The prevalence and association with transfusion, intensive care unit stay and mortality of...

________________________________________________________________________________________________ Society for Advancement of Blood Management (SABM)

Literature Abstracts Society for Advancement of Blood Management August 2011

ANEMIA MANAGEMENT

EVALUATION

Anaesthesia. 2011 Jul 25. doi: 10.1111/j.1365-

2044.2011.06819.x. [Epub ahead of print]

The prevalence and association with transfusion, intensive care unit stay and mortality of pre-operative anaemia in a cohort of cardiac surgery patients*

Hung M, Besser M, Sharples LD, Nair SK, Klein AA.

Source

Fellow Consultant, Department of Anaesthesia and

Intensive Care Consultant, Department of Cardiothoracic

Surgery, Papworth Hospital, Cambridge, UK Consultant,

Department of Haematology, Addenbrookes Hospital,

Cambridge, UK MRC Biostatistics Unit, Cambridge, UK.

Abstract

Anaemia is increasingly prevalent in the United Kingdom.

Despite recommendations to the contrary, many patients

undergo cardiac surgery with undiagnosed and untreated

anaemia. According to the World Health Organization

definition, 1463/2688 (54.4%) patients undergoing cardiac

surgery between 2008 and 2009 in our institution were

anaemic. Compared with non-anaemic patients, anaemia

was significantly associated with transfusion (791 (54.1%)

vs 275 (22.4%), p < 0.001, OR (95% CI) 3.4 (2.8-4.1)),

death (45 (3.1%) vs 13 (1.1%), p = 0.0005, OR 2.4

(1.2-4.5)), and prolonged ICU stay (287 (19.6%) vs 168

(13.7%) p < 0.001, OR 1.3 (1.0-1.6)). The prevalence

of anaemia in this cohort is much greater than that

previously reported. The cause of this excess is not clear.

Pre-operative anaemia is a strong predictor of increased

transfusion requirement, risk of ICU stay and death during

cardiac surgery. The effect of increasing haemoglobin

concentration therapeutically is not yet clear.

© 2011 The Authors. Anaesthesia © 2011 The Association

of Anaesthetists of Great Britain and Ireland.

http://www.ncbi.nlm.nih.gov/pubmed/21790520

Intern Med J. 2011 Jul 25. doi: 10.1111/j.1445-


Anaemia is highly prevalent amongst unselected internal medicine inpatients and is associated with increased mortality, earlier readmission and more prolonged hospital stay: an observational retrospective cohort study.

Literature Abstracts Page 2 _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________ Society for Advancement of Blood Management January 2008

Nathavitharana RL, Murray JA, D'Sousa N, Sheehan T,

Frampton CM, Baker BW.

Source

Senior House Officer, The Royal Marsden Hospital,

London; Registrar, Royal Victoria Hospital Edinburgh;

Registrar, Haematology Department, Palmerston North

Hospital; Senior House Officer, St Richard's Hospital,

Chichester; Associate Professor, Department of Medicine,

University of Otago, Christchurch; Consultant

Haematologist, Haematology Department, Palmerston

North Hospital.

Abstract

Background Anaemia is associated with adverse

outcomes in elderly community-dwelling individuals but

this problem is less well characterised in the inpatient

setting. Aims To determine the prevalence of anaemia

and its associations in a well defined cohort of internal

medicine inpatients. Methods A retrospective cohort

study of non elective admissions under internal medicine

at Palmerston North Hospital, New Zealand, was

conducted for four months of 2008 with outcome analysis

at 1 March 2010. Results At admission, 497 of 1491

(33.3%) patients were anaemic by World Health

Organisation criteria (haemoglobin <130g/L for males;

<120g/L for females). Anaemia was more prevalent in

males (38.1%) than females (28.2%), p < 0.001, in

patients aged 65 years or older (41%) than in those under

65 (21.3%), p < 0.001, in New Zealand Europeans (34.3%)

than in Māori and people from the Pacific Islands (26.4%),

p = 0.04, and in patients admitted primarily because of

malignancy, endocrine/metabolic disease, infection, and

acute coronary syndrome/congestive heart failure (p <

0.001). Anaemia was independently associated with

increased length of hospital stay (7.3 days versus 5.1 days

in non-anemic patients; p < 0.001), with mortality (p <

0.001) and unplanned hospital readmission (p < 0.001)

during the follow-up period. Anaemia was infrequently

acknowledged or investigated. Secondary analysis using a

haemoglobin threshold of 110g/L showed similar results.

Conclusions Anaemia is highly prevalent amongst

medical inpatients with variation due to gender, age, race,

and reason for admission. Anaemia independently predicts

for prolonged hospital stay, increased mortality, and

shorter time to readmission but is usually not documented

or investigated in this setting.

© 2011 Sydney South West Area Health Service. Journal

compilation © 2011 Royal Australasian College of

Physicians.




ANEMIA MANAGEMENT ERYTHROPOIETIC AGENTS

Am J Nephrol. 2011 Aug 9;34(4):298-308. [Epub ahead of

print]

Association of Mean Weekly Epoetin Alfa Dose with Mortality Risk in a Retrospective Cohort Study of Medicare Hemodialysis Patients.

Weinhandl ED, Gilbertson DT, Collins AJ.

Source

Chronic Disease Research Group, Minneapolis Medical

Research Foundation, Minneapolis, Minn., USA.

Abstract

Background/Aims: Randomized trials of hemoglobin

targeting in chronic kidney disease suggest that

erythropoiesis-stimulating agent (ESA) dosing increases

mortality risk, but dosing intensity is confounded by

hemoglobin concentration. Appropriately designed

observational studies are needed to clarify the association

of ESA dosing with mortality risk. Methods: Using

Medicare claims, we conducted a retrospective cohort

study of mortality risk associated with epoetin alfa (EPO)

dosing in prevalent hemodialysis patients (n = 137,918),

2000-2004. We used marginal structural modeling to

account for time-varying confounding attributable to recent

history of blood transfusion and catheter insertion for

vascular access, hemoglobin, hospital admission and

days, and intravenous iron dosing. We stratified mortality

analyses according to hemoglobin level (<10, 10-10.9, 11-

11.9, and ≥12 g/dl). Results: With adjustment for serial

correlation in EPO dosing, hemoglobin, hospital admission

and days, and intravenous iron administration were the

strongest predictors of outpatient EPO dosing. With

hemoglobin <10 g/dl, mean weekly EPO dose in a 3-

month period was negatively associated with subsequent

mortality risk. With hemoglobin 10-10.9 and 11-11.9 g/dl,

EPO dose and mortality risk were associated in a U-

shaped form. With hemoglobin ≥12 g/dl, mean weekly

EPO dose >20,000 IU was positively associated with

mortality risk. Conclusions: ESA dosing may be directly

associated with risk of death, but the nature of the

association likely varies according to hemoglobin

concentration. Small doses with hemoglobin ≤12 g/dl and

large doses with hemoglobin ≥10 g/dl may both be

associated with poor outcomes.

Copyright © 2011 S. Karger AG, Basel.


ANEMIA MANAGEMENT

IRON

Clin Exp Obstet Gynecol. 2011;38(2):159-61.

Total infusion of low molecular weight iron-dextran for treating postpartum anemia.

Daniilidis A, Giannoulis C, Pantelis A, Tantanasis T, Dinas

K.



Source

2nd Department of Obstetrics and Gynecology, Aristotle

University of Thessaloniki, Hippokration General Hospital,

Thessaloniki, Greece. [email protected]

Abstract

AIM:

135 puerperal women with iron deficiency anemia

participated in our prospective randomized controlled trial

in order to investigate alternative treatments to blood

transfusion for anemia.

MATERIALS AND METHODS:

The criteria for the diagnosis of anemia were Hb < 8 g/dl

and ferritine < 10 microg/dl. Women were randomly

separated in two groups, A and B. Women of group A (n =

109 women) received a total amount of 1000 mg low

molecular weight (LMW) iron-dextran intravenously in two

doses. Group B (n = 26) was the control group. They

received orally 800 mg daily for 30 days of iron protein-

succinylate. Three weeks later women of both groups

underwent a full blood count analysis.

RESULTS:

Hemoglobin and ferritin levels increased significantly in

group A compared to group B (p < 0.0001). No adverse

side-effects due to the treatment were noted in either

group.

CONCLUSION:

It seems that total iron-dextran infusion is a safe and rapid

therapy of iron-deficiency postpartum anemia increases

the Hb level more rapidly than oral ferrous sulfate, and it

also appears to replenish iron stores more rapidly.


Trends Mol Med. 2011 Aug 19. [Epub ahead of print]

Iron disorders of genetic origin: a changing world.

Brissot P, Bardou-Jacquet E, Jouanolle AM, Loréal O.

Source

Liver Disease Department, National Center of Reference

for Rare Iron Overload Diseases of Genetic Origin,

INSERM, UMR 991, Liver Metabolisms and Cancer,

University of Rennes 1, CHU Pontchaillou, Rennes,

France.

Abstract

Iron disorders of genetic origin are mainly composed of

iron overload diseases, the most frequent being HFE-

related hemochromatosis. Hepcidin deficiency underlies

iron overload in HFE-hemochromatosis as well as in

several other genetic iron excess disorders, such as

hemojuvelin or hepcidin-related hemochromatosis and

transferrin receptor 2-related hemochromatosis. Deficiency

of ferroportin, the only known cellular protein iron exporter,



produces iron overload in the typical form of ferroportin

disease. By contrast, genetically enhanced hepcidin

production, as observed in matriptase-2 deficiency,

generates iron-refractory iron deficiency anemia.

Diagnosis of these iron storage disorders is usually

established noninvasively through combined biochemical,

imaging and genetic approaches. Moreover, improved

knowledge of the molecular mechanisms accounting for

the variations of iron stores opens the way of novel

therapeutic approaches aiming to restore normal iron

homeostasis. In this review, we will summarize recent

findings about these various genetic entities that have

been identified owing to an exemplary interplay between

clinicians and basic scientists.

Copyright © 2011 Elsevier Ltd. All rights reserved.


J Matern Fetal Neonatal Med. 2011 Aug 23. [Epub ahead

of print]

Efficacy and safety of oral iron(III) polymaltose complex versus ferrous sulfate in pregnant women with iron-deficiency anemia: a multicenter, randomized, controlled study.

Ortiz R, Toblli JE, Romero JD, Monterrosa B, Frer C,

Macagno E, Breymann C.

Source

Hospital Local del Norte , Bucaramanga , Colombia.

Abstract

Objective: To evaluate the efficacy and safety of iron(III)

polymaltose complex (Maltofer(®)) versus ferrous sulfate

in iron-deficient pregnant women using recommended

doses. Methods: An exploratory, open-label, randomized,

controlled, multicenter study was undertaken in 80

pregnant women with iron-deficiency anemia (hemoglobin

≤ 10.5 g/dL, serum ferritin ≤ 15 ng/mL and mean

corpuscular volume < 80 fL). Patients were randomized

1:1 to oral iron(III) polymaltose complex or ferrous sulfate

(each 100 mg iron twice daily) for 90 days. Results: The

primary endpoint, change in hemoglobin from baseline to

days 60 and 90, did not differ significantly between

treatment groups. The mean (SD) change to day 90 was

2.16 (0.67) g/dL in the iron(III) polymaltose complex group

and 1.93 (0.97) g/dL in the ferrous sulfate group (n.s).

Mean serum ferritin at day 90 was 179 (38) ng/mL and 157

(34) ng/mL with iron(III) polymaltose complex and ferrous

sulfate, respectively (p = 0.014). Adverse events were

significantly less frequent in the iron(III) polymaltose

group, occurring in 12/41 (29.3%) patients, than in the

ferrous sulfate group (22/39 [56.4%]) (p = 0.015).

Conclusions: Oral iron(III) polymaltose complex offers at

least equivalent efficacy and a superior safety profile

compared to ferrous sulfate for the treatment of iron-

deficiency anemia during pregnancy.


ANEMIA MANAGEMENT HEMATINICS



ANEMIA MANAGEMENT OTHER

J Anaesthesiol Clin Pharmacol. 2011 Jan;27(1):54-8.

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

Naqash IA, Draboo MA, Lone AQ, Nengroo SH, Kirmani A,

Bhat AR.

Source

Professor, Dept. of Anesthesiology & Critical Care and

Dept. of Neurosurgery, Sher-i-Kashmir Institute of Medical

Sciences, Srinagar, Kashmir, (J&K), India.

Abstract

BACKGROUND:

Several blood conservation strategies have been tried with

the purpose of reducing homologons blood transfusion.

PATIENTS #ENTITYSTARTX00026;

METHODS:

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.

RESULTS:

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.



CONCLUSION:

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.


Transfusion. 2011 Aug 2. doi: 10.1111/j.1537-


Postoperative anemia does not impede functional outcome and quality of life early after hip and knee arthroplasties.

Vuille-Lessard E, Boudreault D, Girard F, Ruel M,

Chagnon M, Hardy JF.

Source

From the Department of Anesthesiology, CHUM Notre-

Dame, and the Department of Mathematics and Statistics

of the University of Montreal, Montreal, Quebec, Canada.

Abstract

BACKGROUND:

Clinicians have adopted a restrictive transfusion threshold

(75-80 g/L) after major orthopedic surgery. Anemia may

be associated with a decrease in postoperative vigor. We

hypothesize that, in these patients, a threshold

hemoglobin (Hb) concentration exists below which

functional recovery and quality of life (QoL) become

difficult.

STUDY DESIGN AND METHODS:

A prospective, observational cohort study in 305 patients

60 years or older undergoing a total hip or knee

arthroplasty was conducted. Major outcome variables

were distance walked in 6 minutes (6MWT), score on the

Borg Scale for perception of effort, maximal dominant

hand strength, and Short Form 36 (SF-36) QoL

assessment in the preoperative and early postoperative

periods. Patients were categorized according to their Hb

level the day of the postoperative 6MWT (≤80, 81-90, 91-

100, and >100 g/L).

RESULTS:

There was no difference between Hb groups in the

decrease of the distance walked preoperatively versus

postoperatively. For both moments of observation, the

6MWT was not significantly different between Hb groups

(p = 0.190). Similar results were found with perception

of effort, maximal dominant hand strength, and SF-36 QoL

assessment scores. In a regression model, the decrease

in Hb concentration could explain only 1.9% of the total

variation observed in the 6MWT (p = 0.008).

CONCLUSION:

Moderate anemia is not associated with an impaired

functional recovery or QoL in the immediate postoperative



period after major arthroplasties. Further studies will be

required to determine the long-term consequences of a

restrictive transfusion strategy in these patients.

© 2011 American Association of Blood Banks.


Arch Intern Med. 2011 Aug 19. [Epub ahead of print]

Diagnostic Blood Loss From Phlebotomy and Hospital-Acquired Anemia During Acute Myocardial Infarction.

Salisbury AC, Reid KJ, Alexander KP, Masoudi FA, Lai

SM, Chan PS, Bach RG, Wang TY, Spertus JA, Kosiborod

M.

Source

Division of Cardiovascular Diseases, Saint Luke's Mid

America Heart and Vascular Institute, Kansas City,

Missouri (Drs Salisbury, Chan, Spertus, and Kosiborod

and Ms Reid); University of Missouri-Kansas City School

of Medicine, Kansas City (Drs Salisbury, Chan, Spertus,

and Kosiborod); Department of Internal Medicine, Division

of Cardiovascular Diseases, Duke Clinical Research

Institute, Durham, North Carolina (Drs Alexander and

Wang); Department of Internal Medicine, Division of

Cardiovascular Diseases, University of Colorado-Denver,

Aurora (Dr Masoudi); Department of Preventive Medicine,

University of Kansas, Kansas City (Dr Lai); and

Department of Internal Medicine, Division of

Cardiovascular Diseases, Washington University School of

Medicine, St Louis, Missouri (Dr Bach).

Abstract

BACKGROUND:

Hospital-acquired anemia (HAA) during acute myocardial

infarction (AMI) is associated with higher mortality and

worse health status and often develops in the absence of

recognized bleeding. The extent to which diagnostic

phlebotomy, a modifiable process of care, contributes to

HAA is unknown.

METHODS:

We studied 17 676 patients with AMI from 57 US hospitals

included in a contemporary AMI database from January 1,

2000, through December 31, 2008, who were not anemic

at admission but developed moderate to severe HAA (in

which the hemoglobin level declined from normal to <11

g/dL), a degree of HAA that has been shown to be

prognostically important. Patients' total diagnostic blood

loss was calculated by multiplying the number and types of

blood tubes drawn by the standard volume for each tube

type. Hierarchical modified Poisson regression was used

to test the association between phlebotomy and moderate

to severe HAA, after adjusting for site and potential

confounders.



RESULTS:

Moderate to severe HAA developed in 3551 patients

(20%). The mean (SD) phlebotomy volume was higher in

patients with HAA (173.8 [139.3] mL) vs those without

HAA (83.5 [52.0 mL]; P < .001). There was significant

variation in the mean diagnostic blood loss across

hospitals (moderate to severe HAA: range, 119.1-246.0

mL; mild HAA or no HAA: 53.0-110.1 mL). For every 50

mL of blood drawn, the risk of moderate to severe HAA

increased by 18% (relative risk [RR], 1.18; 95%

confidence interval [CI], 1.13-1.22), which was only

modestly attenuated after multivariable adjustment (RR,

1.15; 95% CI, 1.12-1.18).

CONCLUSIONS:

Blood loss from greater use of phlebotomy is

independently associated with the development of HAA.

These findings suggest that HAA may be preventable by

implementing strategies to limit blood loss from laboratory

testing.


Am J Med Qual. 2011 Sep-Oct;26(5):349-56.

Establishing a Culture of Blood Management Through Education: A Quality Initiative Study of Postoperative Blood Use in CABG Patients at Methodist DeBakey Heart & Vascular Center.

Masud F, Larson-Pollock K, Leveque C, Vykoukal D.

Source

1Methodist DeBakey Heart & Vascular Center, Houston,

TX.

Abstract

Blood management strategies are crucial in light of

transfusion-related health risks to patients and the relative

scarcity and cost of blood products. The authors describe

a collaborative quality initiative to reduce blood use in their

coronary artery bypass graft (CABG) population and other

cardiovascular intensive care unit (CVICU) patients. A

multidisciplinary team was engaged at all levels of patient

care. The 2-part initiative involved a direct educational

component emphasizing transfusion risk awareness and

patient-centered blood management strategies

accompanied by a data-based component that included

monthly dissemination of blood product use to the relevant

service lines. The authors observed a reduction in

postoperative blood product use among CABG patients

(14.3% decrease in the first year; 30.6% from 2006 to

2008) and an 18.2% reduction in blood product volume

used in the entire CVICU, with no additional harm to

patients and a trend toward better outcomes. This team-

driven paradigm change has made blood management

everyone's initiative.




ANESTHETIC TECHNIQUES ANESTHESIA

Transfusion. 2011 Jul 25. doi: 10.1111/j.1537-


Initial experiences with point-of-care rapid thrombelastography for management of life-threatening postinjury coagulopathy.

Kashuk JL, Moore EE, Wohlauer M, Johnson JL, Pezold

M, Lawrence J, Biffl WL, Burlew CC, Barnett C, Sawyer M,

Sauaia A.

Source

From the Department of Surgery and Anesthesia, Denver

Health Medical Center at the Rocky Mountain Regional

Trauma Center and the Department of Surgery, University

of Colorado Denver, School of Medicine, Denver,

Colorado.

Abstract

BACKGROUND:

Massive transfusion (MTP) protocol design is hindered by

lack of accurate assessment of coagulation. Rapid

thrombelastography (r-TEG) provides point-of-care (POC)

analysis of clot formation. We designed a prospective

study to test the hypothesis that integrating TEG into our

MTP would facilitate goal-directed therapy and provide

equivalent outcomes compared to conventional

coagulation testing.


Thiry-four patients who received more than 6 units of red

blood cells (RBCs)/6 hours who were admitted to our

Level 1 trauma center after r-TEG implementation (TEG)

were compared to 34 patients admitted prior to TEG

implementation (Pre-TEG). Data are presented as mean

± SEM.

RESULTS:

Emergency department pre-TEG versus TEG shock, and

coagulation indices, were not different: systolic blood

pressure (94 mmHg vs.101 mmHg), temperature

(35.3°C vs. 35.9°C), pH (7.16 vs. 7.11), base defic it (-13.0

vs. -14.7), lactate (6.5 vs. 8.1), international normalized

ratio (INR; 1.59 vs. 1.83), and partial thromboplastin time

(48.3 vs. 57.9). Although not significant, patients with

Injury Severity Score range 26 to 35 were more frequent in

the pre-TEG group. Fresh-frozen plasma (FFP) :

RBCs, platelets : RBCs, and cryoprecipitate (cryo) :

RBC ratios were not significantly different at 6 or 12 hours.

INR at 6 hours did not discriminate between survivors and

nonsurvivors (p = 0.10), whereas r-TEG "G" value was

significantly associated with survival (p = 0.03), as was

the maximum rate of thrombin generation (MRTG;

mm/min) and total thrombin generation (TG; area under

the curve) (p = 0.03 for both). Patients with MRTG of

more than 9.2 received significantly less components of

RBCs, FFP, and cryo (p = 0.048, p = 0.03, and p =

0.04, respectively).



CONCLUSION:

Goal-directed resuscitation via r-TEG appears useful for

management of trauma-induced coagulopathy. Further

experience with POC monitoring could result in more

efficient management leading to a reduction of transfusion

requirements.



Int J Obstet Anesth. 2011 Aug 11. [Epub ahead of print]

Anesthetic considerations for placenta accreta.

Lilker SJ, Meyer RA, Downey KN, Macarthur AJ.

Source

Department of Anesthesia, Mount Sinai Hospital, Toronto,

Ontario, Canada.

Abstract

BACKGROUND:

When diagnosed antenatally placenta accreta has often

been managed by cesarean hysterectomy, but recently

techniques involving uterine preservation have been

developed. Uterine artery embolization has become an

adjuvant treatment, although the potential for obstetric

hemorrhage still exists. A multidisciplinary approach has

permitted the development of anesthetic strategies for

these patients.

METHODS:

A retrospective case note review of patients with placenta

accreta between 2000 and 2008 at our institution was

conducted. Anesthetic technique, estimated blood loss,

requirement for blood products and disposition of patients

postoperatively were recorded.

RESULTS:

A total of 23 cases were identified. In six, epidural

anesthesia with progression to general anesthesia was

planned. In 17 cases, neuraxial anesthesia was planned

and in five of these (29%) excessive blood loss

necessitated conversion to general anesthesia. Nine

patients (39%) had intraoperative blood loss estimated at

> 2L, and six required intraoperative blood transfusion.

Eleven patients (48%) required hysterectomy, seven of

which were performed on the day of delivery.

CONCLUSION:

In this case series, the expectation of major blood loss at

cesarean delivery in the presence of placenta accreta and

attempts at uterine conservation surgery initially prompted

a conservative approach using general anesthesia.

Greater experience has permitted modification of this

approach and neuraxial anesthesia is now employed more

frequently. When managed appropriately, most patients



are able to tolerate both prolonged surgery and significant

blood loss under epidural anesthesia.



ANESTHETIC TECHNIQUES AUTOTRANSFUSION

World J Urol. 2011 Aug 17. [Epub ahead of print]

Oncologic outcomes following radical prostatectomy with intraoperative cell salvage.

Gorin MA, Eldefrawy A, Manoharan M, Soloway MS.

Source

Department of Urology, University of Miami Miller School

of Medicine, P.O. Box 016960 (M-814), Miami, FL, 33101,

USA.

Abstract

PURPOSE:

To evaluate oncologic outcomes following the use of

intraoperative cell salvage (IOCS) as a blood loss

management strategy during open radical prostatectomy

(RP).

METHODS:

We retrospectively reviewed all open retropubic RP cases

performed by a single surgeon. Patients were identified

who received IOCS blood and evaluated for an increased

risk of biochemical recurrence (BCR) and overall mortality.

RESULTS:

The study cohort consisted of 1,862 men, 395 (21.2%) of

whom received IOCS blood. At a median follow-up of 47.0

months, men who received IOCS blood were not at an

increased risk of BCR (P = 0.323) or all-cause mortality (P

= 0.892). IOCS use did not confer an increased risk of

BCR within any D'Amico preoperative risk category (low

risk, P = 0.592; intermediate risk, P = 0.107; and high risk,

P = 0.697).

CONCLUSIONS:

IOCS is safe for the management of blood loss during RP.

At long-term follow-up, IOCS use was not associated with

an increased risk of BCR or death. While it remains

preferable to avoid any form of blood transfusion, we

advocate for the use of IOCS in place of allogeneic blood.

These conclusions are drawn from our study of the largest

and longest followed cohort patients who received IOCS

blood during RP.


Int J Gynaecol Obstet. 2011 Aug 26. [Epub ahead of print]



Blood cell salvage during cesarean delivery.

Sullivan JV, Crouch ME, Stocken G, Lindow SW.

Abstract

OBJECTIVE:

To review the use of blood cell salvage performed during

cesarean delivery.

METHODS:

A retrospective review of the case notes of 107 patients

who underwent blood cell salvage during cesarean

delivery. A total of 102 women at high risk of hemorrhage

were prepared preoperatively for cell salvage. A second

group of 5 patients had cell salvage initiated

intraoperatively owing to unexpected severe hemorrhage.

RESULTS:

Of the 107 patients, 36 (33.6%) were re-infused with

salvaged blood. There were no reported incidents of

amniotic embolization or hemolytic disease. Of the 31

patients for whom cell salvage was prepared

preoperatively, only 6 patients required transfusion of

banked blood. In elective procedures, patients were re-

infused with salvaged blood averaging 28% of the volume

of blood lost, without complications.

CONCLUSION:

Cell salvage was acceptable, beneficial, and without

adverse events in both high-risk elective cesareans and

emergency cesareans for unexpected hemorrhaging. The

skills refined during use of cell salvage in elective

cesareans were crucial for successful implementation

during emergency situations.

Copyright © 2011 International Federation of Gynecology

and Obstetrics. Published by Elsevier Ireland Ltd. All rights

reserved.


ANESTHETIC TECHNIQUES FLUID MANAGEMENT

J Surg Oncol. 2011 Jul 25. doi: 10.1002/jso.22048. [Epub

ahead of print]

Effect of intra-operative fluid volume on peri-operative outcomes after pancreaticoduodenectomy for pancreatic adenocarcinoma.

Melis M, Marcon F, Masi A, Sarpel U, Miller G, Moore H,

Cohen S, Berman R, Pachter HL, Newman E.

Source

Department of Surgery, New York University School of

Medicine, New York, New York; Division of Surgical

Oncology, New York University School of Medicine, New

York, New York. [email protected].



Abstract

BACKGROUND:

Excess use of intravenous fluid can increase post-

operative complications. We examined the influence of

intra-operative crystalloid (IOC) administration on

complications following pancreaticodudenectomy (PD) for

pancreatic adenocarcinoma.

METHODS:

We categorized 188 patients who underwent PD for

adenocarcinoma (1990-2009) into two groups: Group I

received <6,000 ml and Group II received ≥6,000 ml IOC.

Differences between groups in length of stay, overall

morbidity, and 30-day mortality were evaluated.

RESULTS:

There were 86 patients in Group I and 102 in Group II.

Group I patients were older and with higher percentage of

women, but similar in regards to performance status, ASA

score, underlying comorbidities, and administration of neo-

adjuvant treatment. Group II patients had longer

operations, increased blood loss, and higher rates of intra-

operative blood transfusions. There were two post-

operative deaths, both in the Group II (P = 0.5). Post-

operative overall morbidity was 45.7%, without differences

between the two groups (44.2% vs. 47.1%, P = 0.7).

Likewise, length of post-operative stay was similar in both

groups (13.8 days vs. 14.5 days, P = 0.5).

CONCLUSIONS:

The volume of IOC increased with duration of surgery,

intra-operative blood losses, and intra-operative blood

transfusion, but did not correlate with post-operative

morbidity. J. Surg. Oncol © 2011 Wiley-Liss, Inc.

Copyright © 2011 Wiley-Liss, Inc.


Anaesthesia. 2011 Aug 18. doi: 10.1111/j.1365-


Anaesthesia for 1131 patients undergoing proximal femoral fracture repair: a retrospective, observational study of effects on blood pressure, fluid administration and perioperative anaemia.

Wood RJ, White SM.

Source

Specialist Trainee in Anaesthesia Consultant in

Anaesthesia, Royal Sussex County Hospital, Brighton, UK.

Abstract

Intra-operative hypotension is a frequent occurrence

during anaesthesia for hip fracture surgery in older

patients with co-morbidities. We analysed retrospective

data from the Brighton Hip Fracture Database to

determine the intra-operative fall in systolic blood

pressure, and the incidence of absolute (lowest systolic



blood pressure < 90 mmHg) and relative (> 20% fall

in systolic blood pressure from baseline) hypotension

during general or spinal anaesthesia among 1131 non-

consecutive patients with hip fracture. General

anaesthesia for 489 patients (43.2%) produced a greater

mean (SD) fall in systolic blood pressure than spinal

anaesthesia for 578 patients (51.1%): 34.2% (13.0%) vs

29.7% (10.8%), respectively (p < 0.0001), mean

difference 4.5% (95% CI 3.1-5.9%), and was associated

with greater mean (SD) intra-operative fluid administration

(1555 (801) ml vs 1375 (621) ml, respectively, p <

0.0001). We observed a correlation between the volume of

subarachnoid hyperbaric bupivacaine 0.5% and fall in

systolic blood pressure (p = 0.004): compared with

patients receiving > 1.5 ml (n = 463), fewer patients

receiving ≤ 1.5 ml bupivacaine 0.5% (n = 97)

experienced episodes of absolute (31.1% vs 11.3%, p <

0.0001) or relative (83.9% vs 26.8%, p < 0.0001)

hypotension. Both mean (SD) intravenous fluid

administration (1097 ml (439) vs 1431 ml (638), p <

0.0001) and mean peri-operative fall in haemoglobin

concentration (2.1 (1.8) g.dl(-1) vs 2.6 (1.7) g.dl(-1) ,

p = 0.009) were lower in the low-dose spinal group. If

these data are confirmed by other researchers, intra-

operative hypotension (and consequent haemodilution

secondary to reactive fluid administration) in this patient

group may be reduced by the simple expedient of

administering more cautious general anaesthesia, or

reduced volumes of subarachnoid local anaesthetic.

© 2011 The Authors. Anaesthesia © 2011 The Association

of Anaesthetists of Great Britain and Ireland.


BLOOD SUBSTITUTES

Artif Organs. 2011 Aug 16. doi: 10.1111/j.1525-


Impact of Hemoglobin Concentration and Affinity for Oxygen on Tissue Oxygenation: The Case of Hemoglobin-based Oxygen Carriers.

Samaja M, Terraneo L.

Source

Dipartimento di Medicina, Chirurgia e Odontoiatria,

Università di Milano-San Paolo, Milano, Italy.

Abstract

In patients undergoing exchange-transfusion with

hemoglobin (Hb)-based oxygen (O(2) ) carriers (HBOC),

native Hb coexists with newly transfused Hb. The two Hb

types share the same arterial and venous PO(2) , but their

affinities for O(2) vary. A simple spreadsheet model is

described aiming at evaluating the contribution of each Hb

type to the overall O(2) transport characteristics as a

function of the batch Hb concentration and O(2) affinity in

the HBOC solution, of the fraction of exchange-transfused

blood/HBOC, and of the arterial PO(2) . This model helps



to yield a quantitative estimate of how tissues with high or

low O(2) extraction respond to the changes cited above.

The results show that the higher the exchange-transfusion

ratio, the O(2) transport to tissues becomes progressively

impaired. However, this effect is more critical at low batch

Hb concentration and high O(2) affinity of the HBOC,

especially for tissues/organs with high O(2) extraction,

whereas the arterial PO(2) does not appear as critical.

© 2011, Copyright the Authors. Artificial Organs © 2011,

International Center for Artificial Organs and

Transplantation and Wiley Periodicals, Inc.


J Trauma. 2011 May;70(5 Suppl):S40-1.

US Navy Experience With Research on, and Development of, Hemoglobin-Based Oxygen Carriers.

Auker CR, McCarron RM.

Source

From the Neurotrauma Department, Operational and

Undersea Medicine Directorate, Naval Medical Research

Center, Silver Spring, Maryland.


BLOOD UTILIZATION

J Perianesth Nurs. 2011 Aug;26(4):262-76.

Blood products and the phases of perianesthesia care-reviewing the implications.

Ead H.

Abstract

Perianesthesia nurses often provide care for patients who

have received blood products. Over the years, great

advances in the safety and technology around blood

products have occurred, yet transfusions are not without

risk. Because 50% of blood transfusions are administered

in the surgical setting, the perianesthesia nurse must know

the indications and potential adverse reactions. The

perianesthesia nurse has an important role in supporting

appropriate use of blood products, which can be a scarce

resource at times. By knowing indications, benefits, and

risks of transfusion, the nurse can better advocate for the

patient's needs. Additionally, with this knowledge, the

nurse is able to support patient education and ensure that

consent obtained is informed in nature. In this article, the

commonly used blood products, potential adverse

reactions, and methods to reduce transfusion errors are

being reviewed. Ideally, nurses should be provided a

periodic review on blood products and transfusion safety

to maintain knowledge, competency, and an acceptable

comfort level overall. Ongoing education can be an

effective means to expand knowledge of the health care

provider and improve patient safety and outcomes.



Copyright © 2011 American Society of PeriAnesthesia

Nurses. Published by Elsevier Inc. All rights reserved.


Am J Cardiol. 2011 Jul 24. [Epub ahead of print]

Conservative Versus Liberal Red Cell Transfusion in Acute Myocardial Infarction (the CRIT Randomized Pilot Study).

Cooper HA, Rao SV, Greenberg MD, Rumsey MP,

McKenzie M, Alcorn KW, Panza JA.

Source

Washington Hospital Center, Washington, DC.

Abstract

Red blood cell transfusion is common in patients with

acute myocardial infarction (AMI). However, observational

data suggest that this practice may be associated with

worse clinical outcomes and data from clinical trials are

lacking in this population. We conducted a prospective

multicenter randomized pilot trial in which 45 patients with

AMI and a hematocrit level ≤30% were randomized to a

liberal (transfuse when hematocrit <30% to maintain 30%

to 33%) or a conservative (transfuse when hematocrit

<24% to maintain 24% to 27%) transfusion strategy.

Baseline hematocrit was similar in those in the liberal and

conservative arms (26.9% vs 27.5%, p = 0.4). Average

daily hematocrits were 30.6% in the liberal arm and 27.9%

in the conservative arm, a difference of 2.7% (p <0.001).

More patients in the liberal arm than in the conservative

arm were transfused (100% vs 54%, p <0.001) and the

average number of units transfused per patient tended to

be higher in the liberal arm than in the conservative arm

(2.5 vs 1.6, p = 0.07). The primary clinical safety

measurement of in-hospital death, recurrent MI, or new or

worsening congestive heart failure occurred in 8 patients

in the liberal arm and 3 in the conservative arm (38% vs

13%, p = 0.046). In conclusion, compared to a

conservative transfusion strategy, treating anemic patients

with AMI according to a liberal transfusion strategy results

in more patients receiving transfusions and higher

hematocrit levels. However, this may be associated with

worse clinical outcomes. A large-scale definitive trial

addressing this issue is urgently required.

Copyright © 2011 Elsevier Inc. All rights reserved.


J Surg Res. 2011 Jul 19. [Epub ahead of print]

Laparoscopic Splenectomy for Patients with Immune Thrombocytopenia and Very Low Platelet Count: Is Platelet Transfusion Necessary?

Chen X, Peng B, Cai Y, Zhou J, Wang Y, Wu Z, Chen S.

Source



Department of Gastrointestinal Surgery, Sichuan

University West China Hospital, Chengdu, Sichuan, China.

Abstract

BACKGROUND:

The safe level of platelet count (PC) and necessity for

platelet transfusion during laparoscopic splenectomy (LS)

remain uncertain in patients with immune

thrombocytopenia (ITP).


From 2005 to 2010, 81 patients with ITP underwent LS by

our surgical team. Of these patients, 10 (group Ⅰa) with

preoperative PC < 10 × 10(9)/L were administered platelet

concentrates during surgery, whereas another 20 (group

Ib) with PC < 10 × 10(9)/L, 24 (group II) with PC = 10-30 ×

10(9)/L and 27 (group III) with PC ≥ 30 × 10(9)/L did not

receive platelet transfusion. Recently, we carried out

comparisons between groups in terms of demographic

data and perioperative outcome.

RESULTS:

The demographic data were similar among groups. The

operative outcome was comparable between group Ia and

Ib. Patients in group Ib had significantly lower preoperative

PC (P < 0.001) and hemoglobin concentration (P = 0.009),

suffered relatively more blood loss (P = 0.151) and

drainage exudates (P = 0.151), received more packed red

blood cell (RBC) transfusions (P = 0.113) than patients in

groups II or Ⅲ. However, blood loss was not correlated

with PC (r = -0.145, P = 0.195), but determined by

operative time (r =0.610, P < 0.001); and packed RBC

transfusion was significantly determined by lower

preoperative hemoglobin and conversion to open surgery

(OR = 7.2 and 46.7, P < 0.001 and P = 0.005,

respectively).

CONCLUSIONS:

Very low platelet count should not be contraindicated for

LS in ITP patients and perioperative platelet transfusion

may be unnecessary.



J Trauma. 2011 Jul;71(1 Suppl):S82-6.

Impact of improved combat casualty care on combat wounded undergoing exploratory laparotomy and massive transfusion.

Simmons JW, White CE, Eastridge BJ, Holcomb JB,

Perkins JG, Mace JE, Blackbourne LH.

Source

From the United States Army Institute of Surgical

Research (C.E.W., B.J.E., L.H.B.), Fort Sam Houston,

Texas; Center for Translational Injury Research (J.B.H.),

University of Texas, Houston, Texas; Department of



Hematology-Oncology (J.G.P.), Walter Reed Army

Medical Center, Washington DC; and Department of

Surgery (J.E.M.), Brooke Army Medical Center, Fort Sam

Houston, Texas.

Abstract

BACKGROUND:

: Studies have shown decreased mortality after

improvements in combat casualty care, including

increased fresh frozen plasma (FFP):red blood cell (RBC)

ratios. The objective was to evaluate the evolution and

impact of improved combat casualty care at different time

periods of combat operations.

METHODS:

: A retrospective review was performed at one combat

support hospital in Iraq of patients requiring both massive

transfusion (≥10 units RBC in 24 hours) and exploratory

laparotomy. Patients were divided into two cohorts based

on year wounded: C1 between December 2003 and June

2004, and C2 between September 2007 and May 2008.

Admission data, amount of blood products and fluid

transfused, and 48 hour mortality were compared.

Statistical significance was set at p < 0.05.

RESULTS:

: There was decreased mortality in C2 (47% vs. 20%).

Patients arrived warmer with higher hemoglobin. They

were transfused more RBC and FFP in the emergency

department (5 units ± 3 units vs. 2 units ± 2 units; 3 units ±

2 units vs. 0 units ± 1 units, respectively) and received less

crystalloid in operating room (3.3 L ± 2.2 L vs. 8.5 L ± 4.9

L). The FFP:RBC ratio was also closer to 1:1 in C2 (0.775

± 0.32 vs. 0.511 ± 0.21).

CONCLUSIONS:

: The combination of improved prehospital care, trauma

systems approach, performance improvement projects,

and improved transfusion or resuscitation practices have

led to a 50% decrease in mortality for this critically injured

population. We are now transfusing blood products in a

ratio more consistent with 1 FFP to 1 RBC.

Simultaneously, crystalloid use has decreased by 61%, all

of which is consistent with hemostatic resuscitation

principles.


Crit Care Med. 2011 Jun;39(6):1507-13.

Survival of trauma patients after massive red blood cell transfusion using a high or low red blood cell to plasma transfusion ratio.

Rajasekhar A, Gowing R, Zarychanski R, Arnold DM, Lim

W, Crowther MA, Lottenberg R.

Source



Division of Hematology/Oncology, Department of

Medicine, University of Florida, Gainesville, FL, USA.

[email protected]

Abstract

OBJECTIVE:

Early and aggressive treatment of trauma-associated

coagulopathy through transfusion of high plasma to

packed red blood cell ratios is gaining favor. Whether this

strategy is associated with improved survival is unclear.

We performed a systematic review to determine whether

higher plasma to packed red blood cell ratios compared

with lower plasma to packed red blood cell ratios were

associated with a survival advantage.

DATA SOURCES:

We searched electronic databases MEDLINE, Embase,

and Web of Science from 1950 to February 2010 for

studies comparing mortality in massively transfused

trauma cohorts receiving different plasma to packed red

blood cell ratios.

STUDY SELECTION:

Two reviewers independently performed study selection.

Discrepancies in study selection were resolved by

discussion and consensus.

DATA EXTRACTION:

Two reviewers independently extracted data from each

study using a standardized form. Two authors

independently assessed study quality using the

Newcastle-Ottawa Scale.

DATA SYNTHESIS:

Eleven observational studies and no randomized

controlled trials were identified. Three studies found a

survival benefit with a 1:1 plasma to packed red blood cell

transfusion ratio compared with either higher or lower

ratios. Six studies did not examine a 1:1 ratio but

concluded that higher plasma to packed red blood cell

ratios improved survival. Secondary outcomes, including

multiorgan system failure, packed red blood cell

transfusion, respiratory outcomes, and coagulation

variables, did not uniformly favor 1:1 or higher plasma to

packed red blood cell ratios.

CONCLUSIONS:

Methodological flaws, including survival bias, and

heterogeneity between studies preclude statistical

comparisons concerning the effects of a 1:1 plasma to

packed red blood cell transfusion ratio. There is insufficient

evidence to support a survival advantage with a 1:1

plasma to packed red blood cell transfusion strategy.

Randomized controlled trials evaluating safety and efficacy

are warranted before a high plasma to packed red blood

cell transfusion ratio can be recommended.



Comment in

• Crit Care Med. 2011 Jun;39(6):1597-8.


Blood Transfus. 2011 Jun 15;4(1):1-6. doi:

10.2450/2011.0108-10. [Epub ahead of print]

Blood management by transfusion triggers: when less is more.

Ansari S, Szallasi A.

Source

Department of Pathology, Monmouth Medical Center,

Long Branch, NJ, United States of America.

Abstract

BACKGROUND:

We reviewed the annual blood utilisation data at our

institution for the past 6 years. The number of packed red

blood cell units for allogeneic transfusions gradually

increased from 3,989 (in 2004) to 4,762 (in 2008): a 19%

increase. This exceeded the 7% increase in annual

admissions of patients during the same period (from

20,470 in 2004 to 21,908 in 2005).


In 2009, we introduced new transfusion guidelines

("triggers"), essentially adopting the recommendations of

the Society for the Advancement of Blood Management.

Most importantly, we reduced the trigger of blood

transfusions in normovolaemic symptomatic chronic

anaemia patients from 8 to 7 g/dL haemoglobin. At the

same time, we created a new trigger of 9 g/dL

haemoglobin for high-risk patients (e.g. those with

cardiovascular and/or chronic pulmonary disease as well

as those undergoing chemotherapy).

RESULTS:

We monitored the indications for blood transfusions during

2009 (2,717 consecutive orders) and sent out letters of

reminder of the new guidelines to our clinicians if criteria

were not met (a total of 102 letters, representing 4% of the

reviewed orders). Our annual blood utilisation in 2009

showed some improvement (4,648 units) compared to the

previous year (4,762 units) despite the increase in

admissions of patients (from 21,908 to 22,734): this

represents a 6% decrease in blood utilisation when

corrected for the admissions of patients. If this trends

holds up, the predicted blood utilisation for 2010 based on

the January to November data (4,280) promises to show a

further improvement (an 11% decrease compared to

2008).

DISCUSSION:

We conclude that blood utilisation may be improved in a

community hospital setting by combining new, evidence-

based transfusion triggers with physicians' education.




COST EFFECTIVENES

J Perianesth Nurs. 2011 Aug;26(4):225-30.

Intraoperative use of cell saver on patients undergoing open abdominal aortic aneurysm surgical repair: a greek hospital experience.

Konstantinou EA, Brady JM, Soultati A, Mitsos A,

Mamoura K, Mariolis TS, Christina DD, Fotis T.

Abstract

Perioperative use of a cell saver device can serve as a

cost-beneficial alternative to the transfusion method,

especially in countries where the cost of a single unit of

blood is high. The purpose of this study, conducted in a

Greek hospital, was to calculate the cost benefit of using a

cell saver device to salvage intraoperative blood during

open surgical abdominal aortic aneurysm repair or open

aortofemoral bypass for occlusive disease. This

retrospective study measured the amounts of salvaged

blood and reinfused blood encountered during the

procedure and then calculated the cost benefit of cell

saver use. With the cost of a unit of blood purchased in

Greece about €450 ($585), the blood units salvaged and

reinfused were calculated at a mean cost benefit of €754

($980) per case.

Copyright © 2011 American Society of PeriAnesthesia

Nurses. Published by Elsevier Inc. All rights reserved.


CRITICAL CARE / ICU

Crit Care. 2011 Jul 22;15(4):172. [Epub ahead of print]

Traumatic brain injury and resuscitation with blood products: what should we do?

Oh BC, Holcomb JB.

Source

Center for Translational Injury Research, Department of

Surgery, University of Texas Health Sciences Center,

Houston, TX 77030, USA. [email protected].

Abstract

ABSTRACT: The study by Dr Peiniger and colleagues in a

recent issue of Critical Care indicates that transfusion

strategies using an early and more balanced ratio between

fresh frozen plasma and red blood cell transfusions

provide a survival benefit in patients with acute traumatic

coagulopathy requiring massive transfusion within the first

24 hours of hospitalization. However, this topic has never

been explored in depth in patients with concomitant severe

traumatic brain injury. While the study is retrospective and

certainly not a substitute for a well-designed prospective

trial, the authors nonetheless should be commended for

addressing this issue with their current work. Currently, the

optimum fluid resuscitation paradigm for patients with both



severe traumatic brain injury and other injuries requiring

significant volume resuscitation is not clear.


HEMATOLOGY

Adv Hematol. 2011;2011:389854. Epub 2011 Jun 26.

Clinical usefulness of haptoglobin levels to evaluate hemolysis in recently transfused patients.

Gupta S, Ahern K, Nakhl F, Forte F.

Source

Department of Hematology and Oncology, Sanford R Nalitt

Institute for Cancer and Blood Related Diseases, Staten

Island University Hospital, 256 C, Mason Avenue, Staten

Island, New York-10305, USA.

Abstract

Introduction. Haptoglobin binds the globin portion of free

hemoglobin. Serum haptoglobin measurement is used as

a laboratory marker for the diagnosis of hemolytic anemia.

Since stored blood contains free hemoglobin, transfusion

may affect haptoglobin levels. Study Objectives. The aim

of the study was to evaluate whether serum haptoglobin

could be measured to assess hemolysis in recently

transfused patients. Patients and Methods. Twenty-one

patients, receiving more than one unit of packed red blood

cells (PRBCs) for presumed nonhemolytic indications,

were enrolled. Serum haptoglobin levels were recorded

before, immediately after, and 24 and 48 hours after

transfusion. Observations and Results. Analysis of

variance with a repeated measures was used to examine

the serum haptoglobin levels at different time periods and

no significant difference was found (P = .28). Conclusion.

The results suggest that serum haptoglobin can be used in

the diagnosis of hemolysis in patients receiving multiple

units of PRBC.


Am J Kidney Dis. 2011 Aug 19. [Epub ahead of print]

When a Patient Refuses Life-Saving Care: Issues Raised When Treating a Jehovah's Witness.

Panico ML, Jenq GY, Brewster UC.

Source

Yale Internal Medicine, Yale University School of

Medicine, New Haven, CT.

Abstract

Patients who are Jehovah's Witnesses frequently cross

the path of nephrologists when they are acutely ill in the

intensive care unit and stable in the long-term setting. It is

important that we as a group have a rudimentary

understanding of their philosophy about blood transfusion

so that we can be proactive in their management. We use

a case as a launching point to discuss the origins of the



faith and the decision to refuse blood, as well as potential

therapeutic strategies that can be used to improve the

care of these patients. Improvement in our understanding

as physicians will facilitate a more productive conversation

with our patients about a complex and emotional issue.

Copyright © 2011 National Kidney Foundation, Inc.

Published by Elsevier Inc. All rights reserved.


HEMOSTATIC MANAGEMENT

J Trauma. 2011 Jul;71(1 Suppl):S9-S14.

Tranexamic Acid for trauma patients: a critical review of the literature.

Cap AP, Baer DG, Orman JA, Aden J, Ryan K,

Blackbourne LH.

Source

From the U.S. Army Institute of Surgical Research, Fort

Sam Houston, Texas.

Abstract

BACKGROUND:

: Tranexamic acid (TXA) is an antifibrinolytic that inhibits

both plasminogen activation and plasmin activity, thus

preventing clot break-down rather than promoting new clot

formation. TXA has been used around the world to safely

control bleeding since the 1960s. A large randomized trial

recently conducted in >20,000 trauma patients adds to the

large body of data documenting the usefulness of TXA in

promoting hemostasis.

METHODS:

: We reviewed the literature describing use of TXA in a

variety of settings including trauma.

RESULTS:

: TXA has been safely used across a wide range of clinical

settings to control hemorrhage. The results of a large,

randomized, placebo-controlled trial support the use of

TXA to treat bleeding trauma patients.

CONCLUSIONS:

: This inexpensive and safe drug should be incorporated

into trauma clinical practice guidelines and treatment

protocols. Further research on possible alternate

mechanisms of action and dosing regimens for TXA

should be undertaken. Concurrent to these endeavors,

TXA should be adopted for use in bleeding trauma

patients because it is the only drug with prospective

clinical evidence to support this application.


Int J Obstet Anesth. 2011 Aug 9. [Epub ahead of print]



Assessment of coagulation in the obstetric population using ROTEM® thromboelastometry.

Armstrong S, Fernando R, Ashpole K, Simons R, Columb

M.

Source

Department of Anaesthesia, University College Hospital,

London, UK.

Abstract

BACKGROUND:

Assessment of maternal coagulation to determine

suitability for neuraxial anaesthesia and management of

obstetric haemorrhage remains a challenge.

Thromboelastography provides point of care patient

assessment of the viscoelastic properties of whole blood

clotting and can assist the clinician in haemostatic

decision-making. The study aim was to determine the

ROTEM® thromboelastometer 95% reference limits for

third trimester parturients and to compare these with non-

pregnant female controls.

METHODS:

Following ethics committee approval and informed

consent, citrated blood was sampled from 120 age-

matched healthy pregnant and non-pregnant women.

Thromboelastometry, using a ROTEM® point of care

monitor, was performed with specific activators to measure

the coagulation time (CT), clot formation time (CFT) and

the maximal clot firmness (MCF) in order to evaluate the

extrinsic (EXTEM® test) and intrinsic (INTEM® test)

coagulation systems, as well as the fibrinogen contribution

to coagulation (FIBTEM® test).

RESULTS:

After exclusions, data from 54 subjects in each group were

analysed. Parturients had significantly lower haemoglobin

values and platelet counts (P<0.01). Despite this,

thromboelastometry exhibited significantly lower INTEM®

CT (7.3%), INTEM® CFT (11.1%) and EXTEM® CFT

(18.0%) in the pregnant group (P<0.001). MCF values

were significantly higher (INTEM® (10.9%), EXTEM®

(10.6%) and FIBTEM® (47.1%)) in the pregnant group

compared to the non-pregnant group (P<0.0001).

CONCLUSIONS:

ROTEM® thromboelastometry clearly demonstrates the

hypercoagulability of pregnancy. Formal reference ranges

for ROTEM® that may be potentially useful in the

haemostatic management of the parturient are presented.



Br J Anaesth. 2011 Aug 27. [Epub ahead of print]

Impact of preoperative maintenance or interruption of aspirin on thrombotic and bleeding events



after elective non-cardiac surgery: the multicentre, randomized, blinded, placebo-controlled, STRATAGEM trial.

Mantz J, Samama CM, Tubach F, Devereaux PJ, Collet

JP, Albaladejo P, Cholley B, Nizard R, Barré J, Piriou V,

Poirier N, Mignon A, Schlumberger S, Longrois D, Aubrun

F, Farèse ME, Ravaud P, Steg PG; for the Stratagem

Study Group.

Source

APHP, Hôpital Beaujon, Service d'Anesthésie

Réanimation et SMUR, Clichy F-92110, France.

Abstract

BACKGROUND:

/st>Patients receiving anti-platelet agents for secondary

cardiovascular prevention frequently require non-cardiac

surgery. A substantial proportion of these patients have

their anti-platelet drug discontinued before operation;

however, there is uncertainty about the impact of this

practice. The aim of this study was to compare the effect

of maintenance or interruption of aspirin before surgery, in

terms of major thrombotic and bleeding events.

METHODS:

/st>Patients treated with anti-platelet agents for secondary

prevention and undergoing intermediate- or high-risk non-

cardiac surgery were included in this multicentre,

randomized, placebo-controlled, trial. We substituted non-

aspirin anti-platelets with aspirin (75 mg daily) or placebo

starting 10 days before surgery. The primary outcome was

a composite score evaluating both major thrombotic and

bleeding adverse events occurring within the first 30

postoperative days weighted by their severity (weights

were established a priori using a Delphi consensus

process). Analyses followed the intention-to-treat principle.

RESULTS:

/st>We randomized 291 patients (n=145, aspirin group,

and n=146, placebo group). The most frequent surgical

procedures were orthopaedic surgery (52.2%), abdominal

surgery (20.6%), and urologic surgery (15.5%). No

significant difference was observed neither in the primary

outcome score [mean values (sd)=0.67 (2.05) in the

aspirin group vs 0.65 (2.04) in the placebo group, P=0.94]

nor at day 30 in the number of major complications

between groups.

CONCLUSIONS:

/st>In these at-risk patients undergoing elective non-

cardiac surgery, we did not find any difference in terms of

occurrence of major thrombotic or bleeding events

between preoperative maintenance or interruption of

aspirin.ClinicalTrials.gov identifier. NCT00190307.




HEMOSTATIC MANAGEMENT SURGICAL

Br J Anaesth. 2011 Aug 19. [Epub ahead of print]

Switch from aprotinin to {varepsilon}-aminocaproic acid: impact on blood loss, transfusion, and clinical outcome in neonates undergoing cardiac surgery.

Martin K, Gertler R, Liermann H, Mayr NP, Macguill M,

Schreiber C, Vogt M, Tassani P, Wiesner G.

Source

Department of Anaesthesiology.

Abstract

BACKGROUND:

/st> With the withdrawal of aprotinin from worldwide

marketing in November 2007, many institutions treating

patients at high risk for hyperfibrinolysis had to update

their therapeutic protocols. At our institution, the standard

was switched from aprotinin to ε-aminocaproic acid

(EACA) in all patients undergoing cardiac surgery with

extracorporeal circulation including neonates. Although

both antifibrinolytic medications have been used widely for

many years, there are few data directly comparing their

blood-sparing effect and their side-effects especially in

neonates.

METHODS:

/st> Perioperative data from 235 neonates aged up to 30

days undergoing primary cardiac surgery were analysed.

Between July 1, 2006 and November 5, 2007, all patients

(n=95) received aprotinin. Starting November 6, 2007 until

December 31, 2009, all patients (n=140) were treated with

EACA. The primary outcome criterion was blood loss;

secondary outcome criteria were transfusion requirements,

renal, vascular, and neurological complications and also

in-hospital mortality.

RESULTS:

/st> All descriptive and intraoperative data variable were

similar. Blood loss was significantly higher in the EACA

group (P=0.001), but there was no difference in the rate of

re-operation for bleeding (P=0.218) nor the number of

transfusions. There were no differences in the incidences

of postoperative renal, neurological, and vascular events

or in-hospital mortality.

CONCLUSIONS:

/st> In neonatal patients undergoing cardiac surgery, the

switch to EACA treatment led to a higher postoperative

blood loss. However, there were no differences in

transfusion requirements or major clinical outcomes.




HEMOSTATIC MANAGEMENT TOPICAL APPLICATIONS

IMMUNOMODULATION / STORAGE LESION

Ann Thorac Surg. 2011 Jul 23. [Epub ahead of print]

Transfusion Increases the Risk for Vasoplegia After Cardiac Operations.

Alfirevic A, Xu M, Johnston D, Figueroa P, Koch CG.

Source

Department of Cardiothoracic Anesthesiology

(Anesthesiology Institute), Cleveland, Ohio.

Abstract

BACKGROUND:

Perioperative vasoplegia is associated with increased

morbidity. Red blood cell (RBC) transfusion increases

plasma concentrations of inflammatory mediators, possibly

contributing to the development of vasoplegia. We

investigated the prevalence of mild and profound

postoperative vasoplegia, identified factors associated with

its development, and examined the role of RBC and

component transfusion on the occurrence of postoperative

vasoplegia.

METHODS:

Between January 1, 2000, and January 1, 2007, 25,960

patients underwent on-bypass cardiac surgical

procedures. The incidence of vasoplegia was defined as

(1) mild vasoplegia requiring norepinephrine infusion for

blood pressure support on the day of operation and

postoperative day 1, and (2) profound vasoplegia requiring

vasopressin, with or without concomitant norepinephrine

infusion, on the day of operation and postoperative day 1.

Separate logistic regression models were used to model

risk factors for development of mild and profound

vasoplegia.

RESULTS:

RBC transfusion increased risk-adjusted odd ratios (ORs)

of developing mild vasoplegia (1.0 [95% confidence limits

(CL), 1.05, 1.10]; p < 0.001) and profound vasoplegia

(1.18 [1.31, 1.46] p < 0.001). The risk-adjusted ORs (95%

CL) for mild vasoplegia and profound vasoplegia were

similarly increased by fresh-frozen plasma (OR, 1.24

[1.10, 1.41], p < 0.001; and OR, 1.20 [1.13, 1.29], p <

0.001) and platelet transfusion (OR, 1.39 [1.25, 1.54], p <

0.001; and OR, 1.22 [1.14, 1.31], p < 0.001), respectively.

CONCLUSIONS:

Red blood cells, fresh-frozen plasma, and platelet

transfusion increased the prevalence of vasoplegia. RBC

transfusion exhibited a dose-dependent response for

developing vasoplegia with each RBC unit transfused.

Further investigation is necessary to determine whether

prophylactic use of vasopressor support in the setting of

transfusion can ameliorate risk and effect outcomes.



Copyright © 2011 The Society of Thoracic Surgeons.

Published by Elsevier Inc. All rights reserved.


OB/GYN

J Obstet Gynaecol Res. 2011 Jul 27. doi: 10.1111/j.1447-


Five-year study assessing the feasibility and safety of autologous blood transfusion in pregnant Japanese women.

Watanabe N, Suzuki T, Ogawa K, Kubo T, Sago H.

Source

Department of Maternal-Fetal Neonatal Medicine, National

Center for Child Health and Development, Setagaya,

Tokyo, Japan.

Abstract

Aim: To assess the feasibility and safety of autologous

blood donation during pregnancy in Japanese women.

Material and Methods: We enrolled patients who were

either at high risk for massive blood loss during delivery or

had blood that was difficult to match for transfusion

between March 2005 and February 2010. After delivery,

we reviewed hospital records of these patients to collect

data on blood donation procedures, obstetric outcome and

blood transfusions received. Results: We enrolled 314

patients during the study period and performed 809 blood

donations. The median volume of donated blood was 1200

mL (range, 400-2000 mL). Vasovagal reflex as an

adverse donor reaction occurred in 10 of the 314 patients

(3.2%) during 11 of the 809 donations (1.4%). There were

no cases of non-reassuring fetal heart rate patterns during

blood donations. Twenty-five (7.8%) of the 322 neonates

were admitted to the neonatal intensive care unit. All 322

infants were healthy 1month after delivery. Among 314

patients, autologous blood re-transfusion was performed

for 56 (17.8%) and homologous blood transfusion was

performed concurrently for 5 (1.6%). Placenta previa was

the indication with the highest re-transfusion rate (42.4%).

All re-transfusions were performed without side-effects.

Conclusion: Autologous blood donation is feasible and

safe for pregnant women and their infants. Although

indications of autologous blood donation are controversial,

it should be considered for cases of placenta previa.

© 2011 The Authors. Journal of Obstetrics and

Gynaecology Research © 2011 Japan Society of

Obstetrics and Gynecology.


PATIENT OUTCOMES

Acta Oncol. 2011 Jul 26. [Epub ahead of print]

Does transfusion improve the outcome for HNSCC patients treated with radiotherapy? - Results from the randomized DAHANCA 5 and 7 trials.



Hoff CM, Lassen P, Eriksen JG, Hansen HS, Specht L,

Overgaard M, Grau C, Johansen J, Bentzen J, Andersen

L, Evensen JF, Overgaard J.

Source

Department of Experimental Clinical Oncology, Aarhus

University Hospital , Denmark.

Abstract

Abstract Background. Patients with head and neck

squamous cell carcinoma (HNSCC) and a low level of

hemoglobin often have a poor response to radiation that

may be related to hypoxia-induced radioresistance. We

have previously published the importance of hemoglobin

level and the effect of transfusion by the results from the

randomized DAHANCA 5 trial, including 414 patients in

the analysis. Aim of the current analysis was to gain

additional power by adding patients from the continued

subrandomization in the DAHANCA 7 trial, now including a

total of almost 1200 patients. Material and methods.

Patients were randomized to treatment in the DAHANCA 5

and 7 study (nimorazole vs. placebo and five fx/week vs.

six fx/week), and in addition, patients with "low" pre-

irradiation hemoglobin values (females <13 g/dl; males

<14.5 g/dl) were subrandomized to plus or minus

transfusion. Transfusion was given with packed red blood

cells with the aim to achieve a hemoglobin level in the

"high" value range. Results. A total of 1166 patients were

included, 701 patients had high hemoglobin levels and 465

had low hemoglobin levels. Among the low hemoglobin

patients, 235 were randomized to receive transfusion.

Patient characteristics and treatment arms were well

balanced. In the majority of patients, transfusion resulted

in increased hemoglobin levels although this decreased

slightly throughout treatment as in the non-transfused

patients. Overall, the patients with low hemoglobin level

had a significant reduced probability of locoregional

control, disease-specific and overall survival. In the low

hemoglobin group, transfusion did not improve the

outcome in locoregional control, disease-specific or overall

survival. In multivariate analyses, HPV/p16 status, T and N

classification were significant factors for all outcome

measures, whereas there was no significant influence of

transfusion or hemoglobin level on endpoints. Conclusion.

Transfusion prior to and during radiation treatment did not

improve the outcome in patients with HNSCC and low

hemoglobin values, but may have a negative impact on

survival.


PEDIATRICS

Haemophilia. 2011 May;17(3):463-9. doi: 10.1111/j.1365-

2516.2010.02445.x. Epub 2010 Dec 1.

The clinical efficacy and safety of the FVIII/VWF concentrate, BIOSTATE®, in children with von Willebrand disorder: a multi-centre retrospective review.



Howman R, Barnes C, Curtin J, Price J, Robertson J,

Russell S, Seldon M, Suppiah R, Teague L, Barrese G.

Source

Princess Margaret Hospital, Perth, WA, Australia.

[email protected]

Abstract

Factor replacement with BIOSTATE(®), a factor VIII

(FVIII)/von Willebrand factor concentrate, forms the

mainstay of treatment for children with von Willebrand

disorder (VWD) in Australia and New Zealand. However,

published data on the clinical efficacy and safety of

BIOSTATE in the VWD paediatric population are limited.

We retrospectively assessed the efficacy and safety of

BIOSTATE in 43 children with VWD who received

treatment for surgery, non-surgical bleeds or continuous

prophylaxis at eight paediatric haemophilia centres in

Australia and New Zealand. Data were collected on patient

demographics, disease history, treatment history, dosage,

administration, adverse reactions, concomitant

medications and excessive bleeding events. BIOSTATE

provided excellent/good haemostatic efficacy in 90% of

surgical procedures (n = 42) with a mean daily FVIII dose

of 47 IU FVIII:C kg(-1) and a median treatment duration of

3 days. Excellent/good haemostatic efficacy was achieved

in 94% of non-surgical bleeding events (n = 72) with a

mean FVIII dose of 45 IU FVIII:C kg(-1) day(-1) and a

median treatment duration of 1 day. There were no

bleeding events attributable to lack of efficacy. One case

of nausea, possibly related to BIOSTATE administration,

was reported. These results suggest that BIOSTATE is

safe and effective for the treatment and prophylaxis of

bleeding in children with VWD.

© 2011 Blackwell Publishing Ltd.


SURGICAL TECHNIQUES

Surg Obes Relat Dis. 2011 Jun 2. [Epub ahead of print]

Incidence and management of bleeding complications after gastric bypass surgery in the morbidly obese.

Heneghan HM, Meron-Eldar S, Yenumula P, Rogula T,

Brethauer SA, Schauer PR.

Source

Bariatric and Metabolic Institute, Cleveland Clinic

Foundation, Cleveland, Ohio.

Abstract

BACKGROUND:

Bleeding after gastric bypass can be a life-threatening

event and challenging to manage. With an increase in the

number of bariatric procedures performed in recent years,

it is important to be cognizant of the frequency,

presentation, and management of this complication. The



purpose of the present study was to evaluate the

incidence and management of bleeding complications

after gastric bypass surgery.

METHODS:

A review of prospectively maintained bariatric surgery

databases was conducted at 2 tertiary bariatric units. All

patients who presented with gastrointestinal and intra-

abdominal bleeding after gastric bypass during a 10-year

period were identified, and their charts were reviewed.

RESULTS:

A total of 4466 patients who underwent gastric bypass

during the 10-year period had reliable morbidity data

available and were included in the present study. Of the

4466 patients, 42 (.94%) experienced a bleeding

complication postoperatively. Of these patients, 20

(47.6%) had undergone previous abdominal surgery.

Bleeding occurred in the early postoperative period (<30 d)

in 30 (71%); the etiology of which included bleeding from

the staple lines, iatrogenic visceral injury, or mesenteric

vessel bleeding. Early postoperative bleeding required

operative intervention to achieve hemostasis in 43%. Late

postoperative bleeding (n = 12) were usually secondary to

marginal ulceration and warranted surgical intervention in

33.3%. Previously undiagnosed bleeding diatheses were

identified in 14.3%.

CONCLUSION:

Gastrointestinal bleeding after gastric bypass, although

infrequent, is a difficult clinical scenario. Nonoperative

management is feasible for hemodynamically stable

patients. Surgical intervention is merited for patients with

hemodynamic compromise, those who do not respond to

transfusion, and those in whom the bleeding source

cannot be adequately identified nonoperatively.

Copyright © 2011 American Society for Metabolic and

Bariatric Surgery. Published by Elsevier Inc. All rights

reserved.


TRANSFUSION HAZARDS

J Trauma. 2011 Aug;71(2):358-63.

Platelet transfusion: an unnecessary risk for mild traumatic brain injury patients on antiplatelet therapy.

Washington CW, Schuerer DJ, Grubb RL Jr.

Source

From the Department of Neurological Surgery (C.W.W.,

R.L.G.); and Division of General Surgery, Section of Acute

and Critical Care Surgery (D.J.E.S.), Washington

University School of Medicine, St. Louis, Missouri.

Abstract



INTRODUCTION:

: To determine whether there is a benefit to platelet

transfusion in mild traumatic brain injury (MTBI) patients

with intracranial hemorrhage (ICH), taking antiplatelet

therapy before hospitalization.


: The study design retrospectively reviewed patients

admitted to a Level I trauma center during a 2-year period

with an isolated MTBI (Glasgow Coma Scale score ≥13,

ICH seen on a head computed tomographic scan (head

computed tomography [HCT]), and taking an antiplatelet

agent before hospitalization. HCT's were categorized

based on the Marshall Classification, Rotterdam Score,

and ICH volume. Hospital records were reviewed noting

neurologic, cardiac, respiratory events, and discharge

Glasgow Outcome Scale.

RESULTS:

: There were 1,101 patients with TBI hospitalized during

the 2-year study period. Three hundred twenty-one of

these patients had an MTBI with ICH at the time of

admission, and from this group, 113 were taking an

antiplatelet agent. Only 4 (1.2%) of the 321 patients

suffered a neurologic decline. All were gradual in nature,

and none required emergent intervention. An analysis of

the 113 patients taking antiplatelet agents, comparing

patients who were not given a platelet transfusion with

those who received a platelet transfusion, found no

significant difference in the rate of HCT progression,

neurologic decline, or Glasgow Outcome Scale at hospital

discharge between the two groups. There was a trend,

which was not significant, toward more medical declines in

patients who received a platelet transfusion. A further

review, analyzing all 321 patients with ICH showed

receiving a transfusion of any type (i.e., platelets, fresh

frozen plasma, or blood) was a strong predictor of medical

decline (p < 0.0001). The odds ratio of having a medical

decline after transfusion was 5.8 (95% confidence interval,

1.2-28.2).

CONCLUSIONS:

: Platelet transfusion did not improve short-term outcomes

after MTBI. Further randomized controlled trials need to be

done to truly assess if there is no benefit in platelet

transfusion in patients taking antiplatelet agents suffering

an MTBI. Because the overall outcome in MTBI patients is

favorable, platelet transfusion in these patients may not be

indicated.


J Trauma. 2011 Aug;71(2):299-305.

Early Blood Product and Crystalloid Volume Resuscitation: Risk Association With Multiple Organ Dysfunction After Severe Blunt Traumatic Injury.

Brakenridge SC, Phelan HA, Henley SS, Golden RM,

Kashner TM, Eastman AE, Sperry JL, Harbrecht BG,



Moore EE, Cuschieri J, Maier RV, Minei JP; The

Inflammation and the Host Response to Injury

Investigators.

Source

From the Department of Surgery, Division of

Burn/Trauma/Critical Care (S.C.B., H.A.P., A.E.E., J.P.M.),

University of Texas Southwestern Medical Center, Dallas,

Texas; Martingale Research Corporation (S.S.H.), Plano,

Texas; Department of Medicine, Loma Linda University

(S.S.H., T.M.K.), School of Medicine, Loma Linda,

California; Center for Advanced Statistics in Education

(T.M.K.), VA Medical Center, Loma Linda, California;

Department of Cognitive Science and Engineering

(R.M.G.), School of Behavioral and Brain Sciences,

University of Texas at Dallas, Richardson, Texas; Division

of General Surgery and Trauma (J.L.S.), University of

Pittsburgh Medical Center, Pittsburgh, Pennsylvania;

Division of General Surgery and Trauma (B.G.H.),

University of Louisville, Louisville, Kentucky; Denver

Health Medical Center (E.E.M.), University of Colorado

Health Sciences Center, Denver, Colorado; and

Harborview Medical Center (J.C., R.V.M.), University of

Washington, Seattle, Washington.

Abstract

BACKGROUND:

Elements of volume resuscitation from hemorrhagic shock,

such as amount of blood product and crystalloid

administration, have been shown to be associated with

multiple organ dysfunction (MOD). However, it is unknown

whether these are causative factors or merely markers of

an underlying requirement for large-volume resuscitation.

We sought to further delineate the relevance of the major

individual components of early volume resuscitation to

onset of MOD after severe blunt traumatic injury.

METHODS:

We performed a secondary analysis of a large, multicenter

prospective observational cohort of severely injured blunt

trauma patients, the NIGMS Trauma Glue Grant, to

assess the relevance of individual components of

resuscitation administered in the first 12 hours of

resuscitation including packed red blood cells (PRBC),

fresh frozen plasma (FFP), and isotonic crystalloid, to the

onset of MOD within the first 28 days after injury. Deaths

within 48 hours of injury were excluded. We used a two

tiered, exhaustive logistic regression model search

technique to adjust for potential confounders from clinically

relevant MOD covariates, including indicators of shock

severity, injury severity, comorbidities, age, and gender.

RESULTS:

The study cohort consisted of 1,366 severely injured blunt

trauma patients (median new Injury Severity Score = 34).

Incidence of 28-day Marshall MOD was 19.6%.

Transfusion of ≥10 Units of PRBC in the first 12 hours

(odds ratio, 2.06; 95% confidence interval 1.44-2.94), but



not FFP (≥8 U) or large volume crystalloid administration

(≥12 L), was independently associated with onset of 28-

day Marshall MOD. PRBC:FFP ratio in the first 12 hours

was not significantly associated with MOD.

CONCLUSIONS:

When controlling for all major components of acute volume

resuscitation, massive-transfusion volumes of PRBC's

within the first 12 hours of resuscitation are modestly

associated with MOD, whereas FFP and large volume

crystalloid administration are not independently associated

with MOD. Previous reported associations of blood

products and large-volume crystalloid with MOD may be

reflecting overall resuscitation requirements and burden of

injury rather than independent causation.


Transfus Med Rev. 2011 Aug 24. [Epub ahead of print]

Red Blood Cell Storage Lesions and Related Transfusion Issues: A Canadian Blood Services Research and Development Symposium.

Pavenski K, Saidenberg E, Lavoie M, Tokessy M, Branch

DR.

Abstract

For centuries, man has been trying to figure out how to

revive sick and traumatized individuals using fluids of

various types, even from animals. In the 17th century, it

was determined that blood was the best fluid to use and, in

the early 1900s, after the discovery of the ABO blood

groups, human blood was found to provide significant

benefit for patients with shock and/or anemia. In the 1950s

and 1960s, various ways to obtain, process, and store

human blood were developed. It soon became apparent

that storage of human blood for transfusion was

problematic because red cells, as they aged in vitro,

underwent a multitude of physicochemical changes that

greatly affected their shelf life, the so-called storage lesion.

More recently, the question has arisen as to the potential

detrimental effects of the storage lesion and suggestions

that older blood may induce increased morbidity and even

mortality despite its acceptable in vivo survival. To address

this issue of the efficacy and safety of transfusion of aged

stored blood, a number of controlled clinical trials have

been instituted to determine if older blood is significantly

detrimental compared with fresher blood in transfusion

recipients.



Thromb Res. 2011 Aug 26. [Epub ahead of print]

Association of blood transfusion and venous thromboembolism after colorectal cancer resection.

Xenos ES, Vargas HD, Davenport DL.

Source



University of Kentucky, Division of Vascular Surgery, USA.

Abstract

INTRODUCTION:

Red blood cell (RBC) transfusion is a common event in the

perioperative course of patients undergoing surgery.

Transfused blood can disrupt the balance of coagulation

factors and modulates the inflammatory cascade. Since

inflammation and coagulation are tightly coupled, we

postulated that RBC transfusion may be associated with

the development of venous thromboembolic phenomena.

We queried the American College of Surgeons' National

Surgical Quality Improvement Program (ACS NSQIP)

database to examine the relationship between

intraoperative blood transfusion and development of

venous thromboembolism (VTE) in patients undergoing

colorectal resection for cancer.


We analyzed the data from 2005 to 2009 for patients

undergoing colorectal resections for cancer based on the

primary procedure CPT-4 code and operative ICD-9

diagnosis code. The primary outcome was 30-day deep

vein thrombosis (DVT) and/or pulmonary embolism (PE).

Intraoperative transfusion of RBC's was categorized as:

none, 1-2 units, 3-5 units and 6 units or more. DVT/PE

occurrences were analyzed by multivariable forward

stepwise regression (p for entry<.05, for exit>.10) to

identify independent predictors of DVT.

RESULTS:

The database contained 21943 colorectal cancer

resections. The DVT rate was 1.4% (306/21943) and the

PE rate was 0.8% (180/21943). Patients were diagnosed

with both only 40 times and the combined DVT or PE rate

(VTE) was 2.0% (446/21943). After adjusting for age,

gender, race, ASA (American Society of

Anesthesiologists) class, emergency procedure, operative

duration and complexity of the procedure (based on

Relative Value Units, RVU's), along with six clinical risk

factors, intraoperative blood transfusion was a significant

risk factor for the development of VTE and the risk

increased with increasing number of units transfused.

Preoperative hematocrit did not enter the multivariable

model as an independent predictor of VTE, nor did open

versus laparoscopic resection or wound class.

CONCLUSION:

In this study of 21943 patients undergoing colorectal

resection for cancer, blood transfusion is associated with

increased risk of VTE. Malignancy and surgery are known

prothrombotic stimuli, the subset of patients receiving

intraoperative RBC transfusion are even more at risk for

VTE, emphasizing the need for sensible use of

transfusions and rigorous thromboprophylaxis regimens.





TRANSFUSION PRACTICE

Anesthesiology. 2011 Jul 25. [Epub ahead of print]

Reducing Noninfectious Risks of Blood Transfusion.

Gilliss BM, Looney MR, Gropper MA.

Source

* Resident Physician, Department of Anesthesia and

Perioperative Care; † Assistant Professor, Cardiovascular

Research Institute, Departments of Medicine and Lab

Medicine; ‡ Professor and Vice-Chair, Department of

Anesthesia and Perioperative Care, and Director, Critical

Care Medicine, University of California, San Francisco.

Abstract

As screening for transfusion-associated infections has

improved, noninfectious complications of transfusion now

cause the majority of morbidity and mortality associated

with transfusion in the United States. For example,

transfusion-related acute lung injury, transfusion-

associated circulatory overload, and hemolytic transfusion-

reactions are the first, second, and third leading causes of

death from transfusion, respectively. These complications

and others are reviewed, and several controversial

methods for prevention of noninfectious complications of

transfusion are discussed, including universal

leukoreduction of erythrocyte units, use of male-only

plasma, and restriction of erythrocyte storage age.


Transfusion. 2011 Jul 25. doi: 10.1111/j.1537-


A randomized controlled pilot study of adherence to transfusion strategies in cardiac surgery.

Shehata N, Burns LA, Nathan H, Hebert P, Hare GM,

Fergusson D, Mazer CD.

Source

From the Departments of Medicine, Anesthesia and

Physiology, University of Toronto, Li Ka Shing Knowledge

Institute, Division of Hematology St. Michael's Hospital;

Central Ontario Region, Canadian Blood Services,

Toronto, Ontario; the Department of Anesthesia, St

Michael's Hospital, University of Toronto, Toronto, Ontario;

the Department of Anesthesia, University of Ottawa,

Ottawa, Ontario; and the Department of Critical Care,

General Campus, and Clinical Epidemiology, Ottawa

Hospital Research Institute, CMAJ, Ottawa, Ontario,

Canada.

Abstract



BACKGROUND:

It is important to determine the optimal hemoglobin (Hb)

concentration for red blood cell (RBC) transfusion for

patients undergoing cardiac surgery because increased

mortality has been associated with the severity of anemia

and exposure to RBCs. Because a definitive trial will

require thousands of patients, and because there is

variability in transfusion practices, a pilot study was

undertaken to determine adherence to proposed

strategies.


A single-center parallel randomized controlled pilot trial

was conducted in high-risk cardiac patients to assess

adherence to two transfusion strategies. Fifty patients

were randomly assigned either to a "restrictive" transfusion

strategy (RBCs if their Hb concentration was 70 g/L or

less intraoperatively during cardiopulmonary bypass [CPB]

and 75 g/L or less postoperatively) or a "liberal"

transfusion strategy (RBCs if their Hb concentration was

95 g/L or less during CPB and less than 100 g/L

postoperatively).

RESULTS:

The percentage of adherence overall was 84% in the

restrictive arm and 41% in the liberal arm. Twenty-two

(88%) patients were transfused 99 units of RBCs in the

liberal group compared to 13 patients who were transfused

50 units in the restrictive group (p < 0.01). There were

no significant differences in individual adverse outcomes;

however, more adverse events occurred in the restrictive

group (38 vs. 15, p < 0.01).

CONCLUSION:

Adherence to the evaluated interventions is vital to all

randomized controlled trials as it has the potential to affect

outcomes. Further pilot studies are required to optimize

enrollment and transfusion adherence before a definitive

study is conducted.



MISCELLANEOUS

Interact Cardiovasc Thorac Surg. 2011 Aug 11. [Epub

ahead of print]

Platelet rich plasma improves the healing process after airway anastomosis.

Gomez-Caro A, Ausin P, Boada M.

Source

General Thoracic Surgery, Thorax Institute, Hospital

Clinic, Barcelona, Spain.

Abstract



This study investigated whether platelet-rich plasma (PRP)

promotes healing and reduces anastomotic complications

following airway surgery in a pig model. PRP was obtained

by spinning down the animal's own blood (60 ml) and

collecting the buffy coat containing platelets and white

blood cells. Fifteen adult pigs were randomized into three

groups: (1) sham treatment (cervicotomy), (2) non-PRP

group (50% tracheal resection and end-to-end

anastomosis), and (3) PRP group (50% tracheal resection,

end-to-end anastomosis and PRP application). Blood

samples were taken at baseline and at one, six and 24

hours. Animals were monitored for anastomotic

complications, infection and local reactivity. Laser Doppler

flowmetry was performed intraoperatively and at 30 days

to assess differences in pre- and post-anastomotic blood

flow. The tensile strength of the anastomosis was also

tested. The platelet level was higher in PRP fluid than in

the baseline blood sample (P<0.002). Vascular endothelial

growth factor, transforming growth factor β-1 and

epidermal growth factor immunoassay readings peaked at

one and six hours in the animals that had received PRP

(P<0.03); these also showed significantly increased

transanastomotic flow and stress-strain resistance

(P<0.04) at 30 days than the animals that had not received

PRP. PRP therefore, accelerates the onset of healing in

airway surgery by promoting an earlier release of platelet-

derived growth factors that stimulate transanastomotic

angiogenesis. Keywords: Platelet-rich plasma; Trachea.


Am J Nurs. 2011 Sep;111(9):24-30.

Original Research: Blood Transfusion: The Patient's Experience.

Adams KW, Tolich D.

Source

Kristine Weiss Adams is an NP at North Coast Health

Ministry in Lakewood, OH. Deborah Tolich is the director

of blood management at the Cleveland Clinic in Cleveland,

OH. The authors would like to acknowledge Charlie Hayes

for his research assistance and editing. Contact author:

Kristine Weiss Adams, [email protected]. The

authors have disclosed no potential conflicts of interest,

financial or otherwise.

Abstract

OBJECTIVE:

Blood transfusion is a standard treatment for anemia in

both inpatients and outpatients. Nonetheless, few studies

on the therapy have examined the patient's perspective.

This study therefore sought to identify how well patients

understand the role of blood transfusion in their treatment

and whether it causes them discomfort.

METHODS:

All medically stable adults who had received a blood

transfusion at an Ohio hospital over a five-week period in



2009 were identified; a convenience sample of 21 of those

patients participated in semistructured interviews lasting

15 to 30 minutes. The researchers recorded and

transcribed the interviews and performed a thematic

analysis.

RESULTS:

Four themes emerged: paternalism and decision making,

patients' knowledge, blood safety and administration, and

the nurse's role. Participants said that because a physician

decided the transfusion would take place, they didn't

understand that there were other options for treating their

anemia; pretransfusion written materials weren't adequate

to explain risks and benefits of the procedure; they had

concerns about the safety of the blood supply; and they

valued nurses' opinions.

CONCLUSIONS:

These qualitative findings suggest that clinicians may be

missing opportunities to improve patients' knowledge of

and comfort with blood transfusion and that they can better

meet patients' needs before, during, and after the

procedure. Further research is warranted. KEYWORDS:

blood transfusion, lived experience, patient education,

qualitative research.


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