Massive Intraoperative Transfusion Research Articles

Determinants of Neurological Outcome Following Elective and Emergency Open Thoracoabdominal Aortic Aneurysm Repair-A Retrospective Multi-Center Study.

Background/Objectives: This study aimed to evaluate and establish the incidence of all types of neurological complications at our high-volume reference center for open TAAA repair in the Netherlands and Germany. Additionally, we sought to identify predictors for various neurological complications. Methods: This retrospective study was conducted in accordance with the STROBE guidelines, with the aim of reporting neurological outcomes for all patients who underwent open thoracoabdominal aortic aneurysm repair at two centers (Maastricht-Aachen) from 2000 to 2023, and to examine the association between these outcomes and pre- and perioperative parameters. The primary endpoints of the study were all-cause mortality, spinal cord ischemia (SCI), stroke, intracerebral bleeding (ICB), critical illness polyneuropathy/myopathy (CIP/CIM), and recurrent laryngeal nerve paralysis. Results: A total of 577 patients were operated on for open TAAA repair in two centers. The total in-hospital mortality rate was 20.6%, while the elective cases in-hospital mortality rate was 14.6%. In all, 28.2% of patients experienced neurological complications. The spinal cord ischemia rate was 7.5%, intracerebral bleeding 3.6%, stroke 5.9%, critical illness polyneuropathy 3.5%, and laryngeal nerve paresis 5.7%. Crawford extent II was significantly associated with increased neurological complications (OR 2.05, 95% CI 1.39-3.03, p = 0.003), while Crawford extent III and IV were significantly associated with fewer postoperative neurological complications (OR 0.61 (0.38-0.98) p = 0.04) (OR 0.52 (0.30-0.92) p = 0.02). Preoperative ASA score > 3 (OR 1.76, 95% CI 1.16-2.67, p = 0.007), COPD (OR 1.82, 95% CI 1.19-2.78, p = 0.006), massive intraoperative transfusion (OR 1.48, 95% CI 1.01-2.17, p = 0.04), and reinterventions during hospital stay (OR 1.98, 95% CI 1.36-2.89, p < 0.001) and surgery time (p =< 0.001) were significantly associated with neurological complications. Patients with neurological complications had higher rates of other postoperative morbidities. Conclusions: Neurological complications after open TAAA repair remain a significant concern, with identified risk factors associated with increased morbidity, mortality, and resource utilization. Identifying at-risk patients could potentially lead to a reduction in neurological complications.

Massive intraoperative red blood cell transfusion during lung transplantation is strongly associated with 90-day mortality

BackgroundThe effect of red blood cell (RBC) transfusion on mortality after lung transplantation (LT) was assessed in some retrospective studies, with contradictory results. The first aim of this study was to assess the 90-day survival of LT recipients according to massive intraoperative transfusion (MIOT). MethodsThis prospective, observational, single-centre study analysed the intraoperative transfusion (IOT) of all consecutive LT recipients between January 2016 and February 2019. MIOT was defined as transfusion of 5 RBC units or more. The results are presented as the median [IQR] and absolute numbers (proportions) and were analysed using χ2, Fisher, and Mann–Whitney tests (p < 0.05 as significance). Multivariate analyses were performed to identify independent risk factors for MIOT, 90-day and one-year mortality and grade 3 PGD at day 3. Ninety-day and one-year survivals were studied (Kaplan–Meier curves, log rank test). The Paris-North-Hospitals Institutional Review Board approved the study. ResultsOverall, 147 patients were included in the analysis, 27 (18%) of them received MIOT. In multivariate analysis, predictive factors of MIOT included preoperative ECMO support (p = 0.017), and bilateral LT (p = 0.023). The SOFA score on ICU admission after LT was higher in cases with MIOT (p < 0.001). MIOT was an independent risk factor for 90-days and one-year mortality (p = 0.002 and 0.008 respectively). The number of RBCs unit transfused during surgery was an independent risk factor for grade 3 PGD at day 3 (OR 1.14, 95% CI [1.00–1.29], p = 0.040). ConclusionIncreased preoperative severity of recipients predicts MIOT. MIOT is associated with increased early postoperative morbidity and mortality rates.

Factors associated with postoperative respiratory conditions and critical outcomes on pediatric liver transplantation: A single-center experience.

Orthotopic liver transplantation (OLT) is an established therapeutic option for pediatric end-stage liver disease (PELD). The postoperative respiratory conditions of OLT recipients may be associated with subsequent clinical outcomes including length of stay (LOS) in the pediatric intensive care unit (PICU). This study aimed to characterize the postoperative respiratory conditions, associated factors, and outcomes after pediatric OLT. Clinical data of children receiving OLT from July 2014 to July 2020 were retrospectively collected. Postoperative respiratory conditions were defined as time to extubation, significant pleural effusion, and initial postoperative PaO2/FiO2 ratio. Logistic and multiple regressions were applied to analyze the associations among clinical factors, postoperative respiratory conditions, and clinical outcomes. Twenty-two patients with median age of 1.4-year-old (range: 25 days to 12 years old) were analyzed. Mortality within 28 days was 4.5% and median LOS in the PICU was 18 days. Of 22 patients, 11 patients (50.0%) were extubated over 24 hours after surgery, and 8 patients (36.4%) required drainage for pleural effusions. Longer LOS in the PICU were noted in patients extubated over 24 hours (p = 0.008), complicated with significant pleural effusions (p = 0.02) after surgery, and having low initial postoperative PaO2/FiO2 (<300 mmHg) (p = 0.001). Among clinical factors, massive intraoperative blood transfusion (>40 mL/kg) was significantly associated with prolonged intubations, significant pleural effusions, low initial postoperative PaO2/FiO2, and prolonged LOS in the PICU (>14 days). The initial postoperative PaO2/FiO2 significantly depended on age, disease severity (PELD score), and whether the patient received massive intraoperative blood transfusion. Pediatric patients of OLT with poor postoperative respiratory conditions including low initial PaO2/FiO2 ratio, extubation over 24 hours or significant pleural effusions have longer LOS in the PICU, and the requirement of massive intraoperative transfusion was a risk factor for both poor postoperative respiratory conditions and prolonged LOS in the PICU.

Effect of cell salvage on bleeding, transfusion of blood products, and bleeding parameters in patients undergoing liver transplantation with intraoperative massive blood transfusion.

Autologous transfusion using a cell saver system has been used in liver transplantation with controversial outcomes. Its efficiency in patients with massive intraoperative transfusion has not been studied yet. This study aimed to evaluate effect of cell salvage (CS) on intraoperative bleeding and transfusion practices in liver transplantation with massive intraoperative transfusion. Consecutive patients aged ≥18 years with intraoperative massive blood transfusion (≥ 6 units) between March 2014 and September 2020 were included. Patients subjected to CS were grouped as CS, whereas other patients were grouped as control. Number of transfused red blood cells was study's primary outcome. There were 38 and 32 patients in CS and control groups, respectively. Median blood loss was significantly lower in CS group than in control group (2500 mL vs. 4000 mL, p = 0.010). There were significantly more transfusions of red blood cells, fresh frozen plasma, platelets, and cryoprecipitates in CS group (p < 0.05). Postoperative median hemoglobin levels were determined as 4.8 g/dL and 8.2 g/dL in CS and control groups (p < 0.001). The decrease in postoperative hemoglobin levels compared to preoperative values was significantly higher in the CS group (p < 0.001). The mortality rate in postoperative first year was significantly higher in CS group than in control group (36.8% vs. 12.5%, p = 0.041). Use of CS in patients undergoing liver transplantation with massive intraoperative transfusion did not improve clinical and transfusion-related outcomes. In conclusion, its usage can be questionable given the absence of any clinical benefit and presence of poor outcomes.

Epidemiology and risk factors for invasive fungal disease in liver transplant recipients in a tertiary transplant center.

Invasive fungal disease (IFD) in liver transplant recipients causes significant morbidity and mortality. We aim to describe institutional epidemiology and risk factors for IFD in the liver transplant population. We conducted a retrospective cohort study of all adult liver transplant recipients in our institution from 2005 to October 2015 to describe the epidemiology of patients with proven and probable IFD according to the European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria. To determine risk factors for IFD, a case-control study was also conducted. Cases were defined as liver transplant recipients with proven or probable IFD, and controls were defined as liver transplant recipients without IFD. Each case was matched to two controls by age (±10years of age), gender, and time of transplant (within one year of the case). 28/554 (5.1%) patients developed IFD. Candidiasis (n=11; 39.3%), Aspergillosis (n=10; 35.7%), and Cryptococcosis (n=3; 10.7%) were the most common fungal infections in the proven and probable IFD groups. Mold infections occurred in 13 (46.4%) cases. Reoperation, roux-en-y anastomosis, and massive intraoperative transfusion of ≥40 units of cellular blood products were major risk factors for IFD in the multivariate analysis. Candida and Aspergillus are the most common causes of IFD in liver transplantation in our center. There is significant overlap in risk factors for such infections post-transplantation. In our cohort, critically ill patients with complicated perioperative course seem to predispose them to mold infections post-transplantation, but larger studies are required to better delineate risk factors for mold infection as well as determine the efficacy and optimal duration of mold prophylaxis in liver transplantation. With increasing echinocandin use for antifungal prophylaxis, it is also important to monitor for emerging antifungal resistance.

Antifibrinolytic Drugs and Allogeneic Transfusion in Pediatric Multilevel Spine Surgery: A Propensity Score Matched Cohort Study.

Observational cohort study with propensity score matching. Determine whether antifibrinolytic drug use is associated with decreased allogeneic blood transfusion in multilevel pediatric spine surgery. Antifibrinolytic drugs are commonly used in adult multilevel spine surgery to reduce blood loss and allogeneic transfusion; however, only small studies have examined their efficacy in pediatric patients having multilevel spine surgery. Pediatric patients who had posterior multilevel spine surgery between 2016 and 2017 were identified in the national surgery quality improvement program participant use file. Propensity score matching was used to reduce bias from confounding and the rate of intraoperative allogeneic transfusion was compared between patients who received antifibrinolytic drugs and those who did not. Secondary outcomes included intraoperative cell saver volume, postoperative allogeneic transfusion, massive intraoperative transfusion, and adverse events including venous thromboembolism and seizure. A total of 6904 patients underwent posterior multilevel spine surgery during the study period and 83% received antifibrinolytics. The matched cohort included 604 patients. Antifibrinolytic use had no association with reduced intraoperative allogeneic transfusion: odds ratio (OR) = 0.71 (99% confidence interval [CI] = 0.40-1.26, P = 0.12) or cell saver volume, median volume = 114 mL (0, 250 mL) in antifibrinolytic group versus 100 mL (0, 246 mL) in control group, P = 0.04. There was also no association with reduced postoperative allogeneic transfusion OR = 1.23 (99% CI = 0.54-2.81, P = 0.52) or massive transfusion OR = 1.0 (99% CI = 0.34-2.92, P = 1.0). No patient in the matched cohort had a venous thromboembolism or seizure. Antifibrinolytic drugs are commonly used in pediatric multilevel spine surgery in the United States, but no efficacy was demonstrated in our study. There were no venous thromboembolisms or seizures implying an excellent safety profile in pediatric patients. 3.

Effect of Fluid Flow Rate on Efficacy of Fluid Warmer: An In Vitro Experimental Study.

Introduction In patients who require a massive intraoperative transfusion, cold fluid or blood transfusion can cause hypothermia and potential adverse effects. One method by which to prevent hypothermia in these patients is to warm the intravenous fluid before infusion. The aim of this study was to determine the effect of the fluid flow rate on the efficacy of a fluid warmer. Methods The room air temperature was controlled at 24°C. Normal saline at room temperature was used for the experiment. The fluid was connected to an infusion pump and covered with a heater line, which constantly maintained the temperature at 42°C. The fluid temperature after warming was measured by an insulated thermistor at different fluid flow rates (100, 300, 600, 900, and 1200 mL/h) and compared with the fluid temperature before warming. Effective warming was defined as an outlet fluid temperature of >32°C. Results The room temperature was 23.6°C ± 0.9°C. The fluid temperature before warming was 24.95°C ± 0.5°C. The outlet temperature was significantly higher after warming at all flow rates (p < 0.001). The increases in temperature were 10.9°C ± 0.1°C, 11.5°C ± 0.1°C, 10.2°C ± 0.1°C, 10.1°C ± 0.7°C, and 8.4°C ± 0.2°C at flow rates of 100, 300, 600, 900, and 1200 mL/h, respectively. The changes in temperature among all different flow rates were statistically significant (p < 0.001). The outlet temperature was >32°C at all flow rates. Conclusions The efficacy of fluid warming was inversely associated with the increase in flow rate. The outlet temperature was <42°C at fluid flow rates of 100 to 1200 mL/h. However, all outlet temperatures reached >32°C, indicating effective maintenance of the core body temperature by infusion of warm fluid.

Maxilary Suppurative Inflammation on Chronic Treatment with Bisphosphonates for Bone Metastasis – A Case Report

Abstract Introduction. Bisphosphonates represent a class of anti-resorbable bone care drugs that inhibit the function of active osteoclasts and reduce bone resorption. They are used in the Oncology and Hematology specialties as adjuvants in the treatment of osteolytic bone metastases and associate osteonecrosis of the maxillo-facial bones, most commonly of the mandible, as an adverse reaction. Material and method: case report. We present the case of a 65-years-old female patient, with breast cancer and bone metastasis, under chronic treatment with bisphosphonates. She presented a chronically odontogenic suppurative maxillary rhinosinusitis induced by maxillary post-extraction osteonecrosis on the background of bisphosphonate treatment and fistula in the upper right vestibule. Surgery under general anesthesia and sequestrectomy were performed. Discussion. The patient also associated coagulation disorders with mixed mechanism, adding an element of major surgical difficulty requiring a massive intraoperative transfusion with fresh refrigerated plasma to control hemostasis. Conclusions: The side effects of bisphosphonates used in the treatment of bone metastasis on the maxillofacial bones are significant. For this reason, the dental extraction in patients treated with bisphosphonates should be done with great caution and maxillary suppurative inflammation in post-extraction context in these patients should raise the suspicion of underlying bone necrosis.

Optimal Plasma Transfusion in Patients Undergoing Cardiac Operations With Massive Transfusion

Observational studies suggest that transfusion of high ratios of fresh frozen plasma (FFP) to red blood cells (RBCs) reduces mortality in severe hemorrhage. There are no studies examining the impact of the FFP to RBC transfusion ratio on mortality in massively transfused patients undergoing cardiac operations. A single-center retrospective cohort study was performed over an 8.5-year period. Massive transfusion was defined as at least 8 RBC units administered during the operation. Patients were classified as having received a high FFP/RBC ratio (greater than 1:1), a moderate ratio (between 1:1 and 1:2), or a low ratio (<1:2). Thirty-day survival was compared between groups using Kaplan-Meier analysis, and Cox proportional hazards modeling was used to identify variables associated with 30-day mortality. In-hospital mortality and postoperative morbidities were also compared between groups using regression analyses. Of 7,492 patients undergoing cardiac operations, 452 (6%) were massively transfused. Thirty-day mortality was 25.4% and in-hospital mortality was 30.6%. Patients with a high transfusion ratio had improved 30-day survival when compared with those with a low ratio (hazard ratio [HR] for death, 0.339; p= 0.002). High transfusion ratios were also associated with fewer reoperations for bleeding, less renal failure, more prolonged ventilation, and more atrial fibrillation compared with low ratios. A high transfusion ratio may improve survival in patients undergoing cardiac operations with massive intraoperative transfusion but may increase the risk for prolonged ventilation and atrial fibrillation.

Intraoperative Transfusion of Small Amounts of Blood Heralds Worse Postoperative Outcome in Patients Having Noncardiac Thoracic Operations

Massive intraoperative transfusion is associated with increased morbidity and mortality in patients undergoing noncardiac thoracic operations. We examined whether this association carries over to patients who receive only 1 to 2 units of packed red blood cells (PRBCs) during their operation. We queried the American College of Surgeon's National Surgical Quality Improvement Project database for patients undergoing noncardiac, nonvascular thoracic operations during a 5-year period. Patient 30-day morbidity (1 or more of 20 complications) and mortality were evaluated. We used propensity-score matching to minimize confounding when estimating the effect of transfusion on postoperative morbidity. We analyzed 8728 nonvascular thoracic operations in patients from 173 hospitals. Of these, 7875 (90.2%) did not receive intraoperative transfusions. The 579 patients (6.6%) who received 1 to 2 units of intraoperative PRBCs had higher unadjusted rates of wound problems, pulmonary complications, sepsis/shock, composite morbidity, mortality, and length of stay than those who did not receive transfusions. These rates further increased with postoperative transfusion of more than 2 units of intraoperative PRBC. After propensity adjustment, transfusion of 1 or 2 units of PRBCs increased the multivariate risk of composite morbidity, pulmonary complications, systemic sepsis, wound complications, and the postoperative length of stay compared with those who did not receive transfusions. In patients undergoing noncardiac thoracic operations, there is a dose-dependent adverse effect of intraoperative blood transfusion on outcomes, with even seemingly small amounts of blood (1 or 2 units of PRBCs) increasing morbidity and resource utilization. Clinicians should be cautious with intraoperative transfusions of 1 or 2 units of PRBC for mildly hypovolemic or anemic patients.

Multi-organ Early Tumor Dissemination After High Urgency Re-transplantation for Hepatocellular Carcinoma in Cirrhosis: Role of Massive Intraoperative Transfusion?

The recurrence rate of hepatocellular carcinoma (HCC) after liver transplantation (LT) ranges between 11 and 18% [1, 2]. Although the role of post-transplant immunosuppression is still unclear [3, 4], most recurrences seem to be related to malignant cells present but not identified at the time of transplantation and/or released during the transplant procedure. Patients whose explanted liver tumors are within currently accepted criteria for transplantation have a low rate of recurrence [5]. While partial tumor necrosis after performance of bridging treatments could result in earlier tumor recurrence post-transplant [6], 100% tumor necrosis is usually associated with very good results [7]. We report on a patient with unexpected multi-organ early tumor dissemination after an initial LT for a complete necrotic HCC in the setting of cirrhosis and a subsequent high urgency re-transplantation for primary non-function. The patient is a 55-year-old man with chronic hepatitis Binduced liver cirrhosis, Child-Turcotte-Pugh class A, and a solitary recurrent HCC meeting the Milan criteria in Segments VI/VIII. The patient had undergone a partial Segment VII resection in December 2003 for a solitary HCC (pT1 G1 V0). Follow-up examinations proved a local recurrence in Segment VI/VIII in January 2005. Further diagnostic workup (abdominal and thoracic computed tomography, bone scintigraphy, positron emission tomography) excluded further tumor manifestations. The patient was evaluated for LT and listed in ‘‘Eurotransplant’’. A computed tomography (CT)-guided radiofrequency ablation was performed for the 4.8 · 3.4 cm HCC in January 2005. Further follow-up studies with CT, magnetic resonance imaging, and positron emissions tomography (PET)-CT showed complete necrosis of the lesion. After a waiting time of 127 days, the patient received a deceased donor full-size liver graft. The last imaging studies were a magnetic resonance imaging and whole-body PET-CT 2 months prior to LT, showing a necrotic area in the ablated liver segment as well as no further malignancy. Intraoperative mismanagement of inferior vena cava and central venous pressure led to excessive bleeding and corresponding transfusion of 46 units of packed red blood cells, plasma, and coagulation factors. Pathological examination of the explanted liver showed 100% necrosis of the HCC lesion as well as no viable tumor in the setting of end-staged liver cirrhosis. The patient experienced primary graft non-function leading to multiorgan failure, and was re-listed as ‘‘high-urgency’’. Three days later he underwent an uneventful re-LT. Neither of the donors had any history or physical evidence of malignancy. After discharge, the patient was followed up at our outpatient liver transplant clinic. The first HCC imaging follow-up at 4 months post-transplant with abdominal and thoracic CT showed no evidence of HCC recurrence. The second HCC follow-up at 8 months post-transplant showed multifocal bilobar intrahepatic HCC recurrence, intraabdominal involved lymph nodes, and multiple bilateral pulmonary and axillary lymph nodes metastases. Percutaneous liver biopsy confirmed the diagnosis of HCC recurrence. Immunosuppression was switched to rapamycin. The patient opted to receive palliative chemotherapy, fully aware of its limited efficacy, and he died 21 months post-transplant. Although the tumor was a well-differentiated HCC without vascular invasion, radiofrequency ablation resulted G. C. Sotiropoulos (&) S. Beckebaum E. P. Molmenti C. G. Klein V. R. Cicinnati C. E. Broelsch M. Malago Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Hufelandstr. 55, 45122 Essen, Germany e-mail: georgios.sotiropoulos@uni-essen.de

Intracerebral hemorrhage after liver transplantation

We report 5 patients with intracerebral hemorrhage afterorthotopic liver transplantation (OLT) and identify the possible risk factors. Between November 1991 and April 1999, 75 adult patients received 77 orthotopic liver transplants at Queen Mary Hospital, Hong Kong. Five patients (6.5%) developed intracerebral hemorrhage postoperatively. Clinical and laboratory data were reviewed, and potential risk factors were analyzed. The 5 patients developed intracerebral hemorrhage within 40 days (range, 1 to 37 days; median, 4 days) after OLT The mortality rate was 80% (4 of 5 patients). The intraoperative blood transfusion volume (median, 17,200 mL; range, 15,750 to 30,360 mL) administered to patients who developed intracerebral hemorrhage postoperatively was significantly greater than that (median, 6,990 nil, range, 1,840 to 22,680 mL) for patients without the complication ( P = .0008). Massive intraoperative transfusion (> 15,000 mL) was required in all 5 patients (100%) with intracerebral hemorrhage but only 9 of 72 patients (12.5%) in the other group ( P = .0001). Four of 5 patients (80%) with intracerebral hemorrhage had intraoperative hypotension compared with 7 of 72 patients (9.7%) in the other group ( P = .001). No significant difference was found in age, prothrombin time (PT), activated partial thromboplastin time (APTT), incidence of hypertension, bleeding at extracerebral sites, cyclosporine A neurotoxicity, thrombocytopenia, hemodialysis, and sepsis between the patients with and without intracerebral bleeding. However, the median cumulative score of coagulation parameters (PT, APTT, platelet count) was significantly greater in the group with than without intracerebral bleeding (median score, 3 ν 1; P = .023). Intracerebral hemorrhage is 1 of the most disastrous complications after OLT Intraoperative hypotension, massive intraoperative transfusion, and coagulopathy may be correlated with this complication.

Intracerebral hemorrhage after liver transplantation.

We report 5 patients with intracerebral hemorrhage after orthotopic liver transplantation (OLT) and identify the possible risk factors. Between November 1991 and April 1999, 75 adult patients received 77 orthotopic liver transplants at Queen Mary Hospital, Hong Kong. Five patients (6.5%) developed intracerebral hemorrhage postoperatively. Clinical and laboratory data were reviewed, and potential risk factors were analyzed. The 5 patients developed intracerebral hemorrhage within 40 days (range, 1 to 37 days; median, 4 days) after OLT. The mortality rate was 80% (4 of 5 patients). The intraoperative blood transfusion volume (median, 17,200 mL; range, 15,750 to 30,360 mL) administered to patients who developed intracerebral hemorrhage postoperatively was significantly greater than that (median, 6,990 mL; range, 1,840 to 22,680 mL) for patients without the complication (P =.0008). Massive intraoperative transfusion (>15,000 mL) was required in all 5 patients (100%) with intracerebral hemorrhage but only 9 of 72 patients (12.5%) in the other group (P =.0001). Four of 5 patients (80%) with intracerebral hemorrhage had intraoperative hypotension compared with 7 of 72 patients (9.7%) in the other group (P =.001). No significant difference was found in age, prothrombin time (PT), activated partial thromboplastin time (APTT), incidence of hypertension, bleeding at extracerebral sites, cyclosporine A neurotoxicity, thrombocytopenia, hemodialysis, and sepsis between the patients with and without intracerebral bleeding. However, the median cumulative score of coagulation parameters (PT, APTT, platelet count) was significantly greater in the group with than without intracerebral bleeding (median score, 3 v 1; P =.023). Intracerebral hemorrhage is 1 of the most disastrous complications after OLT. Intraoperative hypotension, massive intraoperative transfusion, and coagulopathy may be correlated with this complication.

External jugular vein for rapid transfusion during surgery.

The most constant superficial veins for transfusion are the saphenous, cephalic, and external jugular. Frequently the veins of the extremities are unsuitable for massive intra-operative transfusion. In addition, peripheral transfusions are often accompanied by venous spasm. The external jugular vein offers an admirable site for venipuncture and rapid transfusion. The vessel is large, thin-walled, and distensible. The jugular route has proved invaluable during emergency cardiovascular operations, but is indicated whenever massive transfusion is contemplated, or peripheral sites are not readily available. The jugular vein is also more accessible to the anaesthetist during the operative procedure than the saphenous or cephalic veins. The external jugular may also be used for resuscitation preceding emergency operation, and for transfusion and fluid therapy postoperatively. Its use post-operatively is limited by the risk of air embolism and by the fact that many patients are emotionally disturbed by an infusion in this region. Possible complications are interstitial transfusion, cardiac failure from too-rapid transfusion, and venous air embolism.