Morbidity risk assessment in the surgically anemic patient

Surgical Experience of Posterior Fossa Meningioma in a Jehovah's Witnesses Patient

Unexpected bleeding is a common complication that can occur during surgery. This unexpected bleeding can be managed by checking the patients' preoperative hemodynamic state or by autologous transfusion of an appropriate volume during surgery depending on the amount of blood loss and hemodynamic condition. However, patients like Jehovah's Witnesses, who refuse autologous transfusions for religious reasons even in life-threatening situations, present a predicament for treating physicians. The author reports on a large meningioma on the posterior fossa of a Jehovah's Witness patient who underwent surgery without autologous blood transfusion. There were no major problems other than the fear of unexpected massive bleeding. The surgeon's attention and efforts to minimize bleeding during surgery seemed to be the most important factors for success.

RBC Transfusion Triggers: Is There Anything New?

For many years, in daily clinical practice, the traditional 10/30 rule (hemoglobin 10 g/dL - hematocrit 30%) has been the most commonly used trigger for blood transfusions. Over the years, this approach is believed to have contributed to a countless number of unnecessary transfusions and an unknown number of overtransfusion-related deaths. Recent studies have shown that lower hemoglobin levels can safely be accepted, even in critically ill patients. However, even these new transfusion thresholds are far beyond the theoretical limits of individual anemia tolerance. For this reason, almost all publications addressing the limits of acute anemia recommend physiological transfusion triggers to indicate the transfusion of erythrocyte concentrates as an alternative. Although this concept appears intuitive at first glance, no solid scientific evidence supports the safety and benefit of physiological transfusion triggers to indicate the optimal time point for transfusion of allogeneic blood. It is therefore imperative to continue searching for the most sensitive and specific parameters that can guide the clinician when to transfuse in order to avoid anemia-induced organ dysfunction while avoiding overtransfusion-related adverse effects. This narrative review discusses the concept of anemia tolerance and critically compares hemoglobin-based triggers with physiological transfusion for various clinical indications.

Treating Posttransplant Anemia With Erythropoietin Improves Quality of Life but Does Not Affect Progression of Chronic Kidney Disease

OBJECTIVES

Posttransplant anemia affects 30% to 45% of kidney transplant recipients and is associated with increased morbidity. However, there is lack of evidence about safe hemoglobin levels after erythropoietin treatment. Studies are needed to better understand the potential benefits and risks, as well as to define safe target hemoglobin ranges in these patients.

MATERIALS AND METHODS

In this single-center exploratory, open-label randomized controlled trial, kidney trans-plant recipients with anemia 3 months posttransplant were either treated with epoetin beta to a hemoglobin target level of 11.5 to 13.5 g/dL (n = 28) or given no treatment (n = 27). Treatment effects on graft function and health quality of life were assessed.

RESULTS

After 2 years, hemoglobin concentrations were significantly higher in the epoetin beta treatment group than in the no treatment group (12.3 ± 0.18 vs 9.99 ± 0.22 g/dL; P < .0001). Estimated glomerular filtration rate, calculated by Modified Diet in Renal Disease 7, declined by 1.7 mL/min (interquartile range, -6 to 4.24) in the epoetin treatment group and by 4.16 mL/min (interquartile range, -12.42 to 2.78) in the no treatment group (P = .32). Rate of progression, determined by estimated glomerular filtration rate slope, was not significantly different between groups (-0.09 ± 0.1 vs -0.12 ± 0.15 mL/min for treated vs not treated; P = .78). Moreover, we observed no significant differences in proteinuria and blood pressure. Treated patients had greater improvements in the vitality and mental health domains of the Medical Outcomes Short Form Health Survey quality of life scores.

CONCLUSIONS

Treatment of anemia in kidney transplant recipients to a hemoglobin level of 11.5 to 13.5 g/dL with erythropoietin improves some quality of life scores. The treatment was safe and not associated with adverse outcomes. There were no changes in rate of decline of graft function.

Association between ischemic stroke and iron-deficiency anemia: a population-based study

Background

Very little is known about the relationship between non-sickle cell anemia and stroke. The purpose of this study is to evaluate the association of iron-deficiency anemia (IDA) with stroke based on a nationwide coverage database in Taiwan.

Methods

The case-control study subjects were obtained from the Taiwanese Longitudinal Health Insurance Database 2000. We included 51,093 subjects with stroke as cases and randomly selected 153,279 controls (3 controls per case) in this study.Separate conditional logistic regression analyses were used to calculate the odds ratio (OR) for having been previously diagnosed with IDA between cases and controls.We further analyzed the association between stroke and IDA by stroke subtype.

Results

Results showed that 3,685 study subjects (1.81%) had been diagnosed with IDA prior to the index date; of those subjects, 1,268 (2.48%) were cases and 2,417 (1.58%) were controls (p<0.001). Conditional logistic regression shows that the OR of having previously received an IDA diagnosis among cases was 1.49 (95% CI: 1.39~1.60; p < 0.01) that of controls after adjusting for monthly income, geographic region, hypertension, diabetes, coronary heart disease, atrial fibrillation, heart failure, hyperlipidemia, tobacco use disorder, and alcohol abuse/alcohol dependency syndrome. Furthermore, the adjusted OR of prior IDA for cases with ischemic stroke was found to be 1.45 (95% CI: 1.34~1.58) compared to controls. However, we did not find any significant relationship between IDA and subarachnoid/intracerebral hemorrhage even adjusting for other confounding factors (OR=1.17, 95% CI=0.97~1.40).

Conclusion

There is a significant association between prior IDA and ischemic stroke.

Portal triad clamping versus other methods of vascular control in liver resection: a systematic review and meta-analysis

BACKGROUND

Portal triad clamping (PTC) is the most commonly used method of achieving vascular control during liver resection. However, the efficacy and safety of PTC, compared with those of other methods of vascular control, are uncertain.

METHODS

A systematic review was conducted to identify randomized controlled trials (RCTs) comparing PTC with other methods of vascular control during liver resection. Endpoints included in-hospital mortality, need for transfusion, number of complications and length of hospital stay. Meta-analyses were performed using a random-effects model.

RESULTS

Ten RCTs were identified; these included a total of 820 patients. No statistically significant differences between PTC and other forms of vascular control in liver resection were demonstrated.

CONCLUSIONS

There is no evidence, on the basis of this meta-analysis of RCTs, of any difference between PTC and other forms of vascular control in liver resection.

Outcome in hip fracture patients related to anemia at admission and allogeneic blood transfusion: an analysis of 1262 surgically treated patients

BACKGROUND

Anemia is more often seen in older patients. As the mean age of hip fracture patients is rising, anemia is common in this population. Allogeneic blood transfusion (ABT) and anemia have been pointed out as possible risk factors for poorer outcome in hip fracture patients.

METHODS

In the timeframe 2005-2010, 1262 admissions for surgical treatment of a hip fracture in patients aged 65 years and older were recorded. Registration was prospective from 2008 on. Anemic and non-anemic patients (based on hemoglobin level at admission) were compared regarding clinical characteristics, mortality, delirium incidence, LOS, discharge to a nursing home and the 90-day readmission rate. Receiving an ABT, age, gender, ASA classification, type of fracture and anesthesia were used as possible confounders in multivariable regression analysis.

RESULTS

The prevalence of anemia and the rate of ABT both were 42.5%. Anemic patients were more likely to be older and men and had more often a trochanteric fracture, a higher ASA score and received more often an ABT. In univariate analysis, the 3- and 12-month mortality rate, delirium incidence and discharge to a nursing home rate were significantly worse in preoperatively anemic patients.In multivariable regression analysis, anemia at admission was a significant risk factor for discharge to a nursing home and readmission < 90 days, but not for mortality. Indication for ABT, age and ASA classification were independent risk factors for mortality at all moments, only the mortality rate for the 3-12 month interval was not influenced by ABT. An indication for an ABT was the largest negative contributor to a longer LOS (OR 2.26, 95% CI 1.73-2.94) and the second largest for delirium (OR 1.67, 95% CI 1.28-2.20).

CONCLUSIONS

This study has demonstrated that anemia at admission and postoperative anemia needing an ABT (PANT) were independent risk factors for worse outcome in hip fracture patients. In multivariable regression analysis, anemia as such had no effect on mortality, due to a rescue effect of PANT. In-hospital, 3- and 12-month mortality was negatively affected by PANT, with the main effect in the first 3 months postoperatively.

The effect of computer navigation on blood loss and transfusion rate in TKA

The blood loss that accompanies total knee arthroplasty (TKA) can be substantial. Many patients need perioperative blood transfusions. To avoid anemia and transfusion-related complications, the amount of blood loss and need for blood transfusions must be reduced. If standard jig instruments are used, an opening of the femoral medullary canal is required. This operative step has been recognized as a reason for elevated blood loss; it is not required if computer navigation is used. Hence, the purpose of this study was to investigate the effect of computer navigation on blood loss and transfusion rate in TKA. The data of 500 consecutive patients undergoing TKA were analyzed, and patient- and operation-related data and blood loss and transfusion rates were recorded. The total blood loss was calculated by use of the Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) formula. The average blood loss in the drainages (standard procedures, 880 mL; navigated procedures, 761 mL; P=.001) and the calculated total blood loss (standard procedures, 1375 mL; navigated procedures, 1242 mL; P=.036) were significantly reduced in the navigation group. The transfusion rate of navigated procedures was almost halved (standard procedures, 0.23 transfusions/patient; navigated procedures, 0.12 transfusions/patient; P=.035). Our study demonstrated a reduced blood loss if TKAs were implanted by use of computer navigation. The diminished blood loss resulted in a 50% reduction of allogenic blood transfusions. Hence, computer navigation may be attractive for patients with a high risk of transfusions or uncommon blood groups. Prospective studies are required to verify this potential benefit of computer navigation.

Blood use in elective surgery: the Austrian benchmark study

BACKGROUND

Benchmarking transfusion activity may help to eliminate inappropriate use of blood products. The goal of this study was to measure and to compare the current transfusion practice and to identify predictors of transfusion in public hospitals to develop strategies to optimize transfusion practices.

STUDY DESIGN AND METHODS

This was a prospective observational study in 18 randomly selected public hospitals from April 2004 to February 2005. Primary outcome measures were the amount of intra- and postoperative blood components transfused and intercenter variability of transfusion rate. Secondary outcome measures were prevalence of preoperative anemia, calculated perioperative blood loss, and lowest measured perioperative hemoglobin (Hb) level.

RESULTS

Adult patients undergoing primary unilateral total hip replacement (THR, n = 1401), primary unilateral knee replacement (TKR, n = 1296), hemicolectomy (HECOC, n = 148), and coronary artery bypass graft (CABG) surgery (n = 777) were enrolled. Due to the small number, data of HECOC patients were not fully analyzed. In the remaining procedures, there was a large intercenter variability in the percentage of patients who received transfusions: THR 16 to 85 percent, TKR 12 to 87 percent, and CABG 37 to 63 percent. In the patients who received transfusions, the number of red blood cells (RBC) units transfused varied significantly. There was also a considerable intercenter variability in RBC loss. The prevalence of preoperative anemia was 19 percent and identical in both sexes. The incidence of preoperative anemia was three times higher in patients who received transfusions compared to those who did not.

CONCLUSION

This study demonstrates a high intercenter variability in RBC transfusions and RBC loss in standard surgical procedures. Whereas the variability in blood loss remains largely unexplained, the main predictors for allogeneic RBC transfusions are preoperative and nadir Hb and surgical RBC loss.

Orthogonal search-based rule extraction for modelling the decision to transfuse

Data from an audit relating to transfusion decisions during intermediate or major surgery were analysed to determine the strengths of certain factors in the decision making process. The analysis, using orthogonal search-based rule extraction (OSRE) from a trained neural network, demonstrated that the risk of tissue hypoxia (ROTH) assessed using a 100-mm visual analogue scale, the haemoglobin value (Hb) and the presence or absence of on-going haemorrhage (OGH) were able to reproduce the transfusion decisions with a joint specificity of 0.96 and sensitivity of 0.93 and a positive predictive value of 0.9. The rules indicating transfusion were: 1. ROTH > 32 mm and Hb < 94 g x l(-1); 2. ROTH > 13 mm and Hb < 87 g x l(-1); 3. ROTH > 38 mm, Hb < 102 g x l(-1) and OGH; 4. Hb < 78 g x l(-1).

Vascular occlusion to decrease blood loss during hepatic resection

BACKGROUND

Historically, the primary hazard with liver surgery has been intraoperative blood loss. This led to the refinement of inflow and outflow occlusive techniques. The utility of the different methods of inflow and outflow techniques for hepatic surgery were reviewed.

METHODS

A search of the English literature (Medline, Embase, Cochrane library, Cochrane clinical trials registry, hand searches, and bibliographic reviews) using the terms "liver," "hepatic," "Pringle," "total vascular exclusion," "ischemia," "reperfusion," "inflow," and "outflow occlusion" was performed.

RESULTS

A multitude of techniques to minimize blood loss during hepatic resection have been studied. The evidence suggests that inflow occlusion techniques are generally well tolerated. These should be used with caution in patients with cirrhosis, fibrosis, steatosis, cholestasis, and recent chemotherapy, and for prolonged time intervals.

CONCLUSIONS

Harmful effects of intraoperative blood loss and transfusion occur during hepatic resection. Portal triad clamping (PTC) is associated with less blood loss compared with no clamping. In procedures with ischemic times <1 hour in length, PTC-C (continuous) is likely equal to PTC-I (intermittent). In patients with chronic liver disease or undergoing lengthy operations, PTC-I is likely superior to PTC-C. PTC is superior to total vascular exclusion except in patients with tumors that are large and deep seated, hypervascular, and/or abutting the hepatic veins or vena cava and in patients with increased right-sided heart pressures.

Low postoperative hematocrit increases cerebrovascular damage after hypothermic circulatory arrest

OBJECTIVE

The objective of this study was to evaluate the systemic and cerebral effects of different postoperative hematocrit management following cardiopulmonary bypass and deep hypothermic circulatory arrest.

DESIGN

Animal case study.

SETTING

Laboratory.

SUBJECTS

Four-week-old Yorkshire piglets.

INTERVENTIONS

Twelve piglets were subjected to cardiopulmonary bypass (hematocrit = 25%) and 100 mins of deep hypothermic circulatory arrest (15 degrees C). After weaning cardiopulmonary bypass, they were randomized to either group L or H, in which the postoperative hematocrit was maintained approximately 20% vs. approximately 30%, respectively, and survived for 6 hrs.

MEASUREMENTS AND MAIN RESULTS

Changes in body weight, bioimpedance, and colloid oncotic pressure were assessed. Near-infrared spectroscopy and immunohistochemical assays for cerebral transforming growth factor-beta(1) and caspase-3 were performed. Postoperative weight gain (kg) and decreases in bioimpedance (ohms) were significantly less in group H (1.5 +/- 0.2 [H] vs. 2.4 +/- 0.6 [L], p = .01; 39.3 +/- 15.5 [H] vs. 89.1 +/- 29.6 [L], p = .01). Mean colloid oncotic pressure (mm Hg) was significantly higher in group H (10.8 +/- 1.6 [H] vs. 8.2 +/- 0.8 [L], p = .01) at 6 hrs postoperatively. Oxyhemoglobin, oxidized cytochrome aa(3) (muM x differential path-length factor), and tissue oxygenation index (%) were significantly better in group H (65.7 +/- 31.8 [H] vs. -104.7 +/- 55.2 [L], p = .0001; 0.52 +/- 4.1 [H] vs. -12.8 +/- 6.1 [L], p = .0001, and 55.7 +/- 4.6% [H] vs. 45.3 +/- 6.4% [L], p = .004, respectively). Cerebral transforming growth factor-beta(1) and caspase-3 scores were significantly better in group H (3.0 +/- 0.6 [H] vs. 1.9 +/- 0.9 [L], p = .04 and 1.8 +/- 0.5 [H] vs. 3.2 +/- 0.8 [L], p = .02, respectively). Mean arterial pressure (mm Hg) was consistently higher with group H (94.7 +/- 13.0 [H] vs. 78.3 +/- 11.5 [L], p = .003) despite comparable central venous pressure ( approximately 11 mm Hg).

CONCLUSIONS

Lower postoperative hematocrit was associated with increased fluid retention, lower perfusion pressure, and worse cerebrovascular injury following deep hypothermic circulatory arrest. Postoperative hematocrit management may have profound systemic and cerebral effects after deep hypothermic circulatory arrest and merits further investigation.

Anemia in heart failure: implications, management, and outcomes

Despite advances in the treatment of heart failure (HF) over the past decade, the prognosis remains poor. Anemia is a well-recognized comorbidity in many chronic conditions, but its role in HF has only recently been recognized. Anemia is significantly related to symptoms, exercise capacity, and prognosis in HF; it has been identified as an independent risk factor for mortality in those with left ventricular dysfunction. When HF patients have concomitant renal disease, they invariably become anemic owing to erythropoietin deficiency. In chronic HF patients without renal disease, erythropoietin levels may be elevated in response to anemia, but not adequately increased to overcome it. Some degree of erythropoietin resistance may also be present because of elevated plasma levels of cytokines. Several studies in anemic HF patients have shown positive outcomes using erythropoietin and iron supplementation therapy to increase hemoglobin concentrations to more normal levels. This article reviews the current information available regarding anemia in HF and discusses the clinical implications and treatment of this syndrome.

Blood loss and transfusion in elective abdominal aortic aneurysm surgery

BACKGROUND

Intraoperative blood loss and transfusion are known determinants of mortality and morbidity of elective abdominal aortic aneurysm (AAA) repair. The present study analysed the pattern of blood loss and transfusion and evaluated the risk factors of blood loss during open repair of infrarenal AAA.

METHODS

Blood loss, transfusion and fluid replacement during elective open repair operation for patients with infrarenal AAA were correlated to demographic data, operative findings and procedural information.

RESULTS

A total of 129 patients with a mean age of 71 years was analysed. The mean blood loss was 1000 +/- 887 mL (200-6000 mL). Blood transfusion, with a mean transfusion volume of 400 +/- 591 mL (0-3000 mL), was required in 46% of patients. Univariate analysis showed that bodyweight, renal impairment, low haemoglobin and platelet counts, iliac artery involvement, large aneurysm, bifurcated graft, large graft diameter, prolonged aortic clamp time and long operation time were associated with a higher blood loss. A haemoglobin level of <10.5 g/dL (relative risk (RR): 4.6), platelet count <130 x 10(9)/L (RR: 3.9), aortic clamp time >50 min (RR: 15), total operation time >200 min (RR: 11) and type of graft (RR: 3.5) were identified as independent determinants of blood loss on multivariate analysis.

CONCLUSION

Intraoperative blood loss in elective infrarenal aneurysm surgery is influenced by patients' haematological parameters, distal involvement of aneurysm and degree of difficulty of operation.

Erythropoietin should be part of congestive heart failure management

BACKGROUND

Up to 64% of patients referred to nephrologists with chronic kidney insufficiency (CKI) have evidence of congestive heart failure (CHF), and most of these patients are also anemic. We have called this triad of anemia, CKI, and CHF the cardio renal anemia (CRA) syndrome. The 3 components of this syndrome form a vicious circle, with each one capable of causing or worsening the other 2. Anemia is found in one-third to one-half of CHF patients and can either cause or worsen the CHF, and can increase the mortality, hospitalization, and malnutrition in this condition. Anemia is also associated with a worsening of renal function in CHF and CKI, causing a more rapid progression to dialysis than is found in those without anemia. Uncontrolled CHF can cause rapid deterioration of renal function and may also cause anemia. Chronic kidney insufficiency can cause anemia and worsen the CHF.

METHODS

Aggressive therapy of CHF with all the accepted CHF medications in the accepted doses will often fail to improve the CHF if anemia is also present but is not corrected. However, when the anemia was corrected with subcutaneous erythropoietin and, in some cases, with intravenous iron, the cardiac and patient function and quality of life improved, the need for hospitalization and for high-dose oral and intravenous diuretics was strikingly reduced, and renal function, which had previously been deteriorating, stabilized.

RESULTS

Nephrologists should carefully assess the cardiac status of all CKI patients, including routinely getting an echocardiogram and possibly measuring B-type natriuretic peptide. Where CHF is present, the indicated CHF agents in the indicated doses should be used.

CONCLUSION

Studies show that most cardiologists and internists do not recognize, investigate, or treat the anemia frequently seen in their CHF patients. In our experience cooperation between nephrologists and these specialists has increased their awareness about anemia, resulting in its earlier correction, and thus preventing the deterioration of the CHF, the CKI, and the anemia itself.

The importance of anemia and its correction in the management of severe congestive heart failure

About half of all the patients with CHF are anemic (they have a hemoglobin of < 12 g%). The prevalence and severity of this anemia increase with increasing severity of the CHF. The anemia is caused by a combination of poor nutrition, associated renal insufficiency causing inappropriately low Erythropoietin (EPO) levels, bone marrow depression and EPO resistance caused by excessive TNF alpha and other factors, gastrointestinal blood loss caused by aspirin, ACE inhibitors, EPO loss in the urine with proteinuria, and hemodilution caused by the excessive plasma volume. Studies have shown that the anemia is an independent risk factor for death in CHF, almost doubling the mortality rate. Correction of the anemia with subcutaneous EPO and IV iron improves cardiac function and functional capacity, helps prevent the progression of renal failure, markedly reduces hospitalization and diuretic doses, and improves self assessed quality of life. This so-called Cardio Renal Anemia Syndrome is very common in CHF. Its successful treatment demands close cooperation between cardiologists and nephrologists.

The relationship between admission hemoglobin level and outcome after hip fracture

OBJECTIVE

To determine the effect of admission hemoglobin level on patient outcome after hip fracture.

STUDY DESIGN

Prospective, consecutive.

PATIENTS

From July 1991 to June 1997, 395 community-dwelling patients sixty-five years of age or older who had sustained an operatively treated femoral neck or intertrochanteric fracture were prospectively followed up.

MAIN OUTCOME MEASUREMENTS

Postoperative complications, in-hospital mortality rate, hospital length of stay, hospital discharge status, place of residence at one year, and mortality and recovery of ambulatory ability and activities of daily living status at three, six, and twelve months.

RESULTS

Women with admission hemoglobin levels below 12.0 grams per deciliter and men with admission hemoglobin levels below 13.0 grams per deciliter were classified as anemic. One hundred eighty patients (45.6 percent) were considered anemic on admission. Patients who were anemic were more likely to have an American Society of Anesthesiologists rating of III or IV and have sustained an intertrochanteric fracture. Hospital length of stay and mortality rate at six and twelve months were significantly higher for patients who were anemic on admission. There were no differences in the incidence of postoperative complications, hospital discharge status, place of residence at one year, in-hospital mortality rate, and three-month mortality rate between patients who were and were not anemic on admission. In addition, there were no differences in the recovery of ambulatory ability and of basic and instrumental activities of daily living status at three, six, and twelve months between the two patient groups.

CONCLUSIONS

Patients at risk for poor outcomes after hip fracture can be identified by assessing hemoglobin levels at hospital admission.

Reduced kidney function and anemia as risk factors for mortality in patients with left ventricular dysfunction

OBJECTIVES

We sought to evaluate the relationship between the level of kidney function, level of hematocrit and their interaction on all-cause mortality in patients with left ventricular (LV) dysfunction.

BACKGROUND

Anemia and reduced kidney function occur frequently in patients with heart failure. The level of hematocrit and its relationship with renal function have not been evaluated as risk factors for mortality in patients with LV dysfunction.

METHODS

We retrospectively examined the Studies Of LV Dysfunction (SOLVD) database. Glomerular filtration rate (GFR) was predicted using a recently validated formula. Kaplan-Meier survival analyses were used to compare survival times between groups stratified by level of kidney function (predicted GFR) and hematocrit. Cox proportional-hazards regression was used to explore the relationship of survival time to level of kidney function, hematocrit and their interaction.

RESULTS

Lower GFR and hematocrit were associated with a higher prevalence of traditional cardiovascular risk factors. In univariate analysis, reduced kidney function and lower hematocrit, in men and in women, were risk factors for all-cause mortality (p < 0.001 for both). After adjustment for other factors significant in univariate analysis, a 10 ml/min/1.73 m(2) lower GFR and a 1% lower hematocrit were associated with a 1.064 (95% CI: 1.033, 1.096) and 1.027 (95% CI: 1.015, 1.038) higher risk for mortality, respectively. At lower GFR and lower hematocrit, the risk was higher (p = 0.022 for the interaction) than that predicted by both factors independently.

CONCLUSIONS

Decreased kidney function and anemia are risk factors for all-cause mortality in patients with LV dysfunction, especially when both are present. These relationships need to be confirmed in additional studies.

Neurosurgical procedures in Jehovah's Witnesses: an increased risk?

OBJECTIVE

Because of the growing numbers of members worldwide in the sect of Jehovah's Witnesses, the refusal of blood and blood products due to religious reasons is increasingly encountered in clinical practice. As an alternative to blood transfusion, Jehovah's Witnesses accept blood-free volume substitution, and they sometimes accept the intraoperative reinfusion of autologous blood via a so-called cell saver. The aim of this study was to examine whether the refusal of blood transfusion affects the surgical indications for neurosurgery and whether morbidity and mortality rates are higher after neurosurgical interventions in Jehovah's Witnesses.

METHODS

The pre-, intra-, and postoperative hemoglobin and hematocrit values as well as coagulation parameters of a group of Jehovah's Witnesses (n = 103) were compared with those of a valid control group.

RESULTS

The total intraoperative blood loss during spinal and intracranial surgery in Jehovah's Witnesses was often less than in controls, which suggests a less traumatic surgical procedure. Hemodynamically relevant blood loss occurred in two spinal and four intracranial interventions. The patients were managed without receiving blood transfusions or blood products, although increased time in the intensive care unit and increased convalescence days were necessary. Mean surgical times were 17.5 minutes longer for spinal interventions and 36.7 minutes longer for intracranial interventions than for patients in the control group. This may be attributed to a more careful and thus slower surgical technique and to longer and more extensive hemostasis. The length of hospitalization was 15% longer for Jehovah's Witnesses than for controls.

CONCLUSION

The morbidity and mortality rates for Jehovah's Witnesses undergoing neurosurgery were not higher than those of the control group. Thus, it can be concluded that Jehovah's Witnesses did not have a higher risk when microsurgical techniques and extensive anesthetic monitoring were applied during neurosurgery. Because the surgical success rate for Jehovah's Witnesses corresponded to that of the control group, the increase in costs because of longer treatment times is compensated in the long run by avoiding a lengthier illness, sometimes with more expensive conservative therapy.

The effect of correction of mild anemia in severe, resistant congestive heart failure using subcutaneous erythropoietin and intravenous iron: a randomized controlled study

OBJECTIVES

This is a randomized controlled study of anemic patients with severe congestive heart failure (CHF) to assess the effect of correction of the anemia on cardiac and renal function and hospitalization.

BACKGROUND

Although mild anemia occurs frequently in patients with CHF, there is very little information about the effect of correcting it with erythropoietin (EPO) and intravenous iron.

METHODS

Thirty-two patients with moderate to severe CHF (New York Heart Association [NYHA] class III to IV) who had a left ventricular ejection fraction (LVEF) of < or =40% despite maximally tolerated doses of CHF medications and whose hemoglobin (Hb) levels were persistently between 10.0 and 11.5 g% were randomized into two groups. Group A (16 patients) received subcutaneous EPO and IV iron to increase the level of Hb to at least 12.5 g%. In Group B (16 patients) the anemia was not treated. The doses of all the CHF medications were maintained at the maximally tolerated levels except for oral and intravenous (IV) furosemide, whose doses were increased or decreased according to the clinical need.

RESULTS

Over a mean of 8.2+/-2.6 months, four patients in Group B and none in Group A died of CHF-related illnesses. The mean NYHA class improved by 42.1% in A and worsened by 11.4% in B. The LVEF increased by 5.5% in A and decreased by 5.4% in B. The serum creatinine did not change in A and increased by 28.6% in B. The need for oral and IV furosemide decreased by 51.3% and 91.3% respectively in A and increased by 28.5% and 28.0% respectively in B. The number of days spent in hospital compared with the same period of time before entering the study decreased by 79.0% in A and increased by 57.6% in B.

CONCLUSIONS

When anemia in CHF is treated with EPO and IV iron, a marked improvement in cardiac and patient function is seen, associated with less hospitalization and renal impairment and less need for diuretics.

The pathological consequences of anaemia

Many patients with chronic diseases such as chronic renal failure, chronic inflammatory bowel disease and rheumatoid arthritis are anaemic. Recently congestive heart failure (CHF) has also been found to be associated with anaemia. In all these diseases this anaemia or chronic disease is at least partially due to excessive production of cytokines and leukotrines that interfere both with the effect of erythropoietin (EPO) at the bone marrow and the release of stored iron in the reticuloendothelial system. Treating this anaemia with subcutaneous EPO and IV iron improves the weakness, fatigue, cachexia, nutritional state, mood, cognitive function and quality of life. In the case of CHF it also improves cardiac function and patient functional class, prevents deterioration of renal function and markedly reduces hospitalization. Very few agents in medicine improve so many aspects of the patient so well and so quickly. Unfortunately (for the suffering patient) this anaemia is often ignored and goes untreated.

The use of subcutaneous erythropoietin and intravenous iron for the treatment of the anemia of severe, resistant congestive heart failure improves cardiac and renal function and functional cardiac class, and markedly reduces hospitalizations

OBJECTIVES

This study evaluated the prevalence and severity of anemia in patients with congestive heart failure (CHF) and the effect of its correction on cardiac and renal function and hospitalization.

BACKGROUND

The prevalence and significance of mild anemia in patients with CHF is uncertain, and the role of erythropoietin with intravenous iron supplementation in treating this anemia is unknown.

METHODS

In a retrospective study, the records of the 142 patients in our CHF clinic were reviewed to find the prevalence and severity of anemia (hemoglobin [Hb] <12 g). In an intervention study, 26 of these patients, despite maximally tolerated therapy of CHF for at least six months, still had had severe CHF and were also anemic. They were treated with subcutaneous erythropoietin and intravenous iron sufficient to increase the Hb to 12 g%. The doses of the CHF medications, except for diuretics, were not changed during the intervention period.

RESULTS

The prevalence of anemia in the 142 patients increased with the severity of CHF, reaching 79.1% in those with New York Heart Association class IV. In the intervention study, the anemia of the 26 patients was treated for a mean of 7.2 +/- 5.5 months. The mean Hb level and mean left ventricular ejection fraction increased significantly. The mean number of hospitalizations fell by 91.9% compared with a similar period before the study. The New York Heart Association class fell significantly, as did the doses of oral and intravenous furosemide. The rate of fall of the glomerular filtration rate slowed with the treatment.

CONCLUSIONS

Anemia is very common in CHF and its successful treatment is associated with a significant improvement in cardiac function, functional class, renal function and in a marked fall in the need for diuretics and hospitalization.

Hematologic abnormalities among HIV-infected patients: associations of significance for dentistry

OBJECTIVE

The purpose of this study was to determine the prevalence and severity of and the factors associated with peripheral blood cytopenias among HIV-infected patients.

STUDY DESIGN

The investigation involved 516 HIV-infected adults in a longitudinal study of oral disease. Prevalence of hemoglobin, hematocrit, white blood cell, neutrophil, lymphocyte, and platelet values below the lower limit of normal and certain hematologic "critical values" were determined. Demographic, clinical/immunologic/viral stage, medications, and oral lesions were assessed for association with cytopenias by chi(2) and bivariate analyses.

RESULTS

Findings with respect to prevalence were as follows: anemia, 51%; leukopenia, 43. 4%; neutropenia, 27.5%; lymphopenia, 20.7%; thrombocytopenia, 15.5%. Severe cytopenias were detected in fewer than 1% of the patients. Severity of HIV clinical disease and CD4 cell count depletion were significantly associated with all cytopenias. High viral load was associated only with the leukopenias. Black race, antiparasitic therapy, and some oral lesions were associated with certain cytopenias.

CONCLUSIONS

In HIV-infected patients, mild cytopenias are common; however, severe anemia, neutropenia, and thrombocytopenia that may predispose to certain oral manifestations and dental surgical complications are rare.

Anesthesia and surgery in pediatric patients with low hemoglobin values

A low preoperative hemoglobin (Hb) concentration creates a dilemma for the anesthetist to proceed or not. The authors prospectively studied the perioperative morbidity of 200 healthy infants and children (age range 3 mon-5 years) with preoperative Hb values > or = 7 g/dl, undergoing cleft lip and palate surgery under general anesthesia. The patients were later categorized according to preoperative Hb level group A: Hb 7-10 g/dl and group B: Hb > 10 g/dl and the results were compared. One or more episodes of hypoxemia (SpO2 < 91%) were recorded in 8 patients in group A and 6 in group B during airway management. All patients had stable cardiovascular parameters except for transient bradycardia during desaturations. Recovery was similar and rapid. There were no differences in perioperative morbidity between the two groups. However, the safety of general anesthesia in infants and children with difficult airways is questionable when the oxygen reserve is reduced in anemia.

Use of preoperative autologous blood donation in patients undergoing radical retropubic prostatectomy

OBJECTIVES

To evaluate the appropriateness of autologous blood (AB) transfusion during radical retropubic prostatectomy in relation to the cardiopulmonary risk of the patient.

METHODS

We reviewed the medical records of 100 patients with American Society of Anesthesiologists status I, II, or III who underwent radical retropubic prostatectomy under general or combined general and epidural anesthesia. All patients had donated 2 units (U) of autologous blood, received 0, 1, or 2 U of autologous blood perioperatively, and received no allogeneic blood. Patients were placed in three cardiopulmonary risk groups on the basis of risk factors or documented cardiopulmonary disease. The low-risk group was assigned a target discharge hematocrit of 24% or less; moderate-risk, 25% to 28%; and high-risk, 29% or greater. The appropriateness of transfusion was determined by whether patients' hematocrit was in their group's preassigned range at discharge.

RESULTS

On the basis of discharge hematocrit, significantly more low-risk patients underwent inappropriate transfusion than moderate-risk (64% versus 26%, P = 0.006) or high-risk (64% versus 13%, P = 0.001) patients. Seventy-five AB units were discarded and at least 53 U were inappropriately transfused. We found an increase in the number of units of autologous blood transfused when a larger estimated blood loss was reported (P < 0.001). The estimated charge for the units discarded and inappropriately transfused exceeded $12,000.

CONCLUSIONS

Sixty-four percent of autologous blood units were discarded or inappropriately transfused during radical retropubic prostatectomy. Transfusion of autologous blood was not governed by cardiopulmonary risk stratification. If the decision to transfuse had been based on cardiopulmonary risk factors instead of estimated blood loss, fewer patients would have received autologous blood.

The predictive power of baseline hemoglobin for transfusion risk in surgery patients

Preoperative hemoglobin concentration may be an important predictor of transfusion risk in surgical procedures with significant expected blood loss. Contemporary studies investigating transfusion risk with regard to the relationship between perioperative administration of Epoetin alfa and baseline hemoglobin provide data to test this hypothesis. The predictive power of seven preoperative variables (hemoglobin concentration, age, erythropoietin level, ferritin concentration, serum iron, total iron-binding capacity, and predicted blood volume) on transfusion risk was examined via retrospective logistic regression analysis of 276 orthopedic surgical patients. In the two studies used to perform the regression analysis, patients were treated daily with either Epoetin alfa or placebo. Based on the retrospective analyses, a prospective study was conducted to validate the hypothesis. Of the seven variables evaluated, baseline hemoglobin concentration and predicted blood volume were significantly predictive of transfusion risk in both Epoetin alfa- and placebo-treated patients. Further, an inverse correlation between hemoglobin concentration and transfusion risk was demonstrated in placebo-treated patients. Placebo-treated patients with hemoglobin > 10 to < or = 13 g/dL had an approximately twofold greater risk of transfusion than patients with hemoglobin > 13 g/dL. In contrast to placebo treatment, Epoetin alfa significantly reduced transfusion risk in patients with hemoglobin > 10 to < or = 13 g/dL. Baseline hemoglobin concentration is an excellent predictor of transfusion risk in orthopedic surgical patients. As a result, hemoglobin testing should be considered a part of routine preoperative testing for orthopedic surgical patients.

Blood conservation in hip trauma

Patients with hip or pelvic fractures experience significant blood loss as a result of the fracture and from the surgery that subsequently is performed. The emergent and unplanned nature of fracture surgery precludes the use of preoperative blood donation and the optimization of chronic medical problems. Blood transfusion frequently is required to maintain adequate tissue O2 delivery in these injured patients. However, the administration of allogeneic blood causes other problems, including a well documented increase in the risk of infectious complications. Perioperative measures to minimize blood loss such as hypotensive anesthesia and red blood cell salvage are important, but often are inadequate to prevent the need for blood transfusion. Recently, erythropoietin therapy has been shown to stimulate hematopoiesis in patients with hip fractures. The authors discuss their experience with blood loss management in these patients with hip injuries, including aggressive Fe replacement therapy and the use of recombinant human erythropoietin.

Transfusion-free surgery is a treatment plan for all patients

Due to the increased risks associated with allogenic blood transfusion, blood management in surgical procedures, especially in orthopedic settings, should include reduction of perioperative blood loss. Preoperative nursing assessment will help define patients at increased risk for transfusion. Both nonpharmacologic and pharmacologic techniques can help minimize allogenic transfusion by reducing blood loss. One such method of managing anemia and reducing patient exposure to allogenic transfusion is the perioperative use of recombinant human erythropoietin--erythropoietin alfa--an innovative surgical blood management tool. Increased awareness by perioperative nurses of the use of erythropoietin alfa and patient implications can contribute to the overall blood conservation goal.

[Preoperative autologous donation of blood in cardiac surgery--age related factors]

We have studied influence of the age related factors on preoperative autologous donation (PAD) of blood in cardic surgery. PAD was undertaken in 246 cases of elective cardiac surgery by means of simple or leap-frog method, starting at approximately 4.5 weeks before operation. It provided 1726 ml of autologous blood storage on the average. Sorting the patients into three groups with age, leading surgical procedures were as follows: closure of the atrial septal defect (ASD) in teen 30s (group L, n = 51), aortic valve replacement (AVR) or mitral valve replacement (MVR) in 40s-50s (group M, n = 83) and 60s and over (group H, n = 112). Coronary artery bypass grafting (CABG) was more common in group H. Percent-freedom from allogeneic blood transfusion was 82.3% in group L, 80.7% in group M and 61.6% in group H, respectively (p < 0.05; L, M vs. H), donated blood volume in group H was significantly less than that of group M (p < 0.05, M: 1987 +/- 63, H: 1610 +/- 60 ml), because blood volume and hemoglobin level before donation tended to be less in group H. Each group did not differ in blood loss during and after operation, which showed a significant positive correlation with operation time and cardiopulmonary bypass (CPB) time. Comparing factors in ASD, CPB time was relatively long, and postoperative blood loss was significantly larger in group H (p < 0.05; L: 432 +/- 71 ml, M: 369 +/- 34 ml, H: 754 +/- 124 ml). This finding suggests that the secondary lesions in age ASD cases adversely affected hemostasis. As to AVR, MVR and CABG, there were no differences in these factors but donated blood volume among three groups. We conclude that elderly patient (60s and over) tends to necessitate allogeneic blood transfusion in cardiac surgery because of the insufficient PAD. Earlier commencement of PAD or concomitant application of erythropoietin will improve this situation.

Perioperative ischemia and cardiac complications in major vascular surgery: importance of the preoperative twelve-lead electrocardiogram

PURPOSE

To investigate the associations between specific preoperative 12-lead electrocardiogram (ECG) abnormalities, perioperative ischemia, and postoperative myocardial infarction or cardiac death in major vascular surgery.

METHODS

Two prospective studies on perioperative myocardial ischemia performed in two tertiary university hospitals were combined to include 405 patients. All preoperative ECGs were analyzed according to the Sokolow-Lyon criteria for left ventricular hypertrophy by investigators who were blinded to the patients' perioperative clinical course. Perioperative myocardial ischemia was detected by continuous ECG recording, and postoperative cardiac complications included myocardial infarction and cardiac death.

RESULTS

A total of 19 postoperative cardiac complications occurred (two cardiac deaths and 17 myocardial infarctions). Voltage criteria for left ventricular hypertrophy (78 patients, 19%) and ST segment depression greater than 0.5 mm (98 patients, 24.2%) on preoperative ECGs were both significantly associated with postoperative myocardial infarction or cardiac death (odds ratio, 4.2 and 4.7; p = 0.001 and 0.0005, respectively) and with longer intraoperative and postoperative myocardial ischemia. In each of the two study groups, a preoperative ECG abnormality that involved voltage criteria, ST segment depression, or both (134 patients, 33.1%) was more predictive of postoperative cardiac complications than any other preoperative clinical variable, including a history of myocardial infarction or angina pectoris, diabetes mellitus, pathologic Q-wave by ECG, or preoperative myocardial ischemia. The combined duration of intraoperative and postoperative ischemia and the preoperative ECG with either voltage criteria or ST segment depression were the only independent factors associated with adverse cardiac events by multivariate analysis (p < or = 0.0001 and p = 0.02, respectively).

CONCLUSION

Left ventricular hypertrophy and ST segment depression on preoperative 12-lead ECGs are important markers of increased risk for myocardial infarction or cardiac death after major vascular surgery.

New transfusion strategies

The "new transfusion strategies" are designed to minimize exposure to allogeneic transfusion while maximizing the use of autologous red cells. While not always possible in all clinical situations, this approach appears to be the current transfusion strategy paradigm. Physician and patient concerns about the risk of transfusion therapy are driving these strategies. When combined with management of the elements of cardiopulmonary physiology responsible for cardiac output and tissue perfusion, the autologous techniques of hemodilution, cell salvage, and predeposit are reasonable strategies for achieving the desired goals of allogeneic transfusion avoidance. Of the 11 policies and interventions proposed by the Blood Management Conference6 several need to be iterated as underpinnings for these strategies. They include: 1. assessing transfusion needs on a patient case basis; 2. transfusions are to be given and effect-benefit assessed before proceeding with additional transfusion; 3. limited exposure to allogeneic blood if possible; 4. minimize perioperative blood loss ranging from surgical technique to decreasing laboratory assessments; and 5. maximize oxygen delivery physiology as a first step in improving basic oxygen delivery.