ottawa Hospital Research Institute725 Parkdale Ave.OttawaONCanadaK1Y 4E9
| | - Dean A Fergusson
- Ottawa Hospital Research InstituteClinical Epidemiology Program501 Smyth RoadOttawaONCanadaK1H 8L6
| | - Darrell Triulzi
- University of PittsburghThe Institute for Transfusion MedicineFive Parkway Center875 Greentree RoadPittsburghPAUSA15220
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Paul C Hebert
- University of Montreal Hospital Research CentreCentre for Research900 rue St‐Denis, local R04‐402 Tour VigerMontrealQCCanadaH2X 0A9
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Xie H, Pan JK, Hong KH, Guo D, Fang J, Yang WY, Liu J. Postoperative autotransfusion drain after total hip arthroplasty: a meta-analysis of randomized controlled trials. Sci Rep 2016; 6:27461. [PMID: 27364944 PMCID: PMC4929467 DOI: 10.1038/srep27461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 05/17/2016] [Indexed: 01/28/2023] Open
Abstract
The use of a postoperative autotransfusion drain (PATD) to reduce allogenic blood transfusions in total hip arthroplasty (THA) remains controversial. Therefore, we conducted a meta-analysis to evaluate the efficacy and safety of this technique. Randomized controlled trials (RCTs) were identified from PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL). Thirteen RCTs (1,424 participants) were included in our meta-analysis. The results showed that PATD reduced the rate of allogenic transfusions (RR = 0.56; 95% CI [0.40, 0.77]) and total blood loss (MD = -196.04; 95% CI [-311.01, -81.07]). Haemoglobin (Hb) levels were higher in the PATD group on postoperative day 1 (MD = 0.28; 95% CI [0.06, 0.49]), but no significant differences on postoperative days 2 or 3 (MD = 0.29; 95% CI [-0.02, 0.60]; MD = 0.26; 95% CI [-0.04, 0.56]; respectively). There were no differences in length of hospital stay (MD = -0.18; 95% CI [-0.61, 0.25]), febrile reaction (RR = 1.26; 95% CI [0.95, 1.67]), infection (RR = 0.95; 95% CI [0.54, 1.65]), wound problems (RR = 1.07; 95% CI [0.87, 1.33]), or serious adverse events (RR = 0.59; 95% CI [0.10, 3.58]). Our findings suggest that PATD is effective in reducing the rate of allogenic transfusion. However, the included studies are inadequately powered to conclusively determine the safety of this technique.
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Affiliation(s)
- Hui Xie
- Second School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Jian-Ke Pan
- Department of Orthopaedics, Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou 510120, China
| | - Kun-Hao Hong
- Department of Orthopaedics, Guangdong Second Traditional Chinese Medicine Hospital, Guangzhou 510095, China
| | - Da Guo
- Department of Orthopaedics, Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou 510120, China
| | - Jian Fang
- Department of Orthopaedics, Third Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou 510375, China
| | - Wei-Yi Yang
- Department of Orthopaedics, Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou 510120, China
| | - Jun Liu
- Department of Orthopaedics, Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou 510120, China
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Cleland S, Corredor C, Ye JJ, Srinivas C, McCluskey SA. Massive haemorrhage in liver transplantation: Consequences, prediction and management. World J Transplant 2016; 6:291-305. [PMID: 27358774 PMCID: PMC4919733 DOI: 10.5500/wjt.v6.i2.291] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 03/16/2016] [Accepted: 04/11/2016] [Indexed: 02/05/2023] Open
Abstract
From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusion rates over a shorter period of time may reduce the potential for survival bias. Both massive haemorrhage and transfusion are associated with increased risk of mortality and morbidity (need for dialysis/surgical site infection) following liver transplantation although causality is difficult to prove due to the observational design of most trials. The blood loss associated with liver transplantation is multifactorial. Portal hypertension secondary to cirrhosis results in extensive collateral circulation, which can bleed during hepatectomy particular if portal pressures are increased. Avoiding volume loading and maintenance of a low central venous pressure together with the use of vasopressors have been shown to reduce blood loss and transfusion during liver transplantation, but may increase the risk of renal impairment post-operatively. Coagulation defects may be present pre-transplant, but haemostasis is often re-balanced due to a deficit in both pro- and anti-coagulation factors. Further derangement of haemostasis may develop in the anhepatic and neohepatic phases due to absent hepatic metabolic function, hyperfibrinolysis and platelet sequestration in the donor liver. Point-of-care tests of coagulation such as the viscoelastic tests rotation thromboelastometry/thromboelastometry allow and more accurate and rapid assessment of these derangements in coagulation and guide the use of factor replacement and antifibrinolytics. Transfusion protocols guided by these tests have been shown to reduce transfusion rates compared with conventional coagulation tests, but have not shown improvements in mortality or morbidity. Pre-operative factors associated with massive transfusion include previous surgery, re-do transplantation, the aetiology and severity of liver disease. Intra-operatively the use of piggy-back technique and avoiding veno-veno bypass has been shown to reduced blood loss.
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Murphy GJ, Verheyden V, Wozniak M, Sullo N, Dott W, Bhudia S, Bittar N, Morris T, Ring A, Tebbatt A, Kumar T. Trial protocol for a randomised controlled trial of red cell washing for the attenuation of transfusion-associated organ injury in cardiac surgery: the REDWASH trial. Open Heart 2016; 3:e000344. [PMID: 26977309 PMCID: PMC4785436 DOI: 10.1136/openhrt-2015-000344] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/11/2015] [Accepted: 01/11/2016] [Indexed: 11/29/2022] Open
Abstract
Introduction It has been suggested that removal of proinflammatory substances that accumulate in stored donor red cells by mechanical cell washing may attenuate inflammation and organ injury in transfused cardiac surgery patients. This trial will test the hypotheses that the severity of the postoperative inflammatory response will be less and postoperative recovery faster if patients undergoing cardiac surgery receive washed red cells compared with standard care (unwashed red cells). Methods and analysis Adult (≥16 years) cardiac surgery patients identified at being at increased risk for receiving large volume red cell transfusions at 1 of 3 UK cardiac centres will be randomly allocated in a 1:1 ratio to either red cell washing or standard care. The primary outcome is serum interleukin-8 measured at 5 postsurgery time points up to 96 h. Secondary outcomes will include measures of inflammation, organ injury and volumes of blood transfused and cost-effectiveness. Allocation concealment, internet-based randomisation stratified by operation type and recruiting centre, and blinding of outcome assessors will reduce the risk of bias. The trial will test the superiority of red cell washing versus standard care. A sample size of 170 patients was chosen in order to detect a small-to-moderate target difference, with 80% power and 5% significance (2-tailed). Ethics and dissemination The trial protocol was approved by a UK ethics committee (reference 12/EM/0475). The trial findings will be disseminated in scientific journals and meetings. Trial registration number ISRCTN 27076315.
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Affiliation(s)
- G J Murphy
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit , University of Leicester, Clinical Sciences Wing, Glenfield Hospital , Leicester , UK
| | - V Verheyden
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit , University of Leicester, Clinical Sciences Wing, Glenfield Hospital , Leicester , UK
| | - M Wozniak
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit , University of Leicester, Clinical Sciences Wing, Glenfield Hospital , Leicester , UK
| | - N Sullo
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit , University of Leicester, Clinical Sciences Wing, Glenfield Hospital , Leicester , UK
| | - W Dott
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit , University of Leicester, Clinical Sciences Wing, Glenfield Hospital , Leicester , UK
| | - S Bhudia
- University Hospitals Coventry and Warwickshire NHS Trust , Coventry , UK
| | - N Bittar
- Blackpool Victoria Hospital NHS Trust , Blackpool , UK
| | - T Morris
- Leicester Clinical Trials Unit , Leicester Diabetes Centre, Leicester General Hospital , Leicester , UK
| | - A Ring
- Leicester Clinical Trials Unit , Leicester Diabetes Centre, Leicester General Hospital , Leicester , UK
| | - A Tebbatt
- Department of Clinical Perfusion , University Hospital Leicester NHS Trust, Glenfield Hospital , Leicester , UK
| | - T Kumar
- Department of Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit , University of Leicester, Clinical Sciences Wing, Glenfield Hospital , Leicester , UK
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Engels GE, van Klarenbosch J, Gu YJ, van Oeveren W, de Vries AJ. Intraoperative cell salvage during cardiac surgery is associated with reduced postoperative lung injury. Interact Cardiovasc Thorac Surg 2016; 22:298-304. [PMID: 26705299 PMCID: PMC4986566 DOI: 10.1093/icvts/ivv355] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 11/06/2015] [Accepted: 11/12/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES In addition to its blood-sparing effects, intraoperative cell salvage may reduce lung injury following cardiac surgery by removing cytokines, neutrophilic proteases and lipids that are present in cardiotomy suction blood. To test this hypothesis, we performed serial measurements of biomarkers of the integrity of the alveolar-capillary membrane, leucocyte activation and general inflammation. We assessed lung injury clinically by the duration of postoperative mechanical ventilation and the alveolar arterial oxygen gradient. METHODS Serial measurements of systemic plasma concentrations of interleukin-6 (IL-6), myeloperoxidase, elastase, surfactant protein D (SP-D), Clara cell 16 kD protein (CC16) and soluble receptor for advanced glycation endproducts (sRAGEs) were performed on blood samples from 195 patients who underwent cardiac surgery with the use of a cell salvage (CS) device (CS, n = 99) or without (CONTROL, n = 96). RESULTS Postoperative mechanical ventilation time was shorter in the CS group than in the CONTROL group [10 (8-15) vs 12 (9-18) h, respectively, P = 0.047]. The postoperative alveolar arterial oxygen gradient, however, was not different between groups. After surgery, the lung injury biomarkers CC16 and sRAGEs were lower in the CS group than in the CONTROL group. Biomarkers of systemic inflammation (IL-6, myeloperoxidase and elastase) were also lower in the CS group. Finally, mechanical ventilation time correlated with CC16 plasma concentrations. CONCLUSIONS The intraoperative use of a cell salvage device resulted in less lung injury in patients after cardiac surgery as assessed by lower concentrations of lung injury markers and shorter mechanical ventilation times.
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Affiliation(s)
| | - Jan van Klarenbosch
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Y John Gu
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Willem van Oeveren
- HaemoScan B.V., Groningen, Netherlands Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Adrianus J de Vries
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Vaglio S, Prisco D, Biancofiore G, Rafanelli D, Antonioli P, Lisanti M, Andreani L, Basso L, Velati C, Grazzini G, Liumbruno GM. Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:23-65. [PMID: 26710356 PMCID: PMC4731340 DOI: 10.2450/2015.0172-15] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
- Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianni Biancofiore
- Liver Transplant Anaesthesia and Critical Care, University Hospital Pisana, Pisa, Italy
| | - Daniela Rafanelli
- Immunohaematology and Transfusion Unit, Pistoia 3 Local Health Authority, Pistoia, Italy
| | - Paola Antonioli
- Department of Infection Prevention Control and Risk Management, Ferrara University Hospital, Ferrara, Italy
| | - Michele Lisanti
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Lorenzo Andreani
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Leonardo Basso
- Orthopaedics and Trauma Ward, Cottolengo Hospital, Turin, Italy
| | - Claudio Velati
- Transfusion Medicine and Immunohaematology Department of Bologna Metropolitan Area, Bologna, Italy, on behalf of Italian Society of Transfusion Medicine and Immunohaematology (SIMTI); Italian Society of Italian Society of Orthopaedics and Traumatology (SIOT); Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Therapy (S.I.A.A.R.T.I.); Italian Society for the Study of Haemostasis and Thrombosis (SISET), and the National Association of Hospital Medical Directors (ANMDO) working group
| | - Giuliano Grazzini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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Donohue CI, Mallett SV. Reducing transfusion requirements in liver transplantation. World J Transplant 2015; 5:165-182. [PMID: 26722645 PMCID: PMC4689928 DOI: 10.5500/wjt.v5.i4.165] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/10/2015] [Accepted: 11/25/2015] [Indexed: 02/05/2023] Open
Abstract
Liver transplantation (LT) was historically associated with massive blood loss and transfusion. Over the past two decades transfusion requirements have reduced dramatically and increasingly transfusion-free transplantation is a reality. Both bleeding and transfusion are associated with adverse outcomes in LT. Minimising bleeding and reducing unnecessary transfusions are therefore key goals in the perioperative period. As the understanding of the causes of bleeding has evolved so too have techniques to minimize or reduce the impact of blood loss. Surgical “piggyback” techniques, anaesthetic low central venous pressure and haemodilution strategies and the use of autologous cell salvage, point of care monitoring and targeted correction of coagulopathy, particularly through use of factor concentrates, have all contributed to declining reliance on allogenic blood products. Pre-emptive management of preoperative anaemia and adoption of more restrictive transfusion thresholds is increasingly common as patient blood management (PBM) gains momentum. Despite progress, increasing use of marginal grafts and transplantation of sicker recipients will continue to present new challenges in bleeding and transfusion management. Variation in practice across different centres and within the literature demonstrates the current lack of clear transfusion guidance. In this article we summarise the causes and predictors of bleeding and present the evidence for a variety of PBM strategies in LT.
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Goldhammer JE, Marhefka GD, Daskalakis C, Berguson MW, Bowen JE, Diehl JT, Sun J. The Effect of Aspirin on Bleeding and Transfusion in Contemporary Cardiac Surgery. PLoS One 2015; 10:e0134670. [PMID: 26230605 PMCID: PMC4521851 DOI: 10.1371/journal.pone.0134670] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/13/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Despite evidence that preoperative aspirin improves outcomes in cardiac surgery, recommendations for aspirin use are inconsistent due to aspirin's anti-platelet effect and concern for bleeding. The purpose of this study was to investigate preoperative aspirin use and its effect on bleeding and transfusion in cardiac surgery. METHODS This retrospective study involved consecutive patients (n=1571) who underwent CABG, valve, or combined CABG and valve surgery at a single center between March 2007 and July 2012. Of all patients, 728 met the inclusion criteria and were divided into two groups: those using (n=603) or not using (n=125) aspirin within 5 days of surgery. Data were collected on chest tube drainage, re-operation for bleeding, and transfusion of red blood cells (RBCs), fresh frozen plasma (FFP), and platelets. RESULTS No significant difference was observed between the two groups in chest tube drainage or re-operation for bleeding. An increase in patients transfused with RBCs was observed in the aspirin group (61.9 vs 51.2%, adjusted OR 1.77, p=0.027); however, among those transfused RBCs, no significant difference in mean units transfused or massive transfusion was observed. No significant difference was seen in transfusion requirement of FFP or platelets. CONCLUSIONS In patients undergoing CABG, valve, or combined CABG/valve surgery, preoperative aspirin, within 5 days of surgery, was associated with an increased probability of receiving an RBC transfusion. Preoperative aspirin was not associated with an increase in chest tube drainage, re-operation for bleeding complications, or transfusion of FFP or platelets.
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Affiliation(s)
- Jordan E. Goldhammer
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Gregary D. Marhefka
- Division of Cardiology, Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Constantine Daskalakis
- Division of Biostatistics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Mark W. Berguson
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - John E. Bowen
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - James T. Diehl
- Division of Cardiothoracic Surgery, Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Jianzhong Sun
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
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Carling MS, Jeppsson A, Eriksson BI, Brisby H. Transfusions and blood loss in total hip and knee arthroplasty: a prospective observational study. J Orthop Surg Res 2015; 10:48. [PMID: 25889413 PMCID: PMC4383080 DOI: 10.1186/s13018-015-0188-6] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Accepted: 03/16/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND There is a high prevalence of blood product transfusions in orthopedic surgery. The reported prevalence of red blood cell transfusions in unselected patients undergoing hip or knee replacement varies between 21% and 70%. We determined current blood loss and transfusion prevalence in total hip and knee arthroplasty when tranexamic acid was used as a routine prophylaxis, and further investigated potential predictors for excessive blood loss and transfusion requirement. METHODS/MATERIALS In total, 193 consecutive patients undergoing unilateral hip (n = 114) or knee arthroplasty (n = 79) were included in a prospective observational study. Estimated perioperative blood loss was calculated and transfusions of allogeneic blood products registered and related to patient characteristics and perioperative variables. RESULTS Overall transfusion rate was 16% (18% in hip patients and 11% in knee patients, p = 0.19). Median estimated blood loss was significantly higher in hip patients (984 vs 789 mL, p < 0.001). Preoperative hemoglobin concentration was the only independent predictor of red blood cell transfusion in hip patients while low hemoglobin concentration, body mass index, and operation time were independent predictors for red blood cell transfusion in knee patients. CONCLUSIONS The prevalence of red blood cell transfusion was lower than previously reported in unselected total hip or knee arthroplasty patients. Routine use of tranexamic acid may have contributed. Low preoperative hemoglobin levels, low body mass index, and long operation increase the risk for red blood cell transfusion.
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Affiliation(s)
- Malin S Carling
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, SE 413 45, Sweden. .,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden. .,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Bengt I Eriksson
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, SE 413 45, Sweden. .,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Helena Brisby
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, SE 413 45, Sweden. .,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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