Postoperative Blood Transfusion Requirements Research Articles

Comparison of Different Doses of ε-Aminocaproic Acid in Children for Tetralogy of Fallot Surgery: Clinical Efficacy and Safety

The purpose of this study was to compare 2 different doses of ε-aminocaproic acid (EACA) and assess their relative efficacy and safety in children undergoing corrective surgery for tetralogy of Fallot (TOF). A prospective, randomized, controlled study. A tertiary care center. One hundred twenty children undergoing corrective surgery for TOF using cardiopulmonary bypass (CPB). Group 1 received 100 mg/kg of EACA after induction, upon initiation of CPB, and after protamine. Group 2 received 75 mg/kg of EACA after induction, followed by a maintenance infusion of 75 mg/kg/h until chest closure, and an additional 75 mg/kg upon initiation of CPB. Group 3 did not receive any antifibrinolytic agent or placebo. Cumulative mean blood loss, total packed red blood cells, and fresh frozen plasma requirements were significantly less in group 2 (p ≤ 0.01). There were no significant differences in the total platelet concentrate transfused, re-exploration rate, incidence of renal failure, arrhythmias, neurologic complications, mortality, or length of intensive care unit stay among the 3 groups. The incidences of perioperative ST/T changes and chest closure time were significantly less in group 1 and group 2 (p ≤ 0.01). The duration of mechanical ventilation was significantly less in group 2 (p ≤ 0.01). EACA was effective in reducing the postoperative blood loss and transfusion requirements in children undergoing corrective cardiac surgery on CPB for TOF. The dose regimen of 75 mg/kg after induction, followed by a maintenance infusion of 75 mg/kg/h until chest closure, and an additional 75 mg/kg upon initiation of CPB were more effective.

Effects of bipolar and monopolar transurethral resection of the prostate on urinary and erectile function: a prospective randomized comparative study

To evaluate the outcomes of bipolar vs conventional monopolar transurethral resection of the prostate (TURP) on urinary and erectile function. A total of 286 patients with benign prostatic hyperplasia (BPH) were randomized to bipolar or monopolar conventional TURP treatment groups. Operative and early postoperative variables and complications were recorded and all patients were re-evaluated at 1, 3, 6 and 12 months after surgery using the International Prostate Symptom Score (IPSS), uroflowmetry, post-void residual urine volume (PVR) and the erectile function domain of the International Index of Erectile Function (IIEF-ED). A comparative evaluation of erectile function was performed on 188 preoperatively non-catheterized patients with regular sexual partners. The operating time was shorter in the bipolar TURP group. Postoperative bleeding and blood transfusion requirements did not significantly differ between the two groups. Sodium levels were significantly lower in the monopolar group than in the bipolar group. Transuretheral resection syndrome developed in two (1.4%) patients in the monopolar group. Both groups had similar and significantly improved IPSS values, maximum urinary flow rate values and PVR measurement. ED worsened in 32 (17.0%) patients, improved in 53 (28.2%) patients, and was unchanged in 103 (54.8%) patients. Changes in the IIEF scores during the follow-up period were similar between the bipolar and monopolar groups. Bipolar TURP is a safe and effective procedure that is associated with a significantly shorter operating time, a smaller reduction in serum sodium levels and a similar efficacy compared with conventional monopolar TURP.

Reduction of Postoperative Haemorrhage with the Use of a Haemostatic Thrombin Matrix in Patients Who Underwent Decortication

To assess the efficacy of two measures for the control of postoperative haemorrhage in patients with fibrothoracic disease secondary to symptomatic extraparenchymal restrictive disease (e.g.empyema, haematoma) undergoing decortication. This randomized, prospective study was performed in 50 adult patients with fibrothoracic disease secondary to symptomatic extraparenchymal restrictive disease who were scheduled to undergo decortication. Patients were randomized to receive either electrocautery plus hot compressor application or a thrombin-added haemostatic matrix (THM) for intraoperative haemostasis (n=25 per group). Control of postoperative haemorrhage was compared between groups by evaluation of pre- and postoperative blood characteristics and mean postoperative drainage volume and blood transfusion requirements. Mean postoperative drainage and blood transfusion volumes were significantly lower in the THM group versus the electrocautery plus hot compress group. There was no difference in preoperative and postoperative blood tests in the THM group, whereas significant differences were observed in the electrocautery plus hot compress group. There were no infections, systemic allergies or sensitization, or reoperations in either group. Compared with electro cautery plus hot compress, the use of a THM significantly reduced postoperative haemorrhage and blood transfusion requirements in patients who underwent decortication.

Is tranexamic acid really an alternative to aprotinin?

In the April 2011 issue, Schindler et al. [1] presented tranexamic acid as an adequate alternative to aprotinin for antifibrinolytic therapy in pediatric congenital heart surgery. They compared postoperative blood loss and transfusion requirements between two periods of time – a former one with aprotinin and a later one with tranexamic acid – and noted no difference. This conclusion cannot be drawn from their results. The precondition for such study must be that the aprotinin and the tranexamic acid groups are comparable. This precondition is more than questionable because there are striking differences between the two groups: significant differences were observed in the preoperative coagulation values (Table 1), the time of aortic clamping and the amount of intraoperative platelets (Table 2), the postoperative fluid balance (Table 3) and the postoperative coagulation values (Table 4) [1]. For example, the higher preoperative laboratory values of fibrinogen and platelets favour the aprotinin group, whereas the higher amount of intraoperative platelets, the more negative postoperative fluid balance and the shorter postoperative PTT favour the tranexamic acid group. The authors themselves admit that there was a lower average mortality and an increase in the ‘surgical performance’ during the tranexamic acid period. This may simply explain why tranexamic acid was not inferior to aprotinin. The opposite is the case if the two periods of time are really comparable as we could demonstrate recently [2]. Due to the lack of prospective randomized controlled trials, currently retrospective cohort studies are needed to assess the effectiveness (and the side effects) of antifibrinolytic drugs in pediatric cardiac surgery. However, these retrospective cohort studies have to be well controlled which is not the case for the present study by Schindler et al. [1] Therefore, the question if tranexamic acid is a suitable substitute to aprotinin to reduce blood loss and transfusion requirements in pediatric cardiac surgery remains open. With regard to possible side effects [2–5], its off-label use should be limited to individual cases where the probable benefits outweigh the risks.

Transfusion drains versus suction drains in total knee replacement: meta-analysis

The use of autologous blood transfusion drains in orthopaedic surgery has been the subject of debate for several years. The aim of this meta-analysis was to review the use of autologous blood transfusion drains in total knee replacement. The primary outcomes were as follows: the number of patients requiring homologous blood transfusion, pre-operative haemoglobin and post-operative haemoglobin days 5-7. The secondary outcome measures for the meta-analysis were drainage volume, length of hospital stay, average number of units transfused per patient, post-operative wound infection, and deep vein thrombosis. Eight randomised controlled trials met the inclusion criteria and were included in this analysis. Autologous transfusion drains were associated with a decrease in the number of patients requiring post-operative blood transfusion (pooled odds ratio = 0.36, 95% CI = 0.15-0.85, P = 0.02), the number of units transfused per patient (weighted mean difference = -0.84 (95% CI = -1.13 to -0.56), P < 0.0001), and length of hospital stay (weighted mean difference = -0.25 (95% CI = -0.48 to -0.01), P = 0.04). The results of our study highlight both likely clinical and economic benefits within total knee replacement surgery. The clinical benefits of autologous transfusion drains in the total knee replacement surgery suggested by this meta-analysis include a reduced requirement for post-operative blood transfusion and a shorter length of hospital stay. However, further large-scale high-powered randomized controlled trials are recommended to further elucidate subtle effects of autologous drains on post-operative outcome following total knee replacement. II.

Correlation between point-of-care platelet function testing and bleeding after coronary artery surgery

Objectives. To investigate whether point-of-care platelet function testing immediately before coronary artery bypass grafting correlates to postoperative blood loss and transfusion requirements. Design. Blood samples from 50 patients on antiplatelet therapy were analysed by Plateletworks®. Thirty-three of the patients had received clopidogrel, 300–600 mg loading dose followed by 75 mg once daily, within 7 days. Postoperative chest drainage volume was recorded every hour. Results. Plateletworks® ADP-induced platelet aggregation correlated significantly to postoperative chest drainage volume at 5 hours (r = −0.83; p < 0.01) and 12 hours (r = −0.55; p < 0.01), and the tertile of patients with the lowest aggregation had higher postoperative transfusion requirements (p < 0.01) and about three times larger chest drainage volume than remaining patients during the first 5 hours after surgery (p < 0.01). Cessation of clopidogrel correlated to chest drainage volume at 5 hours (r = −0.48; p < 0.01) and 12 hours (r = −0.47; p < 0.01) after surgery. Conclusions. The significant correlation between Plateletworks® ADP-induced platelet aggregation and blood loss suggests that this test may be useful to predict risk of excessive bleeding and to guide timing of surgery and bleeding treatment in patients undergoing coronary artery bypass grafting.

Tranexamic Acid Reduces Blood Transfusions in Elderly Patients Undergoing Combined Aortic Valve and Coronary Artery Bypass Graft Surgery: A Randomized Controlled Trial

To evaluate the effects of tranexamic acid on postoperative blood loss and transfusion requirements in elderly patients undergoing combined aortic valve replacement and coronary artery bypass graft surgery (CABG). A prospective, randomized, double-blinded, placebo-controlled, parallel-group trial. A university hospital (single institution). Sixty-four patients 70 years or older undergoing combined aortic valve replacement and CABG surgery were included. One patient was withdrawn from the study after randomization by the attending surgeon because of a change in the surgical procedure. The remaining 63 patients were analyzed as intention to treat. The included patients were randomized to treatment with either tranexamic acid, 10 mg/kg, as a bolus injection before surgery followed by 1 mg/kg/h as an infusion during surgery, or a corresponding volume of 0.9% sodium chloride. Postoperative blood loss was recorded for 16 hours. The transfusion of blood products was recorded during the entire hospital stay. The number of packed red cell transfusions given to the patients was significantly lower in the tranexamic acid group compared with the placebo group (median, 3.0 [interquartile range, 2-5] v 5.0 [3-7], p = 0.049). Tranexamic acid reduced the number of packed red cell transfusions given to patients 70 years or older undergoing combined aortic valve replacement and CABG surgery.

Postoperative blood loss reduction in computer-assisted surgery total knee replacement by low dose intra-articular tranexamic acid injection together with 2-hour clamp drain: a prospective triple-blinded randomized controlled trial

A high-dose local tranexamic acid has been introduced in total knee arthroplasty for bleeding control. We are not sure about the systemic absorption and side effects. The aim of this study was to evaluate the effect of low dosage of intra-articular tranexamic acid injection combined with 2-hour clamp drain in minimally bleeding computer-assisted surgery total knee replacement (CAS-TKR). A prospective randomized controlled trial was conducted in a total of 48 patients underwent CAS-TKR. The patients were randomly assigned to receive either of a mixed intra-articular solution of tranexamic acid 250 mg with physiologic saline (TXA group), or physiologic saline (control group) and then followed by clamp drain for 2 hours. Postoperative blood loss was measured by three different methods as drainage volume, total hemoglobin loss and calculated total blood loss. Transfusion requirement and postoperative complications were recorded. All patients were screened for deep vein thrombosis and the functional outcomes were evaluated at 6 months after surgery. The mean postoperative drainage volume, total hemoglobin loss and calculated total blood loss in TXA group were 308.8 mL, 2.1 g/dL and 206.3 mL compared to 529.0 mL, 3.0 g/dL and 385.1 mL in the control group (P=0.0003, 0.0005 and <0.0001 respectively). Allogenic blood transfusion was needed for one patient (4.2%) in TXA group and for eight patients (33.3%) in the control group. Postoperative knee scores were not significantly different between groups. No deep vein thrombosis, infection or wound complication was detected in both groups. In this study, low dose intra-articular tranexamic acid injection combined with 2-hour clamping drain was effective for reducing postoperative blood loss and transfusion requirement in CAS-TKR without significant difference in postoperative complications or functional outcomes.

The Effect of Ulinastatin on Postoperative Blood Loss in Patients Undergoing Open Heart Surgery with Cardiopulmonary Bypass

This prospective, randomized, double-blind study evaluated the effect of ulinastatin on postoperative blood loss and transfusion requirements of patients undergoing open-heart surgery with cardiopulmonary bypass (CPB) and aortic cross-clamping (ACC). CPB and ACC produce variable systemic inflammatory reactions that are associated with multiorgan dysfunction via leucocytes, especially polymorphonuclear neutrophils (PMNs). PMNs increase blood loss and transfusion requirements. Ulinastatin, a urinary trypsin inhibitor, inhibits PMN activity and reduces the systemic inflammatory response. Patients received either 5000 U/kg ulinastatin or the equivalent volume of normal saline (control group) before ACC. Postoperative blood loss and transfusion requirements were recorded. Duration of intubation and length of stay in the intensive care unit (ICU) were also noted. There were no statistically significant between-group differences in postoperative blood loss and transfusion requirements. Ulinastatin caused a non-significant decrease in duration of intubation. Patients who received ulinastatin had significantly shorter ICU stays than control patients.

Removal of aprotinin from low-dose aprotinin/tranexamic acid antifibrinolytic therapy increases transfusion requirements in cardiothoracic surgery

This retrospective study investigated whether withdrawal of aprotinin from combined low-dose aprotinin/tranexamic acid (TXA) antifibrinolytic therapy altered postoperative blood loss and transfusion requirements in patients undergoing cardiothoracic surgery employing cardiopulmonary bypass (CPB). The study included data from patients receiving a combination of low-dose aprotinin (2×10(6)KIU in CPB prime; n=615) and 2000mg TXA or patients receiving TXA only (n=587). In both groups, TXA was given after protamine administration. Study endpoints were blood loss, transfusion requirements and reoperation. There were no differences in EuroSCORE, CPB time, antiangial medication and baseline coagulation parameters between groups. There were more males in the TXA group (85%) as compared to the TXA+aprotinin group (77%; P=0.02). Postoperative blood loss (0.80±0.69 vs. 0.66±0.52l; P=0.001) and transfusion of fresh frozen plasma (0.6±0.7 vs. 0.4±0.6U; P<0.001), packed cells (3.9±5.5 vs. 2.7±3.3U; P<0.001) and platelets (0.7±0.6 vs. 0.5±0.6U; P<0.001) was higher in the TXA group than in patients receiving combined therapy, respectively. There were more reoperations for bleeding in the TXA group (53 vs. 34, respectively; P=0.03) with similar mortality and deterioration in glomerular filtration rate. In conclusion, withdrawal of aprotinin from combined antifibrinolytic therapy is associated with increased blood loss, transfusion requirements and reoperations.

Blood transfusion requirements in elective breast reconstruction surgery

Introduction Excess-ordering of cross-matched blood in preparation for elective surgery is expensive with associated blood shortages and time-expired wastage. Although, the maximum surgical blood order schedule (MSBOS) for breast reconstruction recommends pre-operative cross-match of 2–6 units of red cell concentrate, there is no data confirming whether this guideline is observed in practice or whether compliance results in improved outcome. The aim of this study was to examine the utility of this MSBOS in clinical practice by assessing its performance in a validation set of patients. Materials and Methods Over a three year period, 49 patients undergoing 50 consecutive elective breast reconstruction surgery were assessed for demographic data, surgical information and hematological/transfusion data to compare the number of units of blood cross-matched with those subsequently transfused for elective breast reconstruction surgery. This was in lieu of updating the current maximal surgical blood order schedule of cross-matching 2–6 units pre-operatively. Results Fifty elective operations were undertaken during the study period with a zero peri-operative blood transfusion requirement and a 8% post-operative blood transfusion requirement. Pre-operative cross-match to transfusion ratio was unacceptably high with a time-expired blood wastage of 8.7%. Discussion These data thus indicate that adoption of a type and screen policy is satisfactory for haemorrhage risk management of elective breast reconstruction. The MSBOS is not designed to predict post-surgery blood needs and a requirement based blood ordering protocol will optimise blood utilisation efficiency.

A Prospective Study of the Efficacy of Clinical Application of a New Carrier-Bound Fibrin Sealant After Liver Resection

To examine the effectiveness of fibrin sealants as supportive treatment to improve hemostasis and decrease the incidence of bile leakage and intra-abdominal collections. Prospective, controlled, quasiexperimental study. Tertiary referral center, University Hospital Reina Sofía. A total of 115 patients (58 in the control group and 57 in the collagen sponge group) scheduled for conventional hepatectomies. Patients were distributed into groups for major and minor hepatectomies with or without application of a carrier-bound collagen sponge on the raw surface of the liver. The main outcome measures were postoperative mortality, incidence and severity of postoperative surgical complications, and length of hospital stay. The secondary outcome measures were postoperative drainage output volume, transfusion requirements, and changes in biochemical parameters (hemoglobin, bilirubin, alanine aminotransferase, and platelet levels). The fibrin sealant after major liver resection was effective for decreasing drainage volume (mean [SD] volume, 1124.7 [842.8] mL in the control group and 691.2 [499.5] mL in the collagen sponge group; P = .007) with a higher volume of output by drain each postoperative day in the control patients (P = .003); postoperative blood transfusion requirements (18.9% vs 7.0%, respectively; P = .04); moderate to severe postoperative complications (21% vs 8%, respectively; P = .03); and mean (SD) hospital stay (12.6 [6.7] vs 9.6 [5.1] days, respectively; P = .03). The use of a new carrier-bound collagen sponge after major liver resection may be recommended because of its clinical and cost-savings effectiveness.

Usefulness of Monitoring Platelet Function by Multiple Electrode Aggregometry in Primary Coronary Artery Bypass Surgery

Antiplatelet therapy commonly is used for the prevention of cardiovascular complications but increases the risk of perioperative bleeding. Multiple-electrode aggregometry (MEA) was investigated for monitoring platelet inhibition by acetylsalicylic acid (ASA) and clopidogrel in patients undergoing elective coronary artery bypass graft (CABG) surgery with regard to clinical outcome as measured by postoperative blood loss and transfusion requirements. A prospective observational study. A teaching hospital. One hundred fifty patients scheduled for elective CABG surgery were included: without antiplatelet therapy (group A, n = 50), single ASA exposure (group B, n = 50), and combined therapy with ASA and clopidogrel (group C, n = 50). MEA was assessed preoperatively using either collagen (COL-MEA) or ADP (ADP-MEA). Postoperative blood loss and transfusion requirements were recorded for 24 hours after surgery. Postoperative blood loss significantly increased only from combined antiplatelet therapy (group A: 572 ± 297 mL, group B: 721 ± 356 mL, group C: 865 ± 346, p < 0.01) and correlated with ADP (r(p) = -0.35, p < 0.01) and COL-MEA (r(p) = -0.23, p > 0.01). COL-MEA and ADP-MEA discriminated between preoperative ASA and clopidogrel intake (ASA: sensitivity = 86.3%, and specificity = 89.3%; clopidogrel: sensitivity = 87.5%, and specificity = 95.1%). The postoperative transfusion risk was increased in patients diagnosed for clopidogrel treatment by ADP-MEA (odds ratio = 2.92; confidence interval: 1.44-5.92; p = 0.005). MEA is a suitable method for the detection of platelet inhibition by ASA and clopidogrel in patients undergoing CABG surgery. In these patients, preoperative ADP MEA seems to indicate patients at risk for postoperative transfusion requirements.

Laparoscopic splenectomy in patients of β thalassemia: Our experience

BACKGROUND:Laparoscopic splenectomy has become a standard treatment of various haematological disorders, but its feasibility in the setting of β thalassemia has not been established.MATERIALS AND METHODS:Fifty patients of β thalassemia underwent laparoscopic splenectomy between January 2006 and December 2008. “Anterior approach” method was practiced in all cases, with early ligation of splenic artery and delayed ligation of splenic vein. Specimen was extracted piecemeal via the umbilical port in initial 12 cases, while in 37 cases the specimen was extracted through a 7-8-cm pfannenstiel incision. Twelve patients of β thalassemia having grade IV splenomegaly with hepatomegaly were electively operated by conventional open method.RESULTS:The procedure was completed in 49 patients. One (2%) patient required conversion to open surgery. Mean operating time in the first 12 cases was 151 minutes (110-210 minutes), while in 37 cases of splenectomy completed laparoscopically it was 124 minutes (80-190 minutes) [P < 0.05]. Mean intra-operative blood loss was 73.8 ml (30–520 ml). No major intra-operative complications occurred. No patient required per-operative blood transfusion. Mean postoperative hospital stay was 4.7 days (2-11 days). Mean preoperative blood transfusion requirement was 11.98 units per patient per year, while mean postoperative blood transfusion requirement was 4.04 units [P< 0.05].CONCLUSION:Laparoscopic splenectomy is feasible and safe even in patients of β thalassemia with massive splenomegaly. Removal of specimen via a pfannenstiel incision significantly saves time, carries low morbidity and is a cosmetically acceptable alternative.

A comparison before and after aprotinin was suspended in cardiac surgery: Different results in the real world from a single cardiac center in China

Use of aprotinin has been suspended in cardiac surgery since recent studies reported its risks associated with mortality and other adverse events. This study was to investigate the safety and efficacy of aprotinin through a comparison before and after aprotinin was suspended in cardiac surgery. We designed a case-control study in two groups of patients who underwent cardiac surgery just before and after aprotinin was suspended in China. The aprotinin group (n = 1699) was defined as operations performed from June 19, 2007, to December 18, 2007, when aprotinin was used in all the patients. The control group (n = 2225) was defined as operations performed from December 19, 2007, to June 18, 2008, when aprotinin was not used. We compared early postoperative outcomes between the two groups. The aprotinin group had less postoperative blood loss, transfusion requirement, and reoperation for bleeding. Application of aprotinin did not increase the risk of in-hospital mortality (0.5% vs 1.0%; P = .08) and other major adverse outcome events, including renal, cardiac, neurologic, and pulmonary complications. The aprotinin group had a shorter mechanical ventilation time (P = .04), a lower rate of delayed mechanical ventilation time (P = .04), and a higher arterial oxygen tension/inspired oxygen fraction ratio in arterial blood gas analysis (P < .001). Multivariable logistic regression analysis confirmed findings from univariate analysis. After propensity adjustment for the baseline characteristics, we obtained similar results. Use of aprotinin in cardiac surgery could reduce blood loss and transfusion requirement significantly and showed a protective effect on the lungs, but it did not increase the risk of mortality or major complications.

Effect of Topical Aprotinin on Early Postoperative Bleeding and ICU Stay after Coronary Artery Bypass Graft Surgeries

We evaluate the effect of topical application of aprotinin to the heart, pericardia and mediastinum before sternal closure, on early post operative bleeding, blood transfusion requirement and ICU staying time after coronary artery bypass graft surgeries. In a randomized double blinded clinical trial, 128 patients who were scheduled for elective coronary artery bypass graft were allocated into two groups. In group A (aprotinin), patients received 500,000KIU (50 mL) aprotinin and in group S (saline group) the same volume of normal saline was applied. The amount of blood loss collected in chest bottle, the number of pack cells requirement during first 24 h after operation and duration of ICU staying time were recorded. The amount of blood loss in group A (aprotinin) was 451 +/- 218 mL compared with 707 +/- 269 mL in group S (saline) (p = 0.003). The number of pack cells consumption was 0.5 +/- 0.7 units in group A (aprotinin) compared with 1.7 +/- 1 units in saline group (p = 0.002). Intensive Care Unit (ICU) staying time was 48.8 +/- 13.6 h in group A (aprotinin) and 69.4 +/- 16.6 h in saline group (p = 0.001). This study showed that topical application of aprotinin at the end of coronary artery surgeries, significantly reduce postoperative bleeding and blood transfusion requirement during first 24 h after operation and also ICU staying time.

Modified Low-Flow Ultrafiltration Ameliorates Hemodynamics and Early Graft Function and Reduces Blood Loss in Living-Donor Lobar Lung Transplantation

This study analyzed the clinical application of modified low-flow ultrafiltration (MUF) to minimize cardiopulmonary bypass (CPB)-related adverse effects in patients undergoing living-donor lobar lung transplantation (LDLLT). The study enrolled 33 consecutive patients who underwent LDLLT from 1999 to 2004: 8 patients underwent conventional CPB without MUF (control group), and 15 underwent arteriovenous MUF (MUF-treated group). Hemodynamics, graft function, blood loss and blood transfusion requirements, and clinical outcomes were analyzed. There was a significant increase in systolic blood pressure and a decrease in pulmonary to systemic pressure ratio in the MUF-treated group (p < 0.05). No hemodynamic changes occurred in the control group. MUF resulted in significant improvements in arterial oxygen tension/fraction of inspired oxygen ratio (PaO(2)/FiO(2;) 411 +/- 107 vs 272 +/- 107 mm Hg, p < 0.05) and the alveolar-arterial oxygen difference (a-aDO(2); 158 +/- 84 vs 315 +/- 127 mm Hg, p < 0.05) at 15 minutes after CPB. There were no differences in PaO(2)/FiO(2) and A-aDO(2) between the groups beyond 6 hours post-operatively. Post-operative blood loss and blood transfusion requirements were lower in the MUF-treated group than in the control group (p < 0.05). There were no differences in survival, duration of ventilation, intensive care unit stay, and hospital stay between the groups. The low-flow MUF brought improved hemodynamics and gas exchange capacity of transplanted grafts and lowered post-operative blood loss and blood transfusion requirement. This strategy may minimize CPB-related adverse effects in patients undergoing LDLLT.

Calvarial remodelling for sagittal synostosis: does fibrin glue (Tisseel™) reduce post-operative blood transfusion requirements?

Calvarial remodelling for sagittal synostosis is extensive surgery and is associated with potential risks; the most significant of these is blood loss. We studied 16 patients undergoing calvarial remodelling by the same surgical team over a 12-month period to determine whether scalp closure with fibrin glue (Tisseel) could decrease post-operative bleeding and the need for blood transfusion. In the last 5 months of the period studied, fibrin glue (Tisseel) was used and six out of the 16 patients had their wound closure assisted by this means. Data was prospectively collected on age at surgery, the estimated peri-operative blood loss, the volume of blood transfused intra-operatively, the volume drained in the first 8 h post-operatively, the total post-operative drainage and the volume of any post-operative blood transfusion required. The two groups were comparable with a similar mean age at surgery, estimated peri-operative blood loss and intra-operative blood transfusion requirements. The volume drained in the first 8 h post-operatively was 172 ml in the treated group compared to 246 ml in the untreated group (p < 0.02) and the total post-operative drain volume was 301 ml compared to 441 ml (p < 0.01). None out of the six patients treated with fibrin glue required post-operative transfusion compared to two out of ten in the untreated group. The use of fibrin glue has enabled us to reduce post-operative bleeding and the need for post-operative blood transfusion.

Tranexamic acid and aprotinin in low- and intermediate-risk cardiac surgery: a non-sponsored, double-blind, randomised, placebo-controlled trial☆

Tranexamic acid has been suggested to be as effective as aprotinin in reducing blood loss and transfusion requirements after cardiac surgery. Previous studies directly comparing both antifibrinolytics focus on high-risk cardiac surgery patients only or suffer from methodological problems. We wanted to compare the effectiveness of tranexamic acid versus aprotinin in reducing postoperative blood loss and transfusion requirements in the patient group representing the majority of cardiac surgery patients: low- and intermediate-risk patients. We conducted a non-sponsored, double-blind, randomised, placebo-controlled trial in which 298 patients scheduled for low- or intermediate-risk (mean logistic EuroSCORE 4.1) first-time heart surgery with use of cardiopulmonary bypass were randomised to receive either tranexamic acid, high-dose aprotinin, or placebo. All patients had preoperative normal renal function. End points of the study were monitored from the time of surgery until patient discharge. This trial was executed between June 2004 and October 2006. Both antifibrinolytics significantly reduced blood loss and transfusion requirements when compared with placebo. Aprotinin was about twice as effective as tranexamic acid in reducing total postoperative blood loss (estimated median difference 155 ml, 95% confidence interval (CI) 60-260; p < 0.001). Accordingly, aprotinin reduced packed red blood cell transfusions more than tranexamic acid, although the difference did not reach statistical significance. Only aprotinin significantly reduced the proportion of transfused patients when compared with placebo (mean difference -20.9%, 95% CI 7.3-33.5; p = 0.013), and only aprotinin completely abolished bleeding-related re-explorations (mean difference 6.8%, 95% CI 1.6-13.4%; p = 0.004). Neither antifibrinolytic agent increased the incidence of mortality (mean difference tranexamic acid -0.4%, 95% CI -4.6 to 4.4; p = 0.79, mean difference aprotinin -1.3%, 95% CI -6.2 to 3.5; p = 0.62) or other serious adverse events when compared with placebo. Aprotinin has clinically significant advantages over tranexamic acid in patients with normal renal function scheduled for low- or intermediate-risk cardiac surgery.

Effect of Pleurotomy on Blood Loss During Coronary Artery Bypass Grafting

We conducted a retrospective study to compare two different techniques of internal mammarian artery (IMA) preparation concerning pleurotomy upon the effects of blood loss and pulmonary functions. Between January 1998 and November 2006, 1357 consecutive patients undergoing coronary artery bypass grafting (CABG) using the left IMA, either alone or in combination with saphenous vein graft, were included in this study. The patients were divided into two groups according to the pleural opening: Group I (n = 1046) patients underwent IMA harvesting with pleurotomy and Group 2 (n = 311) patients with intact pleura. During the study, 27 hospital deaths (1.9%) occurred. The amount of postoperative blood loss and blood transfusion requirements were significantly higher in Group 1 than in Group 2 (p = 0.029 and p = 0.0001). The mechanical ventilation stay was significantly higher in Group 1 than in Group 2 (p = 0.0001). The incidence of left pleural effusion and atelectasis was significantly higher in Group 1 than in Group 2 on day 1 and day 3 after operation. These results demonstrate that preserving pleural integrity has beneficial effects on the postoperative blood loss. Postoperative blood loss and transfusion requirements were higher in patients with pleurotomy. Left pleural effusion, atelectasis, and mechanical ventilatory stay were significantly reduced in patients with preserved pleural integrity.