Transfusion-Associated Complications

Three-dimensional-printing-guided preoperative planning of upper and lower extremity pediatric orthopedic surgeries: A systematic review of surgical outcomes

Purpose

Three-dimensional printing has evolved into a cost-effective and accessible tool. In orthopedic surgery, creating patient-specific anatomical models and instrumentation improves visualization and surgical accuracy. In pediatric orthopedics, three-dimensional printing reduces operating time, radiation exposure, and blood loss by enhancing surgical efficacy. This review compares outcomes of three-dimensional printing-assisted surgeries with conventional surgeries for upper and lower extremity pediatric surgeries.

Methods

A complete search of medical literature up to August 2023, using Ovid Medline, EMBASE, Scopus, Web of Science, and Cochrane Library was conducted in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Broad search terms included "pediatrics," "orthopedic," and "3D-printing." Eligible studies were assessed for intraoperative time, blood loss, and fluoroscopy exposure.

Results

Out of 3299 initially identified articles, 14 articles met inclusion criteria. These studies included 409 pediatric patients, with ages averaging 9.51 years. The majority were retrospective studies (nine), with four prospective and one experimental study. Studies primarily utilized three-dimensional printing for navigation templates and implants. Results showed significant reductions in operative time, blood loss, and radiation exposure with three-dimensional printing. Complication occurrences were generally lower in three-dimensional printing surgeries, but there was no statistical significance.

Conclusions

Three-dimensional printing is an emerging technology in the field of orthopedics, and it is primarily used for preoperative planning. For pediatric upper and lower extremity surgeries, three-dimensional printing leads to decreased operating room time, decreased intraoperative blood loss, and reduced radiation exposure. Other uses for three-dimensional printing include education, patient communication, the creation of patient-specific instrumentation and implants.

Level of evidence

Level III.

Three-dimensional printing in orthopaedic surgery: a scoping review

Three-dimensional printing (3DP) has become more frequently used in surgical specialties in recent years. These uses include pre-operative planning, patient-specific instrumentation (PSI), and patient-specific implant production.The purpose of this review was to understand the current uses of 3DP in orthopaedic surgery, the geographical and temporal trends of its use, and its impact on peri-operative outcomesOne-hundred and eight studies (N = 2328) were included, published between 2012 and 2018, with over half based in China.The most commonly used material was titanium.Three-dimensional printing was most commonly reported in trauma (N = 41) and oncology (N = 22). Pre-operative planning was the most common use of 3DP (N = 63), followed by final implants (N = 32) and PSI (N = 22).Take-home message: Overall, 3DP is becoming more common in orthopaedic surgery, with wide range of uses, particularly in complex cases. 3DP may also confer some important peri-operative benefits. Cite this article: EFORT Open Rev 2020;5:430-441. DOI: 10.1302/2058-5241.5.190024.

Reevaluating the Importance of Modified Ultrafiltration in Contemporary Pediatric Cardiac Surgery

Objective(s): Modified ultrafiltration has gained wide acceptance as a powerful tool against cardiopulmonary bypass morbidity in pediatric cardiac surgery. The aim of our study was to assess the importance of modified ultrafiltration within conditions of contemporary cardiopulmonary bypass characteristics. Methods: Ninety–eight patients (overall cohort) weighing less than 12 kg undergoing surgical repair with cardiopulmonary bypass were prospectively enrolled in a randomized protocol to receive modified and conventional ultrafiltration (MUF group) or just conventional ultrafiltration (non-MUF group). A special attention was paid to forty-nine neonates and infants weighing less than 5 kg (lower weight (LW) cohort). Results: Post-filtration hematocrit was significantly higher in the MUF group for both cohorts (overall cohort p = 0.001; LW cohort p = 0.04), but not at other time points. During the postoperative course, patients in the MUF group received fewer packed red blood cells, (overall cohort p = 0.01; LW cohort p = 0.07), but required more fresh frozen plasma (overall cohort p = 0.04; LW cohort p = 0.05). There was no difference between groups in hemodynamic state, chest tube output, duration of mechanical ventilation, respiratory parameters, duration of intensive care unit, and hospitalization stay. Conclusions: If conventional ultrafiltration provides adequate hemoconcentration modified ultrafiltration does not provide additional positive benefits except for reduction in blood cell transfusion, This, however, comes at the cost of needing more fresh frozen plasma. Of particular importance is that this also applies to infants with weight bellow 5 kg where modified ultrafiltration was supposed to have the greatest positive impact.

Red blood cell transfusions worsen the outcomes even in critically ill patients undergoing a restrictive transfusion strategy

CONTEXT AND OBJECTIVE

Anemia and blood transfusions are common in intensive care. This study aimed to evaluate epidemiology and outcomes among critically ill patients under a restrictive transfusion strategy.

DESIGN AND SETTING

Prospective observational cohort study in an intensive care unit (ICU) at a tertiary hospital.

METHODS

All adults admitted to the ICU over a one-year period who remained there for more than 72 hours were included, except those with acute coronary syndrome, ischemic stroke, acute hemorrhage, prior transfusion, pregnant women and Jehovah's Witnesses. The restrictive strategy consisted of transfusion indicated when hemoglobin levels were less than or equal to 7.0 g/dl.

RESULTS

The study enrolled 167 patients; the acute physiology and chronic health evaluation II (APACHE II) score was 28.9 ± 6.5. The baseline hemoglobin level was 10.6 ± 2.2 g/dl and on day 28, it was 8.2 ± 1.3 g/dl (P < 0.001). Transfusions were administered to 35% of the patients. In the transfusion group, 61.1% did not survive, versus 48.6% in the non-transfusion group (P = 0.03). Transfusion was an independent risk factor for mortality (P = 0.011; odds ratio, OR = 2.67; 95% confidence interval, CI = 1.25 to 5.69). ICU stay and hospital stay were longer in the transfusion group: 20.0 (3.0-83.0) versus 8.0 (3.0-63.0) days (P < 0,001); and 24.0 (3.0-140.0) versus 14.0 (3.0-80.0) days (P = 0.002), respectively.

CONCLUSIONS

In critically ill patients, there was a reduction in hemoglobin with increasing length of ICU stay. Moreover, transfusion was associated with worse prognoses.

Anemia and transfusion therapy: an update

Anemia is one of the most prevalent diseases in the general population and is a very frequently found condition in medical and surgical patients in all medical specialties. A good evaluation of its clinical impact and its therapeutic possibilities is essential. Allogenic blood transfusion is a useful procedure in anemia management, although it has important adverse effects. It is the responsibility of the clinician to know and to take into account all the available alternatives for the treatment of anemia. Blood transfusions, erythropoiesis-stimulating agents, iron therapy (oral and endovenous) and other therapeutic alternatives must be rationally used, in accordance with the currently available clinical evidence. This review article summarizes some epidemiological characteristics of anemia, its clinical evaluation and the main therapeutic possibilities based on the present knowledge, placing special emphasis on the critically ill patient.

Acquired von Willebrand syndrome after continuous-flow mechanical device support contributes to a high prevalence of bleeding during long-term support and at the time of transplantation

OBJECTIVES

The objective of the study was to determine the prevalence of bleeding during continuous-flow left ventricular assist device support and to identify potential mechanisms for those bleeding events.

BACKGROUND

Bleeding is frequently reported with continuous-flow left ventricular assist devices and may result from anticoagulation coupled with bleeding diathesis such as acquired von Willebrand syndrome. Accordingly, the prevalence of coagulation abnormalities including laboratory assessment for von Willebrand syndrome, bleeding events during device support, and at heart transplantation were evaluated.

METHODS

A retrospective study in all HeartMate II (HM II) (Thoratec Corp., Pleasanton, California) patients who underwent implantation between April 1, 2004, and August 1, 2009, was performed. Bleeding was defined as the need for transfusion >7 days after device insertion of 1 U of packed red blood cells. Transfusion at heart transplantation was compared with that in HeartMate XVE patients.

RESULTS

Seventy-nine HM II devices were implanted. Anticoagulation included warfarin in 68.3%, aspirin in 55.7%, and dipyridamole in 58.2% of the patients. Of the patients, 44.3% had bleeding episodes at 112 ± 183 days after left ventricular assist device implantation, with 50% experiencing an event within 2 months. Gastrointestinal bleeding was the most frequent event. At the index event, the international normalized ratio averaged 1.67 ± 0.53, and the platelet count was 237 ± 119 × 10(9)/l. Comparison of the transfusion requirements at heart transplantation of 35 HM II patients with 62 HeartMate XVE patients demonstrated twice the transfusion requirements in HM II patients (packed red blood cells, 6.3 ± 0.8 U vs. 3.8 ± 0.5 U; platelets, 12.5 ± 5.4 U vs. 8.6 ± 6.4 U; fresh frozen plasma, 9.6 ± 4.9 U vs. 4.9 ± 3.6 U; and cryoprecipitate, 4.3 ± 3.6 U vs. 2.2 ± 3.5 U; p < 0.05 for all). High molecular weight von Willebrand factor multimers were measured in 31 HM II patients and were reduced in all patients; 18 of these 31 (58%) patients had bleeding.

CONCLUSIONS

Patients with the HM II had a high incidence of bleeding events during device support and at heart transplantation. All HM II patients had reduced high molecular weight von Willebrand factor multimers. The role of these abnormalities in the high incidence of bleeding deserves further investigation. Furthermore, alterations in anticoagulation should be considered during device support and before surgery in patients supported with the HM II.

[Anemia and transfusion therapy: an update]

Anemia is one of the most prevalent diseases in the general population and is a very frequently found condition in medical and surgical patients in all medical specialties. A good evaluation of its clinical impact and its therapeutic possibilities is essential. Allogenic blood transfusion is a useful procedure in anemia management, although it has important adverse effects. It is the responsibility of the clinician to know and to take into account all the available alternatives for the treatment of anemia. Blood transfusions, erythropoiesis-stimulating agents, iron therapy (oral and endovenous) and other therapeutic alternatives must be rationally used, in accordance with the currently available clinical evidence. This review article summarizes some epidemiological characteristics of anemia, its clinical evaluation and the main therapeutic possibilities based on the present knowledge, placing special emphasis on the critically ill patient.

Influence of tissue perfusion on the outcome of surgical patients who need blood transfusion

PURPOSE

The aim this study was to evaluate the clinical outcome of patients needing intra-operative blood transfusion by tissue perfusion markers.

METHODS

A prospective single center cohort study. Adult patients needing blood transfusion during the intra-operative period were recruited.

RESULTS

This study included 61 patients. At the time of blood transfusion the hemoglobin level was 8.4+/-1.8 g/dL. Scv02 has been the best tissue perfusion marker to determine mortality, compared with hematemetric values and other tissue perfusion markers, with a cut-off point at ROC curve equal to 80% (AUC=0.75; sensitivity=80%; specificity=65.2%). Patients who received blood transfusion and had Scv02 <or=80% (N=29), in comparison to those with Scv02>80% (N=32), had lower mortality rates (12.5% vs. 47.1%; p=0.008) and lower incidence of postoperative complications (58.9% vs. 72.9%; p=0.06). Blood transfusion with a Scv02 <or=80% was also associated with reduced use of vasopressors (5.9% vs. 36.8%; p=0.009). Lower incidence of hypoperfusion (17.6% vs. 52.6%; p=0.009), and lower incidence of infection (23.5% vs. 52.6%; p=0.038) in the postoperative period.

CONCLUSIONS

In major surgeries, Scv02 appears to be an important variable to be taken into consideration to decide for or against blood transfusion, since blood transfusion with adequate perfusion, reflected by Scv02>80%, are associated with worse clinical outcomes.

Risks and predictors of blood transfusion in pediatric patients undergoing open heart operations

BACKGROUND

Blood transfusion in adults is associated with increased mortality and morbidity after cardiac operations. The aim of this study was to identify the main predictors of blood transfusion and explore the relationship between blood transfusion and adverse outcomes in a pediatric population.

METHODS

We retrospectively analyzed a prospectively collected database (January 2002 to December 2003) of 657 consecutive pediatric patients undergoing open heart procedures in a tertiary pediatric cardiac center. Risk models were calculated for each blood product and for the total amount of blood transfused during the operation and in the first 24 hours. Postoperative adverse events were investigated after propensity score adjustment.

RESULTS

During the postoperative period, 30 patients (4.6%) died, 80 (12.2%) sustained nonvascular pulmonary complications, and 113 (17.2%) had infection. The risk model for the total amount of blood transfusion included weight, preoperative creatinine clearance, preoperative mechanical ventilation, duration of operation and cross-clamp, surgeon, delayed chest closure, inotropic dose, and nitric oxide administration. Univariate analyses demonstrated significant associations between blood transfusion and occurrence of every complication except of neurologic events. After adjustment for propensity score and disease severity, the total amount of blood transfusion was independently associated with an increased risk for infections (odds ratio, 1.01; 95% confidence interval, 1.002 to 1.02; p = 0.01). Transfusion of platelets was associated with lower incidence of nonvascular pulmonary complications (odds ratio, 0.89; 95% confidence interval, 0.79 to 0.99; p = 0.049).

CONCLUSIONS

The amount of blood transfusion is independently associated with infections but not with mortality.

Umbilical cord blood transfusions for prevention of progressive brain injury and induction of neural recovery: an immunological perspective

One of the most promising treatments for neurodegenerative diseases appears to be human umbilical cord blood cell transplantation. A variety of studies demonstrate some benefit of this method of treatment in a number of different animal models and case studies. However, before the methodologies and results of these animal studies and case studies can be translated into successful widespread treatments, aspects relating to the immunological properties of the transplanted cells must be considered. In this perspective, we discuss the benefit of the cellular immaturity of these cells with respect to the immune response, and compare cord blood transplantation to blood transfusions, as well as discussing what future studies should entail.