Use Of Cell Saver Research Articles

Safety and efficacy of biocompatible perfusion strategy in a contemporary series of patients undergoing coronary artery bypass grafting - a two-center study.

ObjectiveThe profile of patients referred for coronary artery bypass grafting (CABG) is continuously changing to include older patients with multiple comorbidities. We assessed the safety and efficacy of a biocompatible perfusion strategy (BPS) in a contemporary series of patients undergoing isolated CABG.MethodsBPS consisted of a membrane oxygenator, tip-to-tip closed-system heparin-bonded cardiopulmonary bypass circuits without a cardiotomy reservoir, low systemic anticoagulation (target ACT – 250-300 sec) using heparin titration curves, low prime volume, avoidance of systemic cooling, and routine use of cell saver and anti-fibrinolytics. Data were prospectively collected using the American Society of Thoracic Surgeons National Adult Cardiac Surgery Database definitions.Results964 consecutive patients (mean age 66 ± 11 years, 83% male) undergoing CABG between 2008 and 2012 were enrolled. 30-day mortality was 1.4%. Rates of postoperative stroke, myocardial infarction, sternal infection and reoperation for bleeding were 0.9%, 1.3%, 1.9% and 4.2%, respectively. Average 24-hour chest tube drainage was 440 ± 280 ml. Blood products were used in 34% of patients (total donor exposure of 1.7 ± 4.7 units/patient). Predictors of hospital mortality in multivariable analysis were left main disease and preoperative treatment with anti-arrhythmic or immunosuppressive medications. Predictors of allogeneic blood transfusions included older age, small body surface area, female gender, increased serum creatinine, lower preoperative LVEF and hematocrit. Priority of surgery, dual antiplatelet therapy and cardiopulmonary bypass time were not predictors of adverse outcomes or blood transfusions.ConclusionsIn a contemporary cohort of patients undergoing CABG, the use of BPS is safe and effective. It is associated with excellent clinical outcomes and reduced allogeneic blood transfusions.Electronic supplementary materialThe online version of this article (doi:10.1186/s13019-014-0196-3) contains supplementary material, which is available to authorized users.

Use of Bivalirudin for Anticoagulation during Implantation of Total Artificial Heart

Heparin-induced thrombocytopenia presents a challenge for anticoagulation techniques during cardiac surgery and ventricular assist device implantation. Bivalirudin is currently recommended for use during cardiopulmonary bypass for patients with heparin-induced thrombocytopenia but requires the use of special techniques to avoid blood stagnation. We report the successful use of bivalirudin during cardiopulmonary bypass for implantation of the Total Artificial Heart with late operative bleeding likely resulting from heavy cell saver use.

The Efficacy and Cost-Effectiveness of Cell Saver Use in Instrumented Posterior Correction and Fusion Surgery for Scoliosis in School-Aged Children and Adolescents

Posterior spinal instrumentation and fusion surgery in school-aged children and adolescents is associated with the potential for massive intraoperative blood loss, which requires significant allogeneic blood transfusion. Until now, the intraoperative use of the cell saver has been extensively adopted; however, its efficacy and cost-effectiveness have not been well established. Therefore, the aim of this study is to determine the efficacy and cost-effectiveness of intraoperative cell saver use. This study was a single-center, retrospective study of 247 school-aged and adolescent patients who underwent posterior spinal instrumentation and fusion surgery between August 2007 and June 2013. A cell saver was used intraoperatively in 67 patients and was not used in 180 patients. Matched case-control pairs were selected using a propensity score to balance potential confounders in baseline characteristics. Allogeneic red blood cell (RBC) and plasma transfusions as well as blood transfusion costs were analyzed. The propensity score matching produced 60 matched pairs. Compared to the control group, the cell saver group had significantly fewer intraoperative allogeneic RBC transfusions (P = 0.012). However, when the combined postoperative and total perioperative periods were evaluated for the use of allogeneic RBC transfusion, no significant differences were observed between the two groups (P = 0.813 and P = 0.101, respectively). With regard to the total cost of perioperative transfusion of all blood products (RBC and plasma), costs for the control group were slightly lower than those of the cell saver group, but this variance did not reach statistical significance (P = 0.095). The use of the cell saver in posterior spinal instrumentation and fusion surgery in school-aged children and adolescents was able to decrease the amount of intraoperative allogeneic RBC transfusion but failed to decrease total perioperative allogeneic RBC transfusion. Moreover, the use of the cell saver was not cost-effective.

Patient Blood Management in Elective Total Hip- and Knee-replacement Surgery (Part 1)

Patient blood management combines the use of several transfusion alternatives. Integrated use of erythropoietin, cell saver, and/or postoperative drain reinfusion devices on allogeneic erythrocyte use was evaluated using a restrictive transfusion threshold. In a factorial design, adult elective hip- and knee-surgery patients with hemoglobin levels 10 to 13 g/dl (n = 683) were randomized for erythropoietin or not, and subsequently for autologous reinfusion by cell saver or postoperative drain reinfusion devices or for no blood salvage device. Primary outcomes were mean allogeneic intra- and postoperative erythrocyte use and proportion of transfused patients (transfusion rate). Secondary outcome was cost-effectiveness. With erythropoietin (n = 339), mean erythrocyte use was 0.50 units (U)/patient and transfusion rate 16% while without (n = 344), these were 0.71 U/patient and 26%, respectively. Consequently, erythropoietin resulted in a nonsignificant 29% mean erythrocyte reduction (ratio, 0.71; 95% CI, 0.42 to 1.13) and 50% reduction of transfused patients (odds ratio, 0.5; 95% CI, 0.35 to 0.75). Erythropoietin increased costs by €785 per patient (95% CI, 262 to 1,309), that is, €7,300 per avoided transfusion (95% CI, 1,900 to 24,000). With autologous reinfusion, mean erythrocyte use was 0.65 U/patient and transfusion rate was 19% with erythropoietin (n = 214) and 0.76 U/patient and 29% without (n = 206). Compared with controls, autologous blood reinfusion did not result in erythrocyte reduction and increased costs by €537 per patient (95% CI, 45 to 1,030). In hip- and knee-replacement patients (hemoglobin level, 10 to 13 g/dl), even with a restrictive transfusion trigger, erythropoietin significantly avoids transfusion, however, at unacceptably high costs. Autologous blood salvage devices were not effective.

Patient Blood Management in Elective Total Hip- and Knee-replacement Surgery (Part 2)

Patient blood management is introduced as a new concept that involves the combined use of transfusion alternatives. In elective adult total hip- or knee-replacement surgery patients, the authors conducted a large randomized study on the integrated use of erythropoietin, cell saver, and/or postoperative drain reinfusion devices (DRAIN) to evaluate allogeneic erythrocyte use, while applying a restrictive transfusion threshold. Patients with a preoperative hemoglobin level greater than 13 g/dl were ineligible for erythropoietin and evaluated for the effect of autologous blood reinfusion. Patients were randomized between autologous reinfusion by cell saver or DRAIN or no blood salvage device. Primary outcomes were mean intra- and postoperative erythrocyte use and proportion of transfused patients (transfusion rate). Secondary outcome was cost-effectiveness. In 1,759 evaluated total hip- and knee-replacement surgery patients, the mean erythrocyte use was 0.19 (SD, 0.9) erythrocyte units/patient in the autologous group (n = 1,061) and 0.22 (0.9) erythrocyte units/patient in the control group (n = 698) (P = 0.64). The transfusion rate was 7.7% in the autologous group compared with 8.3% in the control group (P = 0.19). No difference in erythrocyte use was found between cell saver and DRAIN groups. Costs were increased by €298 per patient (95% CI, 76 to 520). In patients with preoperative hemoglobin levels greater than 13 g/dl, autologous intra- and postoperative blood salvage devices were not effective as transfusion alternatives: use of these devices did not reduce erythrocyte use and increased costs.

Does intraoperative cell salvage system effectively decrease the need for allogeneic transfusions in scoliotic patients undergoing posterior spinal fusion? A prospective randomized study

To determine the safety and efficacy of intraoperative cell salvage system in decreasing the need for allogeneic transfusions in a cohort of scoliosis patients undergoing primary posterior spinal fusion with segmental spinal instrumentation. A total of 110 consecutive scoliosis patients undergoing posterior instrumented spinal fusion were randomized into two groups according to whether a cell saver machine for intraoperative blood salvage was used or not. Data included age, body mass index, perioperative hemoglobin levels, surgical time, levels fused, perioperative estimated blood loss, perioperative transfusions and incidence of transfusion-related complications. A Chi-square test and t tests were performed for intraoperative and perioperative allogeneic transfusion between groups. A regression analysis was performed between selected covariates to investigate the predictive factors of perioperative transfusion. Perioperative allogenic blood transfusion rate was lower in the cell saver group (14.5 versus 32.7%, p = 0.025). Mean intraoperative red blood cell transfusion requirement was also lower (0.21 U/pt versus 0.58 U/pt, p = 0.032). A multivariate analysis demonstrated that no. of fused segments (OR: 1.472; p = 0.005), preoperative hemoglobin level (OR: 0.901; p = 0.001), and the use of cell saver system (OR: 0.133; p = 0.003) had a trend toward significance in predicting likelihood of transfusion. Cell saver use significantly reduces the need for allogeneic blood in spine deformity surgery, particularly in patients with low preoperative hemoglobin or longer operation time. This study confirms the utility of routine cell saver use during PSF with segmental spinal instrumentation for scoliosis patients.

Letter by Saha Regarding Article, “Should Off-Pump Coronary Artery Bypass Grafting Be Abandoned?”

I read with interest the special report by Dr Lazar1 on off-pump coronary artery bypass grafting (OPCAB). I congratulate him for the exhaustive and lucid review. I would like to humbly express my opinion about the conclusions derived by the author. The Randomized On/Off Bypass (ROOBY) trial had 12.4% conversion to cardiopulmonary bypass. This is way too high and depicts the inexperience of the OPCAB surgeon. We have reported that it is possible to achieve nearly zero conversion to cardiopulmonary bypass in nonselected consecutive patients by the timely use of intra-aortic balloon pump and elective use of cell saver.2 OPCAB has a steep learning curve. The poor OPCAB graft patency rate may have resulted from the …

Is it time for a new standard?

Is it time for a new standard?

Fibrin sealants or cell saver eliminate the need for autologous blood donation in anemic patients undergoing primary total knee arthroplasty

Reducing allogeneic blood transfusions remains a challenge in total knee arthroplasty. Patients with preoperative anemia have a particularly high risk for perioperative blood transfusions. 176 anemic patients (Hb < 13.5 g/dl) undergoing total knee replacement were prospectively evaluated to compare the effect of a perioperative cell saver (26 patients), intraoperative fibrin sealants (5 ml Evicel, Johnson & Johnson Wound Management, Ethicon, Somerville, NJ) (45 patients), preoperative autologous blood donation (PABD) (21 patients), the combination of fibrin sealants and preoperative autologous blood donation (44) and no intervention (40 patients) on perioperative blood loss and transfusion requirements. All protocols resulted in significant reduction of allogeneic blood transfusions. Transfusion rates were similar with the use of PABD (19%), Evicel (18%), and cell saver (19%), all significantly lower than the control group (38 %, p < 0.05). Combining Evicel with PABD resulted in significantly higher wastage of autologous units (p < 0.05) with no significant reduction in allogeneic transfusion rate (14%). The use of fibrin sealant resulted in a significant reduction of blood loss compared to the PABD group (603 vs. 810 ml, p < 0.005) as well as the control group (603 vs. 822 ml, p < 0.005). While PABD proved to be the most cost-effective treatment option in anemic patients, fibrin sealants and cell saver show similar reduction in allogeneic transfusion rates compared to controls. The combination of fibrin sealants and PABD is not cost-effective and increases the number of wasted units.

Effect of Spine Fellow Training on Operative Outcomes, Affirming Graduated Responsibility

Retrospective review of prospectively collected surgical data. This study sought to determine the effect of fellow education during the course of the academic year (August-July) on surgical outcomes in adolescent idiopathic scoliosis. One surgeon and one type of surgery were chosen to minimize confounding factors. Educating and training the next generation of physicians and surgeons is necessary for the survival and continuation of medical care. There has been recent momentum to document scientifically that medical education is safe. Spine surgery is complex and demanding, with a steep learning curve, making it an ideal model to detect any potential negative impact of medical education. adolescent patients undergoing posterior spinal surgery, between August 2007 and July 2010, by a single senior surgeon at one institution with a fellow as the only surgical assistant. Demographic and perioperative data were collected and then segmented by surgical date into quarters according to the rotations of the academic year. One fellow was included in each quarter during the 4 years, resulting in 16 fellows across the 4 quarters. An analysis of variance model was used to assess differences in operative time, blood loss, length of stay, and complications between the quarters of the year. There were no significant differences between the groups regarding age, sex, or Lenke curve type. No statistically significant differences were found between the 4 quarters of the fellowship year for estimated blood loss, use of cell saver, length of stay, operative time, and complication rate. This study is the first to show that fellow education during the course of the academic year did not impact the patient outcomes studied. It is clear that while there is significant academic benefit for the fellows as they complete their spine fellowship, there is no negative impact for patients. 4.

Intra-operative cell salvage in South Africa: Feasible, beneficial and economical

Healthcare services in KwaZulu-Natal (KZN) frequently experience shortages of blood products. Alternatives to traditional blood sources are needed. One possibility is cell salvage and autologous blood transfusion. Few data exist relating to their use in the South African context. To ascertain whether cell salvage (CS) is beneficial, feasible and economical in our setting, with the anticipation that results would excite further studies and potentially change current practice and improve existing protocols. Methods. This study reviewed current intraoperative Cell Saver use at Grey's and Edendale hospitals in Pietermaritzburg, KZN. Current practices were observed and compared with the costs of the equivalent amount of red cell concentrate (RCC) purchased from the South African National Blood Service (SANBS). All cases of Cell Saver usage over a 1-year period from July 2012 to June 2013 were analysed. The total volume of blood transfused from CS was 55 735 ml, approximately equivalent to 186 RCC units. The comparative cost of equivalent units of RCC from SANBS was R258 445. The total cost of Cell Saver disposables during the study period was R206 047, or R263 478 when Cell Saver machine depreciation costs were included. More than one CS blood unit was available for transfusion in 66% of cases. No additional staff were required to operate the Cell Saver, which was successfully used by medical officers. This study showed that intraoperative CS use is feasible, has potential patient benefit by reducing blood bank blood transfusion, and is financially comparable to purchasing the equivalent number of SANBS RCC.

Blood Salvage Produces Higher Total Blood Product Costs in Single-Level Lumbar Spine Surgery

Retrospective review. To determine the incremental cost-effectiveness of cell saver for single-level posterior lumbar decompression and fusion (PLDF). Intraoperative cell salvage is used during surgery to reduce the need for perioperative allogeneic blood transfusion. Although the use of cell saver may be beneficial in certain circumstances, its utility has not been clearly established for the common procedure of an adult single-level PLDF. Randomly selected adult patients treated with a single-level PLDF between July 2010 and June 2011 at a single institution were identified. Patients who had a combined anterior and posterior approach were excluded. The final study sample for analysis consisted of 180 patients. Hospital records were reviewed to determine whether: (1) cell saver was available during surgery, (2) recovered autologous blood was infused, and (3) the patient received intra- or postoperative allogeneic transfusions. Estimated blood loss, levels fused, volume(s) transfused, and all related complications were recorded. Costs included the cost of allogeneic blood transfusion, setting up the cell saver recovery system, and infusing autologous blood from cell saver, whereas effectiveness measures were allogeneic blood transfusions averted and quality adjusted life years. The incremental cost-effectiveness ratio was $55,538 per allogeneic transfusion averted, with a decrease in the transfusion rate from 40.0% to 38.7% associated with the cell saver approach. This translated into an incremental cost-effectiveness ratio of $5,555,380 per quality adjusted life years gained, which is well above the threshold for an intervention to be considered cost-effective ($100,000 per quality adjusted life years gained). The use of cell saver during a single-level PLDF does not significantly reduce the need for allogeneic blood transfusion and is not cost-effective. The high cost of cell saver in combination with the low complication rate of allogeneic blood transfusion, suggest that cell saver should not be used for single-level PLDF. Further studies are needed to evaluate the necessity for cell saver among other types of spinal surgery.

Supportive treatment of severe anaemia in a Jehovah's Witness with severe trauma.

Supportive treatment of severe anaemia in a Jehovah's Witness with severe trauma.

Does use of cell saver decrease the inflammatory response in cardiac surgery?

The role of a cell-saver device in the inflammatory response to cardiac surgery has not been well documented. We hypothesized that the use of a cell saver may reduce proinflammatory cytokine concentrations in patients undergoing cardiac surgery. 57 patients presenting for first-time nonemergency cardiac surgery were prospectively randomized to control or cell salvage groups. Blood samples for inflammatory marker assays were collected from the arterial line on induction of anesthesia, at the end of cardiopulmonary bypass, 1 h after surgery, and 24 h after surgery. Plasma proinflammatory cytokines were analyzed using a sandwich solid-phase enzyme-linked immunosorbent assay. The highest cytokine levels were observed 1 h after surgery. When comparing serum interleukin levels in both patient groups during the different perioperative periods, we found a higher interleukin-8 concentration 24 h after the procedure, and higher concentrations of the p40 subunit of interleukin-12 at 1 h and 24 h postoperatively. The concentrations of interleukin-6 and p40 were greater in blood stored by the cardiotomy suction system than in blood processed by the cell saver (p = 0.01 in both cases). The interleukin-8 concentration was higher in the blood processed by the cell saver (p = 0.03). No significant differences were observed in interleukin-1 and interferon gamma levels in blood from both systems. Clinical outcomes were similar in both groups. Our results suggest that cell salvage in low-risk patients undergoing their first elective cardiac procedure does not decrease the inflammatory response after surgery.

Predictive Factors for the Use of Autologous Cell Saver Transfusion in Lumbar Spinal Surgery

Retrospective review. To identify risk factors for cell saver transfusion in lumbar spinal surgery and determine if cell saver transfusions affected intraoperative or postoperative transfusion rates. Cell saver has been used to minimize allogeneic blood transfusion in lumbar spinal surgery. Conflicting reports exist, which call into question the efficacy of cell saver use. We reviewed medical records of randomly selected patients who underwent posterolateral fusion with or without transforaminal interbody fusion from July 2010 to June 2011. Transfusion rates and transfusion-related complications were determined. Binary logistic regression was performed to identify risk factors for use of autologous cell saver transfusion. There were 178 females and 107 males, with a mean age of 57.2 years. Of the 285 cases, 39 had no cell saver available, 147 had cell saver available but no autologous blood was recovered or transfused and 99 had an autologous cell saver transfusion. Patients who had cell saver transfusion had a higher rate of intraoperative allogeneic blood transfusion (52%) compared with those who did not (22%). There was no significant difference in the rate of postoperative transfusions or transfusion-related reactions between patients who did and did not have cell saver transfusion. Patient's age, smoking status, American Society of Anesthesiologists grade, use of anticoagulants preoperatively, primary or revision surgery, iliac crest bone graft harvest, anesthesiologist, or surgeon had no significant effect on cell saver infusion. Body mass index (odds ratio [OR] = 1.06), number of posterolateral fusion levels fused (OR = 2.50), and number of transforaminal interbody fusions performed (OR = 2.41) were independent risk factors for the use of autologous cell saver transfusion. Body mass index, multi-level fusion and transforaminal interbody fusion result in increased use of autologous cell saver transfusion in lumbar spinal surgery. Use of autologous cell saver transfusion did not reduce the requirement for intraoperative or postoperative allogeneic blood transfusion. 2.

The use of cell saver system in cardiac surgery with cardiopulmonary bypass

The use of cell saver (CS) in cardiac surgery is proposed to reduce the use of units of packed red blood cells stored (URBC), which increases morbidity, mortality and causes inflammatory reactions. The objective is to evaluate whether the use of CS decreases the use URBC, is cost /effective and beneficial to the patient. In a prospective study, between November 2009 and October 2011, 100 consecutive patients who underwent cardiovascular surgery with CPB, hemodilution and hemofiltration, were enrolled. Patients were divided into group 1 (no CS) and 2 (CS). The criteria for the replacement of RBC were hemodynamic instability and hemoglobin (Hb) <7-8g/dl. Demographic data, as well as Hb and hematocrit, mediastinal drainage, number of URBC and CPB, ICU and hospital time, were analysed. In groups 1 and 2 the average age was 64.1 and 60.6 years; predominantly male; the logistic EuroSCORE 10.3 and 9.4; mortality 2% and 4%. Group 2 had a higher incidence of reoperations (12% versus 6%), but the average of URBC used (4.31 versus 1.25) and mean length of hospital stay (10.8 versus 7.4 days) was lower. Univariate and multivariate analysis, were performed, which showed no statistically significant values, except in the use of URBC. The relationship between the CS and the cost of RBC was not cost /effective and length of stay was shorter. The use of CS decreases the number of used URBC, is not cost /effective but has shown benefits for patients.

Obesity, Leukocytosis, Embolization, and Injury Severity Increase the Risk for Deep Postoperative Wound Infection After Pelvic and Acetabular Surgery

To determine if preoperative fever and leukocytosis without an established source of untreated infection are independent risk factors for the development of deep postoperative wound infection (DPWI) after surgical treatment of pelvic and acetabular fractures. Retrospective chart and radiographic review; matched case-control comparison. : Level 1 regional referral trauma center. Five hundred ninety-seven skeletally mature patients with pelvic and/or acetabular fractures requiring operative fixation (353 acetabular, 170 pelvic, and 74 combined acetabular and pelvic injuries). Retrospective chart review was performed analyzing for the following variables: injury severity score, preoperative fever, serum and urine white blood cell count; intensive care unit admission, previous infection, Morel-Lavallee lesions, pelvic arterial embolization, open fractures, intraoperative cell saver use, perioperative blood transfusions, subfascial drains, antibiotic use, and obesity [BMI (body mass index) >30]. Open pelvic or acetabular fractures were excluded. Main outcome measure was diagnosis of DPWI. Patients with a diagnosis of DPWI were then compared with a random 1:4 matched cohort of patients without a history of DPWI. Patients were matched and grouped according to injury pattern, age, and surgical procedure. Statistical comparison of the 2 groups was performed using a Mann-Whitney test, Fisher exact test, and odds ratio (OR) with 95% confidence intervals and positive predictive values (PPVs). Seventeen patients (2.8%) developed DPWI, distributed as 8 (2.3%) acetabular, 5 (2.9%) pelvic, and 4 (5.4%) pelvic-acetabular infections. Eighty patients met inclusion criteria for the matched cohort comparison. The median age of those patients with infection was 43 years (range 31-69) and those without infection were 41 years (range 24-71). Both groups were predominantly male (77% and 74% for the 2 groups, respectively). The average BMI and injury severity score of the case (infected) group were significantly higher than that of the control (noninfected) group. Of the variables examined, preoperative leukocytosis, obesity, blood transfusion, and interfacility transfer had a statistical association (P < 0.05) with DPWI after pelvic or acetabular surgery. Preoperative angioembolization reached near statistical significance (P = 0.07). However, determination of PPV and OR suggested that only obesity (OR 8, PPV 33%), obesity plus leukocytosis (OR 12, PPV 39%), and preoperative angioembolization (OR 11, PPV 67%) were strong predictors of postoperative infection. Although the infection rate for combined approaches was twice that of acetabular or pelvic surgery alone, this was not statistically significant. : Based on the findings of this analysis, patients requiring preoperative angioembolization and having a BMI >30 have a significant increase in their risk of postoperative infection, particularly if associated with leukocytosis. Patients with both pelvic and acetabular fractures that require surgical treatment should be counseled that their risk for infection may be higher. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Systematic use of carbetocin during cesarean delivery of multiple pregnancies: a before-and-after study

Cesarean deliveries of multiple pregnancies are associated with a high risk of hemorrhage. The aim of this study is to evaluate the efficacy of carbetocin administered systematically during cesarean deliveries of multiple pregnancies. Single-center retrospective before-and-after study comparing the use of carbetocin to that of oxytocin during cesareans during two consecutive 6-month periods. A composite variable was predefined as the principal endpoint: any one or more of bleeding ≥1,500mL, transfusion, hemoglobin reduction of 4g/dL or more or operative intervention (surgery, embolization). In an intention-to-treat analysis, the comparison of the two groups (n=24 before and n=39 after) showed no difference for the occurrence of the composite variable (16.7 vs. 15.4%, p=0.89). Nor did the per-protocol analysis (n=24 before and n=27 after) differ for it (16.7 vs. 14.8%, p=0.86). Moreover, none of the secondary outcome measures studied-moderate blood loss, prescription of sulprostone, cell-saver use, and intravenous iron infusion-differed significantly between the two periods. In our population of multiple pregnancies delivered by cesarean, carbetocin did not appear more effective than oxytocin in preventing severe postpartum hemorrhage.

Postoperative Blood Use Following Elective Total Hip and Total Knee Arthroplasty

Abstract 1181Use of allogeneic blood in elective procedures should be minimized due to risks of transfusion, potential adverse impact on outcomes, inconvenience to the patient, high cost and limited supply of blood. The purpose of this study was to examine the rate of transfusion following elective total hip (THA) and total knee arthroplasties (TKA) within a preoperative and perioperative blood management program and to examine the relationship between clinical and surgical parameters and blood transfusion. Methods:This was a secondary analysis of prospectively collected data of all consented patients who had undergone joint arthroplasty surgery between January and December, 2011. All patients attended a preoperative clinic 7–14 days prior to their surgery. The preoperative hemoglobin (Hgb) was measured. Transfusion rate was calculated for type of surgery (primary vs. revision and unilateral vs. bilateral). Impact of preoperative Hgb, age, sex, Body Mass Index (BMI), estimated blood loss, type of anaesthetic, type of anticoagulant (rivaroxaban vs. no rivaroxaban), surgeon and drop in hemoglobin (preoperative hemoglobin minus lowest post-operative hemoglobin documented on postoperative day 1, 2 or 3) were examined. Descriptive statistics examined the rate of transfusion in different procedures. Univariate analysis examined the relationship between each factor and having a transfusion. Stepwise logistic regression examined the impact of all factors together. Statistical significance was set at p<0.05. Results:1605 patients [989 females (62%), mean age 66 (SD:11)] had surgery during 2011. Primary TKA: Unilateral 821 (51%), Bilateral TKA: 41 (3%), Revision TKA: 91 (6%), Primary THA: 588 (37%), Bilateral THA: 4 (0.02%), Revision THA: 60 (4%). Four percent (4%) of females had an Hgb <120 mg/L and 3% of males had an Hgb <130 mg/L at the preoperative visit. There were 1555 cases done under regional anaesthesia (spinal or epidural) and 129 cases received a general anaesthetic. Sixty-seven patients (4%) had a blood transfusion while in hospital. Thirty percent (30%) of the transfused women and 9% of the men had a low pre-operative Hgb. THA procedures required more transfusions than TKA (p=0.0012). Transfusion was associated with the following individual factors: age ≥ 80 years, female sex, low BMI (<18.5), increased estimated blood loss, larger drop in hemoglobin, type of anticoagulant (4% in rivaroxaban vs. 8% in non-rivaroxaban), revision surgery (vs. primary), simultaneous bilateral arthroplasty, general anesthesia (vs. spinal), and surgeon. Stepwise logistic regression analysis maintained the intra-operative blood loss, drop in Hgb, female sex, and age as significant independent factors in explaining the variation in blood transfusion. Discussion:This study was carried out in an independent orthopaedic facility for elective joint surgery. All patients are assessed medically prior to surgery and advised to take supplemental iron for 2 months prior to surgery. Four percent of females and 3% of males were found to be anemic preoperatively. Patients are admitted the morning of their surgery. Approximately 97% of the consented patients had a regional anesthetic (spinal and/or epidural) with sedation. Patients are transferred into the operating room after the anaesthetic was administered. Surgery is carried out without the routine use of cell saver, tranexamic acid or drains. Approximately 50% of the surgeons deflate the tourniquet in a total knee arthroplasty prior to closure of the capsule. Thromboprophylaxis is initiated with rivaroxaban 10 mg on postoperative day 1. The general transfusion trigger for symptomatic patients is a hemoglobin of 80 g/L. Transfusions can be ordered by staff surgeon, hospitalist, medical consultant or Orthopaedic fellow. The blood bank does not group and screen patients scheduled for routine primary total hip or total knee arthroplasty. Following these practices, we observed a transfusion rate for primary THA of 5% and primary TKA of 3% while using rivaroxaban for thromboprophylaxis starting on postoperative day 1. Conclusion:The present study confirmed that intra-operative blood loss, drop in the hemoglobin, being a female, and older than 80 years of age as risk factors in relation to need for blood transfusion following elective total joint arthroplasty. Transfusion rates were not higher when rivaroxaban was used for thromboprophylaxis. Disclosures:Murnaghan:Bayer Healthcare: Honoraria, Research Funding. Off Label Use: Rivaroxaban was used perioperatively for thromboprophylaxis. Our protocol gave the intial dose on postoperative day 1 rather than the 6–10 hours post-operatively recommended by the manufacturer in product monograph. Gollish:Bayer Healthcare: Honoraria, Research Funding.

Developing a Prognostic Score to Predict Graft and Patient Survival after Orthotopic Liver Transplantation (OLT)

Background: The current liver organ allocation system strongly favors organ distribution to critically ill recipients who exhibit poor survival outcomes following OLT.A severely limited organ resource, increasing wait list deaths, and rising numbers of critically ill recipients mandate an organ allocation model that balances disease severity with survival outcomes. Such goals can be realized only through the development of prognostic score that predict graft survival following OLT. We developed a novel prognostic score that predicts graft and patient survival outcomes after OLT Methods: We reviewed all adult liver transplants from 1990 to 2011. This data were entered prospectively into a web-based database. The following variables were analyzed using a Cox proportional hazards model to determine predictors of survival:donor age, sex, BMI, and donor risk index (DRI), recipient age, sex, diagnosis, number of re-transplants, combined transplants, MELD, Child score, pre-transplant need for dialysis, intraoperative blood loss, the use of cell saver, warm and cold ischemia time, blood transfusion during or 24hours post transplant and INR/total bilirubin levels at baseline and in the first week after transplant Results: 716 patients were analyzed. Median DRI was 1.52(1.3-1.8), recipient age 57(50-63) years, MELD 20(18-27), warm ischemia time 1.1(1-1.3) hours, cold ischemia time 8.7(6.7-11.3) hours, blood loss 1600(900-2700)ml.HCV as an indication for transplant was in 34% and HCC in 20%. Five-year graft and patient survival were both around 60% with a median overall survival of about 10 years. The following variables were found to contribute significantly to the prognostic model: cold (>10 hours) and warm (>1.5 hours) ischemia time, blood loss(>3000ml), MELD (>30), DRI and the diagnosis of HCV. Prognostic score was generated based on graft survival (Table 1)All these variables were binary (0,1) except for DRI. Risk score results divided patients into 3 groups:Low risk < -1, intermediate risk -1-0, and high risk >0. The high-risk group had almost half the median survival of the overall cohort(Figure 1)[Figure 1]Conclusion: This new prognostic score was generated from our data and needs to be validated.If validated, such a tool can potentially be used to determine prognosis in the early postoperative period and can also serve as an early surrogate marker for interventional studies