Emergency autotransfusion

Resuscitation Patterns and Massive Transfusion for the Critical Bleeding Dog-A Multicentric Retrospective Study of 69 Cases (2007-2013)

Objective: To describe resuscitation patterns of critically bleeding dogs, including those receiving massive transfusion (MT). Design: Retrospective study from three universities (2007-2013). Animals: Critically bleeding dogs, defined as dogs who received ≥ 25 ml/kg of blood products for treatment of hemorrhagic shock caused by blood loss. Measurements and Main Results: Sixty-nine dogs were included. Sources of critical bleeding were trauma (26.1%), intra/perioperative surgical period (26.1%), miscellaneous (24.6%), and spontaneous hemoabdomen (23.1%). Median (range) age was 7 years (0.5-18). Median body weight was 20 kg (2.6-57). Median pre-transfusion hematocrit, total protein, systolic blood pressure, and lactate were 25% (10-63), 4.1 g/dl (2-7.1), 80 mm Hg (20-181), and 6.4 mmol/L (1.1-18.2), respectively. Median blood product volume administered was 44 ml/kg (25-137.4). Median plasma to red blood cell ratio was 0.8 (0-4), and median non-blood product resuscitation fluid to blood product ratio was 0.5 (0-3.6). MT was given to 47.8% of dogs. Survival rate was 40.6%. The estimated odds of survival were higher by a factor of 1.8 (95% CI: 1.174, 3.094) for a dog with 1 g/dl higher total protein above reference interval and were lower by a factor of 0.6 (95% CI: 0.340, 0.915) per 100% prolongation of partial thromboplastin time above the reference interval. No predictors of MT were identified. Conclusions: Critical bleeding in dogs was associated with a wide range of resuscitation patterns and carries a guarded to poor prognosis.

Autologous blood transfusion in dogs with thoracic or abdominal hemorrhage: 25 cases (2007-2012)

OBJECTIVE

To describe the use and outcome following autologous blood transfusion (ABT) in dogs.

DESIGN

Retrospective study (January 2007-July 2012).

SETTING

Private veterinary referral center.

ANIMALS

Twenty-five dogs that underwent ABT secondary to thoracic or abdominal hemorrhage.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The hospital transaction database was searched using the keyword "autotransfusion" from January 2007 to July 2012. Data collected included signalment, body weight, etiology of hemorrhage, source and method of collection, volumes and method of ABT administration, use of anticoagulant, reported complications, and outcome. Twenty-five dogs were included for a total of 27 ABTs. Causes of hemorrhage included vascular trauma (14/25 dogs, 56%), ruptured tumor (8/25, 32%), and coagulopathy attributed to brodifacoum toxicosis (3/25, 12%). Autologous blood was collected from the abdominal (19/25, 76%), thoracic (5/25, 20%), or abdominal and thoracic cavities (1/25, 4%). Anticoagulant was added to the ABT blood in 13 of 25 (52%) cases. A median ABT volume of 29.3 mL/kg (range 2.9-406.9 mL/kg) was infused through either a 210 μm blood administration filter (21/27, 78%) or an 18 μm hemonate filter (6/27, 22%). Reported complications that may have been associated with ABT included hypocalcemia (4/17, 24%), hemolyzed serum (5/19, 26%), and prolonged coagulation times (4/5, 80%). These complications were considered of minimal clinical significance. Additional blood products were administered in 17 of 25 (68%) dogs. Seventeen (68%) dogs survived to discharge. Cause of death in the remaining cases was euthanasia or cardiac arrest secondary to uncontrollable hemorrhage.

CONCLUSIONS

ABT is an adjunct to volume replacement in dogs with thoracic or abdominal hemorrhage secondary to vascular trauma, ruptured tumor, or anticoagulant rodenticide toxicosis. ABT may be used as bridge to definitive hemorrhage control, particularly when other blood products are not available or affordable. Complications may include hypocalcemia, prolonged coagulation times, and hemolysis.

Transoperative refusion: a simple and safe method in emergency surgery

The objective is to reinforce the importance of blood reinfusion as a cheap, safe and simple method, which can be used in small hospitals, especially those in which there is no blood bank. Moreover, even with the use of devices that perform the collection and filtration of blood, more recent studies show that the cost-benefit ratio is much better when autologous transfusion is compared with blood transfusions, even when there is injury to hollow viscera and blood contamination. It is known that the allogeneic blood transfusion carries a number of risks to patients, among them are the coagulation disorders mediated by excess enzymes in the conserved blood, and deficiency in clotting factors, mainly the Factor V, the proacelerin. Another factor would be the risk of contamination with still unknown pathogens or that are not investigated during screening for selection of donors, such as the West Nile Fever and Creutzfeldt-Jacob, better known as "Mad Cow" disease. Comparing both methods, we conclude that blood autotransfusion has numerous advantages over heterologous transfusion, even in large hospitals. We are not against blood transfusions, just do not agree that the patient's own blood is discarded without making sure there will be enough blood in stock to get him out of the hemorrhagic shock.

Autotransfusion in emergent operative trauma resuscitation

PURPOSE

Autotransfusion of red cells is common in many surgical specialties. However, this technique is not uniformly used in abdominal trauma. The purpose of this paper is to study the outcomes of patients who were autotransfused during emergency trauma operations in which they sustained full-thickness hollow viscus injury (HVI).

METHODS

A total of 179 patients in period 1999-2008 with penetrating and blunt abdominal trauma requiring intraoperative blood transfusion were evaluated. Recipients of autotransfusion and banked blood (autotransfused group) were compared with recipients of banked blood products only (control group). The t-test, Chi-squared, and Fisher's exact test were used to evaluate the data. Multivariate regression analysis evaluated the primary outcomes, survival and bloodstream infection (BSI).

RESULTS

Of the 179 patients, 108 controls and 71 autotransfused patients were evaluated. The results showed no statistically significant difference between the control and autotransfusion groups regarding age, injury pattern/severity [Injury Severity Score (ISS)], length of stay, postoperative international normalized ratio (INR), and volume of banked blood products. Both groups were also proportional with colon injury. The estimated operative blood loss (EBL) was 2,472 ± 3,261 for controls and 4,056 ± 3,825 for the autotransfused group (p = 0.0001). The total volume of blood transfused was 2,792 and 5,513 for controls and patients in the autotransfusion group, respectively (p = 0.002). Ninety controls (84 %) and 53 autotransfused patients (76 %) survived to discharge (p = 0.21). Twenty controls (49 %) and 17 autotransfused patients (45 %) developed BSI (p = 0.72). Logistic regression analysis revealed that an ISS >25, systolic blood pressure <90, and EBL >2 L predicted mortality. There was also a trend towards decreased survival with age >50 years.

CONCLUSION

We found no evidence that emergent autotransfusion worsens clinical outcomes in the setting of concomitant HVI.

Efficacy and cost-effectiveness of cell saving blood autotransfusion in adult lumbar fusion

The objective of this study was to explore the use of cell saver blood autotransfusion in spinal surgery and to evaluate the efficacy and cost-effectiveness of cell saver blood autotransfusion during lumbar spine fusion in adults. Specific indications for the use of cell saver in adult lumbar fusion surgery have not yet been clearly determined. A total of 50 consecutive candidates for posterolateral fusion with internal fixation were prospectively randomized into either receiving perioperatively cell saving autotransfusion (Group A: 25 patients) or not (Group B: 25 patients). The use of cell saving technique did not exclude the use of allogenic blood transfusion. Surgical indications were spinal stenosis, spondylolisthesis, adolescent idiopathic scoliosis, degenerative scoliosis and fractures. Medical and financial data were recorded. A cost-analysis was performed. Patients in Group A received 880 +/- 216 mL from cell saver and 175 +/- 202 mL allogenic blood. The patients in Group B received 908 +/- 244 mL allogenic blood. Blood volumes data collected were expressed in mean +/- SD values. The cost of blood transfusion in Group A was 995 +/-euro447 per patient and 1220 +/- 269 in Group B (P < 0.05). In elective lumbar fusion blood requirements can be satisfied with the use of autotransfusion. The use of cell saver appears to be useful and cost-effective during most elective lumbar fusions.

Use of autologous transfusion in the management of acute traumatic haemothorax in the accident and emergency department

A case is described where life threatening haemothorax was treated in the accident and emergency department with the aid of autotransfusion. The technique is outlined and the advantages and potential complications of the procedure are discussed.

Penetrating thoracic trauma in a pediatric population

INTRODUCTION

Penetrating thoracic trauma in the pediatric population is increasing at an alarming rate. We sought to describe this population and to define prognostic factors that might be of benefit in the management of these patients.

METHODS

We retrospectively reviewed the charts and trauma registry records of 65 patients 18 years of age and younger admitted to an urban level I trauma center with the diagnosis of penetrating thoracic trauma.

RESULTS

The majority of the patients were adolescent boys. Injury severity score greater than 25 and a corrected admission pH less than 7.3 were associated with higher mortality and increased need for surgical intervention. Isolated thoracic injury was found to be associated with a high mortality rate. Autotransfused blood was used in 9 of the 65 patients.

CONCLUSIONS

Injury severity score and corrected admission pH are independent predictors of mortality and need for operation in the pediatric population with penetrating chest injuries. Penetrating thoracic wounds demand special attention by the trauma team. The use of autotransfusion may be beneficial in pediatric trauma victims.

Intraoperative blood salvage: medical controversies

Although a great deal has been learned about the medical aspects of intraoperative blood salvage, several fundamental medical issues remain controversial. As pressure increases to maximize the use of IBS, more research will be needed on the application of salvage techniques in cancer surgery and in the presence of bacterial contamination. The reintroduction of the use of devices that do not wash salvaged blood have reopened investigations into the effects of reinfusion of partially hemolyzed and partially clotted salvaged blood on coagulation, renal function, and cardiopulmonary performance. More studies are also needed so that empirically based standards of practice for the collection and storage of salvaged blood can be established. No longer confined to a few pioneering surgical departments, IBS is now widely practiced and likely to continue to grow rapidly. Knowledge and research of the medical issues surrounding its use will become increasingly valuable in transfusion medicine.

Blood component therapy

The emergency physician must have a solid understanding of the use of blood products. This article discusses how to order various blood products, problems with storage, when to administer them, what special equipment is necessary, and possible complications of their use. Special attention is paid to the many different components that are available for specific indications.