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Azami T, Gerritse BM, Daane R, Scohy TV. Platelet-Rich Plasma Sequestration in Cardiac Surgery in a Jehovah's Witness. J Cardiothorac Vasc Anesth 2024; 38:1730-1733. [PMID: 38876809 DOI: 10.1053/j.jvca.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 04/11/2024] [Accepted: 04/17/2024] [Indexed: 06/16/2024]
Affiliation(s)
- Tabesh Azami
- Department of Cardiothoracic Surgery, Amphia Hospital, Breda, The Netherlands
| | - Bastiaan M Gerritse
- Department of Anaesthesiology and Intensive Care, Amphia Hospital, Breda, The Netherlands.
| | - Rene Daane
- Department of Extracorporeal Circulation, Amphia Hospital, Breda, The Netherlands
| | - Thierry V Scohy
- Department of Anaesthesiology and Intensive Care, Amphia Hospital, Breda, The Netherlands
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Kahn RM, Boerner T, Kim M, Lam C, Gordhandas S, Yeoshoua E, Zhou QC, Iasonos A, Al-Niaimi A, Gardner GJ, Long Roche K, Sonoda Y, Zivanovic O, Grisham RN, Abu-Rustum NR, Chi DS. A pre-operative scoring model to estimate the risk of blood transfusion over an ovarian cancer debulking surgery (BLOODS score): a Memorial Sloan Kettering Cancer Center Team Ovary study. Int J Gynecol Cancer 2024; 34:1051-1059. [PMID: 38950927 PMCID: PMC11237961 DOI: 10.1136/ijgc-2024-005660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
OBJECTIVES To develop a pre-operative tool to estimate the risk of peri-operative packed red blood cell transfusion in primary debulking surgery. METHODS We retrospectively reviewed an institutional database to identify patients who underwent primary debulking surgery for ovarian cancer at a single center between January 1, 2001 and May 31, 2019. Receiver operating characteristic curve and area under the receiver operating characteristic curve (AUC) were calculated. Five-fold cross-validation was applied to the multivariate model. Significant variables were assigned a 'BLOODS' (BLood transfusion Over an Ovarian cancer Debulking Surgery) score of +1 if present. A total BLOODS score was calculated for each patient, and the odds of receiving a transfusion was determined for each score. RESULTS Overall, 1566 patients met eligibility criteria; 800 (51%) underwent a peri-operative blood transfusion. Odds ratios (OR) were statistically significant for American Society of Anesthesiologists scores of 3 and 4 (OR 1.34, 95% confidence interval (95% CI) 1.09 to 1.63), pre-operative levels of cancer antigen 125 (CA125) (OR 2.43, 95% CI 1.98 to 2.99), platelets (OR 1.59, 95% CI 1.45 to 1.74), obesity (OR 0.76, 95% CI 0.60 to 0.96), presence of carcinomatosis (OR 2.45, 95% CI 1.93 to 3.11), bulky upper abdominal disease (OR 2.86, 95% CI 2.32 to 3.54), pre-operative serum albumin level (OR 0.31, 95% CI 0.24 to 0.40), and pre-operative hemoglobin level (OR 0.56, 95% CI 0.51 to 0.61). The corrected AUC was 0.748 (95% CI 0.693 to 0.804). BLOODS scores of 0 and 5 corresponded to 11% and 73% odds, respectively, of receiving a peri-operative blood transfusion. CONCLUSIONS We developed a universal pre-operative scoring system, the BLOODS score, to help identify patients with ovarian cancer who would benefit from surgical planning and blood-saving techniques. The BLOODS score was directly proportional to the American Society of Anesthesiologists score, presence of upper abdominal disease, carcinomatosis, CA125 level, and platelets level. We believe this model can help physicians with surgical planning and can benefit patient outcomes.
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Affiliation(s)
- Ryan M Kahn
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Thomas Boerner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michael Kim
- Department of Obstetrics and Gynecology, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA
| | - Clarissa Lam
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sushmita Gordhandas
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Effi Yeoshoua
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Qin C Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ahmed Al-Niaimi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Ginger J Gardner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Rachel N Grisham
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
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Monaco F, Guarracino F, Vendramin I, Lei C, Zhang H, Lomivorotov V, Osinsky R, Efremov S, Gürcü ME, Mazzeffi M, Pasyuga V, Kotani Y, Biondi-Zoccai G, D'Ascenzo F, Romagnoli E, Nigro Neto C, Do Nascimento VTNDS, Ti LK, Lorsomradee S, Farag A, Bukamal N, Brizzi G, Lobreglio R, Belletti A, Arangino C, Paternoster G, Bonizzoni MA, Tucciariello MT, Kroeller D, Di Prima AL, Mantovani LF, Ajello V, Gerli C, Porta S, Ferrod F, Giardina G, Santonocito C, Ranucci M, Lembo R, Pisano A, Morselli F, Nakhnoukh C, Oriani A, Pieri M, Scandroglio AM, Kırali K, Likhvantsev V, Longhini F, Yavorovskiy A, Bellomo R, Landoni G, Zangrillo A. Acute normovolemic hemodilution in cardiac surgery: rationale and design of a multicenter randomized trial. Contemp Clin Trials 2024; 143:107605. [PMID: 38866095 DOI: 10.1016/j.cct.2024.107605] [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: 01/31/2024] [Revised: 05/12/2024] [Accepted: 06/09/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Minimizing the use of blood component can reduce known and unknown blood transfusion risks, preserve blood bank resources, and decrease healthcare costs. Red Blood Cell (RBC) transfusion is common after cardiac surgery and associated with adverse perioperative outcomes, including mortality. Acute normovolemic hemodilution (ANH) may reduce bleeding and the need for blood product transfusion after cardiac surgery. However, its blood-saving effect and impact on major outcomes remain uncertain. METHODS This is a single-blinded, multinational, pragmatic, randomized controlled trial with a 1:1 allocation ratio conducted in Tertiary and University hospitals. The study is designed to enroll patients scheduled for elective cardiac surgery with planned cardiopulmonary bypass (CPB). Patients are randomized to receive ANH before CPB or the best available treatment without ANH. We identified an ANH volume of at least 650 ml as the critical threshold for clinically relevant benefits. Larger ANH volumes, however, are allowed and tailored to the patient's characteristics and clinical conditions. RESULTS The primary outcome is the percentage of patients receiving RBCs transfusion from randomization until hospital discharge, which we hypothesize will be reduced from 35% to 28% with ANH. Secondary outcomes are all-cause 30-day mortality, acute kidney injury, bleeding complications, and ischemic complications. CONCLUSION The trial is designed to determine whether ANH can safely reduce RBC transfusion after elective cardiac surgery with CPB. STUDY REGISTRATION This trial was registered on ClinicalTrials.gov in April 2019 with the trial identification number NCT03913481.
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Affiliation(s)
- Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Guarracino
- Department of Cardiothoracic Anesthesia and ICU, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Igor Vendramin
- Division of Cardiac Surgery, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy; Department of Medicine, University of Udine, Udine, Italy
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xi'an, China
| | - Hui Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xi'an, China
| | - Vladimir Lomivorotov
- E. Meshalkin National Medical Research Center, Department of Anesthesiology and Intensive Care, Novosibirsk, Russia; Penn State Milton S. Hershey Medical Center, Department of Anesthesiology and Perioperative Medicine, Hershey, PA, USA
| | - Roman Osinsky
- E. Meshalkin National Medical Research Center, Department of Anesthesiology and Intensive Care, Novosibirsk, Russia
| | - Sergey Efremov
- Saint Petersburg State University Hospital, Saint-Petersburg, Russian Federation
| | - Mustafa Emre Gürcü
- Koşuyolu High Specialization Education and Research Hospital, Istanbul, Turkey
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Vadim Pasyuga
- Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan, Russian Federation
| | - Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | | | - Fabrizio D'Ascenzo
- Cardiovascular and Thoracic Department, A.O.U. Città della Salute e della Scienza, Turin, Italy; Department of Medical Sciences, University of Turin, Turin, Italy
| | - Enrico Romagnoli
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Via Pineta Sacchetti, 217, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Campus di Roma, Largo Francesco Vito, 1, 00168, Rome, Italy
| | | | | | | | | | - Ahmed Farag
- King Abdullah Medical City - Holy Capital (KAMC-HC), Makkah, Saudi Arabia
| | - Nazar Bukamal
- Cardiothoracic ICU and Anesthesia Department, Mohammed Bin Khalifa Specialist Cardiac Center, Awali 183261, Bahrain
| | - Giulia Brizzi
- Department of Cardiothoracic Anesthesia and ICU, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Rosetta Lobreglio
- Department of Anesthesia, Intensive Care and Emergency, Citta della Salute e della Scienza University Hospital, Turin, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Arangino
- Department of Cardiothoracic Anesthesia and Intensive Care, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | - Gianluca Paternoster
- Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital, Potenza, Italy
| | - Matteo Aldo Bonizzoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Daniel Kroeller
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Ambra Licia Di Prima
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Valentina Ajello
- Department of Cardio Thoracic anesthesia and Intensive Care, Hospital Tor Vergata Roma, Italy
| | - Chiara Gerli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sabrina Porta
- Department of Cardiovascular Anestesia, Azienda Ospedaliera Umberto I Mauriziano, Turin, Italy
| | - Federica Ferrod
- Department of Cardiovascular Anestesia, Azienda Ospedaliera Umberto I Mauriziano, Turin, Italy
| | - Giuseppe Giardina
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Santonocito
- Anaesthesia and Intensive Care Medicine III, Policlinico University Hospital, Catania, Italy
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Italy
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Pisano
- Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera Dei Colli, Monaldi Hospital, Naples, Italy
| | - Federica Morselli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Nakhnoukh
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Kaan Kırali
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Valery Likhvantsev
- Department of Clinical Trials, V. Negovsky Reanimatology Research Institute, Moscow, Russian Federation; Department of Anesthesiology and Resuscitation, First Moscow State Medical University, Moscow, Russian Federation
| | - Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, Italy
| | - Andrey Yavorovskiy
- I.M. Sechenov First Moscow State Medical University, Ministry of Public Health of Russia, Moscow, Russia
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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Davids R, Robinson G, Van Tonder C, Robinson J, Ahmed N, Domingo A. Jehovah's Witness Needing Critical Care: A Narrative Review on the Expanding Arsenal. Crit Care Res Pract 2024; 2024:1913237. [PMID: 38813134 PMCID: PMC11136542 DOI: 10.1155/2024/1913237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 03/08/2024] [Accepted: 04/13/2024] [Indexed: 05/31/2024] Open
Abstract
Present day Jehovah's Witness (JW) religion accounts for 8.5 million followers. A tenant feature of the JW faith is religious objection to transfusions of blood and blood products. Interpatient variability, as it pertains to blood and blood products may occur; hence, a confidential interview will determine which products individual may consent to (Marsh and Bevan, 2002). This belief and practice place great restrictions on treating medical professionals in scenarios of life-threatening anaemia and active haemorrhage. The review to follow explores the physiological and pathophysiological consequences of severe anaemia. Non-blood transfusion practices are explored, many of which are potentially lifesaving. Particular attention is drawn to the evolving science involving artificial oxygen carriers and their use in emergency situations. A greater safety profile ensures its future use amongst religious objectors to be greatly beneficial. Intravenous iron supplementation has enjoyed a lively debate within the critical care community. A review of recent systematic and meta-analysis supports its use in the ICU; however, more investigation is needed into the complementary use of hepcidin.
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Affiliation(s)
- Ryan Davids
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Gareth Robinson
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Charmé Van Tonder
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Jordan Robinson
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Nadiyah Ahmed
- Department of Critical Care, University of Free State, Bloemfontein, South Africa
| | - Abdurragmaan Domingo
- Department of Anaesthesiology and Perioperative Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
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Wakiya T, Ishido K, Kimura N, Nagase H, Kanda T, Kubota S, Fujita H, Takahashi Y, Yamamoto T, Chida K, Saito J, Hirota K, Hakamada K. Postoperative long‑term outcomes of acute normovolemic hemodilution in pancreatic cancer: A propensity score matching analysis. Oncol Lett 2024; 27:236. [PMID: 38601182 PMCID: PMC11005082 DOI: 10.3892/ol.2024.14369] [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: 10/30/2023] [Accepted: 01/31/2024] [Indexed: 04/12/2024] Open
Abstract
Acute normovolemic hemodilution (ANH) is a useful intraoperative blood conservation technique. However, the impact on long-term outcomes in pancreatic ductal adenocarcinoma (PDAC) remains unclear. The present study investigated the impact of ANH on long-term outcomes in patients with PDAC undergoing radical surgery. Data from 155 resectable PDAC cases were collected. Patients were categorized according to whether or not they had received intraoperative allogeneic blood transfusion (ABT) or ANH. Postoperative complications, recurrence-free survival (RFS) and disease-specific survival (DSS), before and after propensity score matching (PSM), were compared among patients who did and did not receive ANH. A total of 44 patients (28.4%) were included in the ANH group and 30 patients (19.4%) were included in the ABT group; 81 (52.3%) patients, comprising the standard management (STD) group, received neither ANH nor ABT. The ABT group had the worst prognosis among them. Before PSM, ANH was significantly associated with decreased RFS (P=0.043) and DSS (P=0.029) compared with the STD group before applying Bonferroni correction; however, no significant difference was observed after applying Bonferroni correction. Cox regression analysis identified ANH as an independent prognostic factor for RFS [relative risk (RR), 1.696; P=0.019] and DSS (RR, 1.876; P=0.009). After PSM, the ANH group exhibited less favorable RFS [median survival time (MST), 12.1 vs. 18.1 months; P=0.097] and DSS (MST, 32.1 vs. 50.5 months; P=0.097) compared with the STD group; however, these differences were not statistically significant. In conclusion, while ANH was not as harmful as ABT, it exhibited potentially more negative effects on long-term postoperative outcomes in PDAC than STD.
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Affiliation(s)
- Taiichi Wakiya
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Keinosuke Ishido
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Norihisa Kimura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Hayato Nagase
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Taishu Kanda
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Shunsuke Kubota
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Hiroaki Fujita
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Yoshiya Takahashi
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Takeshi Yamamoto
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Kohei Chida
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Junichi Saito
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Kazuyoshi Hirota
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8216, Japan
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Perini FV, Montano-Pedroso JC, Oliveira LC, Donizetti E, Rodrigues RDR, Rizzo SRCP, Rabello G, Junior DML. Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Acute normovolemic hemodilution and intraoperative autotransfusion. Hematol Transfus Cell Ther 2024; 46 Suppl 1:S48-S52. [PMID: 38580495 PMCID: PMC11069068 DOI: 10.1016/j.htct.2024.02.019] [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: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 04/07/2024] Open
Abstract
Autologous blood transfusion can be achieved through different techniques, including by the patient donating blood before surgery (pre-deposit), collecting blood from the patient immediately before the operation and replacing the volume with colloids or plasma expanders (acute normovolemic hemodilution) or through the salvage of lost blood, during or immediately after surgery, and its retransfusion after washing (intraoperative or postoperative recovery). We will focus on the two methods used intraoperatively that are of fundamental importance in the management and conservation of the patient's own blood.
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Affiliation(s)
- Fernanda Vieira Perini
- Grupo GSH - Gestor de Serviços de Hemoterapia, São Paulo, SP, Brazil; Associação Beneficente Síria HCOR, São Paulo, SP, Brazil
| | - Juan Carlos Montano-Pedroso
- Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil; Instituto de Assistência Médica do Servidor Público Estadual (Iamspe), São Paulo, SP, Brazil
| | - Luciana Correa Oliveira
- Hemocentro de Ribeirão Preto, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil
| | | | - Roseny Dos Reis Rodrigues
- Hospital Israelita Albert Einstein são Paulo, São Paulo, SP, Brazil; Faculdade de Medicina da Universidade de São Paulo (FM USP), São Paulo, SP, Brazil
| | | | - Guilherme Rabello
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Incor - HCFMUSP), São Paulo, SP, Brazil.
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Yoshinaga K, Iizuka Y, Sanui M, Faraday N. Low-Volume Acute Normovolemic Hemodilution Does Not Reduce Allogeneic Red Blood Cell Transfusion in Cardiac Surgery in the Modern Era of Patient Blood Management: A Propensity Score-Matched Cohort Study. J Cardiothorac Vasc Anesth 2024; 38:394-402. [PMID: 38052691 DOI: 10.1053/j.jvca.2023.11.003] [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: 06/30/2023] [Revised: 10/24/2023] [Accepted: 11/01/2023] [Indexed: 12/07/2023]
Abstract
OBJECTIVES Patients undergoing cardiac surgery often require blood transfusions, which are associated with increased morbidity and mortality. Patient blood management (PBM) strategies, including acute normovolemic hemodilution (ANH), have been implemented to minimize allogeneic transfusion requirements. Older studies suggested that ANH is associated with reduced transfusions; however, its effectiveness in the modern era of PBM remains unclear. DESIGN This was a retrospective cohort study. SETTING The study was held at a single university hospital. PARTICIPANTS 542 patients who underwent elective cardiac surgery with cardiopulmonary bypass (CPB) using low-priming-volume circuits between January 2017 and March 2022. INTERVENTIONS Patients who received ANH were matched with those who did not receive ANH, using propensity scores. MEASUREMENTS AND MAIN RESULTS The primary outcome was the proportion of patients who received perioperative red blood cell (RBC) transfusion. Of the 542 eligible patients, 49 ANH cases were propensity-score matched to 97 controls. The median ANH volume was 450 mL (IQR, 400-800 mL). There was no significant difference in perioperative RBC transfusion rates between the 2 groups (24.5% in the ANH group vs 30.9% in the control group, p = 0.42). The odds ratio for perioperative RBC transfusion in the ANH group versus the control group was 0.72 (95% CI, 0.32-1.55, p = 0.42). CONCLUSIONS Low-volume ANH was not associated with a significant reduction in perioperative allogeneic RBC transfusion during cardiac surgery with CPB using low-priming-volume circuits. The benefits of low-volume ANH in reducing the requirement for RBC transfusion in the modern era of PBM may be smaller than reported previously.
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Affiliation(s)
- Koichi Yoshinaga
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan.
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Nauder Faraday
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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8
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Takahashi Y, Yoshii R, Amaya F, Sawa T, Ogawa S. Effect of acute normovolemic hemodilution in patients undergoing cardiac surgery with remimazolam anesthesia. J Anesth 2024; 38:98-104. [PMID: 38150014 DOI: 10.1007/s00540-023-03290-5] [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: 08/23/2023] [Accepted: 11/24/2023] [Indexed: 12/28/2023]
Abstract
PURPOSE The reduced effects of allogeneic transfusion with acute normovolemic hemodilution (ANH) have been reported. Harvesting a large volume of blood may maximize the effect in patients with low body weight, and the prevention of hypotension is important. Remimazolam is an anesthetic with few circulatory responses. Our aim was to evaluate whether high-volume ANH reduces the need for transfusion in cardiac patients under remimazolam anesthesia. METHODS In this retrospective single-center study, we enrolled cardiopulmonary bypass (CPB) patients who received remimazolam anesthesia. Changes in hemodynamic parameters were assessed. The numbers of blood transfusions and chest tube outputs were also evaluated. RESULTS In a total of 51 patients, ANH was performed in 27 patients with a mean body mass index of 23.2 (ANH volume: 740 ± 222 mL). No significant differences were observed in mean blood pressure during blood collection. The intraoperative amount of red blood cell (RBC) transfusion was significantly lower in the ANH group than in the control group (431 ± 678 and 1260 ± 572 mL, p < 0.001). The avoidance rates of RBC were 66.7 and 4.2%, respectively. The multivariate analysis result revealed that ANH correlated with RBC, with an odds ratio of 0.067 (95% confidence interval 0.005-0.84, p < 0.05). The postoperative bleeding at 24 h was significantly lower in the ANH group (455 ± 228 and 797 ± 535 mL, p < 0.01). CONCLUSION In patients undergoing CPB, ANH reduced intraoperative transfusion amount and postoperative bleeding. Hemodynamic changes during blood collection were minimal under remimazolam anesthesia and high-volume ANH was feasible.
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Affiliation(s)
- Yuya Takahashi
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ryogo Yoshii
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fumimasa Amaya
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo, Kyoto, 602-8566, Japan
| | - Teiji Sawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoru Ogawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan.
- Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo, Kyoto, 602-8566, Japan.
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9
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Rapaport B, Burnside G, Parks C, Duncan C, Richardson D, Ellenbogen J, Sinha A, Craig R, Diwan R, Hennedige A. Part II: Blood Transfusion and Donor Exposure in the Surgical Management of Trigonocephaly Patients: A Protocol From Alder Hey Craniofacial Unit. J Craniofac Surg 2024; 35:114-118. [PMID: 38063395 DOI: 10.1097/scs.0000000000009878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 09/02/2023] [Indexed: 02/01/2024] Open
Abstract
Trigonocephaly is a craniofacial malformation caused by premature fusion of the metopic suture. Surgical correction frequently results in the need for blood transfusion. Transfusion complications include transfusion-transmitted infections (TTIs), immune-mediated reactions, and volume overload. Donor exposure (DE) describes the number of blood products from unique donors with increasing DE equating to an increased risk of TTI. We evaluate data on 204 trigonocephaly patients covering 20 years of practice with respect to blood transfusions and DE. This represents the largest series from a single unit to date. A protocol based on our experiences has been devised that summarizes the key interventions we recommend to minimize blood transfusions and DE in craniofacial surgery. Patients operated on between 2000 and 2020 were included. DE and a range of values were calculated including estimated red cell loss (ERCL) and estimated red cell volume transfused (ERCVT). Groups were established by relevant interventions and compared using the Mann-Whitney U test. Mean DE fell from 1.46 at baseline to 0.85 ( P <0.05). Median allogenic transfusion volume fell from 350 mL at baseline to 250 mL ( P <0.05). Median ERCL fell from 15.05 mL/kg at baseline to 12.39 mL/kg and median ERCVT fell from 20.85 to 15.98 mL/kg. Changes in ERCL and ERCVT did not reach statistical significance. DE can be minimized with the introduction of key interventions such as a restrictive transfusion policy, preoperative iron, cell saver, tranexamic acid, and use of a matchstick burr for osteotomies.
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Affiliation(s)
| | - Girvan Burnside
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Chris Parks
- Craniofacial Centre, Alder Hey Children's Hospital
| | | | | | | | - Ajay Sinha
- Craniofacial Centre, Alder Hey Children's Hospital
| | | | - Rishi Diwan
- Craniofacial Centre, Alder Hey Children's Hospital
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10
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Jenkins DP, Martinez G, Salaunkey K, Reddy SA, Pepke-Zaba J. Perioperative Management in Pulmonary Endarterectomy. Semin Respir Crit Care Med 2023; 44:851-865. [PMID: 37487525 DOI: 10.1055/s-0043-1770123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH), provided lesions are proximal enough in the pulmonary vasculature to be surgically accessible and the patient is well enough to benefit from the operation in the longer term. It is a major cardiothoracic operation, requiring specialized techniques and instruments developed over several decades to access and dissect out the intra-arterial fibrotic material. While in-hospital operative mortality is low (<5%), particularly in high-volume centers, careful perioperative management in the operating theater and intensive care is mandatory to balance ventricular performance, fluid balance, ventilation, and coagulation to avoid or treat complications. Reperfusion pulmonary edema, airway hemorrhage, and right ventricular failure are the most problematic complications, often requiring the use of extracorporeal membrane oxygenation to bridge to recovery. Successful PEA has been shown to improve both morbidity and mortality in large registries, with survival >70% at 10 years. For patients not suitable for PEA or with residual PH after PEA, balloon pulmonary angioplasty and/or PH medical therapy may prove beneficial. Here, we describe the indications for PEA, specific surgical and perioperative strategies, postoperative monitoring and management, and approaches for managing residual PH in the long term.
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Affiliation(s)
- David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Guillermo Martinez
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Kiran Salaunkey
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - S Ashwin Reddy
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
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11
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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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12
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Zhu D, Li Y, Tian AY, Wang HN. Comparing acute normovolumic hemodilution with autologous platelet-rich plasma for blood preservation during aortic surgery : study protocol for a randomized controlled clinical trial. Trials 2023; 24:741. [PMID: 37980486 PMCID: PMC10657030 DOI: 10.1186/s13063-023-07800-4] [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: 12/09/2022] [Accepted: 11/10/2023] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND Both acute normovolumic hemodilution (ANH) and autologous platelet-rich plasma (aPRP) have been demonstrated blood-protective effects in cardiac aortic surgery; however, the efficacies of the two methods have not been compared. This study aims to compare the effects of aPRP and ANH prior to aortic surgery on postoperative bleed and other outcomes. METHODS AND ANALYSIS This is a prospective, single-center, double-blind controlled clinical trial including 160 patients randomized 1:1 to receive aPRP (test group) or autologous whole blood (ANH, control group). The primary objective is to compare the drainage volumes in the two groups at 24, 48, and 72 h postoperatively. Secondary outcomes include input of allogeneic blood and blood products and durations of aortic block, extracorporeal circulation, deep hypothermic arrest of circulation, tracheal extubation, hospital stay, requirement for secondary surgical hemostasis, and application of intra-aortic balloon pump or extracorporeal membrane oxygenation in the two groups. In addition, heart rate, systolic blood pressure, diastolic blood pressure, central venous pressure, and thromboelastography recorded before blood reservation (T1), after blood reservation (T2), before blood transfusion (T3), and after the blood is returned (T4) to the transfusion will be compared between the two groups of patients. DISCUSSION This study will demonstrate if the use of aPRP could reduce the risk of bleeding after aortic surgery compared with ANH. The results are expected to have practical clinical applications in terms of more effective blood protection and shorter hospital stay. TRIAL REGISTRATION This study was registered with the Chinese Clinical Trial Registry ( http://www.chictr.org.cn/ ) with the ID ChiCTR 1900023351.Registered on May 23, 2019. TRIAL STATUS Recruiting start date: July 1, 2019; expected recruiting end date: July 1, 2024 Version number and date: Version 2 of 05-04-2019.
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Affiliation(s)
- Dan Zhu
- Department of Anesthesiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang City, Liaoning Province, China
| | - Yu Li
- Department of Anesthesiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang City, Liaoning Province, China
| | - A-Yong Tian
- Department of Anesthesiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang City, Liaoning Province, China
| | - Hong-Nan Wang
- Department of Anesthesiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang City, Liaoning Province, China.
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Putaggio A, Tigano S, Caruso A, La Via L, Sanfilippo F. Red Blood Cell Transfusion Guided by Hemoglobin Only or Integrating Perfusion Markers in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis With Trial Sequential Analysis. J Cardiothorac Vasc Anesth 2023; 37:2252-2260. [PMID: 37652848 DOI: 10.1053/j.jvca.2023.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/30/2023] [Accepted: 08/02/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE Strategies for red blood cell (RBC) transfusion in patients undergoing cardiac surgery have been traditionally anchored to hemoglobin (Hb) targets. A more physiologic approach would consider markers of organ hypoperfusion. DESIGN The authors conducted a systematic review and meta-analysis with trial sequential analysis of randomized controlled trials (RCTs). SETTING Cardiac surgery. PARTICIPANTS Adult patients. INTERVENTION RBC transfusion targeting only Hb levels compared with strategies combining Hb values with markers of organ hypoperfusion. MEASUREMENTS AND MAIN RESULTS Primary outcomes were the number of RBC units transfused, the number of patients transfused at least once, and the average number of transfusions. Secondary outcomes were postoperative complications, intensive care (ICU) and hospital lengths of stay, and mortality. Only 2 RCTs were included (n = 257 patients), and both used central venous oxygen saturation (ScvO2) as a marker of organ hypoperfusion (cut-off: <70% or ≤65%). A transfusion protocol combining Hb and ScvO2 reduced the overall number of RBC units transfused (risk ratio [RR]: 1.57 [1.33-1.85]; p < 0.0001, I2 = 0%), and the number of patients transfused at least once (RR: 1.33 [1.16-1.53]; p < 0.0001, I2 = 41%), but not the average number of transfusions (mean difference [MD]: 0.18 [-0.11 to 0.47]; p = 0.24, I2 = 66%), with moderate certainty of evidence. Mortality (RR: 1.29, [0.29-5.77]; p = 0.73, I2 = 0%), ICU length-of-stay (MD: -0.06 [-0.58 to 0.46]; p = 0.81, I2 = 0%), hospital length-of-stay (MD: -0.05 [-1.49 to 1.39];p = 0.95, I2 = 0%), and all postoperative complications were not affected. CONCLUSIONS In adult patients undergoing cardiac surgery, a restrictive protocol integrating Hb values with a marker of organ hypoperfusion (ScvO2) reduces the number of RBC units transfused and the number of patients transfused at least once without apparent signals of harm. These findings were preliminary and warrant further multicentric research.
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Affiliation(s)
- Antonio Putaggio
- School of Anesthesia and Intensive Care, University Magna Graecia, Catanzaro, Italy
| | - Stefano Tigano
- School of Anesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Alessandro Caruso
- School of Anesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Luigi La Via
- University Hospital Policlinico, G. Rodolico - San Marco, Catania, Italy
| | - Filippo Sanfilippo
- University Hospital Policlinico, G. Rodolico - San Marco, Catania, Italy; Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy.
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14
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Liu T, Bai Y, Yin L, Wang JH, Yao N, You LW, Guo JR. Effect of acute normovolemic hemodilution on anesthetic effect, plasma concentration, and recovery quality in elderly patients undergoing spinal surgery. BMC Geriatr 2023; 23:689. [PMID: 37875833 PMCID: PMC10598930 DOI: 10.1186/s12877-023-04397-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/09/2023] [Indexed: 10/26/2023] Open
Abstract
OBJECTIVE To explore the effect of acute normovolemic hemodilution (ANH) on the anesthetic effect, plasma concentration, and postoperative recovery quality in elderly patients undergoing spinal surgery. METHODS A total of 60 cases of elderly patients aged 65 to 75 years who underwent elective multilevel spinal surgery were assigned randomly into the ANH group (n = 30) and control group (n = 30). Hemodynamic and blood gas analysis indexes were observed and recorded before ANH (T1), after ANH (T2), immediately after postoperative autologous blood transfusion (T3), 10 min (T4), 20 min (T5), 30 min (T6), 40 min (T7), and 50 min (T8) after the transfusion, and at the end of the transfusion (i.e., 60 min; T9). At T3 ~ 9, bispectral index (BIS) and train-of-four (TOF) stimulation were recorded and the plasma propofol/cisatracurium concentration was determined. The extubation time and recovery quality were recorded. RESULTS The ANH group presented a lower MAP value and a higher SVV value at T2, and shorter extubation and orientation recovery time (P < 0.05) compared with the control group. BIS values at T8 and T9 were lower in the ANH group than those in the control group (P < 0.05). TOF values at T7 ~ 9 were lower in the ANH group than those in the control group (P < 0.05). There were no statistically significant differences in the postoperative plasma concentrations of propofol and cisatracurium between the groups (P > 0.05). CONCLUSION During orthopedic surgery, the plasma concentration of elderly patients is increased after autologous blood transfusion of ANH, and the depth of anesthesia and muscle relaxant effect are strengthened, thus leading to delayed recovery of respiratory function and extubation.
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Affiliation(s)
- Tong Liu
- Department of Anesthesiology and Perioperative Medicine, Shanghai Gongli Hospital, Naval Military Medical University, No.219 Miaopu Road, Pudong New Area, Shanghai, 200135, China
| | - Yu Bai
- Department of Anesthesiology and Perioperative Medicine, Shanghai Gongli Hospital, Naval Military Medical University, No.219 Miaopu Road, Pudong New Area, Shanghai, 200135, China
| | - Lei Yin
- Department of Anesthesiology and Perioperative Medicine, Shanghai Gongli Hospital, Naval Military Medical University, No.219 Miaopu Road, Pudong New Area, Shanghai, 200135, China
| | - Jin-Huo Wang
- Department of Anesthesiology and Perioperative Medicine, Shanghai Gongli Hospital, Naval Military Medical University, No.219 Miaopu Road, Pudong New Area, Shanghai, 200135, China
| | - Na Yao
- Department of Anesthesiology and Perioperative Medicine, Shanghai Gongli Hospital, Naval Military Medical University, No.219 Miaopu Road, Pudong New Area, Shanghai, 200135, China
| | - Lai-Wei You
- Department of Anesthesiology and Perioperative Medicine, Shanghai Gongli Hospital, Naval Military Medical University, No.219 Miaopu Road, Pudong New Area, Shanghai, 200135, China
| | - Jian-Rong Guo
- Department of Anesthesiology and Perioperative Medicine, Shanghai Gongli Hospital, Naval Military Medical University, No.219 Miaopu Road, Pudong New Area, Shanghai, 200135, China.
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15
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Lindgren T, Kodakandla H, Caraway SM, Shah KB, Huang X, Ibekwe SO. Red Blood Cell Conservation and Use in the Cardiovascular Operating Rooms at Ben Taub General Hospital. J Cardiothorac Vasc Anesth 2023; 37:1946-1950. [PMID: 37455220 DOI: 10.1053/j.jvca.2023.06.026] [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: 03/13/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES A conservative hemoglobin transfusion threshold is noninferior to a liberal threshold in cardiac surgery. However, red blood cell (RBC) transfusion remains common during cardiac surgery. The authors' single-center, retrospective study aimed to decrease RBC transfusions for hemoglobin >7.5 g/dL in nonemergent cardiovascular surgeries utilizing cardiopulmonary bypass (CPB), by educating the anesthesiology and surgical staff on the benefits of a conservative threshold for transfusions, and incorporating the discussion and routine use of blood conservation methods for all nonemergent cardiac surgeries. DESIGN This was a single-center, retrospective study that included all nonemergent coronary artery bypass grafting and single-valve cases utilizing CPB from January 2018 to December 2021 before and after the intervention in July 2019. SETTING The data involved a single community hospital. PARTICIPANTS A total of 417 patients were included in the study. INTERVENTIONS The authors adopted a conservative threshold for blood transfusion and implemented a collaborative multidisciplinary approach to blood conservation. MEASUREMENTS AND MAIN RESULTS Baseline patient characteristics were summarized, and the incidence of RBC transfusion before and after the intervention on July 26, 2019, were compared by Wilcoxon rank sum and chi-square tests. Multivariate logistic regression was used. The intervention was significantly associated with reduced RBC transfusion rate after adjusting for confounding variables (p < 0.05). The odds of receiving an RBC transfusion among patients after the intervention was 0.615 times the odds among patients before intervention (95% CI: 0.3913-0.9663). CONCLUSIONS The authors' goal was to improve patient outcomes and the quality of perioperative care during cardiac surgery. By implementing a protocol and educating anesthesiologists, surgeons, and perfusionists, they successfully decreased the incidence of RBC transfusion above a hemoglobin of 7.5 g/dL.
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Affiliation(s)
- Taylor Lindgren
- Department of Anesthesiology. Baylor College of Medicine, Houston, TX.
| | - Harica Kodakandla
- Department of Anesthesiology. Baylor College of Medicine, Houston, TX
| | - Shelley M Caraway
- Department of Anesthesiology. Baylor College of Medicine, Houston, TX
| | - Krishna B Shah
- Department of Anesthesiology. Baylor College of Medicine, Houston, TX
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16
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Ming Y, Zhang F, Yao Y, Cheng Z, Yu L, Sun D, Sun K, Yu Y, Liu M, Ma L, HuangYang Y, Yan M. Large volume acute normovolemic hemodilution in patients undergoing cardiac surgery with intermediate-high risk of transfusion: A randomized controlled trial. J Clin Anesth 2023; 87:111082. [PMID: 36848777 DOI: 10.1016/j.jclinane.2023.111082] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/02/2023] [Accepted: 02/17/2023] [Indexed: 02/27/2023]
Abstract
STUDY OBJECTIVE To investigate whether large volume acute normovolemic hemodilution (L-ANH), compared with moderate acute normovolemic hemodilution (M-ANH), can reduce perioperative allogeneic blood transfusion in patients with intermediate-high risk of transfusion during cardiac surgery with cardiopulmonary bypass (CPB). DESIGN Prospective randomized controlled trial. SETTING University hospital. PATIENTS Patients with transfusion risk understanding scoring tool ("TRUST") ≥2 points undergoing cardiac surgery with CPB in the Second Affiliated Hospital of Zhejiang University from May 2020 to January 2021 were included. INTERVENTIONS The patients were randomly assigned with a 1:1 ratio to M-ANH (5 to 8 mL/kg) or L-ANH (12 to 15 mL/kg). MEASUREMENTS The primary outcome was perioperative red blood cell (RBC) transfusion units. The composite outcome included new-onset atrial fibrillation, pulmonary infection, cardiac surgery associated acute kidney injury (CSA-AKI) class ≥2, surgical incision infection, postoperative excessive bleeding, and resternotomy. MAIN RESULTS Total 159 patients were screened and 110 (55 L-ANH and 55 M-ANH) were included for final analysis. Removed blood volume of L-ANH is significantly higher than M-ANH (886 ± 152 vs. 395 ± 86 mL, P < 0.001). Perioperative RBC transfusion was median 0 unit ([25th, 75th] percentiles: 0-4.4) in M-ANH group vs. 0 unit ([25th, 75th] percentiles: 0-2.0) in L-ANH group (P = 0.012) and L-ANH was associated with lower incidence of transfusion (23.6% vs. 41.8%, P = 0.042, rate difference: 0.182, 95% confidence interval [0.007-0.343]). The incidence of postoperative excessive bleeding was significantly lower in L-ANH vs. M-ANH (3.6% vs. 18.2%, P = 0.029, rate difference: 0.146, 95% confidence interval [0.027-0.270]) without significant difference for other second outcomes. The volume of ANH was inversely related to perioperative RBC transfusion units (Spearman r = -0.483, 95% confidence interval [-0.708 to -0.168], P = 0.003), and L-ANH in cardiac surgery was associated with a significantly reduced risk of perioperative RBC transfusion (odds ratio: 0.43, 95% confidence interval: 0.19-0.98, P = 0.044). CONCLUSIONS Compared with M-ANH, L-ANH during cardiac surgery inclined to be associated with reduced perioperative RBC transfusion and the volume of RBC transfusion was inversely proportional to the volume of ANH. In addition, LANH during cardiac surgery was associated with a lower incidence of postoperative excessive bleeding.
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Affiliation(s)
- Yue Ming
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Fengjiang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Yuanyuan Yao
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Zhenzhen Cheng
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Lina Yu
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Dawei Sun
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Kai Sun
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Yang Yu
- School of Anesthesiology, Weifang Medical University, Weifang, Shandong 261053, China
| | - Mingxia Liu
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Longfei Ma
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Yuxin HuangYang
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province; Leading Health Talents of Zhejiang Province, Zhejiang Health Office No. 18(2020), China.
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17
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Ripoll JG, Warner MA, Hanson AC, Marquez A, Dearani JA, Nuttall GA, Kor DJ, Mauermann WJ, Smith MM. Coagulation Tests and Bleeding Classification After Cardiopulmonary Bypass: A Prospective Study. J Cardiothorac Vasc Anesth 2023; 37:933-941. [PMID: 36863984 PMCID: PMC10149589 DOI: 10.1053/j.jvca.2023.01.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE No recent prospective studies have analyzed the accuracy of standard coagulation tests and thromboelastography (TEG) to identify patients with excessive microvascular bleeding following cardiopulmonary bypass (CPB). The aim of this study was to assess the value of coagulation profile tests, as well as TEG, for the classification of microvascular bleeding after CPB. DESIGN A prospective observational study. SETTING At a single-center academic hospital. PARTICIPANTS Patients ≥18 years of age undergoing elective cardiac surgery. INTERVENTIONS Qualitative assessment of microvascular bleeding post-CPB (surgeon and anesthesiologist consensus) and the association with coagulation profile tests and TEG values. MEASUREMENTS AND MAIN RESULTS A total of 816 patients were included in the study-358 (44%) bleeders and 458 (56%) nonbleeders. Accuracy, sensitivity, and specificity for the coagulation profile tests and TEG values ranged from 45% to 72%. The predictive utility was similar across tests, with prothrombin time (PT) (62% accuracy, 51% sensitivity, 70% specificity), international normalized ratio (INR) (62% accuracy, 48% sensitivity, 72% specificity), and platelet count (62% accuracy, 62% sensitivity, 61% specificity) displaying the highest performance. Secondary outcomes were worse in bleeders versus nonbleeders, including higher chest tube drainage, total blood loss, transfusion of red blood cells, reoperation rates (p < 0.001, respectively), readmission within 30 days (p = 0.007), and hospital mortality (p = 0.021). CONCLUSIONS Standard coagulation tests and individual components of TEG in isolation agree poorly with the visual classification of microvascular bleeding after CPB. The PT-INR and platelet count performed best but had low accuracy. Further work is warranted to identify better testing strategies to guide perioperative transfusion decisions in cardiac surgical patients.
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Affiliation(s)
- Juan G Ripoll
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Matthew A Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Andrew C Hanson
- Statistician, Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Alberto Marquez
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - William J Mauermann
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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18
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Kiyatkin ME, Mladinov D, Jarzebowski ML, Warner MA. Patient Blood Management, Anemia, and Transfusion Optimization Across Surgical Specialties. Anesthesiol Clin 2023; 41:161-174. [PMID: 36871997 PMCID: PMC10066799 DOI: 10.1016/j.anclin.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Patient blood management (PBM) is a systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood and minimizing allogenic transfusion need and risk. According to the PBM approach, the goals of perioperative anemia management include early diagnosis, targeted treatment, blood conservation, restrictive transfusion except in cases of acute and massive hemorrhage, and ongoing quality assurance and research efforts to advance overall blood health.
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Affiliation(s)
- Michael E Kiyatkin
- Department of Anesthesiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA.
| | - Domagoj Mladinov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Mary L Jarzebowski
- Department of Anesthesiology, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI 48109, USA
| | - Matthew A Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, 200 1st Street, Rochester, MN 55905, USA
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19
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Schupper AJ, Kaufman M, Reidler JS, Arginteanu MS, Moore FM, Steinberger A, Syed ON, Yao KC, Gologorsky Y. Spinal deformity surgery in patients for whom blood transfusion is not an option: a single-center experience. J Neurosurg Spine 2023; 38:348-356. [PMID: 36866794 DOI: 10.3171/2022.11.spine221061] [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: 09/21/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Spinal deformity surgery is associated with significant blood loss, often requiring the transfusion of blood and/or blood products. For patients declining blood or blood products, even in the face of life-threatening blood loss, spinal deformity surgery has been associated with high rates of morbidity and mortality. For these reasons, patients for whom blood transfusion is not an option have historically been denied spinal deformity surgery. METHODS The authors retrospectively reviewed a prospectively collected data set. All patients declining blood transfusion who underwent spinal deformity surgery at a single institution between January 2002 and September 2021 were identified. Demographics collected included age, sex, diagnosis, details of any prior surgery, and medical comorbidities. Perioperative variables included levels decompressed and instrumented, estimated blood loss, blood conservation techniques used, length of surgery, length of hospital stay, and complications from surgery. Radiographic measurements included, where appropriate, sagittal vertical axis correction, Cobb angle correction, and regional angular correction. RESULTS Spinal deformity surgery was performed in 31 patients (18 male, 13 female) over 37 admissions. The median age at surgery was 41.2 years (range 10.9-70.1 years), and 64.5% had significant medical comorbidities. A median of 9 levels (range 5-16 levels) were instrumented per surgery, and the median estimated blood loss was 800 mL (range 200-3000 mL). Posterior column osteotomies were performed in all surgeries, and pedicle subtraction osteotomies in 6 cases. Multiple blood conservation techniques were used in all patients. Preoperative erythropoietin was administered prior to 23 surgeries, intraoperative cell salvage was used in all, acute normovolemic hemodilution was performed in 20, and perioperative administration of antifibrinolytic agents was performed in 28 surgeries. No allogenic blood transfusions were administered. Surgery was staged intentionally in 5 cases, and there was 1 unintended staging due to intraoperative blood loss from a vascular injury. There was 1 readmission for a pulmonary embolus. There were 2 minor postoperative complications. The median length of stay was 6 days (range 3-28 days). Deformity correction and the goals of surgery were achieved in all patients. Two patients underwent revision surgery during the follow-up period: one for pseudarthrosis and the other for proximal junctional kyphosis. CONCLUSIONS With proper preoperative planning and judicious use of blood conservation techniques, spinal deformity surgery may be performed safely in patients for whom blood transfusion is not an option. The same techniques can be applied widely to the general population in order to minimize blood loss and the need for allogeneic blood transfusion.
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Affiliation(s)
| | - Margit Kaufman
- and Departments of2Anesthesiology and Critical Care Medicine
| | - Jay S Reidler
- 3Orthopaedic Surgery, Mount Sinai Health System, New York, New York
- 4Orthopaedic Surgery, and
| | - Marc S Arginteanu
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Frank M Moore
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Alfred Steinberger
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Omar N Syed
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Kevin C Yao
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Yakov Gologorsky
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
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20
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Muacevic A, Adler JR, Murata H, Sekino M, Hara T. Management of Combined Cardiac Surgery Using Cardiopulmonary Bypass With Acute Normovolemic Hemodilution in a Jehovah's Witness: A Case Report. Cureus 2023; 15:e33442. [PMID: 36751150 PMCID: PMC9897691 DOI: 10.7759/cureus.33442] [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] [Accepted: 01/05/2023] [Indexed: 01/09/2023] Open
Abstract
Combined cardiac surgery under cardiopulmonary bypass (CPB) has a high risk of requiring blood transfusion. Performing this surgery on Jehovah's Witnesses (JWs) is challenging as they strictly refuse allogeneic blood transfusions due to their religious beliefs. A 73-year-old female JW patient underwent combined surgery involving coronary artery bypass grafting and mitral valvuloplasty under CPB. Preoperative hematopoiesis maintained the hemoglobin (Hb) level at >12 g/dL preoperatively; the Hb level was maintained at >7 g/dL during CPB for effective acute normovolemic hemodilution (ANH). Compared with the values obtained immediately after CPB weaning, the Hb level and coagulation functions (measured using viscoelastic tests) improved after autologous transfusion at the end of the surgery. When cardiac surgery under CPB is performed on JWs, ANH can be useful for maintaining postoperative Hb levels and coagulation factors. Sufficient preoperative hematopoiesis and determination of an appropriate volume for intraoperative ANH may be important for effective ANH.
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21
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Kopanczyk R, Lester J, Long MT, Kossbiel BJ, Hess AS, Rozycki A, Nunley DR, Habib A, Taylor A, Awad H, Bhatt AM. The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:47. [PMID: 36676669 PMCID: PMC9867461 DOI: 10.3390/medicina59010047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.
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Affiliation(s)
- Rafal Kopanczyk
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Jesse Lester
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Micah T. Long
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Briana J. Kossbiel
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Aaron S. Hess
- Department of Anesthesiology and Pathology & Laboratory Medicine, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Alan Rozycki
- Department of Pharmacology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - David R. Nunley
- Department of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Alim Habib
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Ashley Taylor
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Hamdy Awad
- Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesia, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Amar M. Bhatt
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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22
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O'Shaughnessy S, Tangel V, Chaturvedi R, Javaid A, White R, Hoyler MM. Medicare and Medicaid insurance status is associated with increased allogeneic red blood cell transfusion in cardiac surgery patients: 2007-2018. J Card Surg 2022; 37:5162-5171. [PMID: 36378897 DOI: 10.1111/jocs.17168] [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: 06/24/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIM Allogeneic red blood cell (RBC) transfusion and health insurance status are independently associated with perioperative morbidity. The aim of this study was to evaluate the effect of insurance status on allogeneic and autologous transfusion risk in cardiac surgery patients. METHODS We conducted a retrospective observational study of data spanning 2007-2018 from six states from the State Inpatient Databases. Patients were cohorted by medical insurance type. Rates and risk-adjusted odds ratios (aOR) were calculated for allogenic and autologous RBC transfusions. Interactions between insurance and race/ethnicity were assessed. RESULTS A total of 710,296 cardiac surgery patients were included. Allogeneic infusions occurred in 34.7% of Medicare patients, 31.9% of Medicaid patients, 24.7% of privately insured patients, and 26.1% of uninsured patients. Autologous rates were 2.3%, 2.5%, 3.4%, and 2.6% for Medicare, Medicaid, privately insured, and uninsured patients, respectively. Medicare and Medicaid patients were more likely to receive allogeneic RBC than privately insured patients (Medicare: aOR: 1.42, 99% confidence interval [CI]: 1.40-1.44, p < .001, Medicaid: aOR: 1.18, 99% CI: 1.14-1.21, p < .001). Nonwhite Medicare patients showed higher odds of allogeneic transfusion compared with White patients with private insurance (Black Medicare: aOR 1.74, 99% CI: 1.65-1.83, p < .001, Hispanic Medicare: aOR 1.92, 99% CI: 1.84-2.00, p < .001). CONCLUSION Cardiac surgery patients with Medicare and Medicaid insurance demonstrate increased risk of allogeneic RBC transfusion; nonwhite patient groups are particularly vulnerable. Further research is needed to understand the causes and implications of these disparities, and to help ensure equitable care across patient groups.
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Affiliation(s)
- Sinead O'Shaughnessy
- Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA
| | - Virginia Tangel
- Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA
| | - Rahul Chaturvedi
- Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA
| | - Amal Javaid
- Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA
| | - Robert White
- Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA
| | - Marguerite M Hoyler
- Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA
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23
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Dahmen AS, Phuoc VH, Cohen JB, Sexton WJ, Patel SY. Bloodless surgery in urologic oncology: A review of hematologic, anesthetic, and surgical considerations. Urol Oncol 2022; 41:192-203. [PMID: 36470804 DOI: 10.1016/j.urolonc.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/01/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022]
Abstract
The urologic oncology patient who refuses blood transfusion can present unique challenges in perioperative blood management. Since blood loss and associated transfusion can be expected in many complex urologic oncology surgeries, a multidisciplinary approach may be required for optimal outcomes. Through collaboration with the hematologist, anesthesiologist, and urologist, various techniques can be employed in the perioperative phases to minimize blood loss and the need for transfusion. We review the risks and benefits of these techniques and offer recommendations specific to the urologic oncology patient.
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Affiliation(s)
- Aaron S Dahmen
- Department of Urology, University of Chicago, Chicago, IL
| | - Vania H Phuoc
- Department of Medical Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jonathan B Cohen
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Wade J Sexton
- Department of Genitourinary Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Sephalie Y Patel
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL.
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24
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Delgado C, Komatsu R. Patient Blood Management programs for post-partum hemorrhage. Best Pract Res Clin Anaesthesiol 2022; 36:359-369. [PMID: 36513431 DOI: 10.1016/j.bpa.2022.09.001] [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: 09/01/2022] [Accepted: 09/08/2022] [Indexed: 12/15/2022]
Abstract
Patient blood management (PBM) strategies aim to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss to improve patient outcomes. Because postpartum hemorrhage (PPH) is a leading cause of maternal mortality and blood product utilization, PBM principles can be applied in its therapeutic approach. First, pre-operative identification of risk factors for PPH and identification of peri-delivery anemia should be conducted. Iron supplementation should be used to optimize hemoglobin concentration before delivery; it can also be used to treat anemia in the postpartum period after severe PPH. Both acute normovolemic hemodilution and intraoperative cell salvage can be effective techniques to reduce allogeneic blood transfusion during or after surgical procedures. Furthermore, these strategies appear to be safe when used in the pregnant population.
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Affiliation(s)
- Carlos Delgado
- Department of Anesthesiology and Pain Medicine, University of Washington, 1959 NE Pacific Street, Box 356340, Seattle, WA 98195, USA.
| | - Ryu Komatsu
- Department of General Anesthesiology and Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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25
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Vance JL, Irwin L, Jewell ES, Engoren M. Intraoperative blood collection without fluid replacement for cardiac surgery - A retrospective analysis. Ann Card Anaesth 2022; 25:399-407. [PMID: 36254902 PMCID: PMC9732948 DOI: 10.4103/aca.aca_30_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 08/03/2021] [Accepted: 09/12/2021] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Transfusion rates in cardiac surgery are high. AIM To determine if intraoperative autologous blood removal without volume replacement is associated with fewer homologous blood transfusions without increasing acute kidney injury. SETTING AND DESIGN Retrospective, comparative study. MATERIALS AND METHODS Adult patients undergoing cardiac surgery, excluding those who underwent ventricular assist device surgery, heart transplants, or cardiac surgery without cardiopulmonary bypass were excluded, who had 1-3 units of intraoperative autologous blood removal were compared to patients without blood removal for determination of volume replacement, vasopressor support, acute kidney injury, and transfusions. RESULTS Autologous blood removal was associated with fewer patients receiving homologous transfusions: intraoperative red cell transfusions fell from 75% (Control) to 48% (1 unit removed), 40% (2 units), and 30% (3 units), P < 0.001. Total intraoperative and postoperative homologous RBC units transfused were lower in the blood removal groups: median (interquartile range) 3 (1, 6) in Control patients and 0 (0, 2), 0 (0, 2) and 0 (0, 1) in the 1, 2, and 3 units removed groups, P < 0.001. Similarly, plasma, platelet, and cryoprecipitate transfusions decreased. After adjustment for confounders, increased amounts of autologous blood removal were associated with increased intravenous fluids, only when 2 units were removed, and trivially increased vasopressor use. However, it was not associated with acidosis or acute kidney injury. CONCLUSIONS Intraoperative autologous blood removal without volume replacement of 1-3 units for later autologous transfusion is associated with decreased homologous transfusions without acidosis or acute kidney injury.
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Affiliation(s)
| | - Lisa Irwin
- Department of Anesthesiology, University of Michigan, USA
| | | | - Milo Engoren
- Department of Anesthesiology, University of Michigan, USA
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26
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Hemodilution on microvascular oxygen delivery potential of the blood during coronary bypass surgery. J Anesth 2022; 36:723-730. [PMID: 36161534 DOI: 10.1007/s00540-022-03109-9] [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: 07/10/2022] [Accepted: 09/14/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE The hematocrit-to-whole blood viscosity ratio (Hct/WBV) reflects the blood O2 delivery potential (O2-DP). WBV is variable to the dynamic vascular shear rate (SR), 1-5/s at microcirculation and 300/s at larger vessels. To estimate the impact of hemodilution on the blood O2-DP to the myocardium, we analyzed the hemodilution-induced change of Hct/WBV at SR 5/s (Hct/WBV5) during off-pump coronary bypass (OPCAB) surgery. METHODS During OPCAB surgery (n = 21), 10% acute normovolemic hemodilution (HD 10%) was applied. Arterial blood samples were taken: one before and two after HD 10%. One of which after HD 10% underwent an additional 33% in vitro hemodilution (reaching 40% hemodilution in total, HD 40%). WBV of all blood samples was determined using a scan-capillary tube viscometer (Hemovister™). The changes of Hct/WBV5 were analyzed as a primary measure of the study and compared with those of Hct/WBV at SR 300/s (Hct/WBV300). RESULTS Median[IQR] of Hct/WBV5 [3.5 (2.8-4.2)%/cPoise] was significantly increased by HD 10 and HD 40% [3.6 (3.2-4.6)%/cPoise and 4.2 (3.3-5.2)%/cPoise, respectively, all P < 0.001], but the degrees of changes after HD 10 and HD 40% were not different. Median[IQR] of Hct/WBV300 [10.3(8.6‒10.8)%/cPoise] was not changed by HD 10% [10.3(9.1-11.1)%/cPoise], but it was significantly decreased by HD 40% [8.4(7.4‒9.2)%/cPoise, P < 0.001]. CONCLUSION The increased Hct/WBV5 suggests that 10-40% hemodilution improves the blood O2-DP to the myocardium during OPCAB surgery. The SR-specific discrepancy in Hct/WBV changes advocates using microvascular WBV and Hct/WBV to evaluate the blood O2-DP changes to the myocardium. Further study is warranted to assess the actual changes in myocardial O2 delivery.
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27
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Uchida S, Kinoshita H, Takekawa D, Saito J, Hirota K. Acute normovolemic hemodilution reduced the frequency and amount of perioperative allogeneic blood transfusion in pediatric and adolescent scoliosis surgery: a retrospective observational study. J Anesth 2022; 36:484-492. [PMID: 35676440 DOI: 10.1007/s00540-022-03078-z] [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: 03/11/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of the present study is to investigate whether acute normovolemic hemodilution (ANH) can reduce the frequency and amount of perioperative allogeneic blood transfusion (ABT) (intraoperative ABT and postoperative ABT until discharge from the hospital) in pediatric and adolescent scoliosis surgery. METHODS This single-center, retrospective, observational study included the perioperative data of 147 patients who were 18 years old or younger and underwent scoliosis surgery. Patients were divided into groups according to whether they received ANH: i.e., an ANH group and control group. Propensity-score-adjusted multivariable logistic regression analysis was performed to determine whether ANH can reduce the frequency of perioperative ABT. RESULTS A total of 125 patients were analyzed, 95 and 30 in the ANH and control group, respectively. The intraoperative/postoperative ABT frequency was significantly lower in the ANH group than in the control group (17.9% vs. 36.7%, p = 0.044). The amount of ABT [median (IQR): 0 (0, 0) mL/kg vs. 0 (0, 16.3) mL/kg, p = 0.033] was also significantly lower in the ANH group than in the control group. Propensity-score-adjusted multivariable logistic regression analysis indicated that ANH use [odds ratio: 0.15; 95% confidence interval: 0.03, 0.77; p = 0.023)] was associated with a lower risk of ABT after adjusting for intraoperative blood loss and duration of surgery. CONCLUSION ANH use can reduce the frequency and amount of perioperative ABT in pediatric and adolescent scoliosis surgery.
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Affiliation(s)
- Satoshi Uchida
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
| | - Hirotaka Kinoshita
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
| | - Daiki Takekawa
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan.
| | - Junichi Saito
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
| | - Kazuyoshi Hirota
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
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O'Shaughnessy S, Tangel V, Dzotsi S, Jiang S, White R, Hoyler M. Non-White Race/Ethnicity and Female Sex Are Associated with Increased Allogeneic Red Blood Cell Transfusion in Cardiac Surgery Patients: 2007-2018. J Cardiothorac Vasc Anesth 2022; 36:1908-1918. [PMID: 34969561 DOI: 10.1053/j.jvca.2021.11.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate racial and/or ethnic and sex disparities in allogeneic and autologous red blood cell (RBC) transfusions in cardiac surgery. DESIGN A retrospective observational study. SETTING 2007 to 2018 data from FL, MD, KY, WA, NY, and CA from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. PARTICIPANTS A total of 710,296 inpatients who underwent elective or emergency coronary artery bypass grafting (CABG), cardiac valve surgery,or combination CABG and/or valve surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were cohorted by race and/or ethnicity and sex, as defined by SID-HCUP. Demographic characteristics and comorbidities were compared. Rates and risk-adjusted odds ratios (aOR) were calculated for allogeneic and autologous RBC transfusion (primary outcomes). Additional secondary analyses were conducted for in-hospital mortality, 30-day readmission, 90-day readmission, hospital length of stay, and total charges to examine the effect of RBC transfusion status. Effect modification between race and sex was assessed. When controlling for patient demographics, comorbidities, and hospital characteristics, non-White patients were more likely to receive an allogeneic RBC transfusion during cardiac surgery than White patients (Black: aOR 1.17, 99% CI 1.13-1.20, p < 0.001, Hispanic: aOR 1.22, 99% CI 1.19-1.22, p < 0.001). Women were more likely to receive allogeneic RBC than men (aOR 1.69, 99% CI 1.66-1.72, p < 0.001). In interaction models, non-White women had the highest odds of allogeneic blood transfusion as compared to White men (reference category; Black women: aOR 2.04, 99% CI 1.91-2.17, p < 0.001, Hispanic women: aOR 2.03, 99% CI 1.90-2.16, p < 0.001). CONCLUSION These findings highlighted the differences in the rates of allogeneic RBC transfusion for non-White and female patients undergoing cardiac surgery, which is a well-established marker of poorer outcomes.
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Affiliation(s)
- Sinead O'Shaughnessy
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY.
| | - Virginia Tangel
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Safiya Dzotsi
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Silis Jiang
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Robert White
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Marguerite Hoyler
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
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29
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Mladinov D, Padilla LA, Leahy B, Norman JB, Enslin J, Camp RS, Eudailey KW, Tanaka K, Davies JE. Hemodilution in high-risk cardiac surgery: Laboratory values, physiological parameters, and outcomes. Transfusion 2022; 62:826-837. [PMID: 35244229 DOI: 10.1111/trf.16844] [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: 07/07/2021] [Revised: 01/20/2022] [Accepted: 02/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute normovolemic hemodilution (ANH) is a blood conservation strategy in cardiac surgery, predominantly used in coronary artery bypass graft (CABG) and/or valve procedures. Although higher complexity cardiac procedures may benefit from ANH, concerns for hemodynamic instability, and organ injury during hemodilution hinder its wider acceptance. Laboratory and physiological parameters during hemodilution in complex cardiac surgeries have not been described. STUDY DESIGN AND METHODS This observational cohort (2019-2021) study included 169 patients who underwent thoracic aortic repair, multiple valve procedure, concomitant CABG with the aforementioned procedure, and/or redo sternotomies. Patients who received allogeneic blood were excluded. Statistical comparisons were performed between ANH (N = 66) and non-ANH controls (N = 103). ANH consisted of removal of blood at the beginning of surgery and its return after cardiopulmonary bypass. RESULTS Intraoperatively, the ANH group received more albumin (p = .04) and vasopressor medications (p = .01), while urine output was no different between ANH and controls. Bilateral cerebral oximetry (rSO2 ) values were similar before and after hemodilution. During bypass, rSO2 were discretely lower in the ANH versus control group (right rSO2 p = .03, left rSO2 p = .05). No differences in lactic acid values were detected across the procedural continuum. Postoperatively, no differences in extubation times, intensive care unit length of stay, kidney injury, stroke, or infection were demonstrated. DISCUSSION This study suggests hemodilution to be a safe and comparable blood conservation technique, even without accounting for potential benefits of reduced allogenic blood administration. The study may contribute to better understanding and wider acceptance of ANH protocols in high-risk cardiac surgeries.
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Affiliation(s)
- Domagoj Mladinov
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Luz A Padilla
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Benjamin Leahy
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joseph B Norman
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jacob Enslin
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Riley S Camp
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kyle W Eudailey
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - James E Davies
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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O'Connor MK, Emanuelli E, Garg RK. Le Fort I maxillary osteotomy in a Jehovah's Witness patient: strategies for minimizing blood loss and maximizing safety. Maxillofac Plast Reconstr Surg 2022; 44:10. [PMID: 35235074 PMCID: PMC8891397 DOI: 10.1186/s40902-022-00338-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Watch Tower Society, the main governing organization of the Jehovah's Witness (JW) faith, introduced the doctrine to refuse blood in 1945 and has been enforcing it since 1961. A member can be expelled for accepting prohibited blood components. Many reconstructive surgeries place patients at an increased risk for blood loss. There have been attempts at reducing the rate of transfusions in craniofacial surgery, even in patients not opposed to it. PRESENTATION A 15-year-old female patient, who refused blood transfusion due to her faith, presented with a class III malocclusion, transverse maxillary constriction, and a lateral open bite. Surgery was deferred until the patient reached 18 years of age and had undergone preoperative orthodontics. A two-piece Le Fort I osteotomy was performed. Erythropoietin, oral iron, and tranexamic acid were used to minimize intraoperative blood loss. CONCLUSION Here we discuss preoperative and intraoperative management strategies to ensure a transfusion-free environment for patients with religious objections to blood transfusions undergoing operations with increased bleeding risk.
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Affiliation(s)
| | - Elisa Emanuelli
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Ravi K Garg
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, KS, USA.
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Smeltz AM, Coleman P, Mondal S. TEMPORARY REMOVAL: Pro – Acute normovolemic hemodilution (ANH) should be used in infective endocarditis (IE) patients coming for primary or redo cardiac surgery. J Cardiothorac Vasc Anesth 2022; 36:2811-2814. [DOI: 10.1053/j.jvca.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/10/2022] [Indexed: 01/28/2023]
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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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Wu WK, Stokes JW, Ukita R, Ziogas IIA, Patel YJ, Alexopoulos SP, Bacchetta M, Benson C. Acute Normovolemic Hemodilution-assisted Terminal Blood Procurement in Swine for Ex Vivo Organ Perfusion. JOURNAL OF THE AMERICAN ASSOCIATION FOR LABORATORY ANIMAL SCIENCE : JAALAS 2022; 61:101-104. [PMID: 34879898 PMCID: PMC8786374 DOI: 10.30802/aalas-jaalas-21-000074] [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: 06/17/2021] [Revised: 08/17/2021] [Accepted: 09/09/2021] [Indexed: 06/13/2023]
Abstract
Swine (Sus scrofa domesticus) are commonly used large animal subjects for the study of disease and preclinical therapies. Organ machine perfusion is a therapy that has gained momentum as a research platform for the study of ex vivo organ preservation and therapeutics. However, complex perfusion circuits and research protocols often require large volumes of blood as perfusate. Here, we report a technique for increasing terminal blood yield during swine organ and blood procurement; our method involves acute normovolemic hemodilution and exsanguination via the femoral artery. We collected a total of 47 ± 4 mL/kg of blood and 4.3 ± 0.6 g/kg of hemoglobin, representing 73% ± 6% of the estimated blood volume and 64% ± 8% of the total estimated intravascular hemoglobin (n = 4). Neither pH, lactate, nor pO2 levels changed significantly during blood procurement. Acute normovolemic hemodilution is an effective method for increasing RBC and hemoglobin yield during blood procurement in swine.
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Affiliation(s)
- W Kelly Wu
- Department of Thoracic Surgery
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery
| | | | | | - Ioannis IA Ziogas
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery
| | | | | | - Matthew Bacchetta
- Department of Thoracic Surgery
- Department of Biomedical Engineering, and
| | - Clayne Benson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Borgmeier E, Lawrence H, Morton C, McEvoy MD. Perioperative anemia management. Int Anesthesiol Clin 2022; 60:1-7. [PMID: 34897216 DOI: 10.1097/aia.0000000000000350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Emilee Borgmeier
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
| | - Heather Lawrence
- Hi-RiSE Preoperative Optimization Clinic, Vanderbilt University Medical Center
| | - Colleen Morton
- Department of Medicine, Vanderbilt University Medical Center
| | - Matthew D McEvoy
- Vanderbilt University School of Medicine
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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35
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Hill SE, Nonaka DF. Perioperative Management of Bleeding and Transfusion. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00027-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Elnaghy KM, Nasr IE, Kamal EM. Acute hypervolemic hemodilution combined with controlled hypotension to minimize blood loss during operations of spine fusion: remifentanil versus magnesium sulfate. AIN-SHAMS JOURNAL OF ANESTHESIOLOGY 2021; 13:51. [DOI: 10.1186/s42077-021-00165-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 04/07/2021] [Indexed: 09/01/2023]
Abstract
Abstract
Background
Blood loss is one of the major problems during operations of spine fusion. Several blood-conservative measures were applied to reduce the incidence of blood loss—among them, acute hypervolemic hemodilution (AHH) and controlled hypotension (CH). This study was designed to detect the effect of combination of AHH with CH induced by remifentanil versus magnesium sulfate on the volume of blood loss, allogeneic blood transfusion, hemodynamics, coagulation, and electrolytes during operations for spine fusion which are risky operations with high incidence of blood loss and blood transfusion. Sixty patients scheduled for posterior fusion of the spine were randomly allocated into three groups of 20 patients each (group I (AHH), group II (AHH combined with remifentanil-based CH), and group III (AHH combined with magnesium sulfate-based CH)). Estimated blood loss and total volume of packed red blood cells (PRBCS) transfused were recorded. Arterial blood pressure (ABP) and heart rate (HR) measures were recorded. Blood samples were obtained for the detection of hemoglobin (Hb) and hematocrit (HCT).
Results
Estimated blood loss, percentage blood loss, and intraoperative RBC transfusion units were significantly high in group I in relation to group II and group III (Table 2). Cardiac output was significantly higher in group I in relation to group II and group III at 10, 15, 30, 45, and 60 min after start of AHH. MBP and HR results were significantly high in group I in comparison with group II and group III at 30, 45, 60, and 90 min and 2 and 3 h after start of study drugs. CVP results were significantly high in group I in relation to group II and group III at 15, 30, 45, 60, and 90 min after start of AHH. PTT was significantly increased in the three study groups in comparison with baseline inside each group after AHH.
Conclusion
Combination of AHH with CH induced by remifentanil or magnesium sulfate was associated with reduction in estimated blood loss, and total volume of PRBCS transfused. There was no significant difference between hemodynamic parameters with the use of remifentanil or magnesium sulfate except that SBP, DBP, and MBP results were significantly high with magnesium sulfate at 15 min after drug infusion. There was significant increase in PT and PTT after AHH that was not reflected by significant blood oozing from the operative field, or by difficulty in hemostasis.
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Salenger R, Mazzeffi MA. The 7 Pillars of Blood Conservation in Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:504-509. [PMID: 34821153 DOI: 10.1177/15569845211051683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rawn Salenger
- Division of Cardiac Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA.,University of Maryland Saint Joseph Medical Center, Towson, MD, USA.,Departments of Anesthesiology and Critical Care Medicine, 43989George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Michael A Mazzeffi
- Division of Cardiac Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA.,University of Maryland Saint Joseph Medical Center, Towson, MD, USA.,Departments of Anesthesiology and Critical Care Medicine, 43989George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Caruso JP, Pernik MN, Johnson ZD, El Ahmadieh TY, Ogunnaike B, Adogwa O, Aoun SG, Bagley CA. Blood preservation techniques in complex spine surgery: Illustrative case and review of therapeutic options. Surg Neurol Int 2021; 12:515. [PMID: 34754565 PMCID: PMC8571196 DOI: 10.25259/sni_901_2021] [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: 09/06/2021] [Accepted: 09/18/2021] [Indexed: 01/28/2023] Open
Abstract
Background: Complex spine surgery predisposes patients to substantial levels of blood loss, which can increase the risk of surgical morbidity and mortality. Case Description: A 29-year-old achondroplastic male required thoracolumbar deformity correction. However, he refused potential allogeneic blood transfusions for religious reasons. He, therefore, underwent pre-operative autologous blood donation and consented to the use of the intraoperative cell salvage device. Immediately prior to the incision, he underwent acute normovolemic hemodilution. Throughout the case, we additionally utilized meticulous hemostasis. Postoperatively, he was supplemented with iron and erythropoietin and recovered well. When he required a revision procedure 3 months later, similar strategies were successfully employed. Conclusion: Numerous strategies exist pre-operatively, intraoperatively, and post-operatively to optimize blood loss management for patients who refuse blood transfusions but warrant major spinal deformity surgery.
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Affiliation(s)
- James P Caruso
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, United States
| | - Mark N Pernik
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, United States
| | - Zachary D Johnson
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, United States
| | - Tarek Y El Ahmadieh
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, United States
| | - Babatunde Ogunnaike
- Department of Anesthesia and Pain Management, University of Texas Southwestern, Dallas, Texas, United States
| | - Owoicho Adogwa
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, United States
| | - Salah G Aoun
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, United States
| | - Carlos A Bagley
- Department of Neurosurgery, University of Texas Southwestern, Dallas, Texas, United States
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Huang J, Firestone S, Moffatt-Bruce S, Tibi P, Shore-Lesserson L. 2021 Clinical Practice Guidelines for Anesthesiologists on Patient Blood Management in Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 35:3493-3495. [PMID: 34654633 DOI: 10.1053/j.jvca.2021.09.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY; Department of Cardiovascular & Thoracic Surgery, University of Louisville, Louisville, KY; Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY; Department of Pharmacology & Toxicology, University of Louisville, Louisville, KY; Department of Medicine, University of Louisville, Louisville, KY.
| | | | - Susan Moffatt-Bruce
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, Prescott, AZ
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell Northshore University Hospital, Manhasset, NY
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Kanda T, Wakiya T, Ishido K, Kimura N, Nagase H, Kubota S, Fujita H, Hagiwara Y, Hakamada K. Intraoperative Allogeneic Red Blood Cell Transfusion Negatively Influences Prognosis After Radical Surgery for Pancreatic Cancer: A Propensity Score Matching Analysis. Pancreas 2021; 50:1314-1325. [PMID: 34860818 DOI: 10.1097/mpa.0000000000001913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE We aimed to investigate the real impact of allogeneic red blood cell transfusion (ABT) on postoperative outcomes in resectable pancreatic ductal adenocarcinoma (PDAC) patients. METHODS Of 128 patients undergoing resectable PDAC surgery at our facility, 24 (18.8%) received ABT. Recurrence-free survival (RFS) and disease-specific survival (DSS), before and after propensity score matching (PSM), were compared among patients who did and did not receive ABT. RESULTS In the entire cohort, ABT was significantly associated with decreased RFS (P = 0.002) and DSS (P = 0.014) before PSM. Cox regression analysis identified ABT (risk ratio, 1.884; 95% confidence interval, 1.015-3.497; P = 0.045) as an independent prognostic factor for RFS. Univariate and multivariate analysis identified preoperative hemoglobin value, preoperative total bilirubin value, and intraoperative blood loss as significant independent risk factors for ABT. Using these 3 variables, PSM analysis created 16 pairs of patients. After PSM, the ABT group had significantly poorer RFS rates than the non-ABT group (median, 9.8 vs 15.8 months, P = 0.022). Similar tendencies were found in DSS rates (median, 19.4 vs 40.0 months, P = 0.071). CONCLUSIONS This study revealed certain negative effects of intraoperative ABT on postoperative survival outcomes in patients with resectable PDAC.
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Affiliation(s)
- Taishu Kanda
- From the Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Nielsen VG, Kazui T, Horn EA, Dotson VE. Thrombocytosis and neutrophilia associated with oxygenator failure and protamine reaction after cardiopulmonary bypass: a case report and literature review. J Thromb Thrombolysis 2021; 52:1220-1226. [PMID: 34581944 DOI: 10.1007/s11239-021-02574-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2021] [Indexed: 11/24/2022]
Abstract
Thrombocytosis has been feared as a source of thrombotic complications during the conduct of cardiopulmonary bypass (CPB) for patients undergoing cardiac procedures. We present a patient urgently requiring repair/replacement of three heart valves that had preexisting myelofibrosis with thrombocytosis (platelet count of 800,000 per µl) and neutrophilia (40,000 per µl). Despite achieving an activated clotting time > 500 s with heparin and antithrombin concentrate administration prior to CPB, the pump oxygenator and reservoir demonstrated significant clot just prior to restoration of the patient's circulation. The patient subsequently suffered a severe protamine reaction that was successfully managed. A review of the literature of similar patients and the relevant cellular and biochemical mechanisms in this setting are presented, with potential therapeutic approaches to prevent such complications noted.
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Affiliation(s)
- Vance G Nielsen
- Department of Anesthesiology, The University of Arizona College of Medicine, 1501 North Campbell Avenue, P.O. Box 245114, Tucson, AZ, 85724-5114, USA.
| | - Toshinobu Kazui
- Departments of Anesthesiology and Surgery, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Evan A Horn
- Department of Anesthesiology, The University of Arizona College of Medicine, 1501 North Campbell Avenue, P.O. Box 245114, Tucson, AZ, 85724-5114, USA
| | - Victoria E Dotson
- Perfusion Department, Banner University Medical Center Tucson, Tucson, AZ, USA
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Sebastian R, Ahmed MI. Blood Conservation and Hemostasis Management in Pediatric Cardiac Surgery. Front Cardiovasc Med 2021; 8:689623. [PMID: 34490364 PMCID: PMC8416772 DOI: 10.3389/fcvm.2021.689623] [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: 04/01/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
Pediatric cardiac surgery is associated with significant perioperative blood loss needing blood product transfusion. Transfusion carries serious risks and implications on clinical outcomes in this vulnerable population. The need for transfusion is higher in children and is attributed to several factors including immaturity of the hemostatic system, hemodilution from the CPB circuit, excessive activation of the hemostatic system, and preoperative anticoagulant drugs. Other patient characteristics such as smaller relative size of the patient, higher metabolic and oxygen requirements make successful blood transfusion management extremely challenging in this population and require meticulous planning and multidisciplinary teamwork. In this narrative review we aim to summarize risks and complications associated with blood transfusion in pediatric cardiac surgery and also to summarize perioperative coagulation management and blood conservation strategies.
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Affiliation(s)
- Roby Sebastian
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Children's Medical Center, Dallas, TX, United States
| | - M Iqbal Ahmed
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Children's Medical Center, Dallas, TX, United States
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Mladinov D, Eudailey KW, Padilla LA, Norman JB, Leahy B, Enslin J, Parker K, Cornelius KF, Davies JE. Effects of acute normovolemic hemodilution on post-cardiopulmonary bypass coagulation tests and allogeneic blood transfusion in thoracic aortic repair surgery: An observational cohort study. J Card Surg 2021; 36:4075-4082. [PMID: 34431128 DOI: 10.1111/jocs.15943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/22/2021] [Accepted: 08/08/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIM Perioperative blood transfusion is associated with increased morbidity and mortality. Acute normovolemic hemodilution (ANH) is a blood conservation strategy associated with variable success, and rarely studied in more complex cardiac procedures. The study aim was to evaluate whether ANH improves coagulopathy and reduces blood transfusions in thoracic aortic surgeries. METHODS Single-center observational cohort study comparing ANH and standard institutional practice in patients who underwent thoracic aortic repair with cardiopulmonary bypass (CPB) from 2019 to 2021. RESULTS A total of 89 patients underwent ANH and 116 standard practice. There were no significant differences between the groups in terms of demographic or major perioperative characteristics. In the ANH group coagulation tests before and after transfusion of autologous blood showed decreased INR and increased platelets, fibrinogen, all with p < 0.0005. Coagulation results in the ANH and control groups were not statistically different. The average number of transfused allogeneic products per patient was lower in the ANH versus control group: FFP 1.1 ± 1.6 versus 1.9 ± 2.3 (p = 0.003), platelets 0.6 ± 0.8 versus 1.2 ± 1.3 (p = 0.0008), and cryoprecipitate 0.3 ± 0.7 versus 0.7 ± 1.1 (p = 0.008). Reduction in red blood cell transfusion was not statistically significant. The percentage of patients who received any transfusion was 53.9% in ANH and 59.5% in the control group (p = 0.42). There was no significant difference in major adverse outcomes. CONCLUSIONS ANH is a safe blood conservation strategy for surgical repairs of the thoracic aorta. Laboratory data suggests ANH can improve some coagulation values after separation from CPB, and significantly reduce the number of transfused FFP, platelets and cryoprecipitate.
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Affiliation(s)
- Domagoj Mladinov
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kyle W Eudailey
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Luz A Padilla
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joseph B Norman
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Benjamin Leahy
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jacob Enslin
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Keli Parker
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Katherine F Cornelius
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James E Davies
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Madrigal J, Tran Z, Hadaya J, Sanaiha Y, Benharash P. Impact of Chronic Lymphocytic Leukemia on Outcomes and Readmissions following Cardiac Operations. Ann Thorac Surg 2021; 114:152-159. [PMID: 34437856 DOI: 10.1016/j.athoracsur.2021.07.059] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/15/2021] [Accepted: 07/16/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Outcomes of cardiac operations in patients with chronic lymphocytic leukemia (CLL) have been examined in limited series. The present study aimed to assess the impact of CLL on clinical outcomes and resource utilization following cardiac operations in a nationally representative cohort. METHODS All adult patients undergoing elective coronary artery bypass grafting, valve repair or valve replacement were identified utilizing the 2010-2017 Nationwide Readmissions Database. Patients were stratified by history of CLL. Incidence of in-hospital mortality, perioperative complications, blood transfusions and readmission within 90 days were examined. We subsequently performed 3:1 nearest neighbor matching between CLL and non-CLL patients for all primary and secondary outcomes of interest. RESULTS Of an estimated 1,250,882 patients undergoing cardiac operations, 0.23% had a diagnosis of CLL. Among 11,237 propensity matched patients, those with CLL had similar rates of in-hospital mortality (3.8 vs 2.6%, P=0.08) and perioperative complications (33.4 vs 33.6%, P=0.92) compared to their non-CLL counterparts. Although the incidence of infection was comparable (8.5 vs 9.4%, P=0.38), CLL patients did require blood transfusions more frequently (33.7 vs 28.4%, P=0.003) than others. Furthermore, CLL patients were more likely to be readmitted with respiratory etiologies contributing significantly to re-hospitalization. CONCLUSIONS Patients with CLL generally have similar outcomes following cardiac operations but may more commonly require blood transfusion. Blood conserving interventions may be considered in this at-risk population to improve outcomes. Furthermore, interventions to mitigate readmission deserve further exploration.
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Affiliation(s)
- Josef Madrigal
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles.
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STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:97-124. [PMID: 34194077 DOI: 10.1182/ject-2100053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/06/2021] [Indexed: 12/16/2022]
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Perioperative Management of Patients for Whom Transfusion Is Not an Option. Anesthesiology 2021; 134:939-948. [PMID: 33857295 DOI: 10.1097/aln.0000000000003763] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Jin C, Lv X, Sun Y, Jiang H. Effect of continuous infusion of dexmedetomidine on blood loss in orthognathic surgery: a retrospective study. Eur J Med Res 2021; 26:78. [PMID: 34284825 PMCID: PMC8290530 DOI: 10.1186/s40001-021-00551-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 07/14/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Patients with maxillofacial deformities require orthognathic surgeries to correct occlusion. The surgical procedure may lead to massive bleeding, which is associated with haematoma, respiratory obstruction, and asphyxia. Dexmedetomidine has been used in controlled hypotension and may reduce blood loss in orthognathic surgery. We conducted a retrospective cohort study to evaluate the effect of dexmedetomidine on blood loss in orthognathic surgeries. METHODS The primary outcome examined was blood loss, and secondary outcomes were postoperative haemoglobin level; intraoperative heart rate and blood pressure (T1: at incision; T2: 30 min after incision; T3: 60 min after incision; T4: 120 min after incision); dosage of fentanyl, remifentanil, urapidil, and esmolol; operation time; and incidence of allogeneic blood transfusion. RESULTS A total of 1247 patients were included in this study, and 540 patient pairs were matched via propensity score matching. There were significant decreases in mean blood loss, heart rate at T1-T4, blood pressure at T1, and remifentanil and esmolol dosage in the dexmedetomidine group compared with those in the control group. There was also a significant increase in the postoperative haemoglobin level of the dexmedetomidine group. CONCLUSIONS Continuous infusion of dexmedetomidine can decrease blood loss in orthognathic surgery. TRIAL REGISTRATION ChiCTR1800018794 (retrospectively registered) Name of registry: Chinese Clinical Trial Registry Date of registration: 2018/10/09 URL: www.chictr.org.cn/showproj.aspx?proj=30612.
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Affiliation(s)
- Chenyu Jin
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xiang Lv
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Yu Sun
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China.
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, 639 Zhizaoju Road, Shanghai, China.
| | - Hong Jiang
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China.
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, 639 Zhizaoju Road, Shanghai, China.
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Tibi P, McClure RS, Huang J, Baker RA, Fitzgerald D, Mazer CD, Stone M, Chu D, Stammers AH, Dickinson T, Shore-Lesserson L, Ferraris V, Firestone S, Kissoon K, Moffatt-Bruce S. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. Ann Thorac Surg 2021; 112:981-1004. [PMID: 34217505 DOI: 10.1016/j.athoracsur.2021.03.033] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, Prescott, Arizona
| | - R Scott McClure
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky
| | - Robert A Baker
- Cardiac Surgery Research and Perfusion, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David Fitzgerald
- Division of Cardiovascular Perfusion, Medical University of South Carolina, Charleston, South Carolina
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marc Stone
- Department of Anesthesia, Mount Sinai Medical Center, New York, New York
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Tim Dickinson
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell Northshore University Hospital, Manhasset, New York
| | - Victor Ferraris
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, Kentucky
| | | | | | - Susan Moffatt-Bruce
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.
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Tibi P, McClure RS, Huang J, Baker RA, Fitzgerald D, Mazer CD, Stone M, Chu D, Stammers AH, Dickinson T, Shore-Lesserson L, Ferraris V, Firestone S, Kissoon K, Moffatt-Bruce S. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. J Cardiothorac Vasc Anesth 2021; 35:2569-2591. [PMID: 34217578 DOI: 10.1053/j.jvca.2021.03.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, Prescott, Arizona
| | - R Scott McClure
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky
| | - Robert A Baker
- Cardiac Surgery Research and Perfusion, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David Fitzgerald
- Division of Cardiovascular Perfusion, Medical University of South Carolina, Charleston, South Carolina
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marc Stone
- Department of Anesthesia, Mount Sinai Medical Center, New York, New York
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Tim Dickinson
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell Northshore University Hospital, Manhasset, New York
| | - Victor Ferraris
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, Kentucky
| | | | | | - Susan Moffatt-Bruce
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.
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Effects of whole blood storage in a polyolefin blood bag on platelets for acute normovolemic hemodilution. Sci Rep 2021; 11:12201. [PMID: 34108583 PMCID: PMC8190119 DOI: 10.1038/s41598-021-91725-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 05/31/2021] [Indexed: 12/04/2022] Open
Abstract
Acute normovolemic hemodilution (ANH) is a potential transfusion method for platelets, as well as for red blood cells. However, previous studies have shown that whole blood storage in ANH decreases platelet aggregability by 14.7–76.3% and that this decrease is not recovered by reinfusion. We investigated whether a new whole blood storage method for 6 h using a polyolefin bag, based on the platelet concentrates storage method, would maintain platelet function better than the conventional method using a polyvinyl chloride bag. We demonstrated that storage of whole blood in a polyolefin bag maintained ADP-induced aggregation rates at more than twofold higher than those in a polyvinyl chloride bag, and also significantly suppressed P-selectin expression, a platelet activation marker (ADP-induced aggregation rates: 24.6 ± 5.1% vs. 51.7 ± 11.5%, p = 0.002; P-selectin expression; 50.3 ± 8.4MFI vs. 31.6 ± 9.3MFI, p = 0.018). These results could be attributed to the high gas permeability of polyolefin, which lowered PCO2 and maintained a high pH with or without agitation. There were no significant changes in platelet count and red blood cell parameters due to the storage methods. Our results suggest that ANH using polyolefin bags is advantageous in improving hemostatic function compared to the conventional method.
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