Blood Conservation Techniques Research Articles

The Role of Cell Salvage Autotransfusion in Abdominal Aortic Aneurysm Surgery

Abdominal aortic aneurysm (AAA) repairs, both elective and rupture, are associated with significant blood loss often requiring transfusion. Cell-salvage autotransfusion has been developed to reduce the need for allogeneic blood. We review the literature to delineate the role of cell salvage in reducing allogeneic blood use in open AAA repairs. A systematic search of the English-language literature was performed using the PubMed, Embase and Cochrane databases up to August 2010. Twenty-three studies were identified. Whilst some data are conflicting, cell salvage appears to reduce overall use and exposure to allogeneic blood, and reduces length of intensive care unit and hospital stay after elective AAA repairs. There may be additional benefit by combining cell salvage with other blood-conservation techniques. Use of cell salvage in ruptured AAA repairs consistently reduced blood-product requirements. Cell salvage appears to reduce blood-product use in both elective and rupture AAA repairs. Owing to the heterogeneity in methodology of published data, further study may be required before cell salvage becomes standard practice in open AAA repairs.

Transfusion Free Management of Gastrointestinal Bleeding: An Analysis of Outcomes

Purpose: Gastrointestinal hemorrhage is a common cause of hospitalization accounting for 300,000 admissions in the United States yearly. The mortality rate from gastrointestinal bleeding has remained constant at 10% despite advances in the diagnostic and therapeutic approach to this condition. Englewood Hospital and Medical Center has developed The Institute for Patient Blood Management and Bloodless Medicine and Surgery to address the needs of patients who require intervention but object to blood transfusion because of religious or ethical issues. The Institute serves as a tertiary referral center for patients requiring a bloodless approach to medical care. As in the general population, gastrointestinal bleeding is a common cause of hospitalization in the community who refuse blood transfusion. We aim to share our vast experience in managing this challenging population of patients. Methods: From 2003 through 2008, we performed a retrospective chart review of patients who presented with significant gastrointestinal bleeding and identified themselves as belonging to the Bloodless Institute. Significant gastrointestinal hemorrhage was defined as overt bleeding with a presenting hemoglobin of less than 12 g/dl or a decrease in hemoglobin of greater than 1.5 g/dl. A list of patients was provided by a data bank maintained by the Bloodless Institute and collaborated by the Medical Records Department. Results: There were 60 patients who met the inclusion criteria and were included in the analysis. There were 31 females and 29 males with a mean age of 63.8 (range 34-91). Thirty two patients were transferred from other institutions. There were 32 upper gastrointestinal bleeding sites and 27 lower gastrointestinal sources identified; one site of bleeding was never identified. Hemodynamic instability was a presenting feature in 8 patients, of these patients 6 (75%) survived. The average hemoglobin (Hb) on presentation was 8.9 g/dl (range 3.8-14.5) and the average nadir Hb was 7.0 g/dl (range 2.5-13). Of the 21 patients with a Hb of less than 6.0 g/dl, 17 patients (80.9%) survived. There were 3 patients with a Hb of less than 3 g/dl who survived. Endoscopic therapy was utilized in 20 patients, 18 of whom survived. Surgery was necessary in 4 patients with an average preoperative Hb of 7.4 g/dl, 2 patients (50%) survived. Of the 60 patient cohort, there were 5 deaths with an overall mortality rate of 8.4%. Conclusion: Gastrointestinal hemorrhage can be successfully managed in a population of patients who refuse blood transfusion. With a dedicated multidisciplinary team approach knowledgeable in techniques of blood conservation, mortality rates from gastrointestinal hemorrhage can equal those seen in the population who accept blood transfusion.

A Technique for Autologous Priming of the Veno-Venous Bypass Circuit during Liver Transplantation

Orthotopic liver transplantations (OLT) have been associated with significant blood loss and hemodilution, necessitating significant homologous blood component replacement. Increasing administration of homologous blood products has been found to be inversely related to patient and graft survival. Various methods to reduce the amount of blood products patients receive during OLT, such as antifibrinolytic therapy, thromboelastography-guided transfusion, phlebotomy, reduced central venous pressures intraoperatively, and the use of the veno-venous bypass (VVB) circuit, have been explored. The asanguineous priming volume of the VVB circuit increases the likelihood of the patient receiving homologous blood products due to hemodilution. It was reasoned that autologous priming of the VVB circuit in OLT surgery was a plausible adjunctive blood conservation technique given its application to the extracorporeal circuit during cardiac surgery. We describe our technique of modifying the VVB circuit for autologous priming. This technique adds minimal risk and a small amount of cost to the procedure, requires slightly more communication among members of the surgical team, and with proper sequencing, adds no additional length to the surgical procedure. It is recommended that this technique be considered for addition to the arsenal of blood conservation techniques when VVB is used during OLT.

Antiplatelet Drugs: Mechanisms and Risks of Bleeding Following Cardiac Operations

Preoperative antiplatelet drug use is common in patients undergoing coronary artery bypass grafting (CABG). The impact of these drugs on bleeding and blood transfusion varies. We hypothesize that review of available evidence regarding drug-related bleeding risk, underlying mechanisms of platelet dysfunction, and variations in patient response to antiplatelet drugs will aid surgeons as they assess preoperative risk and attempt to limit perioperative bleeding. The purpose of this review is to (1) examine the role that antiplatelet drugs play in excessive postoperative blood transfusion, (2) identify possible mechanisms to explain patient response to antiplatelet drugs, and (3) formulate a strategy to limit excessive blood product usage in these patients. We reviewed available published evidence regarding bleeding risk in patients taking preoperative antiplatelet drugs. In addition, we summarized our previous research into mechanisms of antiplatelet drug-related platelet dysfunction. Aspirin users have a slight but significant increase in blood product usage after CABG (0.5 U of nonautologous blood per treated patient). Platelet adenosine diphosphate (ADP) receptor inhibitors are more potent antiplatelet drugs than aspirin but have a half-life similar to aspirin, around 5 to 10 days. The American Heart Association/American College of Cardiology and the Society of Thoracic Surgeons guidelines recommend discontinuation, if possible, of ADP inhibitors 5 to 7 days before operation because of excessive bleeding risk, whereas aspirin should be continued during the entire perioperative period in most patients. Individual variability in response to aspirin and other antiplatelet drugs is common with both hyper- and hyporesponsiveness seen in 5 to 25% of patients. Use of preoperative antiplatelet drugs is a risk factor for increased perioperative bleeding and blood transfusion. Point-of-care tests can identify patients at high risk for perioperative bleeding and blood transfusion, although these tests have limitations. Available evidence suggests that multiple blood conservation techniques benefit high-risk patients taking antiplatelet drugs before operation. Guidelines for patients who take aspirin and/or thienopyridines before cardiac procedures include some or all of the following: (1) preoperative identification of high-risk patients using point-of-care testing; (2) withdrawal of aspirin or other antiplatelet drugs for a few days and delay of operation in patients at high risk for bleeding if clinical circumstances permit; (3) selective perioperative use of evidence-based blood conservation interventions (e.g., short-course erythropoietin, off-pump procedures, and use of intraoperative blood conservation techniques), especially in high-risk patients; and (4) platelet transfusions if clinical bleeding occurs.

Management of Intraoperative Fluid Balance and Blood Conservation Techniques in Adult Cardiac Surgery

Blood transfusions are associated with adverse physiologic effects and increased cost, and therefore reduction of blood product use during surgery is a desirable goal for all patients. Cardiac surgery is a major consumer of donor blood products, especially when cardiopulmonary bypass (CPB) is used, because hematocrit drops precipitously during CPB due to blood loss and blood cell dilution. Advanced age, low preoperative red blood cell volume (preoperative anemia or small body size), preoperative antiplatelet or antithrombotic drugs, complex or re-operative procedures or emergency operations, and patient comorbidities were identified as important transfusion risk indicators in a report recently published by the Society of Cardiovascular Anesthesiologists. This report also identified several pre- and intraoperative interventions that may help reduce blood transfusions, including off-pump procedures, preoperative autologous blood donation, normovolemic hemodilution, and routine cell saver use.A multimodal approach to blood conservation, with high-risk patients receiving all available interventions, may help preserve vital organ perfusion and reduce blood product utilization. In addition, because positive intravenous fluid balance is a significant factor affecting hemodilution during cardiac surgery, especially when CPB is used, strategies aimed at limiting intraoperative fluid balance positiveness may also lead to reduced blood product utilization.This review discusses currently available techniques that can be used intraoperatively in an attempt to avoid or minimize fluid balance positiveness, to preserve the patient's own red blood cells, and to decrease blood product utilization during cardiac surgery.

Evaluation of acute normovolemic hemodilution and autotransfusion in neurosurgical patients undergoing excision of intracranial meningioma

Several blood conservation strategies have been tried with the purpose of reducing homologons blood transfusion. PATIENTS #ENTITYSTARTX00026; In a prospective randomized study, the potential benefits of acute normovolemic hemodilution (ANH) with autologous transfusion were investigated as a blood conservation technique in surgical excision of intracranial meningioma. Over a period of 2 years, 40 patients undergoing excision of intracranial meningioma were randomly assigned to two groups of 20 patients each. Group I (Control Group) received conventional homologous blood intraoperatively and were not subjected to ANH. In Group II (ANH Group), Acute Normovolemic Hemodilution was initiated to a target hematocrit of 30% after induction of anesthesia. Parameters studied included changes in hemoglobin, hematocrit and hemodynamic parameters. The mean value of blood withdrawn in ANH group was 802.5 ± 208 ml. This was replaced simultaneously with an equal volume of 6% Hydroxyethyl starch to maintain normovolemia. There was no statistically significant variation in mean hemoglobin levels between the two groups at various stages of study. Hematocrit decreased significantly in both the groups at various stages as compared to preoperative values , the decrease being more but insignificant in group II. Changes in heart rate and mean blood pressure were similar and without statistically significant differences in either group at various stages of study. The amount of surgical blood loss in group I was 835.29 ± 684.37 ml, as compared to 865 + 409.78 ml in group II. The difference was statistically insignificant (p>0.05). The mean volume of homologous blood transfused in group I was 864.71 ± 349.89 ml, as compared to 165 ± 299.6 ml in group II which was statistically significant (p<0.05). In group II (ANH Group) only 5 patients (25%) required homologous blood whereas in group I I all patients (100%) needed homologous blood. We conclude that acute normovolemic hemodilution up to a target hematocrit of 30% is safe and effective in reducing the need for homologous blood in neurosurgical patients undergoing excision of intracranial meningioma.

Blood Conservation in Surgery: Current Concepts and Practice

Blood conservation is based on the principle of avoiding allogeneic blood transfusion with the aim of improving outcome and protecting patients' rights. Surgical patients receive a significant proportion of the allogeneic blood transfused in the hospital. Blood conservation in surgery greatly reduces overall allogeneic blood use, thereby reducing costs, hazards, and adverse outcomes. Blood conservation techniques aim to lower the "transfusion trigger," optimize the hematocrit, minimize blood loss, and optimize tissue oxygenation. Successful blood conservation involves a combination of techniques tailored to the individual patient. It requires planning and a multidisciplinary team approach but usually little technology. Bloodless medicine and surgery programs represent the gold standard in blood conservation. Blood conservation is evidence based, and it results in faster recovery, lower morbidity, lower mortality, shorter hospital stay, lower cost, and better patient (and physician) satisfaction while avoiding the hazards of allogeneic blood transfusion. Blood conservation is thus the current standard of care.

Relationship Between Intraoperative Fluid Administration and Perioperative Outcome After Pancreaticoduodenectomy

Pancreaticoduodenectomy (PD) can be associated with significant blood loss and transfusion requirements, with potential adverse short- and long-term consequences. The aim of this study was to determine whether acute normovolemic hemodilution (ANH), an established blood conservation technique, reduces perioperative allogeneic transfusions in patients undergoing PD. One hundred thirty patients undergoing PD were randomized to ANH or standard management (STDM). In the ANH group, intraoperative blood collection was performed to a target hemoglobin of 8.0 g/dL; crystalloid and colloid were used for volume replacement. Strict transfusion triggers were applied during and after operation. Perioperative complications were prospectively assessed and graded for severity. From July 2005 to May 2009, 209 patients were registered, 79 excluded, 65 were randomized to ANH, and 65 to STD. The groups were well matched for demographic, operative, and histopathologic variables. Patients undergoing ANH received over 2 L more fluid intraoperatively (6250 mL, range 2000-11850) compared with patients undergoing STD (3900 mL, range 2000-9000) (P < 0.001). Transfusion rates were similar (ANH = 16.9%, 30 units vs STD = 18.5%, 33 units; P = 0.82), as was overall perioperative morbidity (ANH = 49.2% vs STD = 47%, P = 0.86). There was, however, a trend toward more grade-3 complications in patients undergoing ANH (32% vs 23.1% STD, P = 0.17), and complications related to the pancreatic anastomosis (leak/fistula/abscess) were significantly higher in the ANH group (21.5% vs 7.7%, P = 0.045). The intraoperative fluid volume was higher for all patients with pancreatic anastomotic complications (n = 19), regardless of randomization arm (ANH 6000 mL, range 2800-11350 mL vs STD 5000 mL, range 2000-11850 mL, P < 0.042). In this randomized trial of patients undergoing PD, ANH did not reduce allogeneic transfusions and resulted in more pancreatic anastomotic complications, likely related to greater intraoperative fluid administration. The benefits of ANH do not necessarily extend to all procedures, and restrictive intravenous fluid management during PD may help improve postoperative outcome.

Maintenance of normal hematocrit in high-risk thyroid surgery without allogeneic blood transfusion: a case report

Bloodless surgery was introduced initially for the care of patients who refused blood transfusion. Recently however, adverse outcome with blood transfusion has been reported in virtually all subspecialties of surgery and conversely, improved outcome with non-transfusion surgery. Thus blood conservation is the standard of care because it is evidence-based. Thyroid surgery is historically associated with blood loss, and a lower hematocrit would be expected postoperatively. We report a case of subtotal thyroidectomy for a large simple multinodular goiter using planned blood-conservation techniques tailored to the patient that resulted in maintenance of a normal hematocrit throughout the perioperative period. The patient received oral hematinics preoperatively, while acute normovolemic hemodilution and other techniques were used to minimize intraoperative blood loss. The outcome was an optimized hematocrit preoperatively, minimal blood loss intraoperatively, and hematocrit which remained optimal on the third postoperative day and 3 weeks postoperatively. No allogeneic blood was used at any stage. This suggests that maintenance of normal hematocrit can be regarded as an achievable goal in high-risk surgery through blood-conservation techniques. Avoiding allogeneic blood transfusion is possible in a resource-poor setting, where HIV prevalence is high and screening of blood may be suboptimal, and it is the ideal clinical approach as demonstrated in this case report.

So you want to be … a cardiac surgeon

Cardiac surgery emerged as a specialty in the 1950s following the development of diagnostic angiography, the heart–lung machine and cardioplegic solutions to provide reversible cardiac standstill. Bioengineering laboratories contributed prosthetic heart valves, vascular grafts, pacemakers and artificial hearts. Many of the great pioneers had the courage to fail: deaths were frequent and regarded as inevitable. This gradually changed throughout the 1980s with improved cardiopulmonary bypass technology, blood conservation techniques and critical care (Westaby, 1997). Publication of cardiac surgical outcomes in the USA (Burack et al, 1999) and the Bristol Inquiry in 2001 then changed the landscape irreversibly.

Management of women who decline blood and blood products in pregnancy

Women decline blood products in pregnancy for religious reasons or because of concerns regarding their safety. Mortality is significantly increased in pregnant women who decline blood products. Antenatal counselling and planning must involve a senior multidisciplinary team. Considerable efforts are needed to optimise pre‐delivery haemoglobin and identify risk factors for haemorrhage. Intrapartum techniques to avoid blood transfusion include cell salvage and early recourse to definitive surgical management in the event of massive obstetric haemorrhage. Learning objectives: To understand the reasons why women decline blood and blood products in pregnancy and how this impacts on their health. To understand the law relating to women who decline treatment in pregnancy. To learn how to make the most of antenatal care opportunities. To be able to plan labour and postpartum care. To review the differences in managing massive obstetric haemorrhage between women who decline blood products and those who do not. Ethical issues: Women's autonomy can be supported with accurate information and empathic counselling. Given real concerns regarding the safety and availability of donor blood transfusion, should blood conservation techniques in obstetrics be applied to all women? Please cite this article as: Currie J, Hogg M, Patel N, Madgwick K, Yoong W. Management of women who decline blood and blood products in pregnancy. The Obstetrician &amp; Gynaecologist 2010;12:13–20.

Predicting the Risk of Perioperative Transfusion for Patients Undergoing Elective Hepatectomy

To develop 2 instruments that predict the probability of perioperative red blood cell transfusion in patients undergoing elective liver resection for primary and secondary tumors. Hepatic resection is the most effective treatment for several benign and malign conditions, but may be accompanied by substantial blood loss and the need for perioperative transfusions. While blood conservation strategies such as autologous blood donation, acute normovolemic hemodilution, or cell saver systems are available, they are economically efficient only if directed toward patients with a high risk of transfusion. Using preoperative data from 1204 consecutive patients who underwent liver resection between 1995 and 2000 at Memorial Sloan- Kettering Cancer Center, we modeled the probability of perioperative red blood cell transfusion. We used the resulting model, validated on an independent dataset (n = 555 patients), to develop 2 prediction instruments, a nomogram and a transfusion score, which can be easily implemented into clinical practice. The planned number of liver segments resected, concomitant extrahepatic organ resection, a diagnosis of primary liver malignancy, as well as preoperative hemoglobin and platelets levels predicted the probability of perioperative red blood cell transfusion. The predictions of the model appeared accurate and with good discriminatory abilities, generating an area under the receiver operating characteristic curve of 0.71. Preoperative factors can be combined into risk profiles to predict the likelihood of transfusion during or after elective liver resection. These predictions, easy to calculate in the frame of a nomogram or of a transfusion score, can be used to identify patients who are at high risk for red cell transfusions and therefore most likely to benefit from blood conservation techniques.

Preoperative autologous blood donation versus intraoperative blood salvage: intraindividual analyses and modeling of efficacy in 1103 patients

Preoperative autologous blood donation (PABD) and intraoperative blood salvage (IBS) represent established blood conservation measures. However, data comparing PABD to IBS are very sparse. We analyzed data from 1103 patients undergoing PABD and subsequent major orthopedic surgery in one center. We then used a validated model to compare PABD to IBS. We calculated maximal allowable blood losses (MABLs) for both IBS and PABD. We also identified criteria for efficacious use of either PABD or IBS. Our calculations were based on exclusive application of either technique, complete exhaustion of predeposited or salvaged blood, and one round of IBS. The vast majority of patients would have tolerated greater MABLs if subjected to IBS rather than PABD (425 of 432 with 1 PABD unit, 580 of 664 patients with 2 PABD units, 3 of 7 patients with 3 PABD units). For a few patients, however, our model demonstrated greater MABL with PABD than with IBS. These patients were characterized by 1) lower initial hematocrit (Hct), 2) recovery from PABD with return to baseline Hct or above by the time of surgery, and 3) longer time between first PABD and surgery. IBS appears to be the superior blood conservation technique if PABD cannot be performed under optimal conditions. Tolerable predonation anemia and sufficient time for regeneration appear to be crucial for post-PABD erythropoiesis. If these goals cannot be accomplished, PABD should be abandoned and be replaced by IBS.

Prophylactic Use of Factor IX Concentrate in a Jehovah's Witness Patient

In Jehovah's Witness patients, the use of red blood cells, platelets, and fresh frozen plasma is not optional. Various blood conservation techniques are available, but complex cardiac surgery remains a major challenge. The feasibility of fractions of "primary components" has not been fully considered in published case reports. For Jehovah's Witness patients who preoperatively give consent, factor IX concentrates may be acceptable for hemostatic therapy. We hereby describe a combination of "secondary components" to prevent excessive bleeding in a Jehovah's Witness patient undergoing complex replacement of the aortic arch.

Recombinant Human Erythropoietin Therapy in Critically Ill Jehovah's Witnesses

Blood transfusions and blood products are often given as a life-saving measure in patients with critical illness. However, some patients, such as Jehovah's Witnesses, may refuse their administration due to religious beliefs. Jehovah's Witnesses accept most available medical treatments, but not blood transfusions or blood products due to their religion's interpretation of several passages from the Bible. Since recombinant human erythropoietin (rHuEPO) became available, several cases have been reported in which rHuEPO was successfully administered to critically ill Jehovah's Witnesses. Administration of rHuEPO in combination with other blood conservation techniques has been shown to increase hemoglobin levels and survival in patients who experienced trauma, burns, general surgery, or gastrointestinal hemorrhage. We performed a literature search of the MEDLINE and International Pharmaceutical Abstracts databases of rHuEPO therapy in the Jehovah's Witness population. Fourteen cases were identified in which rHuEPO was administered to Jehovah's Witnesses who required the drug for critical care resuscitation as an alternative to blood products. In each clinical situation, rHuEPO enhanced erythropoiesis; however, time to the start of treatment, dosages, route of administration, and treatment duration varied widely. Supplementation with adjunctive agents, such as iron, folic acid, and vitamin B12, was also beneficial. Use of rHuEPO in Jehovah's Witnesses may provide an alternative to blood transfusions or blood products. Other alternatives, such as hemoglobin-based oxygen carriers and perfluorocarbons, are also being explored.

Épargne transfusionnelle en chirurgie orthopédique

In addition to more restrictive “transfusion triggers”, presently available allogeneic blood conservation strategies in surgery include preoperative increase in red blood cells (RBC) mass, techniques or pharmaceutical agents that reduce blood loss, and perioperative blood salvage. Because of very important risk reduction in allogeneic blood, benefit/risk of preautologous blood donation (PAD) is quite questionable at this moment. Indeed, at this moment in France, we focus to avoid any transfusion (allogeneic and autologous blood). Therefore the most important techniques used are pharmacological: erythropoietin before surgery with a number of injections related to baseline Hb, and tranexamic acid during and after surgery. Cell saving is used only if bleeding is enough important like arthroplasty revisions. All blood conservation techniques carry their own efficiency limits, constraints and risks that, in addition to institutional considerations and individual patient characteristics are determinant to settle a blood conservation strategy. The choice of a technique should take into account (a) the delay before surgery, (b) the anticipated blood loss for the procedure that varies among institutions, (c) the tolerable blood loss without transfusion for the patient, and (d) the efficacy of the blood conservation technique in the given setting. Nevertheless, at this moment in France, it is quite important to notice that the risk of delay or lack of transfusion induces much more deaths that the transfusion itself during or after anesthesia [Anesthesiology 105, 1087–97].

Blood Conservation Techniques in Spinal Deformity Surgery

A retrospective review. To review the effectiveness of blood conservation techniques in the spinal fusion of patients that refuse blood transfusion; specifically the Jehovah's witnesses population. Spinal surgery can be challenging in patients refusing blood transfusion. There is paucity in the literature examining blood conservation techniques in spinal surgery. The radiographic and medical records of 19 Jehovah's witnesses patients who underwent spinal deformity surgery at a single institution between 2000 and 2003 were reviewed. Patients were assessed for excessive blood loss (EBL), deformity correction, operative time, perioperative complications, and hospital stay. At latest follow-up (mean, 40 months; range, 8-76) the patients were examined for radiographic fusion, progression and complications. Spinal fusion was attempted in 19 patients, with a mean age of 17 years (range, 10-36 years). All 19 patients were identified through the "Bloodless Surgery Program." Hypotensive anesthesia, hemodilution, and cell saver was employed for all 19 cases. Erythropoietin with supplemental iron was used in 15 patients. Aprotinin was used in 3 patients. EBL and blood returned by cell saver averaged 855 and 341 mL, respectively. Operative times average 315 minutes. The average drop in hemoglobin from after surgery was 3.1 g/dL. There were 2 intraoperative complications: (i) transient loss of somatosensory evoked potential/motor evoked potential signals; and (ii) one surgery abandoned due to EBL. The average spinal deformity correction was 58%. There were 3 postoperative complications, none related to their refusal of a transfusion. 17 patients were available for radiographic and clinic follow-up of at least 24 months. All displayed radiographic fusion without progression. These blood conservation techniques allow satisfactory completion of deformity surgery on those patients not willing to be transfused and without major anesthetic or medical complications.

A Prospective Randomized Trial of Acute Normovolemic Hemodilution Compared to Standard Intraoperative Management in Patients Undergoing Major Hepatic Resection

Hepatic resection is the most effective treatment for many malignant and benign conditions affecting the liver and biliary tree. Despite improvements, major partial hepatectomy can be associated with considerable blood loss and transfusion requirements. Transfusion of allogeneic blood products, although potentially life-saving, is associated with many potential complications. The primary aim of this study was to determine if acute normovolemic hemodilution (ANH), an established blood conservation technique, reduces the requirement for allogeneic red cell transfusions in patients undergoing major hepatic resection. One hundred thirty patients undergoing major hepatic resection (> or =3 segments) were prospectively randomized to undergo either ANH or standard anesthetic management (STD). In the ANH group, intraoperative blood collection was performed to a target hemoglobin of 8.0 g/dL. Low central venous pressure anesthetic technique was used intraoperatively for both groups. A standardized transfusion protocol was applied to all patients intraoperatively and throughout the hospital stay. From April 2004 to March 2007, 63 patients were randomized to ANH and 67 to STD. Demographics, diagnoses, liver function, extent of resection, intraoperative blood loss, operative time, incidence and grade of complications, and length of hospital stay were similar between the 2 groups. ANH reduced the overall allogeneic red cell transfusion rate by 50% compared with STD [12.7% (n = 8) vs. 25.4% (n = 17), respectively; P = 0.067. ANH patients were less often transfused intraoperatively (n = 1, 1.6%) compared with the STD group (n = 7, 10.4%) (P = 0.036), had higher postoperative hemoglobin levels (P = 0.01), and tended to require fewer red cell units overall (28 vs. 47 units). In patients with intraoperative blood loss > or =800 mL, ANH reduced not only the allogeneic red cell transfusion rate (18.2% vs. 42.4%, P = 0.045) but also the proportion of patients requiring fresh frozen plasma (21.1% vs. 48.3%, P = 0.025). For patients undergoing major liver resection, ANH is safe, effectively reduces the need for allogeneic transfusions, and should be considered for routine use. Given the modest transfusion rate in the STD arm, future efforts should attempt to target ANH use to patients most likely to benefit.

Efficacy of Aprotinin as a Blood Conservation Technique for Adult Deformity Spinal Surgery

A retrospective study that involved a total of 82 adult deformity patients who underwent spinal fusion surgery with instrumentation of 6 or more levels. The purpose of this study is to assess the efficacy and safety of aprotinin in reducing blood loss in adult spinal deformity patients. Aprotinin is an antifibrinolytic agent, which has been proven to be effective as a blood-conserving agent in cardiac surgery. This study focused specifically on adult spine deformity patients. This retrospective study analyzed a total of 82 adult deformity patients (patients with diagnosis of adult scoliosis and kyphosis) who underwent spinal fusion surgery with instrumentation of 6 or more levels. Forty-one patients who received aprotinin were compared with a control group of 41 patients who did not receive aprotinin. Specific surgical outcome parameters and postoperative complications were assessed. The average age of the patients was 47 years and 41 years for the aprotinin group and the control group respectively. Thirty-nine percent of cases and 44% of controls had staged anterior/posterior fusion surgery, 39% of cases and 41% of controls underwent single stage posterior fusion surgery and the remaining 27% of cases and 15% of controls had same day anterior and posterior fusion surgery. The average number of levels fused and instrumented was 11.2 for the aprotinin group and 10.7 for the control group. The differences in mean blood loss and blood returned by cell-saver were statistically significantly lower in the aprotinin group (1324 mL vs. 2113 mL; P = 0.005 and 390 mL vs. 657 mL; P = 0.003). The amount of drainage after surgery was similar (1421 mL vs. 1388 mL; P = 0.982). The aprotinin group received an average of 2.73 units of blood. This was significantly lower than the average 5.02 units that the controls received (P = 0.003). The rate of complications was comparable and no allergic reaction to aprotinin was noted. One case exhibited a transitory elevation of blood urea nitrogen/creatinine which resolved before discharge. The results of our study suggest that the administration of aprotinin is a safe and effective method to reduce blood loss and to decrease the need for transfusions without increasing risk of complication in the younger patients in relatively good general health undergoing spinal deformity surgery requiring 6 or more levels of fusion.

Blood Conservation in a Congenital Cardiac Surgery Program

Bloodless surgery programs are being instituted because of increasing public concerns about blood transfusions and the need to accommodate some patients' religious beliefs. Patients' desires to forego transfusion must be identified during the preoperative screening process and subsequently reflected on the surgical consent. Patients are managed preoperatively with erythropoietin and dietary supplements. The surgical team employs a variety of intraoperative and postoperative blood conservation techniques to help avoid the need for transfusion. A retrospective review of congenital cardiac procedures in a blood conservation program confirmed that bloodless cardiac surgery is effective.