Seth I. Perelman

From bloodless surgery to patient blood management.

Safety and efficacy concerns of allogeneic blood transfusions and their impact on patient outcomes and associated staggering costs and restricted supply have fueled the quest for other modalities and strategies to reduce use of blood components. Patient blood management focuses on multidisciplinary and multimodal preventive measures to reduce or obviate the need for transfusions and ultimately to improve the clinical outcomes of patients. Patient blood management strategies can be applied at every stage of care to surgical and nonsurgical patients, and they generally fall under one of these three categories (the so-called pillars of blood management): optimizing hematopoiesis and appropriate management of anemia, minimizing bleeding and blood loss, and harnessing and optimizing physiological tolerance of anemia through employing all available modalities while treatment is initiated. Several tools and modalities are available to address each of these pillars. Examples include hematinic agents, systemic and topical hemostatic agents, autotransfusion, and blood-sparing perfusion and surgical techniques. Additionally, changes in practice of clinicians (e.g., adherence to restrictive, evidence-based transfusion strategies with emphasis on physiologic indications for transfusion, minimization of iatrogenic blood loss, and adequate planning) play an important role in patient blood management. Emerging evidence supports that appropriate use of these strategies as part of a multimodal program is a safe and effective way of reducing allogeneic transfusions and improving patient outcomes.

Multidisciplinary management of a Jehovah’s Witness patient for the removal of a renal cell carcinoma extending into the right atrium

PurposeTo highlight the management of a Jehovah’s witness surgical patient presenting for cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest.Clinical featuresA 47-yr-old male, Jehovah’s Witness, with renal cell carcinoma was admitted for left radical nephrectomy and excision of tumour thrombus extending into the junction of the inferior vena cava (IVC) and right atrium (RA). The preoperative goals were to maximize red blood cell mass, delineate the extent of tumour extension and develop a surgical plan incorporating blood conservation strategies to minimize blood loss. A midline abdominal incision was made to optimize removal of the non-caval portion of the tumour from the intra-abdominal region. CPB and deep hypothermic circulatory arrest were instituted to aid in removing the tumour from the IVC and RA. Intraoperative blood conservation strategies included the use of acute normovolemic hemodilution, antifibrinolytics, cell salvage, point-of-care monitoring of heparin and protamine blood concentrations, leukocyte-depleting filter, and meticulous surgical techniques. The patient was successfully weaned from CPB and was transported to the cardiothoracic intensive care unit without complication. The patient was discharged home one week after the operation with a hemoglobin of 10.2 g·dL−1 and a hematocrit of 31.2%.ConclusionMultiple blood conservation techniques were employed to manage this Jehovah’s Witness patient through complex cardiac surgery, which was previously denied to him at other institutions. The successful outcome of this patient, while respecting the right to refuse allogeneic blood products, is a result of a multidisciplinary collaboration as well as the application of established blood conservation techniques.RésuméObjectifPrésenter la prise en charge d’un opéré Témoin de jéhovah pendant la circulation extracorporelle (CEC) et l’arrêt circulatoire hypothermique profond.Éléments cliniquesUn homme de 47 ans, Témoin de Jéhovah, atteint d’un hypernéphrome, devait subir une néphrectomie radicale gauche et l’excision d’un thrombus tumoral qui s’étendait à la jonction de la veine cave inférieure (VCI) et de l’oreillette droite (OD). Les objectifs préopératoires étaient d’augmenter la masse des globules rouges, de préciser l’extension de la tumeur et d’élaborer un plan chirurgical comprenant des stratégies de conservation du sang afin d’en réduire les pertes. Une incision abdominale médiane a été faite pour optimaliser le retrait, de la région intraabdominale, de la portion de la tumeur hors de la veine cave. La CEC et l’arrêt circulatoire hypothermique profond ont été établis pour faciliter le dégagement de la tumeur de la VCl et de l’OD. Les stratégies peropératoires de conservation du sang ont comporté l’usage d’hémodilution normovolémique aiguë, d’antifibrinolytiques, de récupération des cellules, de monitorage de chevet pour les concentrations sanguines d’héparine et de protamine, de filtre pour la déplétion leucocytaire et de techniques chirurgicales méticuleuses. Le sevrage de la CEC a été réussi et le patient a été transporté à l’unité des soins intensifs cardiothoraciques, sans complication. Il a reçu son congé une semaine après l’opération. Son hémoglobine était alors de 10,2 g·dL− 1 et l’hématocrite à 31,2%.ConclusionDiverses techniques de conservation du sang ont été employées pour la prise en charge d’un patient Témoin de Jéhovah au cours d’une intervention cardiaque complexe, laquelle avait été refusée précédemment dans d’autres hôpitaux. Tout en respectant le droit au refus de produits sanguins allogéniques, l’intervention a été bien réussie chez ce patient grâce à une collaboration multidisciplinaire et à une application des techniques de conservation du sang.

Geographic Regional Differences in Rocuronium Bromide Dose-Response Relation and Time Course of Action An Overlooked Factor in Determining Recommended Dosage

Background:Geographic location is not acknowledged as a stratifying factor that can directly affect drug potency, because drugs are still licensed with the same recommended dose for different geographic regions. The aim of the current study was to compare the potency and duration of action of rocuronium bromide in 54 patients in three countries with different life habits, diet, and ambient conditions, namely white Austrians, white North Americans, and Han Chinese in China. Methods:Neuromuscular block of six consecutive 50-&mgr;g/kg rocuronium incremental doses followed by 300 &mgr;g/kg was evaluated using the Relaxometer mechanomyograph (Groningen University, Groningen, Holland). Dose–response curves were created using log-dose-probit transformation. The authors compared rocuronium bromide ED50, ED90, and ED95 (effective doses required for 50%, 90%, and 95% first twitch depression, respectively) as well as Dur25 and Dur0.8 (times from last incremental dose administration until 25% first twitch and 0.8 train-of-four ratio recovery, respectively) in patients of the three countries. Results:Rocuronium ED50, ED90, and ED95 were significantly higher in Austrian patients (258 ± 68, 530 ± 159, and 598 ± 189 &mgr;g/kg) and Chinese patients (201 ± 59, 413 ± 107, and 475 ± 155 &mgr;g/kg) compared with American patients (148 ± 48, 316 ± 116, and 362 ± 149 &mgr;g/kg, respectively). Dur25 and Dur0.8 were significantly shorter in Austrian patients (22.3 ± 5.5 and 36.9 ± 12.8 min) and Chinese patients (30.4 ± 7.5 and 45.7 ± 15.9 min) compared with American patients (36.7 ± 8.5 and 56.2 ± 16.7 min, respectively). Conclusions:The authors demonstrated a significant difference in rocuronium potency and duration of action among patients in the three countries. Larger studies are required for determining dosage recommendations for different geographic regions.

Postoperative blood loss and transfusion associated with use of Hextend in cardiac surgery patients at a blood conservation center

BACKGROUND: Hydroxyethyl starch (HES) solutions are readily available colloids, but their widespread use is shadowed by controversies surrounding their effects on bleeding. This retrospective study was conducted to evaluate the relationship between Hextend (HEX; Hospira, Inc.) doses of 1 to 20 mL/kg and allogeneic transfusion and 24‐hour chest tube drainage (CTD) in cardiac surgeries at a blood conservation center.

Does acute normovolemic hemodilution work in cardiac surgery

To the Editor:—In a recent article by Höhn et al., it was concluded that acute normovolemic hemodilution (ANH) in addition to aprotinin was not beneficial in preventing allogeneic blood transfusions compared to aprotinin alone in cardiac surgery. In this randomized, controlled trial, the patients were hemodiluted to a hematocrit of 28% pre–cardiopulmonary bypass (CPB). The transfusion threshold was set at 17% during CPB and at 25% for post-CPB. The total fluid replacement was in excess relative to the amount of ANH (autologous blood) removed (6.4 2.1 l of crystalloid, 2.0 0.7 l of colloid). This led to excessive hemodilution, reducing the hematocrit below the transfusion threshold in the ANH group. Indeed, 50% of the patients in the ANH group required either all (33%) or a portion (22%) of the autologous blood to be transfused during CPB, thus negating its positive effects on erythrocytes and coagulation protection. Consequently, allogeneic erythrocyte transfusion rates and the indirect clinical markers for surgical bleeding (cell saver and 24-h chest tube drainage) were not different between the two groups. One of the goals of ANH is to protect the autologous blood from the negative effects of CPB and to return it after heparin neutralization. Additional hemodilution occurs with the onset of CPB; therefore, hemofiltration or ultrafiltration and/or diuresis should have been employed to remove excess fluid. Alternatively, ANH can be performed just prior to the onset of CPB (by diverting heparinized blood into a storage bag), thus preventing excessive dilutional anemia. The criteria for exclusion from this study were left main disease, severe aortic stenosis, recent myocardial infarction, unstable angina, ejection fraction below 30%, severe carotid stenosis, combined coronary artery bypass grafting and valve cases, respiratory insufficiency, renal insufficiency, and anemia (hemoglobin 12 g/dl). This exclusion process resulted in the selection of a group of patients that we know are at low risk for allogeneic transfusions. Our data (shown below) and those of other investigators demonstrate that patients presenting with adequate hemoglobin levels (average starting hematocrit of 43.3%, body surface area of 1.86) rarely require allogeneic blood. At our institution, the cardiac surgery program utilizes a multidisciplinary approach to blood conservation. In over 300 cardiac surgery cases (coronary artery bypass grafting, valves, and combined procedures), we remove on average 1280 ml of ANH blood per case (based on a formula to reach a target hematocrit on bypass of 20%). The average amount of fluid used for replacement was 1680 ml of crystalloid and 591 ml of colloid (Hextend, Abbott Laboratories, North Chicago, IL). Hemofiltration or ultrafiltration and/or induced diuresis is frequently utilized on CPB to remove excess fluids and to reduce the dilutional effect from the CPB prime. The starting hematocrit averages 39%. We use -aminocaproic acid for low-risk cases and reserve aprotinin (Trasylol, Bayer, West Haven, CT) for high-risk cases. The total amount of cell saver returned is approximately 200 ml, and 24-h chest tube drainage is 428 ml. Allogeneic transfusion rates for packed erythrocytes, fresh frozen plasma, and cryoprecipitate are 11%, 3%, and less than 1%, respectively.