Use Of Cell Saver Research Articles

Ten Years of Experience on the Effectiveness and Efficiency of the Cleanfield Device in Cardiothoracic Surgery

AbstractThe process of blood management and treatment from the surgical field to produce concentrated red blood cells (RBC) is crucial in the context of cardiothoracic surgery and in other branch of surgery. The role of autotransfusion reservoir is not well described in the literature in terms of superiority suction for hemolysis prevention. In this context, we presented a ten-year single-center retrospective analysis on suction, filtering, and blood collection from surgical field through the use of the Cleanfield Autotransfusion Reservoir (Eurosets SRL, Medolla, Italy) in terms of performance, effectiveness, and safety. From January 2013 to January 2023 were collected and analyzed the consecutive uses of Cleanfield Autotransfusion Reservoir in a single cardiothoracic surgery center Anthea Hospital Gvm Care & Research, Bari, Italy. For single procedure, the number of cleanfield disposable used, the relative maximum blood volume filtered and collected, the suction pressure from devices through vacuum meter and the electronic suction pressure measurements in the devices for suctions and the presence and the incidence of adverse events during the use (implosion, clot formation, inability to cell saver use, inability to suction during the use) were analyzed. 5202 Cleanfield disposable autotransfusion reservoir were analyzed for blood volume suction, filtering and collection on 5199 cardiac surgery procedures, the maximum blood volume filtered and collected was 1997 ± 123 ml, the mean suction pressure measured from the device with vacuum meter during suction use was 38 ± 3 mmHg, the mean suction pressure measured in the device during suction use was 38 ± 2 mmHg, no presence of adverse event was reported for implosion, clot formation, inability to cell saver use, and inability to suction during the use. In our retrospective report, the use of Cleanfield autotransfusion reservoir (Eurosets SRL, Medolla Italy) in cardiothoracic surgery context was safe and effective for blood volume suction, filtering, and collection.

The use of cell salvage in adult cardiac surgery at Queen Alia Heart Institute

Background: Objective of the study was to determine the incidence of use cell salvage, indications, efficacy in blood conservation and benefits on recovery after adult cardiac surgery. Methods: This is an observational analysis of adult cardiac surgical patients presenting for cardiac surgery at Queen Alia Heart Institute in the period between September 2023 and December 2023. Patients’ demographics, type of surgery (cardiac pathology), comorbidities, preoperative and postoperative laboratory results, blood transfusion requirements, extubation and intensive care unit (ICU) length of stay were recorded and statistically analysed to determine the effectiveness of cell salvage. Patients were divided into two groups: The cell saver group and the no cell saver group for comparison. Results: Data from 141 adult cardiac surgeries is included in this analysis. Indications for cell saver use were recent anticoagulation (41.4%), more complex surgery (20.7%), high risk of bleeding (13.8%), preoperative anaemia (6.9%), intraoperative major bleeding (6.9%), coagulopathy (6.9%) and rare patient blood type (3.45%). Patients from the cell saver group required blood transfusion 2.1% more than the no cell saver group. There was no significant difference in the length of hospitalization between those who had and those who had not cell saver used during surgery (11.9 and 12 days, respectively). Conclusions: Cell saver was used in one fifth of adult cardiac surgeries. Most common indications for cell saver use during cardiac surgery were recent anticoagulation and more complicated cardiac surgery. The use of cell saver had no impact on postoperative haematocrit or overall time of hospitalization.

A secure blood-saving protocol for Jehovah's Witnesses in primary total hip replacement.

The study aimed to analyze the efficacy of the blood management protocol developed by our team for patients who are Jehovah's Witnesses (JW) presenting for primary total hip replacement (THR). Thirty JW patients (6 males, 24 females; mean age: 70.1±9.8 years; range, 65 to 81 years) and 30 age- and sex-matched controls (6 males, 24 females; mean age: 68.7±9.1 years; range, 62 to 79 years) who underwent primary THR at our institution between January 2018 and June 2020 were retrospectively evaluated. While the surgical technique of THR was not different among the groups, blood loss management differed between the groups. Patients in the control group were given 1 g of intravenous tranexamic acid (TXA) 15 min before the surgical incision. In addition to the same TXA protocol, intraoperative cell salvage with a continuous autologous transfusion system was used for JW patients. The estimated blood loss (EBL) was determined using Meunier's formula. Hemoglobin (Hgb) decline, EBL on the first and third postoperative days, allogenic blood transfusion (ABT) requirement, and complications were analyzed between groups. There were no significant differences between groups regarding demographic and clinical characteristics (p>0.05), ABT requirement (p>0.999), and Hgb decline in the first and third postoperative days (p=0.540 and p=0.836, respectively). Furthermore, both groups did not significantly differ between EBL in the first and third postoperative days (p=0.396 and p=0.616, respectively) and the length of hospital stay (p=0.547). Similar complication rates were noted for both groups. Hemoglobin level assessments revealed that values on the first and third postoperative days were significantly lower than the baseline Hgb value in both cohorts (p<0.001). A combination of intravenous administration of 1 g of TXA, meticulous hemostasis, and intraoperative use of cell saver constitutes a reasonable strategy for achieving the goal of transfusion-free primary THR with predictable levels of blood loss that are similar to non-JW patients.

A survey evaluating practice pattern in management of obstetric hemorrhage.

Hemorrhage anticipation and management has shifted significantly over the past decade due to evolution of data surrounding management of obstetric hemorrhage. Limited data exists which describe the practical use and clinical application of hemorrhage management. Our goal was to identify obstetric hemorrhage management patterns in a cohort of practicing Maternal Fetal Medicine physicians. We administered a survey to Maternal Fetal Medicine (MFM) fellows and faculty that addressed the management of hemorrhage including risk assessment, uterotonic use, antifibrinolytic use, cell saver use, and abnormal placentation management. An email was sent out regarding the survey to a listserv of all Maternal Fetal Medicine fellow program coordinators to disseminate to their faculty and fellows. Eighty responses were obtained. A total of 78 surveys were analyzed. Participants preferred methylergonovine as a first line agent (n = 57; 73%, n = 62; 80%). Most participants would consider using cell salvage when also activating MTP (28, 48%) or during scheduled deliveries who are high risk of hemorrhage (40, 69%). Approximately a third of providers would use TXA (tranexamic acid) prophylactically (n = 21; 28%). Only 26% of MFM fellows felt comfortable performing cesarean hysterectomy without Gynecologic Oncology. In comparison to prior reports, TXA use has increased substantially. Further, when looking at the management of abnormal placentation, the use of magnetic resonance imaging and embolization have both increased. Possibly due to the rise in centers of excellence for treatment of accreta spectrum disorders, Maternal Fetal Medicine fellows still feel largely unprepared to perform a cesarean hysterectomy without Gynecologic Oncology.

Incremental benefits of circumferential minimally invasive surgery for increasingly frail patients with adult spinal deformity.

Circumferential minimally invasive surgery (cMIS) may provide incremental benefits compared with open surgery for patients with increasing frailty status by decreasing peri- and postoperative complications. Operative patients with adult spinal deformity (ASD) ≥ 18 years old with baseline and 2-year postoperative data were assessed. With propensity score matching, patients who underwent cMIS (cMIS group) were matched with similar patients who underwent open surgery (open group) based on baseline BMI, C7-S1 sagittal vertical axis, pelvic incidence to lumbar lordosis mismatch, and S1 pelvic tilt. The Passias modified ASD frailty index (mASD-FI) was used to determine patient frailty stratification as not frail, frail, or severely frail. Baseline and postoperative factors were assessed using two-way analysis of covariance (ANCOVA) and multivariate ANCOVA while controlling for baseline age, Charlson Comorbidity Index (CCI) score, and number of levels fused. After propensity score matching, 170 ASD patients (mean age 62.71 ± 13.64 years, 75.0% female, mean BMI 29.25 ± 6.60 kg/m2) were included, split evenly between the cMIS and open groups. Surgically, patients in the open group had higher numbers of posterior levels fused (p = 0.021) and were more likely to undergo three-column osteotomies (p > 0.05). Perioperatively, cMIS patients had lower intraoperative blood loss and decreased use of cell saver across frailty groups (with adjustment for baseline age, CCI score, and levels fused), as well as fewer perioperative complications (p < 0.001). Adjusted analysis also revealed that compared to open patients, increasingly frail patients in the cMIS group were also more likely to demonstrate greater improvement in 1- and 2-year postoperative scores for the Oswestry Disability Index, SRS-36 (total), EQ-5D and SF-36 (all p < 0.05). With regard to postoperative complications, increasingly frail patients in the cMIS group were also noted to experience significantly fewer complications overall (p = 0.036) and fewer major intraoperative complications (p = 0.039). The cMIS patients were also less likely to need a reoperation than their open group counterparts (p = 0.043). Surgery performed with a cMIS technique may offer acceptable outcomes, with diminishment of perioperative complications and mitigation of catastrophic outcomes, in increasingly frail patients who may not be candidates for surgery using traditional open techniques. However, further studies should be performed to investigate the long-term impact of less optimal alignment in this population.

ОПЕРАЦІЯ ДЕВІДА ЧИ БЕНТАЛЛА – ПОРІВНЯННЯ РАННІХ ПІСЛЯОПЕРАЦІЙНИХ УСКЛАДНЕНЬ

The aim of the work: to analyze and compare the early postoperative complications in patients operated due to the presence of aneurysms of the root and ascending aorta and aortic valve pathology by the David and Bentall technique. Materials and Methods. It was a retrospective study. There were 107 patients who were routinely treated surgically at the Heart Institute of the Ministry of Health of Ukraine from 2015 to 2023. Patients were divided into two groups depending on the type of surgical intervention: in group A – David operation was performed, in group B – Bentall operation. All data were collected and compared in preoperative, intraoperative, and postoperative period. Results and Discussion. According to the duration of operations, the indicators are higher in patients of group A. Thus, the total duration of the operation was (291.23±12.67) minutes in group A and (244.418±7.67) min. in group B, respectively (p 0.001). The total duration of artificial blood circulation was (170.28±8.77) minutes in group A and (138.73±6.47) min. in group B, respectively (p 0.003). Aorta clamping time – (122.02±5.92) min. in group A and (95.82±4.79) min. in group B, respectively (p 0.000). Patients of group A had faster extubation. They spent less days in the intensive care unit and in the hospital in general. Among the early postoperative complications, it is important to note a greater proportion of arrhythmias in patients after Bentall operation. The share of acute respiratory failure with repeated reintubation is statistically higher in group B. Other indicators did not differ statistically among patients. The frequency of cell saver use was almost the same in the two groups of patients. The rate of reoperations due to bleeding did not differ statistically and was 3 (5.66 %) for group A and 6 (10.91 %) for group B (p 0.328).

P29. Decreasing the rate of unnecessary pediatric deformity surgery allogenic blood transfusions

<h3>BACKGROUND CONTEXT</h3> Spinal deformity surgery is associated with a high perioperative blood loss and risk for allogenic blood transfusion (ABT). Previous studies have shown ABT has an increased risk of surgical site infection, acute hemolytic reaction, and transfusion-related lung injury. During our yearly review, our institution was noted to have a high rate of ABT compared to other hospitals in the United States. In this study, we examined the efficacy of strategies taken to decrease our transfusion rate. <h3>PURPOSE</h3> To decrease the rate of allogenic blood transfusions in a pediatric spinal deformity population by increasing awareness and scrutiny. <h3>STUDY DESIGN/SETTING</h3> Prospective cohort. <h3>PATIENT SAMPLE</h3> Patients included had a diagnosis of AIS, underwent posterior instrumentation and fusion (PSIF), were between ages 10-18, and had a major cobb angle between 45-70°. <h3>OUTCOME MEASURES</h3> Allogenic blood transfusion rate. <h3>METHODS</h3> Interventions to reduce ABT included a meeting with the postoperative care unit (PCU) and pediatric intensive care unit (PICU) where scoliosis patients recovered, encouraging increased use of cell saver or intraoperative blood salvage, a change in our postoperative protocol template stating, "notify spine surgery team if blood transfusion is considered," aweekly report of AIS surgeries and if transfusion occurred. <h3>RESULTS</h3> A total of 197 patients met criteria over 3 years. The rate of ABT from January 2019 to 2020 was 19.5% (15/77) and from January 2020 to 2021 13.3% (8/60). The interventions to reduce ABT rates were implemented between November 2020 to January 2021. From January 2021 to November 2021 only 5% (3/60) of patients received an ABT, representing a significant decrease from 2020 to 2021 (p<0.01). No significant difference in demographics between groups existed including gender or age. <h3>CONCLUSIONS</h3> The rate of ABT at our institution was significantly lowered from 19.5% to 5%. This was accomplished by increasing scrutiny prior to transfusion, including meeting with the postoperative care units, change in our protocol template and increasing scrutiny after transfusion by performing a weekly review of AIS surgeries and if transfusion occurred. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Efficacy of Red Cell Salvage Systems in Open Acetabular Surgery.

Over the past 50 years, treatment of displaced acetabular fractures has moved away from conservative treatment with bedrest to operative intervention to achieve anatomic reduction, stable fixation, and allow early range of motion of the hip. However, operative fixation is not without complications. Internal fixation of traumatic acetabular fractures has been coupled with large volume of blood loss both at the time of injury and surgery. This often results in the need for allogenic blood products, which has been linked to increase morbidity (Vamvakas and Blajchman, 2009). In an attempt to avoid the risk associated with allogenic blood transfusion numerous techniques and methods have been devised. Red blood cell salvage (CS) is an intraoperative blood salvage tool where blood is harvested from the operative field. It is washed to remove the plasma, white blood cells, and platelets. The red cells are resuspended in a crystalloid solution. If the hematocrit of the resuspended red blood cells is sufficient, it is transfused to the patient intravenously. The benefits of CS in major spine surgery, bilateral knee replacement, and revision hip surgery are well established (Goulet et al. 1989, Gee et al. 2011, Canan et al. 2013). However, literature reviewing the use of cell saver in orthopedic trauma surgery, specifically acetabular surgery is limited. Our institute performed a retrospective review of 63 consecutive operative acetabular fractures at a level one trauma center. Our study revealed that patients with blood loss of less than 400 mL were 13 times less likely to receive autologous blood, and patients with hemoglobin less than 10.5 were 5 times less likely to receive autologous transfusion (p < 0.05). We also found that no patients with a hemoglobin level less than 10.5 and EBL less than 400 mL received autologous blood return. Autologous blood transfusion had no effect on volume or rate of allogenic blood transfusion. We believed that if a patient's preoperative hemoglobin is less than 10.5 or expected blood loss is less than 400 mL, then CS should have a very limited role, if any, in the preoperative blood conservation strategy. We found ASA greater than 2, BMI greater than 24 and associated fracture type to be a risk factor for high blood loss.

Perioperative Trajectory of Haemoglobin, Predictors of Blood Transfusion and Tailoring Targets for Patient Blood Management Interventions: A Single-centre, Retrospective Study of Non-emergent Cardiac Surgery Patients.

Anaemia and blood transfusion are two independent contributing factors to perioperative morbidity in cardiac surgery. While preoperative treatment of anaemia has been shown to improve outcomes, in real life, logistical difficulties remain substantial, even in high-income countries. The adequate trigger for transfusion in this population remains controversial, and there is a wide variability in transfusion rates among centres. To assess the impact of preoperative anaemia on perioperative transfusion in elective cardiac surgery,todescribe the perioperative trajectory of haemoglobin (Hb), to stratify outcomes based on preoperative presence of anaemia and to identify predictors of perioperative blood transfusion. and Methods: We included a retrospective cohort of consecutive patients who underwent cardiac surgery with cardiopulmonary bypass in a tertiary centre of cardiovascular surgery. Recorded outcomes included hospital and intensive care unit (ICU) length of stay (LOS), surgical re-exploration due to bleeding, packed red blood cell (PRBC) transfusion pre-, intra- and postoperatively. Other record perioperative variables were preoperative chronic kidney disease, duration of surgery, use of rotation thromboelastometry (ROTEM) and cell saver, and fresh frozen plasma (FFP) and platelet (PLT) transfusion. Hb values were recorded at four distinct time points: Hb1 - at hospital admission, Hb2 - last Hb recorded preoperatively, Hb3 - first Hb recorded postoperatively and Hb4 - at hospital discharge. We compared the outcomes between anaemic and non-anaemic patients. Transfusion was decided by the attending physician on a case-by-case basis. Results: Of the 856 patients operated during the selected period, 716 underwent non-emergent surgery and 710 were included in the analysis. Also, 40.5% (n = 288) of patients were anaemic preoperatively (Hb <13 g/dl); 369 patients (52%) were transfused PRBCs, with differences found between anaemic and non-anaemic patients regarding the percentage of transfused patients perioperatively (71.5% vs 38.6%, p < 0.001) and in the total median number of units transfused (2 [IQR 0-2] vs 0 [IQR 0-1], p <0.001). We built a multivariate model, and logistic regression analysis showed that preoperative Hb <13 g/dl (odds ratio [OR] 3.462 [95% CI 1.766-6.787]), female sex (OR 3.224 [95% CI 1.648-6.306]), age (1.024 per year [95% CI 1.0008-1.049]), hospital LOS (OR 1.093 per day of hospitalisation [95% CI 1.037-1.151]) and FFP transfusion (OR 5.110 [95% CI 1.997-13.071]) are associated with PRBC transfusion. Untreated preoperative anaemia leads to more transfusion in elective cardiac surgery patients, both as a ratio of transfused patients and as the number of units of PRBCs per patient, and this is associated with an increased use in FFP.

Identifying Risk Factors for Complications During Exposure for Anterior Lumbar Interbody Fusion.

IntroductionAn anterior approach to lumbar interbody fusion is a widely utilized method of access to the lumbar spine. Due to the potential for vascular complications with spine exposure, vascular surgeons are frequently included in the care of these patients as part of a team-based approach. Identifying risk factors for such complications is difficult and not well-defined in the literature. In this investigation, we evaluate the potential risk factors for complications during anterior lumbar inter-body fusion (ALIF).MethodsThis is a retrospective review of 106 patients who underwent ALIF at a single institution between May 1, 2007, and April 30, 2017. Patients were identified through operating room case logs and Current Procedural Terminology (CPT) codes correlating with ALIF. Vascular surgeons performed all anterior exposures. Patient demographics and data regarding their surgical care and postoperative course were obtained from a review of operative and progress notes in the electronic medical record. Statistical methods employed included a t-test for normally distributed data and the Wilcoxon rank-sum test for non-normally distributed data. Categorical variables were compared using Fisher’s exact and chi-square tests. A logistic regression model was applied to predict complications by controlling other significant covariates.ResultsOf the 106 patients included in this analysis, 16 patients experienced a defined complication, giving an overall complication rate of 15%. Patients with complications were more likely to be of male gender (n=11, P=0.016), with older average age (54.6, P=0.017), with higher estimated blood loss, with higher use of blood products, and with higher use of cell-saver. A venous injury was the most common complication (n=11, 10.4%); ileus and nerve injury were the next most common (n=3, 2.8%). The 30-day mortality was 0%. Male gender demonstrated an odds ratio of 3.78 (P=0 .034) in a logistic regression model after adjusting for age and blood products.ConclusionsOverall complication rates were comparable to those in the published literature and male gender was identified as a predictor for risk of complications in those undergoing ALIF. This is the first study to identify male sex as a risk factor for complications following ALIF. The results of this study will hopefully guide future studies in gaining more insight into the predictors of complications in larger series.

Efficacy and cost-effectiveness of cell saver usage in the repair of thoracic aortic aneurysms and dissections.

A substantial amount of blood loss occurs during the open repair of aortic aneurysms or dissections. The aim of the present study is to determine the efficacy and cost-effectiveness of cell saver devices in blood conservation during the open repair of thoracic aortic pathologies. The present study prospectively collected the data pertaining to 25 patients who underwent surgical management of thoracic aortic aneurysms or dissections using a cell saver (Group 1, n = 25). The volume and cost of transfusion and postoperative outcomes were compared with the second group of patients who underwent surgery without the use of cell savers in the previous year (Group 2, n = 25); the data pertaining to the same were retrospectively collected from the hospital records. The patient characteristics and categorical variables were compared using the x2 test and Fisher's exact test. Transfusion volume and costs were compared using the independent samples t-test and Mann-Whitney U test. The patients in both the groups displayed similar characteristics and risk factors. The total volume of allogenic red blood cell (p < 0.001) and total blood product (p = 0.01) transfusions were significantly lower in Group 1. The cost of red blood cell (p < 0.001) and total transfusions (p = 0.03) were lower in Group 1. The two groups displayed similar in-hospital morbidity and mortality rates. There was a significant association between the use of cell savers and the decreased need for red blood cell and total blood product transfusions. Considering the cost of the cell saver set, transfusion costs in the two groups were comparable.

Effect of the application of the “Patient blood management” programme on the approach to elective hip and knee arthroplasties

Background and objectivesThe “Patient Blood Management” (PBM) programmes have demonstrated their value in the continuous improvement of care practice, due to continuous systematic reviewing of results and their dynamic and multidisciplinary updating in accordance with new clinical evidence. Our goal is to demonstrate the effectiveness of simple protocols, applicable in second level hospitals. Patients and methods702 patients undergoing scheduled arthroplasty from 2011 to 2018 were retrospectively analyzed. During this period, the evolution of transfusion rates and anaemia and bleeding management were recorded in the patients’ computerized clinical histories. ResultsStages and transfusion rates were: Year 2011–2012, “Universal self-donation programme”: 62.4%; year 2013, “Optimization of preoperative haemoglobin and universal self-donation withdrawal”: 22.5%; year 2015, “Stopping the use of cell-savers and drains”: 13.2%; and year 2017, “Introduction of routine tranexamic acid”: 3.6%. A significant reduction in the transfusion rate and volume (p<0.001) and the average hospital stay (8–6 days) (p<0.001) was achieved. In multivariate models, transfused patients have a 0.5-day stay and there is a trend towards a reduction in complications, being fewer in patients receiving tranexamic acid (OR 0.44). ConclusionA simple progressive and multidisciplinary PBM programme, with continued re-evaluation, has allowed a reduction in transfusion rates and average hospital stay.

Primary isolated CABG restrictive blood transfusion protocol reduces transfusions and length of stay.

Cardiac surgery accounts for 10-15% of blood transfusions in the US, despite benefits and calls of limiting its use. We sought to evaluate the impact of a restrictive transfusion protocol on blood use and clinical outcomes in patients undergoing isolated primary coronary artery bypass grafting (CABG). Blood conservation measures, instituted in 2012, include preoperative optimization, intraoperative anesthesia, and pump fluid restriction with retrograde autologous priming and vacuum-assisted drainage, use of aminocaproic acid and cell saver, intra- and postoperative permissive anemia, and administration of iron and low-dose vasopressors if needed. Medical records of patients who underwent isolated primary CABG from 2009 to 2012 (group A; n = 375) and 2013 to 2016 (group B; n = 322) were compared. CABG with grafting to three or four coronary arteries was performed in 262 (70%) and 222 (69%) patients and bilateral internal thoracic artery grafting in 202 (54%) and 196 (61%) patients in groups A and B, respectively. Mean preoperative and intraoperative hematocrit was 40.3% and 40.7%, 28.9% and 29.4% in groups A and B, respectively. Total blood transfusion was 24% and 6.5%, intraoperative transfusion 11% and 1.2%, and postoperative transfusion 20% and 5.6% (P < .0001 for all) in groups A and B, respectively. Median postoperative length of stay was 5.0 days in group A and 4.5 days in group B (P = .02), with no significant differences in mortality or morbidity. A restrictive transfusion protocol reduced blood transfusions and postoperative length of stay without adversely affecting outcomes following isolated primary CABG.

Efecto de la aplicación del programa Patient blood management en el abordaje de las artroplastias de cadera y rodilla programada

Background and objectivesThe “Patient Blood Management” (PBM) programmes have demonstrated their value in the continuous improvement of care practice, due to continuous systematic reviewing of results and their dynamic and multidisciplinary updating in accordance with new clinical evidence. Our goal is to demonstrate the effectiveness of simple protocols, applicable in second level hospitals. Patients and methods702 patients undergoing scheduled arthroplasty from 2011 to 2018 were retrospectively analysed. During this period, the evolution of transfusion rates and anaemia and bleeding management were recorded in the patients’ computerised clinical histories. ResultsStages and transfusion rates were: Year 2011-2012, “Universal self-donation programme”: 62.4%; year 2013, “Optimization of preoperative haemoglobin and universal self-donation withdrawal”, 22.5%; year 2015, “Stopping the use of cell-savers and drains”, 13.2%; and year 2017, “Introduction of routine tranexamic acid”, 3.6%. A significant reduction in the transfusion rate and volume (P<.001) and the average hospital stay (8 to 6 days) (P<.001) was achieved. In multivariate models, transfused patients have a .5-day stay and there is a trend towards a reduction in complications, being fewer in patients receiving tranexamic acid (OR .44). ConclusionA simple progressive and multidisciplinary PBM programme, with continued re-evaluation, has allowed a reduction in transfusion rates and average hospital stay.

Anemia before reimplantation surgery - An overlooked modifiable risk factor of septic revision knee arthroplasty failure.

Introduction: Preoperative anemia in patients undergoing a two-stage septic revision arthroplasty may be a factor of reinfection, even in the presence of aggressive antimicrobial therapy. Patient Blood Management (PBM) in such patients is challenging. We evaluate the impact of anemia existing before re-implantation on a failure rate after two-stage septic total knee arthroplasty (rTKA), and explore feasibility of a PBM strategy implementation in these patients. Materials and methods: A retrospective study of patients from January 2010 to January 2015 in a French regional referral center was performed. Patients undergoing a two-stage rTKA for infection after successful primary TKA were identified and followed up to 31.12.2018. The primary outcome (failure) was defined as surgical site infection after re-implantation requiring new surgery. The secondary outcomes were time to failure, the time between explantation/reimplantation, transfusion rate during the second stage. Preoperative anemia was defined as Hb level < 12 g/L before the re-implantation. Results: 69 patients were identified; 17 (24%) developed reinfection of rTKA in 105 [11.4–156] days. In these patients pre-implantation anemia was more frequent (n = 13(76.5%) in failed vs. n = 21(40%) in non-failed, p = 0.0110). During the explantation stage, there were no significant group differences in age, sex, comorbidity, type of spacer and antimicrobial therapy, iron supplementation, or transfusion rate. The median time between explantation/reimplantation surgery was 51 [43–71.5] days, indifferent between the two groups. Intraoperative transfusion during reimplantation was required in 12 (17%) patients, more frequent in failed patients. None of the patients had contraindications for the PBM strategy except the cell-saver use. Conclusion: In two-stage septic rTKA preoperative anemia was almost two times more frequent and associated with an elevated rate of septic failure. The time-frame between explantation and-re-implantation is sufficient to implement a PBM strategy for all anemic patients. Before-after studies would be of interest to determine the best PBM strategy to prevent anemia-associated septic failure in such a condition.

Assessing the multidisciplinary team approaches to placenta accreta spectrum across five institutions within the University of California fetal Consortium (UCfC)

Purpose To describe the multidisciplinary approaches to placenta accreta spectrum (PAS) across five tertiary care centers that comprise the University of California fetal Consortium (UCfC) and to identify potential best practices. Materials and methods Retrospective review of all cases of pathologically confirmed invasive placenta delivered from 2009 to 2014 at UCfC. Differences in intraoperative management and outcomes based on prenatal suspicion were compared. Interventions assessed included ureteral stent use, intravascular balloon use, anesthetic type, gynecologic oncology (Gyn Onc) involvement, and cell saver use. Intervention variation by institution was also assessed. Analyses were adjusted for final pathologic diagnosis. Chi-square, Fisher’s exact, Student’s t-test, and Mann–Whitney’s U-test were used as appropriate. Binary logistic regression and multivariable linear regression were used to adjust for confounders. Results One hundred and fifty-one cases of pathologically confirmed invasive placenta were identified, of which 82% (123) were suspected prenatally. There was no correlation between the degree of invasion on prenatal imaging and use of each intervention. Ureteral stents were placed in 33% (41) of cases and did not reduce GU injury. Intravascular balloons were placed in 29% (36) of cases and were associated with shorter OR time (161 versus 236 min, p < .01) and lower estimated blood loss (EBL) (1800 versus 2500 ml, p < .01). General endotracheal anesthesia (GETA) was used in 70% (86). EBL did not differ between GETA and regional anesthesia. Gyn Onc was involved in 58% (71) of cases and EBL adjusted for final pathology was reduced with their involvement (2200 versus 2250 ml, p = .02) while OR time and intraoperative complications did not differ. Cell saver was used in 20% (24) and was associated with longer OR time (296 versus 200 min, p < .01). Use of cell saver was not associated with a difference in EBL or number of units of packed red cells transfused. All analyses were adjusted for pathologic severity of invasion. Conclusions Intravascular interventions such as uterine artery balloons and the inclusion of Gynecologic Oncologists as part of a multidisciplinary approach to treating PAS reduce EBL. Additionally, the placement of intravascular balloons may reduce OR time. No significant differences were seen in outcomes when comparing the use of ureteral stents, general anesthesia, or institutions. A team of experienced operators with a standard approach may be more significant than specific practices.

Hidden blood loss following 2- to 3-level posterior lumbar fusion

BACKGROUND CONTEXTPatients undergoing single-level posterior lumbar decompression and fusion (PLDF) usually do not need transfusions. However, patients undergoing two or three-level PLDF occasionally require transfusion postoperatively even when estimated blood loss (EBL) or blood loss from drains appears acceptable. Estimating the volume of HBL is critical in perioperative fluid management. PURPOSETo determine the volume of hidden blood loss (HBL) in two- or three-level PLDF. STUDY DESIGNSingle-center, multisurgeon, secondary analysis from a prospective randomized clinical trial of cell saver use. PATIENT SAMPLEPatients enrolled in a prospective randomized trial of cell saver undergoing two- or three-level PLDF were included in this analysis. METHODSTotal blood loss was calculated using four estimation formulas including Bourke's, Gross’, Camarasa's, and Lopez-Picado's formulas. HBL was determined by subtracting the visible loss (EBL and blood loss from drains) from the calculated total blood loss. RESULTSA total of 89 patients (36 males, mean age 62 years) were included. Seventy-five patients underwent open two-level fusion while 14 had three-level fusions. Intervertebral fusion was performed in 20 patients. Mean surgical time was 261 minutes, and EBL was 685 mL. Mean blood loss from drains was 824 mL. Seventy patients received allogenic blood whereas 47 cell saver blood reinfused intraoperatively. HBL was calculated to be 678 mL, 963 mL, 1,267 mL, and 819 mL using each formula. CONCLUSIONSHBL following two or three-level PLDF was substantial and more than EBL. Postoperative management of blood loss should take HBL into account.

Cardiac Surgery without Donor Blood Transfusion at a Referral Cardiac Institute in Bangladesh

Background: Blood transfusion is always associated with some hazards despite economic and work burden on laboratory staffs. Pre-donation and blood conservation can help to avoid transfusion related hazards with good posto-perative outcome.&#x0D; Objective: The main objective of this study was to show the varieties of cardiac surgery without donor blood transfusion.&#x0D; Methodology: Patients were selected conveniently. Preoperative proper counseling was done to the guardians of minor and all the adult patients about the procedure and written informed consent was taken accordingly. All patients were operated under cardio-pulmonary bypass (CPB) following a standard protocol through mid-sternotomy, systemic heparinization, antegrade intermittent cold cardioplegic arrest of the heart. After weaning from CPB protamine was administered to neutralize the action of heparin. A pre-operative hemoglobin (Hb) and hematocrit (Hct) measured just before systemic heparinization. One bag of blood drawn from the patient’s body when the Hb and Hct more. Meticulous hemostasis done after weaning from cardio-pulmonary bypass. Both systemic and local tranexamic acid plus calcium injection was given before sternal wires are tighten. All the blood in the cardio-pulmonary bypass machine was returned at the end of operation. Patient’s hemoglobin and hematocrit checked to detect the need for transfusion. All other variables were studied.&#x0D; Results: Ten patients were operated without pre-operative blood transfusion of donor blood. Out of ten patients male=5 female=5, Male:Female=1:1 age range 5-26 years mean ±SD (13±-6.88) years. Preop diagnosis ASD 4/10=40%,VSD 3/10=30% TOF 2/10=20% AVR=1/10=10%. pre-operative Hb Range: 12.4-17.3 gm/dl. Mean ±SD (14.25±-1.66 gm/dl. Pre-operative Hct mean±SD (43.7±4.5). Per-operative Hct during CPB Mean±SD (24.9±4). Post-operative Hb mean ±SD (11.25gm±1.18gm). Post-operative Hct mean ±SD (34.3±3.80). Use of cell saver 1/8(12.5%) Post-operative blood loss for ASD,VSD, TOF and AVR were mean ±SD = 140±20.60ml, 156.44±33.84.320.80±60.22ml and 280 ml respectively. Varieties of ionotropes used were: Dopamine Dobutamin Adrenaline. Single ionotrope Dopa/Dobuta5/10=50% Double ionotrope Dopa/dobuta+Adrin=3/10(30%) tripple ionotrope 2/10(20%). Morbidity and mortality 0%. All the patients were discharged home uneventfully, in hospital outcome was good.&#x0D; Conclusion: In our setup we can do cardiac surgery without pre-operative donor blood use by following blood pre-donation and other blood conservative techniques.]&#x0D; Journal of National Institute of Neurosciences Bangladesh, 2019;5(1): 53-58

How a Standardized Approach to Care for Patients With Suspected Morbidly Adherent Placentas Improved Patient Outcomes

To highlight the positive impacts of a nurse-driven initiative on patient outcomes in women with suspected morbidly adherent placentas (MAPs). The initiative is a multidisciplinary collaboration and has affected outcomes such as estimated blood loss (EBL), units of blood transfused (pRBCs), postoperative x-rays, intensive care unit (ICU) admissions, and total hysterectomies. To develop a collaborative process with representatives from 10 departments, including labor and delivery, anesthesia, operating room, interventional radiology, urology, gynecology–oncology, NICU, blood bank, pharmacy, and house supervisor. Representatives evaluate individual unit responsibilities and develop flowcharts for patient care. Collaborative review of flowcharts assesses for overlapping responsibilities and opportunities to refine. After several births of patients diagnosed with suspected MAPs, teams identified issues regarding communication, disorganization, and “turf wars” in different departments. Meetings, beginning in October 2017, discussed efficient processes and challenges identified with these births. Departmental flowcharts were created and then reviewed at the collaborative meetings for reformations. Meetings after subsequent MAP deliveries were used to debrief and evaluate for potential revisions. An order set was developed to be used in conjunction with current sets that includes additional considerations for suspected MAP births. There have been 11 births since the inception of this initiative; 45% were unscheduled or emergent. A single instrument set-up has eliminated incorrect counts and postoperative x-rays. Use of cell saver and tranexamic acid has decreased EBL and total pRBCs transfused. The median EBL (range = 650–6,500 ml) is 1,200 ml. Forty percent of the patients received 1–4 units pRBCs, all of which had an EBL of at least 1,800 ml. ICU admissions have decreased to only 27% of the cases. Several births were completed under epidural anesthesia, and a support person has been present in the delivery room. A total hysterectomy was not required in 3 patients. This multidisciplinary collaboration has strengthened interdepartmental relationships and improved transitions of care hospital-wide. Power struggles have been alleviated, and roles and responsibilities are better understood by those involved. Departmental flowcharts have been used, with positive feedback from staff and providers. Patient outcomes have improved, subsequently decreasing maternal morbidity.

Association between perioperative surgical home implementation and transfusion patterns in adolescents with idiopathic scoliosis undergoing spinal fusion.

Blood transfusions in patients with adolescent idiopathic scoliosis after fusion have been associated with increased morbidity, mortality, and cost. The aim of this study was to evaluate the association between implementation of blood-conservation strategies within the perioperative surgical home on transfusion rates for patients with adolescent idiopathic scoliosis undergoing spinal fusion. Two hundred and thirteen patients (44 preperioperative surgical home, 169 postperioperative surgical home) who underwent posterior spine fusion for adolescent idiopathic scoliosis between 23 June 2014, and 30 July 2017, were enrolled in this case control study. The perioperative surgical home implemented in March 2015 involved evidence-based perioperative interventions to create a standardized clinical pathway including judicious use of crystalloid management, restrictive transfusion strategy, routine use of cell saver, and standardized administration of anti-fibrinolytics. The primary outcome was odds of perioperative transfusion. Secondary outcomes included volumes of crystalloid, albumin, cell saver, packed red blood cells as well as calculated blood loss. Other variables that were documented included antibrinolytic total dose, mean arterial pressure, temperature, laboratory values, intrathecal morphine dosing, and surgical time. Statistical methods included t test and logistic regression. For the postperioperative surgical home, the odds of perioperative transfusion were 0.30 (95% CI 0.13-0.70), as compared to preperioperative surgical home. In terms of secondary outcomes, calculated blood loss was significantly lower in the postperioperative surgical home patients (27.0mL/kg preperioperative surgical home vs 22.8mL/kg postperioperative surgical home; mean difference=-0.24 [-0.44, -0.04]). Although no difference was noted in the amount of intraoperative cell saver or albumin administered, a reduction was noted in mean intraoperative crystalloid given postperioperative surgical home (41.4mL/kg±20.4mL/kg preperioperative surgical home vs 28.0mL/kg±13.7mL/kg postperioperative surgical home; log mean difference=0.37 [95% CI 0.21-0.53], P<0.001). Postperioperative surgical home patients also had a significantly higher temperature nadir (mean difference=-0.47 [95% CI -0.70 to -0.23]; P<0.001), received a significantly higher total anti-fibrinolytic dose (mean difference=-3939 [95% CI -5364 to -2495]; P<0.001), and were exposed to shorter surgical times (mean difference=0.72 [95% CI 0.36-1.09]; P<0.001). Implementation of blood-conservation strategies as part of a perioperative surgical home for patients with adolescent idiopathic scoliosis undergoing posterior spine fusion resulted in significant decrease in perioperative blood transfusions.