Rapid Infusion System Research Articles

Clinical Implications of a Persistent Left Superior Vena Cava in a Patient With Right Superior Vena Cava Thrombosis Undergoing Emergency Deceased Donor Liver Transplantation: A Case Report

Persistent left superior vena cava (PLSVC) is the most common congenital thoracic venous anomaly. It is usually found incidentally on examination or during invasive procedures. In most cases, the blood flows back to the right atrium through the coronary sinus without hemodynamic abnormalities and it is usually asymptomatic. There is some controversy regarding the clinical use of PLSVC. In a few cases, a PLSVC has been used for hemodialysis or large-bore intravenous access. A 62-year-old woman with a previous hepatectomy for hepatocellular carcinoma and liver cirrhosis developed hepatic failure. Owing to her worsening condition, she needed liver transplantation (LT). However, a superior vena cava thrombus was found between the right atrium and proximal superior vena cava on preoperative transesophageal echocardiography. Usually, right-sided central venous catheterization is performed for LT preparation, but the embolic risk was very high in our patient. Fortunately, she had already been diagnosed with PLSVC. Therefore, we decided to perform fluoroscopy-guided catheterization through the PLSVC. For the safe use of a PLSVC catheter during surgery, the rapid infusion system pressure, coronary sinus inflow pressure, and intraoperative transesophageal echocardiography were monitored. The patient successfully underwent LT. Based on a literature review and this case, PLSVC can be used clinically when accompanied by a detailed history, preoperative imaging examination, and close intraoperative monitoring. We suggest that a PLSVC is a feasible alternative to central venous access for LT.

Effects of a Single Rapid Infusion System on Platelet Function in Stored Whole Blood: An Ex Vivo Study

IntroductionRapid infusion systems (RIS) are used to warm and rapidly infuse crystalloids and blood products. Current guidelines do not approve of platelet transfusion through a RIS, but data supporting these guidelines are scarce. Our hypothesis was that an infusion of whole blood through a RIS would degrade platelet quantity, impede viscoelastic clot strength, and inhibit platelet aggregation response to adenosine diphosphate pathway (ADP) activation.MethodsTen iterations of a simulated scenario of transfusing whole blood via a single brand and make of RIS (Belmont Fluid Management System 2000, Belmont Medical Technologies, Billerica, MA) were performed. Units of whole blood, which were two to nine days old, were leukoreduced prestorage. Blood was used to prime the RIS and then warmed and infused at 100 mL/min into a reservoir. Blood samples were collected before and immediately after infusion. Samples were tested for platelet count, size, and viscoelastic clot strength using thromboelastographic and aggregation assays.ResultsThe study sample (n = 10) included platelets with an average age of 5.3 days. The infusion through the RIS had a detrimental effect on all the maximal amplitudes (MA) of viscoelastic testing: MA ADP (mean difference = −18.7 mm; 95% CI: −24.1 to −13.3, P = 0.004), MA rapid thromboelastography (MA rTEG) (mean difference = −6.0; 95% CI: −10.0 to −2.0, P = 0.008), MA TEG (mean difference = −7.1; 95% CI: −10.9 to −3.4, P = 0.004), mean platelet volume (MPV) (mean difference = −0.3; 95% CI: −0.6 to −0.1, P = 0.02), and platelet count (mean difference = −68.3 × 103/µL; 95% CI: −86.9 to −49.7, P = 0.004).ConclusionsPlatelet quantity, viscoelastic clot strength, and platelet aggregation response to ADP each decline after infusion through a RIS. Further studies regarding microaggregates and platelet activation are required.

Whole lung lavage using a rapid infusion system to treat a patient with pulmonary alveolar proteinosis.

Whole lung lavage (WLL) is a therapeutic procedure to remove accumulated material by infusing and draining the lungs with lavage fluid. This procedure has been regarded as the current standard of care to treat pulmonary alveolar proteinosis. However, the WLL protocol has not yet been standardized and the technique has been refined and modified a number of times. A rapid infusion system is a device used to infuse blood or other fluids at precise rates and normothermic conditions. This device is not typically used in WLL, which relies on the passive infusion of fluids using the gravitational force. However, in this study we performed WLL using a rapid infusion system, since we aimed to take advantage of its shorter operation time and greater degree of control over fluid volume and temperature. The patient’s symptoms improved without the occurrence of any complications.

Anesthetic management for intestinal transplantation: A decade of experience.

Intestinal transplantation (ITx) is the definitive therapy for patients suffering from intestinal failure. Previously published reports suggest that these cases should be managed perioperatively with the same intensive monitors and techniques as in liver transplantation. We retrospectively reviewed the anesthetic management of 67 isolated intestinal, intestinal-pancreas, and intestinal-kidney transplants over the previous decade (2005-2015) in our tertiary care institution. Patients were typically managed with a single arterial line, a single central venous catheter, and rarely intensive modalities such as a pulmonary artery catheter, a transesophageal echocardiography, a second arterial catheter or central venous catheter, a rapid infusion system, a cell salvage device, or viscoelastic testing. Significant hemodynamic derangements were rare, and the rate of postreperfusion syndrome was 8.96%. Our fluid administration type and volume and transfusion type and volume were similar to previous reports in which more intensive anesthetic management was employed. We demonstrate that ITx can safely occur without utilizing the intensive resources requisite for a liver transplant.

Effect of External Pressure and Catheter Gauge on Flow Rate, Kinetic Energy, and Endothelial Injury During Intravenous Fluid Administration in a Rabbit Model.

The effects of intravenous (IV) catheter gauge and pressurization of IV fluid (IVF) bags on fluid flow rate have been studied. However, the pressure needed to achieve a flow rate equivalent to that of a 16 gauge (G) catheter through smaller G catheters and the potential for endothelial damage from the increased kinetic energy produced by higher pressurization are unclear. Constant pressure on an IVF bag was maintained by an automatic adjustable pneumatic pressure regulator of our own design. Fluids running through 16 G, 18 G, 20 G, and 22 G catheters were assessed while using IV bag pressurization to achieve the flow rate equivalent to that of a 16 G catheter. We assessed flow rates, kinetic energy, and flow injury to rabbit inferior vena cava endothelium. By applying sufficient external constant pressure to an IVF bag, all fluids could be run through smaller (G) catheters at the flow rate in a 16 G catheter. However, the kinetic energy increased significantly as the catheter G increased. Damage to the venous endothelium was negligible or minimal/patchy cell loss. We designed a new rapid infusion system, which provides a constant pressure that compresses the fluid volume until it is free from visible residual fluid. When large-bore venous access cannot be obtained, multiple smaller catheters, external pressure, or both should be considered. However, caution should be exercised when fluid pressurized to reach a flow rate equivalent to that in a 16 G catheter is run through a smaller G catheter because of the profound increase in kinetic energy that can lead to venous endothelium injury.

In-line pressure within a HOTLINE® Fluid Warmer, under various flow conditions.

Roller pump infusion devices are widely used for rapid infusion, and may be combined with separate warming devices. There may be instances however, where the pressures generated by the roller pump may not be compatible with the warming device. We assessed a commonly used roller pump in combination with a HOTLINE® Fluid Warmer, and found that it could generate pressures exceeding the HOTLINE® manufacturers specifications. This was of concern because the HOTLINE® manufacturer guideline states that not for use with pressure devices generating over 300 mmHg. Pressure greater than 300 mmHg may compromise the integrity of the HOTLINE® Fluid Warming Set. The aim of this study was to compare in-line pressure within a HOTLINE® Fluid Warmer at different infusion rates of a roller pump using various sizes of intravenous cannulae. The rapid infusion system comprised a 500 mL-normal saline bag, roller pump type infusion device, HOTLINE® Fluid Warmer (blood and fluid warmer system), and six different sizes of intravenous cannulae. In-line pressure was measured proximal to the HOTLINE® (pre-warmer) and proximal to the cannula (post-warmer), at flow rate of 50-160 mL/min. The in-line pressures increased significantly with increasing flow rate. The pre-warmer pressures exceeded 300 mmHg when the flow rate was ≥120 mL/min with 20-gauge, 48 mm length cannula, 130 with 20-gauge, 25 mm cannula, and 160 mL/min with 18-gauge, 48 mm cannula. However, they were <300 mmHg at any flow rates with 18-gauge, 30 mm cannula and 16-gauge cannulae. The post-warmer pressures exceeded 300 mmHg at the flow rate of 140 mL/min with 20-gauge, 48 mm cannula, and 160 mL/min with 20-gauge, 25 mm cannula, while they were <300 mmHg at any flow rates with 18 and 16-gauge cannulae. The in-line pressure within a HOTLINE® could exceed 300 mmHg, depending on the flow rate and size and length of cannula. It is important to pay attention to the size and length of cannulae and flow rate to keep the maximum in-line pressure<300 mmHg when a roller pump type infusion device is used.

Specialized operating room for cesarean section in the perinatal care unit: a review of the opening process and operating room management.

We have opened an operating room in the perinatal care unit (PNCU), separate from our existing central operating rooms, to be used exclusively for cesarean sections. The purpose is to meet the increasing need for both emergency cesarean sections and non-obstetric surgeries. It is equipped with the same surgical instruments, anesthesia machine, monitoring system, rapid infusion system and airway devices as the central operating rooms. An anesthesiologist and a nurse from the central operating rooms trained the nurses working in the new operating room, and discussed solutions to numerous problems that arose before and after its opening. Currently most of the elective and emergency cesarean sections carried out during the daytime on weekdays are performed in the PNCU operating room. A total of 328 and 347 cesarean sections were performed in our hospital during 2011 and 2012, respectively, of which 192 (55.5 %) and 254 (73.2 %) were performed in the PNCU operating room. The mean occupancy rate of the central operating rooms also increased from 81 % in 2011 to 90 % in 2012. The PNCU operating room was built with the support of motivated personnel and multidisciplinary teamwork, and has been found to be beneficial for both surgeons and anesthesiologists, while it also contributes to hospital revenue.

Utilization of rapid infusion system with cold saline in the induction of therapeutic hypothermia

To examine the cooling effectiveness of a rapid infusion system (RIS) during induction of therapeutic hypothermia. This laboratory study simulated the effect of three fluid delivery methods: rapid dripping without any other equipment (control); RIS; pressure bag. Cold energy loss (℃ × min) was calculated as: (temperature of the proximal thermoprobe--temperature of the distal thermoprobe) × (total infusion time). Infusion time was significantly shorter and cold energy loss significantly lower in the RIS group than in the two other groups. RIS preserves the cold energy of fluid more effectively than pressure bag or control. RIS allows for rapid infusion at a constant pressure and can be easily applied in an emergency setting.

The intermittent bolus infusions of rapid infusion system caused hypothermia during liver transplantation

CC Hypothermia is frequently encountered during major operations despite many efforts to prevent this complication. Numer ous reports have identified the adverse effects of hypo thermia including coagulopathy, acidosis, alterations in response to pharmacological agents, detrimental cardiac arrhythmias, and a mortality rate of near 100% for cases with a core body temperatures of 32 o C [1,2]. Therefore, a variety of devices have been developed to achieve rapid fluid warming and infusion because prevention of hypothermia via intravenous infusion of warm fluid is probably the most cost effective intervention, particularly for circumstances in which large volumes of fluid are required. However, after the utilization of the rapid infusion system (RIS) in liver transplantation (LT) recipients, we noticed a considerably lower intraoperative body temperature (BT) compared to the recipients before RIS. Therefore, in this study, we aimed to compare the BTs of LT recipients before and after receiving RIS. Medical records of adult patients who underwent first LT were reviewed. Twenty-three recipients were divided into nonRIS (n = 12) and RIS (n = 11) groups. The exclusion criteria in cluded patients with model for end-stage liver disease score less than 9 or greater than 25, total input greater than 20 L, and RIS infusion less than 4 L. After induction, either RIS (Haemonetics Corp., Braintree, MA, USA) or Level 1 (Level 1 Technologies, Rockland, MA, USA) was connected to the Advanced Venous Access catheter (Edwards Lifesciences LLC, Irvine, CA, USA) placed in the right internal jugular vein. For external methods of warming and body temperature preservation, a water circulating heating mattress was used and the extremities were insulated with cotton rolls and vinyl covers. The operating room tempera

Air elimination capability in rapid infusion systems

Air elimination capability in rapid infusion systems

Air elimination capability in rapid infusion systems

Pressure infusion devices are used in clinical practice to apply large volumes of fluid over a short period of time. Although air infusion is a major complication, they have limited capability to detect and remove air during pressure infusion. In this investigation, we tested the air elimination capabilities of the Fluido(®) (The Surgical Company), Level 1(®) (Level 1 Technologies Inc.) and Ranger(®) (Augustine Medical GmbH) pressure infusion devices. Measurements were undertaken with a crystalloid solution during an infusion flow of 100, 200, 400 and 800 ml.min(-1). Four different volumes of air (25, 50, 100 and 200 ml) were injected as boluses in one experimental setting, or infused continuously over the time needed to perfuse 2 l saline in the other setting. The perfusion fluid was collected in an airtight infusion bag and the amount of air obtained in the bag was measured. The delivered air volume was negligible and would not cause any significant air embolism in all experiments. In our experimental setting, we found, during high flow, an increased amount of uneliminated air in all used devices compared with lower perfusion flows. All tested devices had a good air elimination capability. The use of ultrasonic air detection coupled with an automatic shutoff is a significant safety improvement and can reliably prevent accidental air embolism at rapid flows.

The Population Pharmacokinetics of Fentanyl in Patients Undergoing Living-Donor Liver Transplantation

Fentanyl, an opioid analgesic with a high hepatic extraction ratio, is frequently used to supplement general anesthesia during liver transplantation and is also continuously infused to provide postoperative analgesia. However, because fentanyl is metabolized mainly in the liver, the pharmacokinetics of fentanyl may vary widely during the different phases of the surgery, potentially leading to adverse events. Using nonlinear mixed-effects modeling, we characterized the pharmacokinetics of fentanyl in 15 patients (American Society of Anesthesiologists Physical Status Classification 2 or 3) undergoing living-donor liver transplantation (LDLT). Fentanyl was continuously infused at the rate of 200-400µg/h throughout the operation. The time course of the fentanyl plasma concentration levels was best described in terms of a two-compartment model. Estimates were made of the pharmacokinetic parameters during the preanhepatic, anhepatic, and neohepatic phases: central volume of distribution (V(1)) (l): 59.0 + hourly volume infused by rapid infusion system (RIS) × 42.5, 113.0, and 189.0, respectively, × (body weight/69)(1.3); peripheral volume of distribution (V(2)) (l): 94.3, 412.0, and 427.0, respectively; intercompartmental clearance (Q) (l/h): 96.4 × (cardiac output (CO)/6.7)(2.5), 22.6, and 28.2, respectively; metabolic clearance (Cl) (l/h): 21.7 during the preanhepatic and neohepatic phases, and 0 during the anhepatic phase. The preanhepatic central volume of distribution was found to be markedly influenced by the massive infusion of fluids and blood products. The more hyperdynamic the circulation was during the preanhepatic phase, the higher the distributional clearance.

Ventricular fibrillation by hypothermia in spinal fusion surgery: A case report.

A 63-year-old man was scheduled for T12-S1 posterolateral spinal fusion surgery. The patient's vital signs were stable and there were no specific laboratory findings except for high triglycerides. In addition, echocardiography showed mild left ventricular hypertrophy, but normal left ventricular function, no regional wall abnormal contractility and normal ejection fraction. During the operation, a warming blanket and fluid warmer were applied. Near the end of the operation, the blood pressure waveform from the radial artery and pulse oxymeter became flat. Cardiotonics were administered and an infusion of intraoperative salvage of blood was administered using the cell-saver. However, the hemodynamic status of the patient deteriorated to severe hypotension, with ventricular fibrillation. The patient's vital signs with temperature became stabilized after warming for 4 hours using active warming methods, including a forced air warming blanket and warming of the fluids and blood components with a rapid infusion system.

Unexpected Massive Bleeding during Liver Transplantation in Patients with Budd-Chiari Syndrome - A case report -

Budd-Chiari syndrome (BCS) is a heterogenous group of disorders characterized by obstruction of hepatic venous outflow. Severe liver cirrhosis and limited cardiac reserve in patients with BCS makes them less tolerant to liver transplantation. We experienced two cases of massive bleeding during living donor liver transplantation in patients with BCS. Blood products and fluids were rapidly infused with a rapid infusion system, final infusion volume in these two patients were 177 L and 193 L, and the use of Cell Savers allowed for the patient’s blood prod ucts to be saved. The patients were managed successfully and recovered uneventfully with advanced monitoring, including monitoring of their jugular venous oxygen saturation and continuous cardiac output. Therefore, rapid infusion systems and Cell Savers, along with advanced monitoring, are necessary in the event of massive bleeding during liver transplantation. (Korean J Anesthesiol 2007; 53: 796∼802)

Alternative Route Transfusion for Transplantation Surgery in Patients Lacking Accessible Veins

Alternative Route Transfusion for Transplantation Surgery in Patients Lacking Accessible Veins

Hypothermia Induced by Incorrect Monitoring of Core Temperature: A case report

A 55-year-old man was scheduled to undergo revisional total hip arthroplasty under general anesthesia. During the operation, a warm blanket and fluid warmer were applied, with his body temperature maintained at 35, as assessed with the use of a temporal-artery thermometer. In the course of the operation, severe bleeding developed, which required a massive transfusion of packed red blood cells and other blood components to correct the electrolyte and pH balances; the infusion of cardiovascular drugs was also preformed. However, the hemodynamic status of the patient deteriorated to severe hypotension, with atrial fibrillation, non-sustaining paroxysmal ventricular tachycardia and ventricular fibrillation. The patient was re-evaluated, and it was realized the temporal-artery thermometer had been incorrectly monitored, causing hemodynamic deterioration, which was assessed as hypothermia from a nasopharyngeal temperature of 29. Active warming methods, including a condensed humidifier, and warming of the fluids and blood compounds with a rapid infusion system, were instigated, resulting in stabilization of the patient's hemodynamic status and the disappearance of his dysrhythmia.

Utilization of rapid-infuser devices for massive blood loss

Rapid volume replacement for severe hemorrhage continues to challenge the clinician involved in the care of the patient suffering hemorrhagic shock. We report on the development and utilization of two rapid-infuser systems for volume replacement in critically ill patients presenting in extremis. We have developed rapid-infusion circuits by using commercially available devices available at our institution. The primary pumping mechanism is either a centrifugal pump (Revolution--COBE Cardiovascular, Arvada, CO, USA), or the Myocardial Protection System (MPS Quest Medical, Allen, TX, USA), and offers advantages over commercially available devices. Both circuits consist of a cardiotomy reservoir, a cardioplegia delivery set, assorted tubing and connectors, and a heater-cooler system. Between January and October of 2003, 15 procedures were performed which utilized one of these two devices. There were nine ruptured aneurysms, five traumas and one radical nephrectomy. The rapid infusion time averaged 228.5 +/- 105.7 min where 10.4 +/- 9.4 L of autotransfusion volume was processed, with 3.9 +/- 4.2 L of red cell volume reinfused. The allogeneic blood products that were transfused included packed red blood cells and fresh frozen plasma, as well as 5% albumin. There were no intraoperative deaths and the rapid-infuser was considered lifesaving in all instances. Mechanical rapid infusion systems may be lifesaving when severe hypovolemia or hemorrhagic shock is encountered. While both devices are able to meet the requirements of rapid fluid replacement, the MPS offers the most safety features and has become the standard of care at our institution.

Percutaneous bypass cannulae can interfere with rapid infusion during liver transplantation

VENOVENOUS BYPASS (VVB) may be used during orthotopic liver transplantation (OLT) to maintain adequate preload when blood return to the heart is interrupted by cross-clamping of the inferior vena cava. Traditionally, when VVB is used, 1 drainage cannula is inserted via surgical cutdown into a femoral vein, and another is used to cannulate the portal vein directly. A centrifugal pump is used to aspirate venous blood from these sites and return it through a cannula inserted via surgical cutdown into an axillary vein. To avoid the complications of surgical cutdowns, percutaneous VVB has been used. 1 Tisone G Mercadante E Dauri M et al. Surgical versus percutaneous technique for veno-venous bypass during orthotopic liver transplantation: A prospective randomized study. Transplant Proc. 1999; 31: 3162-3163 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar , 2 Frenette L Cox J Singer D et al. Five years of experience with percutaneous cannula for establishing venous bypass access in orthotopic liver transplantation. Transplant Proc. 1996; 28: 2974-2977 PubMed Google Scholar , 3 Manas DM Gibbs P Talbot D et al. Use of percutaneously placed catheters for venovenous bypass in orthotopic liver transplantation. Transplantation. 1996; 62: 144-145 Crossref PubMed Scopus (3) Google Scholar , 4 Spiekermann BF Bogdonoff DL Hershey JE McLaughlin JD A method for percutaneous cannulation for veno-veno bypass during orthotopic liver transplantation. Anesth Analg. 1995; 80: 432-433 PubMed Google Scholar , 5 Scherer R Erhard J Giebler R et al. Percutaneous portofemoro-subclavian venovenous bypass during orthotopic liver transplantation. Transplantation. 1994; 57: 472-473 Crossref PubMed Google Scholar , 6 Scherer R Giebler R Schmutzler M et al. Effect of high shunt flows during portofemoro-subclavian venovenous bypass in human orthotopic liver transplantation. Transplant Proc. 1993; 25: 2591 PubMed Google Scholar , 7 Washburn WK Lewis WD Jenkins RL Percutaneous venovenous bypass in orthotopic liver transplantation. Liver Transpl Surg. 1995; 1: 377-382 Crossref PubMed Scopus (9) Google Scholar , 8 Ozaki CR Langnas AN Bynon JS et al. A percutaneous method for venovenous bypass in liver transplantation. Transplantation. 1994; 57: 472-473 Crossref PubMed Google Scholar , 9 Scherer R Giebler R Erhard J et al. A new method of veno-venous bypass during human orthotopic liver transplantation. Anaesthesia. 1994; 49: 398-402 Crossref PubMed Scopus (15) Google Scholar , 10 Johnson SR Marterre WF Alonso MH Hanto DW A percutaneous technique for venovenous bypass in orthotopic cadaver liver transplantation and comparison with the open technique. Liver Transpl Surg. 1996; 2: 354-361 Crossref PubMed Scopus (16) Google Scholar Although these reports all use at least 1 percutaneous cannula in the VVB circuit, they vary in their choice of cannulation sites, types and sizes of percutaneous cannulae, and VVB circuit configuration. The authors' VVB technique also varies from what has been reported. The authors routinely insert percutaneously a left femoral venous drainage cannula and a right internal jugular (RIJ) venous return cannula. The RIJ cannula serves a dual role as the major conduit for intravenous infusions from the rapid infusion system (RIS) (Haemonetics Corporation, Braintree, MA); this eliminates the need for additional large-bore intravenous access. In the following case, an unusually high VVB flow rate limited the maximal intravenous infusion rate of the RIS.

Ruminations of an Ordinary Hepatic Surgeon: A Journey Through the Pitfalls of Major Liver Resections

Historically, major hepatic resections have been fraught with voluminous blood losses and, at times, high mortality rates. Improvements in patient selection and operative technique over the past 20 years have resulted in marked reduction in death and complications and have given the impression that liver surgery can be relatively effortless. Contrary to this belief, the present review illustrates some of the pitfalls and dangers of major hepatectomy and may serve to alert ordinary surgeons to approach this operation with a degree of trepidation and careful planning. Over a 22-year period, 147 liver resections were performed by one surgeon for solid liver tumors (range 0 to 21/yr). Of these, 101 were major hepatectomies comprising at least three anatomic segments (63 right, 24 left, 11 extended right, and 3 extended left) and form the basis for this report. The major resections were performed for benign disease in 16 patients and malignant tumors in 85 (24 primary and 61 metastatic lesions). All but one patient were noncirrhotic. Seventeen patients were more than 70 years and 84 were less than 70 years of age. There were five postoperative deaths among these 101 patients: two intraoperative (coagulopathy after venovenous bypass in 1 and air embolus in 1), two from postoperative liver failure, and one resulting from a myocardial infarction. Three deaths were in patients older than 70 (18%), and two were in patients younger than 70 (2%) ( P = 0.03). Complications developed in 20 of 96 survivors, three patients required reoperation for postoperative bleeding, and nine patients had some duration of bile leakage. In contrast, among those undergoing “minor” hepatectomies (n = 46), there were no deaths and six (13%) patients had complications. In patients undergoing major hepatectomies, estimated blood loss was 3836 ± 3346 ml. Estimated blood loss was unaffected by experience (first 50 patients vs. second 51 patients) or use of the ultrasonic surgical aspirator, but has been reduced by the use of the Harmonic scalpel (2650 ± 2706.1 ml vs. 3997 ± 3405.8 ml, P = 0.026). The use of rapid-infusion systems aided in preventing intraoperative hypotension and hypothermia. Estimated blood loss was significantly greater than with minor anterior or lateral segmentectomies (n = 24) (3836 ± 3346 ml vs. 975 ± 518.8 ml, P < 0.0001). Hospital length of stay has been shortened, primarily by the use of closed suction drainage compared to open drainage (7.5 2 ± .4 days vs. 18.8 ± 8.4 days, P < 0.0001). Major hepatectomies continue to be formidable operations with the potential for copious blood loss and intraoperative instability. Proper patient selection, anesthesia support and availability of rapid-infusion technology, and familiarity with liver anatomy are important in keeping operative mortality and postoperative morbidity at an acceptable level. ( J Gastrointest Surg 2002;6:625–629.)

Rapid Transfusion Devices for Hemorrhagic Cardiothoracic Trauma

Cardiothoracic trauma patients are frequently hypovolemic and hypothermic and may require massive transfusion, which can itself causesuch complications as acidosis, electrolyte imbalance (hypocalcemia and hyperkalemia), hypothermia, di lutional coagulopathy, and adultrespiratory distress syn drome. At the present time, there are a number of rapid infu sion devices such as Level I® (capable of delivering 37°C at a flow rate of up to 600 ml/min), Fluid Management System® (FMS®) (which can deliver 37.5°C of fluid at a flow rate of up to 500 ml/min), Rapid Infusion System® (RIS®) (which can pro vide up to 1,500 ml of 37°C fluid in one and one half minutes), and Rapid Solution Administration Set® (RSASO) (which can not only deliver a maximum of 2,200 m/min, but can warm the fluid to normothermia at a flow rate of 500 ml/min). However, pressurized devices such as Level IO can cause air embolism, interstitial infiltration and the compartment syndrome, and the flow rate is not operator-controlled. Devices such as FMS®, RIS®, and RSAS® incorporate a cardiotomy reservoir which has the potential for clot formation when any calcium-con taining solution is added. In this article, rapid infusion devices are compared, and complications associated with massive transfusion are described.