Perioperative Red Cell Transfusion Research Articles

Acute kidney injury following cardiopulmonary bypass in Jamaica

ObjectivesThe study objectives were to describe the incidence, risk factors, and outcomes of acute kidney injury after cardiopulmonary bypass in Jamaica. MethodWe performed a review of the medical records of adult patients (aged ≥ 18 years) with no prior dialysis requirement undergoing cardiopulmonary bypass at the University Hospital of the West Indies, Mona, between January 1, 2016, and June 30, 2019. Demographic, preoperative, intraoperative, and postoperative data were abstracted. Acute kidney injury was defined using Kidney Disease Improving Global Outcomes criteria. The primary outcomes were acute kidney injury incidence and all-cause 30-day mortality. Multivariable logistic regression and Cox proportional analyses were used to examine the association between the acute kidney injury risk factors and the primary outcome. ResultsData for 210 patients (58% men, mean age 58.1 ± 12.9 years) were analyzed. Acute kidney injury occurred in 80 patients (38.1%), 44% with Kidney Disease Improving Global Outcomes I, 33% with Kidney Disease Improving Global Outcomes II, and 24% with Kidney Disease Improving Global Outcomes III. From multivariable logistic regression models, European System for Cardiac Operative Risk Evaluation II (odds ratio, 1.19; 95% confidence interval, 1.01-1.39 per unit), bypass time (odds ratio, 1.94; 95% confidence interval, 1.40-2.67 per hour), perioperative red cell transfusion (odds ratio, 3.03; 95% confidence interval, 1.36-6.76), and postoperative neutrophil lymphocyte ratio (odds ratio, 1.65; 95% confidence interval, 1.01-2.68 per 10-unit difference) were positively associated with acute kidney injury. Acute kidney injury resulted in greater median hospital stay (18 vs 11 days, P < .001) and intensive care unit stay (5 vs 3 days, P < .001), and an 8-fold increase in 30-day mortality (hazard ratio, 8.15; 95% confidence interval, 2.76-24.06, P < .001). ConclusionsAcute kidney injury after cardiopulmonary bypass surgery occurs frequently in Jamaica and results in poor short-term outcomes. Further studies coupled with quality interventions to reduce the mortality of those with acute kidney injury are needed in the Caribbean.

Society of Cardiovascular Anesthesiologists Clinical Practice Update for Management of Acute Kidney Injury Associated With Cardiac Surgery.

Cardiac surgery-associated acute kidney injury (CS-AKI) is common and is associated with increased risk for postoperative morbidity and mortality. Our recent survey of the Society of Cardiovascular Anesthesiologists (SCA) membership showed 6 potentially renoprotective strategies for which clinicians would most value an evidence-based review (ie, intraoperative target blood pressure, choice of specific vasopressor agent, erythrocyte transfusion threshold, use of alpha-2 agonists, goal-directed oxygen delivery on cardiopulmonary bypass [CPB], and the "Kidney Disease Improving Global Outcomes [KDIGO] bundle of care"). Thus, the SCA's Continuing Practice Improvement Acute Kidney Injury Working Group aimed to provide a practice update for each of these strategies in cardiac surgical patients based on the evidence from randomized controlled trials (RCTs). PubMed, EMBASE, and Cochrane library databases were comprehensively searched for eligible studies from inception through February 2021, with search results updated in August 2021. A total of 15 RCTs investigating the effects of the above-mentioned strategies on CS-AKI were included for meta-analysis. For each strategy, the level of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Across the 6 potentially renoprotective strategies evaluated, current evidence for their use was rated as "moderate," "low," or "very low." Based on eligible RCTs, our analysis suggested using goal-directed oxygen delivery on CPB and the "KDIGO bundle of care" in high-risk patients to prevent CS-AKI (moderate level of GRADE evidence). Our results suggested considering the use of vasopressin in vasoplegic shock patients to reduce CS-AKI (low level of GRADE evidence). The decision to use a restrictive versus liberal strategy for perioperative red cell transfusion should not be based on concerns for renal protection (a moderate level of GRADE evidence). In addition, targeting a higher mean arterial pressure during CPB, perioperative use of dopamine, and use of dexmedetomidine did not reduce CS-AKI (a low or very low level of GRADE evidence). This review will help clinicians provide evidence-based care, targeting improved renal outcomes in adult patients undergoing cardiac surgery.

Changes in perioperative red cell transfusion practice over time in patients undergoing surgery for upper gastrointestinal and liver cancer: a retrospective cohort study at a single tertiary centre.

ObjectivesOptimum transfusion trigger for adults undergoing cancer surgery is uncertain. Published guidelines recommend restrictive transfusion strategies in hospitalised adults. We aimed to measure the red cell transfusion rate and haemoglobin trigger in patients undergoing cancer surgery and how closely practice reflected published guidelines.DesignRetrospective cohort study.SettingSingle tertiary centre.ParticipantsAdult patients undergoing surgery for upper gastrointestinal or liver malignancy.ExposurePostguideline change (2015–2017) versus preguideline change (2011–2012).Outcome measuresPrimary: transfusion rate, secondary: transfusion trigger. Multivariable logistic regression was used to assess factors and adjust for confounders affecting our outcome measures.Results1578 surgical records were identified for 1520 patients. 946/1530 (62%) patients had preoperative anaemia. The transfusion rate decreased from 23% in 2011–2012 to 14% in 2015–2017. This change remained significant after adjusting for other variables associated with transfusion rates. Mean pretransfusion haemoglobin in those who were transfused was 78±13 g/L in 2011–2012 and 80±15 g/L in 2015–2017. This change in haemoglobin transfusion triggers was not significant.ConclusionTransfusion rate has decreased over the study period in patients undergoing surgery for malignancy and is consistent with a restrictive transfusion strategy.

A retrospective file audit of preoperative anaemia in patients referred to an anaesthesiology clinic before elective orthopaedic surgery

ABSTRACT BACKGROUND: Preoperative anaemia has been shown to be associated with increased postoperative morbidity and mortality, prolonged hospital stay, and increased allogeneic blood transfusions. With elective surgery there is time to manage preoperative anaemia. The aim was to determine the prevalence of preoperative anaemia and evaluate how anaemia was investigated and managed in adult patients who were referred from the Orthopaedic Clinic to the Universitas Academic Hospital Anaesthesiology Clinic between January 2016 and December 2018 METHODS: The retrospective file audit included patient demographics, comorbidities and chronic medication, indication for elective surgery, haemoglobin level at first clinic visit, laboratory investigations done for anaemia, dates of clinic visits and surgery, whether the anaemia was corrected before surgery, and if there were any perioperative red cell transfusions RESULTS: A total of 178 patients were included. The cut-off value for anaemia was 13 g/dL in both sexes. Forty-four patients (25%, 95% CI 19-32%) had preoperative anaemia with a median haemoglobin of 12.25 g/dL (IQR 11.2; 12.7). Their mean age was 63.3 (SD ± 10.0) years. Fifteen patients (34%) were booked for knee arthroplasty and 24 patients (55%) for hip replacement surgery. No workup was done for the anaemia, and only 15/44 (34%) anaemic patients received any form of treatment. Eighteen anaemic patients (41%) received perioperative red cell transfusions. Eight of the transfused patients (44%) developed postoperative sepsis, while five were still anaemic postoperatively CONCLUSION: The prevalence of preoperative anaemia before elective orthopaedic surgery (25%) was the same as that reported before patient blood management was introduced internationally. None of the anaemic patients had a diagnostic workup and therefore did not receive therapy targeted at the cause of the anaemia. Perioperative red cell transfusions could have been significantly reduced. The clinic now focuses on managing preoperative anaemia Level of evidence: Level 3 Keywords: preoperative anaemia, elective orthopaedic procedures, patient blood management, preoperative care, blood transfusion

Prevalence of iron deficiency and red blood cell transfusions in surgical patients.

Background and ObjectivesWhile iron deficiency (ID) is the most common cause of anaemia, little is known about the prevalence and type of ID in preoperative surgical patients. The aims of the present study were to investigate the prevalence and types of ID in a large cohort of surgical patients, and how these are related to perioperative blood use after correction for confounders such as haemoglobin level.Materials and MethodsData were retrospectively extracted from electronic case records of all patients who underwent elective surgery between September 2016 and November 2017 (n = 2711). Iron parameters, haemoglobin and details of perioperative red cell transfusions were collected.ResultsOf 2711 patients, 618 (22.8%) were iron deficient (= transferrin saturation [TSAT] < 16%) preoperatively, 173 (6.4% of the cohort) had an absolute iron deficiency (AID; TSAT < 16% and ferritin < 30 μg/L) and 445 (16.4%) had functional/mixed ID (TSAT < 16% and ferritin ≥ 30 μg/L). Corrected for Hb level, iron‐deficient patients received significantly more red cell units than patients without ID (p = 0.026). AID was not associated with a significantly higher incidence of transfusions (7.5% of patients transfused; p = 0.12 after correction for Hb) than patients without ID, whereas patients with functional/mixed deficiency did receive significantly more transfusions (6.1%; p = 0.021) as compared to patients without ID (1.7%).ConclusionPreoperative ID, in particular the functional/mixed type, was associated with a higher risk of receiving perioperative red cell transfusions as compared to patients without ID. Adequately treating ID might, therefore, reduce the need for perioperative red cell transfusions.

Evaluation of Hemoglobin Trigger and Appropriateness of Perioperative Red Cell Transfusion in Surgical Departments

Evaluation of Hemoglobin Trigger and Appropriateness of Perioperative Red Cell Transfusion in Surgical Departments

Use of prothrombin complex concentrate for management of coagulopathy after cardiac surgery: a propensity score matched comparison to plasma

BackgroundAn important cause of coagulopathy in cardiac surgery is impaired thrombin generation. While plasma is often used to correct this element of the coagulopathy, studies in vitro suggest that prothrombin complex concentrates (PCCs) might be more effective. Comparative data, however, are scant. MethodsWe compared the outcomes of those who received only plasma with those who received PCCs (with or without plasma) for management of coagulopathy in patients who underwent cardiac surgery with cardiopulmonary bypass at a single institution from 2012 to 2016. Propensity score matching was used to obtain between-group balance. Primary outcome was avoidance of perioperative red cell transfusions. Other outcomes were incidence of massive transfusion (more than nine red cell units), refractory bleeding (requiring factor VIIa), and adverse events. ResultsOf 6362 patients, 1151 (18.2%) received plasma without any PCCs, and 204 (3.2%) received PCCs, either with (n=125) or without plasma (n=79). Overall, patient risk-profile was higher in the PCCs group. In a well-balanced propensity score match that included 117 patients per group, the odds ratio (OR) for red cell avoidance was 2.4-fold [95% confidence interval (CI) 1.2–4.8] higher in the PCCs group. Massive transfusion (OR 0.58; 95% CI 0.33–1.0) and refractory bleeding (OR 0.49; 95% CI 0.24–1.03) incidences were almost significantly lower in the PCCs group. The adverse event profiles were similar. ConclusionsOur exploratory study suggests that the use of PCCs as part of a multifaceted coagulation management strategy may have blood-sparing effects. Their incorporation into clinical practice, however, must await determination of their risk-benefit profile via multicentre randomised trials.

Correcting preoperative iron deficiency as part of patient blood management in the ‘real world’: results of an audit on an Australian cohort

BackgroundThe perioperative module of the Australian Patient Blood Management guidelines recommended preoperative iron therapy for surgical patients with, or at risk of, iron deficiency anaemia. After implementing a preoperative haemoglobin optimization programme in our institution, an audit was undertaken to evaluate the benefit of preoperative iron therapy in ‘real world’ clinical practice.MethodsElective major surgery patients assessed in surgical pre‐admission clinics from 1 July 2013 to 30 June 2014 were screened for iron deficiency and anaemia. Those who were iron deficient (ferritin &lt;30 μg/l), regardless of haemoglobin level, received either daily oral iron supplementation until day of surgery or intravenous iron polymaltose 1 g preoperatively (intervention group). Control patients who were not iron deficient were matched to the intervention group using propensity scores based on age, sex and surgical unit. The primary end‐point was the proportion of patients requiring perioperative red cell transfusion in intervention and control groups.ResultsOne hundred and fourteen patients (8·75%) had iron deficiency. Ninety‐three patients received preoperative iron therapy, 17 (18·3%) of whom required red cell transfusions postoperatively. Of the 332 control patients, 71 (21·4%) required red cell transfusion. After adjusting for preoperative haemoglobin and time from screening to surgery, the odds of red cell transfusion were significantly lower in the intervention group compared to controls (odds ratio: 0·512, 95% confidence interval: 0·268–0·977; P = 0·04).ConclusionPreoperative iron therapy was associated with reduced need for postoperative red blood cell transfusion in elective major surgery patients who were initially iron deficient.

Implementation of a Preoperative Anemia Management Clinic in a Tertiary Academic Medical Center

Background:Preoperative anemia is commonly encountered with a reported incidence of 5-75% in elective presurgical populations. Anemia is an independent risk factor for perioperative morbidity and mortality and is a strong predictor of perioperative blood transfusion. Approximately 50% of all blood transfusions occur in the perioperative setting and transfusions are a significant financial burden for healthcare institutions. Although preoperative anemia management has been shown to reduce transfusion requirements and improve perioperative outcomes, the optimal delivery model for this service remains unclear. We describe the implementation of a novel preoperative anemia management clinic (AMC) workflow and report patient volume trends since its implementation in Jan 2015 at the University Of Iowa Hospitals & Clinics.Methods:We identified patients undergoing elective high blood loss (HBL) surgical procedures (defined as predicted blood loss >500 cc) with a preoperative hemoglobin (Hb) <12 g/dl as the target population for preoperative anemia management. We identified HBL procedures by ICD codes using information derived from our institutional maximum surgical blood-ordering schedule (MSBOS), intraoperative estimated blood loss (EBL) data from the electronic medical record (EMR) and surgical provider input. In calendar year 2014, 3262 elective HBL surgical patients were identified, out of which 452 (13.9%) received perioperative red cell transfusions. 232 (51.3%) of these patients had a preoperative Hb <12 g/dl. 61 (26%) of these patients were transfused 1 unit PRBCs, 62 (27%) were transfused 2 units and the remaining 109 (47%) patients were transfused > 2 units. Assuming 1- 2 unit transfusions were preventable by preoperative anemia managment, the calculated cost savings to the institution by avoiding these transfusions was estimated to be $200,000/year, not including potential improvement in length of stay. Using these data as baseline, a business plan for an AMC was presented to and approved by our hospital administration. An outpatient clinic was initiated in a temporaray location in early 2015 and later moved to a permanent location with infusion capabilities in August 2015 with two full time staff including a nurse practitioner and a medical assistant supervised by a nurse manager and a medical director. To streamline workflow, a stepwise algorithm for diagnosis and management of anemia was created by a multidisciplinary team that included Hematology, Anesthesiology, Surgery, Internal Medicine, Nursing and Pharmacy. We established referral mechanisms primarily from surgical clinics via automatic EMR alerts for elective HBL procedures linked to case scheduling through the EMR and secondarily through direct outpatient consultations.Results:We observed an overall trend of reduction in the percentage of patients transfused perioperatively in the two quarters following implementation of the preoperative AMC compared with the preceding quarterly intervals since Jan 2014 (Figure). In the same time period we observed a steady increase in number of patient visits to the AMC and number of iron infusions administered. Patient visits and iron infusions more than doubled in the first two quarters of 2016 compared to same time period in 2015 (594 vs 195 and 366 vs 124 respectively). There was a significant reduction in average length of stay (2.78 days) for patients who received transfusions after an AMC visit compared with patients who were not seen in the AMC.Conclusions:Implementation of a structured preoperative anemia management clinic (AMC) with an automatic referral workflow is feasible at a large academic medical center and appears to result in reductions in blood transfusions and hospital length of stay. The heterogeneity of our surgical population and the short timespan since implementation of the AMC are limitations of this analysis. We have ongoing efforts to minimize system errors in our referral mechanisms (ie appropriate EMR alerts to surgeons) and enhance surgical provider education to maximize preoperative anemia management opportunities. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Romiplostim in Management of the Thrombocytopenic Surgical Patient

Background: The thrombopoietin (TPO) mimetics are FDA-approved for the treatment of chronic immune thrombocytopenia (ITP) and have the potential for use in several additional clinical settings. At our institution, the TPO-mimetic romiplostim has been used to boost platelet counts in the perioperative setting.Objective: Use of romiplostim for perioperative thrombocytopenia was examined with regards to patient characteristics, dosing and duration of use, success in achieving platelet counts high enough for surgery, and clinical outcomes.Methods: A retrospective review of patients with thrombocytopenia who received romiplostim prior to an operative intervention in 2010-2014 was performed. Inclusion criteria included age 18 or older, thrombocytopenia (baseline platelet count <150,000/uL), administration of at least one dose of romiplostim, and documentation of platelet counts before and after administration of romiplostim.Results: 18 patients undergoing 22 procedures were included. Median age at surgery was 61 years (range 47-74). Etiologies of baseline thrombocytopenia (some patients had more than one) included mild ITP (not on romiplostim at baseline) in 8 patients, liver disease in 12 patients (5 with hepatitis C, 2 with hepatitis B, 2 with alcoholic cirrhosis, 1 with fatty liver, and 2 with hepatocellular carcinoma), hematologic malignancy in 4 patients (2 with lymphoma, 1 with MDS, and 1 with myeloma) and drug-related thrombocytopenia in 3 patients (2 chemotherapy induced and 1 antibiotic-related). 3 patients were Jehovah’s witnesses. Median platelet count at time of romiplostim initiation was 46,500/uL (range, 11,000-120,000) and median starting dose of romiplostim was 2.5 mcg/kg (range 1-7.5). Patients remained on romiplostim for a median of 5 weeks prior to surgery (receiving doses on average once weekly) and while on therapy the dose of romiplostim was changed on average one time. Procedures performed included 5 orthopedic surgeries (3 total hip replacements, 1 total knee replacement, and 1 open reduction/internal fixation), 3 open cardiac surgeries, 2 cholecystectomies, 2 EGD/colonoscopies, 2 biopsies of masses, and 1 each of: angioplasty and stenting, dental extraction, eyelid resection, liver biopsy, lung resection, prostate surgery, spinal surgery, and a TACE procedure. Median platelet count at the time of surgery was 144,000/uL (range 28,000-370,000). All patients had a rise in platelet count between time of initiation of romiplostim and time of surgery (see Figure); median rise was 97,500/uL (range 17,000-252,000). There were no surgical delays or cancellations for thrombocytopenia. Four bleeding events occurred: one thigh hematoma (at a platelet count of 185,000/uL), one episode of hematemesis (at a platelet count of 98,000/uL), one episode of melena (at a platelet count of 88,000/uL), and one persistent oozing from a tooth extraction (platelets 82,000/uL). Four patients received perioperative platelet transfusions and 3 received perioperative red cell transfusions. One patient developed a Foley-catheter associated clot after prostate surgery. No other thromboembolic events were recorded during the time of romiplostim administration and for up to 30 days following the last dose.Conclusions: 18 patients with thrombocytopenia due to several conditions (primarily ITP and liver disease) received romiplostim prior to 22 surgical procedures. Romiplostim prompted a rise in platelet count in all patients, allowing all planned procedures to be performed without delays or cancellations for thrombocytopenia. Few patients received perioperative platelet transfusions. Four bleeding episodes occurred (none in the context of significant thrombocytopenia), and one patient developed a clot (likely procedure-related). Romiplostim may be of clinical utility in the preoperative management of thrombocytopenic patients, and further trials are indicated. [Display omitted] DisclosuresOff Label Use: Romiplostim (Nplate) used for periprocedural management of thrombocytopenia. Kuter:Amgen: Research Funding.

Efficacy and Safety of Erythropoietin and Intravenous Iron in Perioperative Blood Management: A Systematic Review

The use of erythropoietin (EPO) and intravenous (IV) iron as bloodless therapeutic modalities is being explored in the current era of restrictive transfusion strategies and perioperative blood management. It is unclear, however, whether the evidence in the literature supports their safety and efficacy in reducing perioperative red cell transfusions. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we conducted a systematic review to evaluate their use in a variety of perioperative settings. We performed a literature search of English articles published between July 1997 and July 2012 in MEDLINE via PubMed, The Cochrane Library, and CINAHL. Only studies with a comparator group were eligible for inclusion. Twenty-four randomized controlled trials (RCTs) and 15 nonrandomized studies were included in the final review. Using the Cochrane risk of bias tool, 8 RCTs were assessed to be at low risk for methodological bias. Of these, however, only 4 RCTs were adequately powered to detect a reduction in transfusion rates. Patients with preoperative iron deficiency anemia may have an earlier and more robust hemoglobin recovery with preoperative IV iron therapy than with oral iron supplementation. A short preoperative regimen of EPO, or a single dose of EPO plus IV iron in the preoperative or intraoperative period, may significantly reduce transfusion rates (number needed to treat to avoid any transfusion ranged from 3 to 6). With regard to the safety of erythropoietin-stimulating agent therapy, IV iron appears to be as well tolerated as oral iron; however, the incidence of severe anaphylactic-type reactions attributable to IV iron is difficult to estimate in prospective trials because of its relatively infrequent occurrence. Furthermore, EPO may increase the risk of thromboembolism in spinal surgery patients who receive mechanical antithrombotic prophylaxis in the perioperative period so pharmacological thromboprophylaxis is advised. Future low risk of bias, adequately powered prospective efficacy, and safety trials in various surgical settings that traditionally require red cell transfusions would be required to make evidenced-based conclusions about the clinical significance of erythropoietin-stimulating agent as a transfusion avoidance strategy in perioperative blood management.

Pancreatoduodenectomy With or Without Early Ligation of the Inferior Pancreatoduodenal Artery: Comparison of Intraoperative Blood Loss and Short‐Term Outcome

Some of the significant predictive risk factors for complications after pancreatoduodenectomy are increased intraoperative blood loss and the need for blood transfusion. The impact of pancreatoduodenectomy (PD) with early ligation of the inferior pancreatoduodenal artery (IPDA) on intraoperative blood loss and short-term outcomes is not well known. A retrospective review of patients who underwent standard PD (n=112) and pancreatoduodenectomy with early ligation of the IPDA (n=175) was undertaken. Early ligation of the IPDA, body mass index, sex, and operative time were independent risk factors for intraoperative blood loss. Intraoperative median blood loss in patients with early ligation of the IPDA was 380ml, which was significantly lower than 850ml in patients who had a standard PD (p<0.001). Although 51 patients (46%) with standard PD needed a perioperative blood transfusion, only four patients (2%) with early ligation of the IPDA received a perioperative red cell transfusion (p<0.001). The overall complication rates were 61% for patients with standard PD versus 45% for patients with early ligation of the IPDA (p=0.007). There were five in-hospital deaths (4.5%) of patients with standard PD versus zero in-hospital deaths (0.0%) of patients with early ligation of the IPDA (p=0.002). Early ligation of the inferior pancreatoduodenal artery not only reduced intraoperative blood loss during PD but also alleviated postoperative morbidity and mortality.

Two-surgeon technique of parenchymal transection contributes to reduced transfusion rate in patients undergoing major hepatectomy: Analysis of 1,557 consecutive liver resections

Blood transfusions are an independent risk factor for adverse outcomes after hepatectomy. In-hospital transfusions are still reported in one third of patients in major series. Data on factors affecting blood transfusions in large series of liver resection are limited. The aim of this study was to evaluate factors predictive of blood transfusion in hepatectomies performed at a tertiary referral center. Records of 1,477 patients who underwent 1,557 liver resections between 1998 and 2007 were reviewed. Multivariate analysis of risk factors for red cell transfusion was performed. Median intra-operative blood loss was 250 cc, and 30-day peri-operative red cell transfusion rate was 27%. On multivariate analysis, factors that significantly predicted increased red cell transfusion rates were female sex, pre-operative hematocrit<30%, platelet count<100,000/mm3, simultaneous resection of other organs, major hepatic resection, use of the Pringle maneuver, and tumors>10 cm. Parenchymal transection technique was an independent risk factor for perioperative red cell transfusion; the usage of the 2-surgeon technique (combined saline-linked cautery and ultrasonic dissection) was associated with a lower transfusion rate than other techniques, including ultrasonic dissection alone, finger fracture, and stapling (P<.001). Although most factors that affect the red cell transfusion rate for liver resection are patient- or tumor-related, the parenchymal transection technique is under the surgeon's control. The decrease in transfusion rate associated with the use of the 2-surgeon technique emphasizes the important role of the hepatobiliary surgeon in determining outcomes after liver resection.

Preoperative portal vein embolization for extended hepatectomy.

To examine the authors' experience with preoperative ipsilateral portal vein embolization (PVE) and assess its role in extended hepatectomy. Extended hepatectomy (five or more liver segments) has been associated with higher complication rates and increased postoperative liver dysfunction than have standard hepatic resections involving lesser volumes. Recently, PVE has been used in patients who have a predicted (postresection) future liver remnant (FLR) volume less than 25% of total liver volume in an attempt to increase the FLR and reduce complications. Sixty patients from 1996 to 2002 were reviewed. Thirty-nine patients had PVE preoperatively. Eight patients who had PVE were not resected either due to the discovery of additional unresectable disease after embolization but before surgery (n = 5) or due to unresectable disease at surgery (n = 3). Therefore, 31 patients who had PVE subsequently underwent extended hepatic lobectomy. A comparable cohort of 21 patients who had an extended hepatectomy without PVE were selected on the basis of demographic, tumor, and liver volume characteristics. Patients had colorectal liver metastases (n = 30), hepatocellular carcinoma (n = 15), Klatskin tumors (n = 9), peripheral cholangiocarcinoma (n = 3), and other tumors (n = 3). The 52 resections performed included 42 extended right hepatectomies, 6 extended left hepatectomies, and 4 right hepatectomies extended to include the middle hepatic vein and the caudate lobe but preserving the majority of segment 4. Concomitant vascular reconstruction of either the inferior vena cava or hepatic veins was performed in five patients. There were no differences between PVE and non-PVE groups in terms of tumor number, tumor size, tumor type, surgical margin status, complexity of operation, or perioperative red cell transfusion requirements. The predicted FLR was similar between PVE and non-PVE groups at presentation. After PVE the FLR was higher than in the non-PVE group. No complications were observed after PVE before resection. There was no difference in postoperative mortality, with one death from liver failure in the non-PVE group and no operative mortality in the PVE group. Postoperative peak bilirubin was higher in the non-PVE than the PVE group, as were postoperative fresh-frozen plasma requirements. Liver failure (defined as the development of encephalopathy, ascites requiring sustained diuretics or paracentesis, or coagulopathy unresponsive to vitamin K requiring fresh-frozen plasma after the first 24 hours postresection) was higher in the non-PVE patients than the PVE patients. The hospital stay was longer in the non-PVE than the PVE group. Preoperative PVE is a safe and effective method of increasing the remnant liver volume before extended hepatectomy. Increasing the remnant liver volume in patients with estimated postresection volumes of less than 25% appears to reduce postoperative liver dysfunction.

Use of blood products for elective surgery in 43 European hospitals

SUMMARY. The objective of this study was to assess the use of blood products and artificial colloids in six commonly performed elective surgical procedures in 43 teaching hospitals in 10 European countries. 7,195 patient data were analysed. For each product wide differences were found between hospitals, both in the proportion of patients transfused and the amount of product used for the same patient category. Adjustment for age, gender, preoperative haematocrit and blood loss, left major differences among hospitals in patient red unit transfusion. Hospitals in the Mediterranean area used less albumin and artificial colloids and more autotransfusion than those of central‐northern Europe. The reasons for perioperative red cell transfusion were stated in the patient's medical record for 23% of patients. The ratio of preoperative blood request to transfusion was maximal in cholecystectomy, where it exceeded 10. The documentation of blood request and transfusion, and of transfusion complications in medical records, did not fully agree with that in the transfusion service in 49, 53 and 92% of the hospitals, respectively.The wide differences in blood product used for the same patient category were due to a variety of causes of which only some could be explained by the clinical factors taken into account. This suggests that consensus conferences and guidelines have so far had a limited impact on transfusion practice in many clinical units, even in teaching environments.

Preoperative transfusion in sickle cell anemia

American Journal of HematologyVolume 38, Issue 2 p. 156-157 Letter to the EditorFree Access Preoperative transfusion in sickle cell anemia Samuel Charache, Samuel Charache Professor of Medicine and Laboratory Medicine Johns Hopkins University School of Medicine Baltimore, MarylandSearch for more papers by this author Samuel Charache, Samuel Charache Professor of Medicine and Laboratory Medicine Johns Hopkins University School of Medicine Baltimore, MarylandSearch for more papers by this author First published: October 1991 https://doi.org/10.1002/ajh.2830380220Citations: 5AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. References 1 National Institutes of Health: Perioperative red cell transfusion. Cons Dev Conf Statement 7: 1– 6, 1988. 2 National SCA Preoperative Transfusion Study Group: Preoperative transfusion in sickle cell anemia (abstract). Blood 74: 184a, 1989. 3 Lane PK, Embury SH, Toy PTCY: Oxygen-induced marrow red cell hypoplasia leading to transfusion in sickle painful crisis. Am J Hematol 27: 67– 68, 1988. 4 Taylor C, Rogers G, Goodman C, Baynes RD, Bothwell TH, Bezwoda WR, Kramer F, Hattingh J: Hematologic, iron-related, and acute-phase protein responses to sustained strenuous exercise. J Appl Physiol 62: 464– 469, 1987. 5 Schooley JC, Kullgren B, Allison AC: Inhibition by interleukin-1 of the action of erythropoietin on erythroid precursors and its possible role in the pathogenesis of hypoplastic anaemias. Br J Haematol 67: 11– 7, 1987. 6 Maury CPJ, Lahdevirta J: Correlation of serum cytokine levels with haematological abnormalities in human immunodeficiency virus infection. J Int Med 227: 253– 257, 1990. 7 Owren PA: Congenital hemolytic jaundice. The pathogenesis of the “hemolytic crisis”. Blood, 3: 231– 248, 1948. 8 Pattison JR, Jones SE, Hodgson J: Parvovirus infections and hypoplastic crisis in sickle cell anaemia. Lancer 1: 664– 665, 1981. Citing Literature Volume38, Issue2October 1991Pages 156-157 ReferencesRelatedInformation

Red blood cell transfusions for anemia

N THE LAST FOUR decades many advances have increased the safety and effectiveness of blood transfusion, t'2 including the identification of numerous clinically significant red cell antigens and antibodies. The risk of contracting transfusiontransmitted diseases has been vastly reduced by donor testing and thorough history screening. Technological developments have all but eliminated the use of whole blood, with most units being separated into components soon after blood donation. Concentrated products, such as packed red cells, maximize therapeutic benefit while limiting the risk of circulatory overload. This advance has had a significant impact on the treatment of oncology patients. Highly toxic treatment regimens, combined with aggressive transfusion support, are decreasing the morbidity and mortality of malignant disease and treatment. In spite of refinements in transfusion medicine practice which have made red blood cell (RBC) transfusion seem simple and safe, there are still potentially serious consequences. Approximately l in 100 transfusions is accompanied by fever, chills, or urticaria. Although these reactions are usually mild, 1 in 6,000 RBC transfusions results in an acute or delayed hemolytic reaction. Thirty fatal transfusion reactions are reported each year, almost all related to errors involving ABO incompatibility. The chance of contracting the human immunodeficiency virus (HIV) through transfusion is estimated to be 1 in 150,000, while 1 in 500 multiple-transfused recipients develop abnormal liver function studies, indicating some type of viral hepatitis) At the 1988 National Institutes of Health (NIH) Consensus Conference on Perioperative Red Cell Transfusion, experts in the field presented data which indicate that patients with hemoglobin levels below 10 g/dL do not have an increased incidence of surgical complications. There is no increase in anesthesia-induced hypotension or cardiac arrythmias, and wound healing is not delayed if perfusion remains adequate. 4 The recommendation resulting from the conference--to abolish hemoglobin trigger values and determine transfusion needs by the patient's clinical statushas significantly changed transfusion medicine practice.

Summary of NIH consensus development conference on perioperative red cell transfusion

Summary of NIH consensus development conference on perioperative red cell transfusion

National Institutes of Health Consensus Development Conference on Perioperative Red Cell Transfusion

National Institutes of Health Consensus Development Conference on Perioperative Red Cell Transfusion

NIH Consensus Statement available on perioperative red cell transfusion.

NIH Consensus Statement available on perioperative red cell transfusion.