Assessment of the need for routine intraoperative cell salvage in liver transplantation

Purpose: This study aimed to assess the necessity of routine intraoperative cell salvage in liver transplantations. Methods: A total of 327 liver transplants performed between 2014 and 2016 was included in the analysis. Patient data, including pre-transplant examinations, intraoperative red blood cell transfusions, and procedural information, were collected. Results: The median age of the patients was 54 years old, with 67% (219) being male. The most prevalent ABO blood type was O, accounting for 48% (155) of cases. The leading causes of liver disease were hepatitis C (113 cases, 34.6%) and alcohol-related liver disease (97 cases, 29.7%). Out of the 327 liver transplants, allogeneic red blood cell transfusions were administered in 110 cases (34%) with a median of two units of red blood cells per case. Cell salvage was employed in 237 transplants (73%), and successful blood recovery was achieved in 221 cases (93%). Among the group that recovered more than 200 mL of blood, the median volume of recovered blood was 417 mL, with no transfusion of allogeneic blood required. A total of 90 transplants was performed without utilizing cell salvage, and, among these cases, 19 required blood transfusions, with a median of zero units transfused. Conclusions: This study suggests that routine cell salvage is unnecessary for all liver transplantations. The most suitable indication for its use is in patients presenting with portal vein thrombosis and abnormal creatinine levels.

Implantação da técnica de recuperação intraoperatória de sangue em serviço público de atendimento ao trauma / Implementation of intraoperative blood recovery technique in public trauma care service / Implementación de la técnica de recuperación de sangre intraoperatoria en el servicio público de atención traumatológica

Objetivo: relatar a vivência de uma equipe interdisciplinar na implantação da técnica de Recuperação Intraoperatória de Sangue em um serviço público de atendimento ao trauma. Método: estudo descritivo, do tipo relato de experiência, desenvolvido no Instituto Dr. José Frota, Fortaleza, Ceará, Brasil. Resultados: a técnica foi implantada no segundo semestre de 2015 no hospital de trauma, e a vivência permitiu listar as atividades da implantação da técnica, como a disponibilização do equipamento, materiais e profissional capacitado; aulas e palestras direcionadas ao corpo clínico e residentes de anestesiologia; identificação de cirurgias com benefício potencial; abordagem direta da enfermagem aos cirurgiões no centro cirúrgico; divulgação sistemática da disponibilidade do método e dos resultados obtidos no hospital, com o apoio da chefia cirúrgica; criação de estratégia de comunicação na interface entre enfermeiros, cirurgiões e anestesistas; e ampliação da equipe de enfermeiros para o atendimento 24 horas. Conclusão: a implantação da técnica de Recuperação Intraoperatória de Sangue no hospital de trauma permitiu identificar critérios para sua utilização e disponibilizar a estratégia de conservação de sangue para todos os procedimentos com benefício potencial, ampliando o uso de forma sistemática. (AU)

Objective: To report the experience of an interdisciplinary team in the implementation of the Intraoperative Blood Recovery technique in a public trauma care service. Methods: Descriptive study, of the experience report type, developed at Instituto Dr. José Frota, Fortaleza, Ceará, Brazil. Results: The technique was implemented in the second half of 2015 at the trauma hospital, and the experience allowed listing the activities of the technique's implementation, such as the availability of equipment, materials and trained professionals; classes and lectures aimed at clinical staff and anesthesiology residents; identification of surgeries with potential benefit; direct nursing approach to surgeons in the operating room; systematic dissemination of the availability of the method and the results obtained in the hospital, with the support of the surgical leadership; creation of a communication strategy at the interface between nurses, surgeons and anesthetists; and expansion of the team of nurses to provide 24-hour care. Conclusion: The implementation of the Intraoperative Blood Recovery technique in the trauma hospital allowed identifying criteria for its use and making this blood conservation strategy available for all procedures with potential benefit, expanding its use in a systematic way. (AU)

Objetivo: Reportar la experiencia de un equipo interdisciplinario en la implementación de la técnica de Recuperación Sanguínea Intraoperatoria en un servicio público de atención traumatológica. Métodos: Estudio descriptivo, del tipo informe de experiencia, desarrollado en el Instituto Dr. José Frota, Fortaleza, Ceará, Brasil. Resultados: La técnica fue implementada en el segundo semestre de 2015 en el hospital de trauma, y la experiencia permitió enumerar las actividades de implementación de la técnica, como la disponibilidad de equipos, materiales y profesionales capacitados; clases y conferencias dirigidas al personal clínico y residentes de anestesiología; identificación de cirugías con beneficio potencial; abordaje directo de enfermería a los cirujanos en el quirófano; difusión sistemática de la disponibilidad del método y los resultados obtenidos en el hospital, con el apoyo del liderazgo quirúrgico; creación de una estrategia de comunicación en la interfaz entre enfermeras, cirujanos y anestesistas; y ampliación del equipo de enfermeras para brindar atención las 24 horas. Conclusión: A implantação da técnica de RIOS no hospital de trauma permitiu identificar criterios para su utilización y disponibilidad es una estrategia de conservación de sangue para todos los procedimientos con beneficio potencial, ampliando o uso de forma sistemática. (AU)

Autologous blood salvage in cardiac surgery: clinical evaluation, efficacy and levels of residual heparin

ABSTRACT Objective: Intraoperative blood salvage (cell saver technique) in cardiac surgery is universally used in surgical procedures with a marked risk of blood loss. The primary objectives of this study were to determine the concentration of residual heparin in the final product that is reinfused into the patient in the operating room and to evaluate the efficacy and safety of the cell saver technique. Method: Twelve patients undergoing elective cardiac surgery were enrolled in this study. Using the XTRA Autotransfusion System, blood samples were collected from the cardiotomy reservoir, both prior to blood processing (pre-sample) and after it, directly from the bag with processed product (post-sample). Hematocrit and hemoglobin levels, the protein, albumin and residual heparin concentrations, hemolysis index, and the platelet, erythrocyte and leukocyte counts were measured. Results: Hematocrit and hemoglobin levels and red blood cell counts were higher in post-processing samples, with a mean variation of 54.78%, 19.81 g/dl and 6.84 × 106/mm3, respectively (p < 0.001). The mean hematocrit of the processed bag was 63.49 g/dl (range: 57.2-67.5). The residual heparin levels were ≤0.1 IU/ml in all post-treatment analyses (p = 0.003). No related adverse events were observed. Conclusion: The reduced residual heparin values (≤0.1 IU/ml) in processed blood found in this study are extremely important, as they are consistent with the American Association of Blood Banks guidelines, which establish target values below 0.5 IU/ml. The procedure was effective, safe and compliant with legal requirements and the available international literature.

Effects of transfusion load and suction pressure on renal function in intraoperative salvage autotransfusion

Although some investigations have been performed to determine the effects of transfusion load and suction pressure on renal function during intraoperative salvage autotransfusion, the precise threshold is still undetermined. A total of 625 patients undergoing surgery with the Continuous AutoTransfusion System (CATSplus) were enrolled and divided into groups according to the utilized suction pressure and transfusion volume. Plasma free hemoglobin (FHB) and creatinine clearance (CCr) were assayed to indicate the renal function. Both 0.03 MPa suction (≥4-unit load) and >5 units transfusion changed the levels of FHB and CCr significantly when measured 24 h post-operation compared to pre-operation. Under 0.02 MPa suction (≥4-unit load), the alteration of FHB and CCr returned to normal after 24 h. Under 3 units transfusion, the levels of FHB and CCr at 6 and 12 h post-operation changed significantly compared to pre-operation (P<0.05 or P<0.01, respectively), and this alteration could be restored to normal at 72 h post-operation. After an exhaustive investigation, less than 4 units transfusion and less than 0.03 MPa suction pressure are recommended for intraoperative salvage autotransfusion.

Anestesia en el angiofibroma juvenil: un reto al anestesiólogo / Anesthesia in juvenile angiofibroma: an challenge for the anesthesiologist

Introducción: La anestesia para el angiofibroma juvenil es una de las intervenciones más complejas dentro de la otorrinolaringología, pues el sangramiento incoercible causa hipovolemia aguda la cual se produce en un breve período y lleva al shock hipovolémico y a la muerte de no tratarse adecuadamente. Objetivo: Realizar una actualización sobre el perioperatorio de la anestesia en el angiofibroma juvenil. Desarrollo: Se debe minimizar las pérdidas sanguíneas a toda costa. La mejor asociación fue la hipotensión inducida, la hemodilución hipovolémica y el predepósito de sangre autóloga, con la angiografia y embolización arterial selectiva del tumor. Conclusiones: La exéresis quirúrgica del angiofibroma juvenil es una intervención de alto riesgo. El equipo de trabajo constituye un elemento primordial. La asociación de hipotensión inducida, hemodilución hipovolémica y predepósito de sangre autóloga son los pilares fundamentales para la mejor evolución de estos pacientes(AU)

Introduction: Anesthesia for juvenile angiofibroma is one of the most complex interventions within otolaryngology, since incoercible bleeding causes acute hypovolemia, which occurs in a short period and leads to hypovolemic shock and death if not treated properly. Objective: To carry out an update about the perioperative period of anesthesia in juvenile angiofibroma. Development: Blood losses must be minimized at all costs. The best association was induced hypotension, hypovolemic hemodilution, and autologous blood predeposit, with angiography and selective arterial embolization of the tumor. Conclusions: Surgical removal of juvenile angiofibroma is a high-risk intervention. The work team is an essential element. The association of induced hypotension, hypovolemic hemodilution, and autologous blood predeposit are the fundamental pillars for the best evolution of these patients(AU)

Bacteremia in the red blood cells obtained from the cell saver in patients submitted to heart surgery / Bacteremia nos glóbulos vermelhos obtidos do "cell saver" em pacientes submetidos a cirurgia cardíaca / Bacteriemia en los glóbulos rojos obtenidos del "cell saver" en pacientes intervenidos de cirugía cardíaca

Objective: to determine the microbiological characteristics of the red blood cells obtained with the cell saver in heart surgery patients on an extra-body circuit. Method: a cross-sectional and descriptive study conducted with 358 patients scheduled for heart surgery where the saver was used. Sociodemographic variables were collected, as well as from the saver and of the microbial identification in the re-infusion bag proceeding from the cell saver. Informed consent performed. Results: of the 170 GRAM+ bacteria isolations, the most frequent species were Staphylococcus epidermidis in 69% (n=138) of the cases and Streptococcus sanguinis with a report of 10% (n=20). Significant differences were found in the Staphylococcus epidermidis strain in patients with a Body Mass Index ≥25 (p=0.002) submitted to valve surgery (p=0.001). Vancomycin was the antimicrobial which resisted the Staphylococcus epidermidis strain with a minimum inhibitory concentration of >16 µg/ml. Conclusion: the microbiological characteristics of the red blood cells obtained after processing autologic blood recovered with the cell saver during heart surgery are of GRAM+ bacterial origin, the most isolated species being Staphylococcus epidermidis. Consequently, in order to reduce the presence of these GRAM+ cocci, an antibiotic should be added to the cell saver reservoir, according to a previously established protocol.

Objetivo: determinar as características microbiológicas dos glóbulos vermelhos obtidos com o "cell saver" em pacientes submetidos à cirurgia cardíaca em circuito extracorpóreo. Método: estudo descritivo transversal com 358 pacientes de cirurgia cardíaca em que o "cell saver" foi utilizado. Foram coletadas variáveis sociodemográficas e identificação microbiana da bolsa de reinfusão do "cell saver". Foi confirmado o Termo de Consentimento. Resultados: das 170 baterias isoladas GRAM+, as mais frequentes foram Staphylococcus epidermidis em 69% (n=138) dos casos e Streptococcus sanguinis com um registro de 10% (n=20). Diferenças significativas foram encontradas na cepa Staphylococcus epidermidis em pacientes com índice de massa corporal ≥25 (p=0,002) submetidos a cirurgia valvular (p=0,001). A vancomicina foi o antimicrobiano resistente à cepa Staphylococcus epidermidis com uma concentração inibitória mínima >16 µg/ml. Conclusão: as características microbiológicas dos glóbulos vermelhos obtidas após o processamento do sangue autólogo recuperado com o "cell saver" em cirurgia cardíaca são de origem bacteriana GRAM+, sendo a espécie mais isolada o Staphylococcus epidermidis. Portanto, para reduzir a presença desses cocos GRAM+, um antibiótico deve ser adicionado ao "cell saver", de acordo com um protocolo previamente estabelecido.

Objetivo: determinar las características microbiológicas de los glóbulos rojos obtenidos con el "cell saver" en el paciente de cirugía cardíaca bajo un circuito extracorpóreo. Método: estudio descriptivo transversal con 358 pacientes programados para cirugía cardíaca donde se utilizó el "cell saver". Se recogieron variables sociodemográficas e identificación microbiana de la bolsa de reinfusión procedente del "cell saver". Consentimiento informado realizado. Resultados: de 170 aislamientos de bacterias GRAM+, las especies más frecuentes fueron el Staphylococcus epidermidis en el 69% (n=138) de los casos y el Streptococcus sanguinis con un reporte del 10% (n=20). Se encontraron diferencias significativas en la cepa Staphylococcus epidermidis en pacientes con índice de masa corporal ≥25 (p=0,002) sometidos a cirugía valvular (p=0,001). La vancomicina fue el antimicrobiano resistente a la cepa Staphylococcus epidermidis con una concentración mínima inhibitoria >16 ug/ml. Conclusión: las características microbiológicas de los glóbulos rojos obtenidos tras el procesamiento de sangre autóloga recuperada con el "cell saver" en cirugía cardíaca son de origen bacteriano GRAM+ siendo la especie más aislada el Staphylococcus epidermidis. Por ello, con el fin de reducir la presencia de estos cocos GRAM+ se debería añadir un antibiótico en el reservorio del "cell saver", según un protocolo previamente establecido.

Clinical Application of Preoperative Autologous Blood Donation in Selective General Surgery / 中国实验血液学杂志

OBJECTIVE@#To study the clinical effects of preoperative autologous blood donation (PABD) in selective general surgery.@*METHODS@#Paired study was performed in PABD group with 70 PABD cases screened from selective general surgery during the period from November 2017 to August 2018 in our hospital, and the control group included 70 cases without preoperative autologous blood donation, the baseline data before surgery were not significantly different. The transfusion quantities of allogeneic RBC and plasma, the levels of perioperative hemoglobin and platelets, the time and expense of hospitalization were compared between two groups.@*RESULTS@#The levels of Hb and Plt in PABD group before and after blood collection were determined as follows: 138.26±14.73 g/L vs 127.52±13.36 g/L (P＜0.05) and (221.67±52.86)×10/L vs (198.35±52.65)×10/L (P＞0.05) respectively. The analysis of allo-RBC and allo-plasma transfusion in PABD group and control group showed that: the quantity of allogeneic RBC transfusion was 0.20±0.71 U and 0.89±0.97 U, and the quantity of allogeneic plasma transfusion was 30.43±100.81 ml and 106.52±152.61 ml (P＜0.05) respectirdy during perioperation. The comparison results of preoperative Hb and plt in PABD group and control group were 135.65±14.16 g/L vs 134.15±11.98 g/L and (270.36±58.28)×10/L vs (271.67±65.02) ×10/L respectively. The levels of postoperative Hb and plt in PABD group and control group were 120.24±14.40 g/L vs 121.20±14.30 g/L at 1 d after operation, and (241.80±63.58)×10/L vs (241.30±69.11)×10/L at 1 d after operation respectively; 123.15±13.80 g/L vs 121.65±14.33 g/L at 3 d after operation and (251.26±72.94)×10/L vs (255.54±73.85)×10/L at 3 d after operation; 122.78±13.92 g/L and 122.00±13.82 g/L (before discharge) and (262.50±80.96)×10/L and (264.56±71.08)×10/L (before discharge, platelet). These data were not statistically different (P＞0.05). The hospitalization time was 14.84±3.37 days and 14.84±2.24 days, respectively, without statistical difference (P＞0.05) in two groups. The expenses of hospitalization and the blood transfusion in two groups were 50627.27±9889.45 RMB and 50979.43±8195.00 RMB; 354.39±362.57 RMB and 684.02±425.53 RMB (P＜0.05).@*CONCLUSION@#The application of PABD reduces the use of allogeneic blood and costs for patients undergoing selective surgery with blood losts of 1000 ml.

Autotransfusão imediata em cão - relato de caso / Instant autotransfusion in dog - case report

As hemorragias podem levar à morte, em caso de não interrupção e recuperação da volemia. A substituição do sangue pode ser realizada por transfusão homóloga ou autóloga. Na transfusão homóloga, o sangue é obtido de um doador, na autotransfusão ou transfusão autóloga, o sangue é coletado do próprio paciente. Objetivou-se relatar a autotransfusão em um cão como um método simples, rápido e barato, e discutir esse procedimento como uma alternativa emergencial para clínicas e hospitais que não possuem bancos de sangue ou animais doadores. Foi atendido um cão Rottweiler fêmea, 42,8kg, 10 anos de idade, com queixa principal de tumor mamário e para realização de castração. Após o procedimento, a paciente apresentou hemoperitônio, sendo encaminhada para novo procedimento cirúrgico, durante o qual se observou grande quantidade de sangue livre na cavidade abdominal. Foi realizada a autotransfusão de emergência, pela técnica das duas seringas, devido à indi1111sponibilidade de sangue ou animal doador no momento do procedimento cirúrgico emergencial, demonstrando ser uma opção eficiente, econômica, de fácil acesso e segura, por ser uma transfusão normotérmica, apresentar diminuição do risco de sobrecarga circulatória e por ser o sangue compatível, devendo ser mais explorada, pois existem poucos dados descritos na literatura.(AU)

Hemorrhages can lead to death in case of non-interruption and recovery of blood volume. Blood replacement may be performed by homologous or autologous transfusion. In homologous transfusion, blood is obtained from a donor, in autotransfusion or autologous transfusion, blood is collected from the patient himself. We aimed to report autotransfusion in a dog as a simple, quick, and inexpensive method, and discuss it as an emergency alternative for clinics and hospitals that do not have blood banks or animal donors. A female Rottweiler dog, 42.8kg, 10 years of age, was treated with a primary complaint of mammary tumor and for castration. After the procedure the patient presented hemoperitoneum, being referred to a new surgical procedure, where a large amount of free blood was observed in the abdominal cavity. The emergency autotransfusion was performed by the two syringes technique, due to the unavailability of blood or donor animal at the time of the emergency surgical procedure, proving to be an efficient, economical, easily accessible and safe option because it is a normothermic transfusion, risk of circulatory overload and blood is compatible. It should be more exploited because there are few data described in the literature.(AU)

Acute Normovolemic Hemodilution in Spinal Deformity Surgery / Hemodiluição normovolêmica aguda em cirurgias de deformidade da coluna

Abstract Objective To prospectively compare the clinical and laboratorial aspects of patients undergoing spine deformity surgery, using the acute normovolemic hemodilution technique with tranexamic acid, versus a control group with tranexamic acid alone, and to evaluate the influence of hemodilution in intraoperative bleeding and the need for homologous transfusion. Materials and Methods Comparative prospective study with patients aged between 12 and 65 years undergoing spine deformity surgery with the acute normovolemic hemodilution technique associated with tranexamic acid versus a control group to which only tranexamic acid (15 mg/kg) was administered. Laboratorial exams were performed and analyzed in three different moments. Results A total of 30 patients were included in the present study: 17 in the hemodilution group, and 13 in the control group. The mean duration of the surgery in the hemodilution group was longer. The number of levels submitted to surgery ranged from 7 to 16 in the hemodilution group, and from 4 to 13 in the control group. Osteotomy, predominantly of the posterior kind, was performed in 20 patients. There was more intraoperative bleeding in the control group. All patients were stable during the procedures. Only 6 participants needed homologous blood transfusion, mostly from the control group (p > 0.05). Conclusion There was no significant difference between the two groups regarding the need for blood transfusion and intraoperative bleeding. The severity of the deformity was the main determinant for homologous blood transfusion.

Resumo Objetivo Comparar de modo prospectivo os parâmetros clínicos e laboratoriais dos pacientes submetidos a hemodiluição normovolêmica aguda associada ao ácido tranexâmico com um grupo de controle que recebeu apenas ácido tranexâmico, durante cirurgia de correção de deformidades da coluna, e avaliar a influência da técnica de hemodiluição no sangramento perioperatório e a necessidade de transfusão de sangue homólogo. Materiais e Métodos Estudo prospectivo comparativo, com pacientes entre 12 e 65 anos submetidos a cirurgia para correção de deformidades da coluna vertebral, com a técnica de hemodiluição normovolêmica aguda associada ao ácido tranexâmico, versus grupo de controle com ácido tranexâmico isolado na dose de 15 mg/kg. Exames laboratoriais foram feitos e analisados em três momentos de avaliação diferentes. Resultados Participaram deste estudo 30 pacientes: 17 no grupo de hemodiluição e 13 no grupo de controle. O tempo médio de cirurgia foi maior para o grupo de hemodiluição. O número de níveis operados variou entre 7 e 16 no grupo de hemodiluição, e entre 4 e 13 no grupo de controle. Fez-se osteotomia, predominantemente posterior, em 20 pacientes. O valor médio de sangramento intraoperatório foi maior no grupo de controle. Os parâmetros clínicos se mantiveram estáveis durante todos os procedimentos. Apenas 6 pacientes necessitaram de transfusão sanguínea homóloga, a maioria dos quais pertencia ao grupo de controle (p > 0,05). Conclusão Não houve diferença significativa entre os dois grupos quanto à necessidade de transfusão e sangramento intraoperatório. A gravidade da deformidade foi o principal fator determinante da transfusão.

Is Intraoperative Blood Cell Salvage Effective in Hip Surgery? / A recuperação intraoperatória de células sanguíneas é eficaz em cirurgias de quadril?

Abstract Objective The present study aims to evaluate the efficacy of blood cell salvage (CS) as a method of reducing allogeneic blood transfusion in patients submitted to transtrochanteric femoral and hip surgeries due to injury. Methods Prospective cohort of 38 patients froma school hospital submitted to hip or trochanteric surgeries and divided into two groups from August 2015 to February 2017. Patients with any malignancy or infectious condition were excluded from the study. Cell savage group (19 patients) received autologous blood using cell saver, whereas control group (19 patients) received just allogeneic blood, if needed. Red blood cell parameters, blood transfusion requirements, and clinical and surgical characteristics, such as age, gender, ASA scale and type of surgery, were compared both preoperatively and postoperatively. Data was processed in SPSS 20.0. Results There were no differences in the clinical parameters studied (age, gender and ASA scale). Red blood cell parameters on the first day postoperative were higher in the cell savage group (p < 0.05). No significant reduction of intraoperative and postoperative allogeneic blood transfusion requirements was found. Conclusion This study found that CS was not effective in reducing intraoperative and postoperative allogeneic blood transfusion requirements in patients submitted to transtrochanteric femoral and hip surgery.

Resumo Objetivo O estudo visa avaliar a eficácia da recuperação intraoperatória de sangue (RIOS) na redução de hemotransfusão alogênica em pacientes submetidos à cirurgia por fratura de fêmur e quadril. Métodos Coorte prospectiva com 38 pacientes submetidos a cirurgia traumatológica para fraturas em quadril e transtrocantéricas de fêmur, divididos em dois grupos em um hospital de ensino de agosto de 2015 a fevereiro de 2017. Pacientes com qualquer enfermidade ou condição infecciosa foram excluídos do presente estudo. O grupo RIOS (19 pacientes) recebeu sangue autólogo com a utilização de Cell Saver, enquanto o grupo controle (19 pacientes) recebeu apenas sangue alogênico, quando necessário.. Grupos comparados em relação ao gênero, idade na cirurgia, escala da Sociedade Americana de Anestesiologistas (ASA) (I, II ou III), uso intraoperatório da RIOS, volume sanguíneo reinfundido pela RIOS, parâmetros hematimétricos pré- e pósoperatórios, volume intra e pós-operatório de sangue alogênico transfundido. Dados processados no software SPSS Statistics for Windows, Versão 20.0 (IBM Corp, Armonk, NY, EUA). Resultados Sem diferenças significativas entre os grupos com as variáveis: idade, gênero e ASA. Percebeu-se que os valores finais de hemoglobina e hematócrito (no 1° dia de pós-operatório) foram mais elevados no grupo que utilizou o dispositivo (p < 0,05). Não houve redução significativa da transfusão alogênica intra e pósoperatória no grupo RIOS em comparação ao controle. Conclusões O presente estudo constatou que a RIOS não foi eficaz em reduzir a transfusão alogênica no intra e pós-operatório de pacientes submetidos à cirurgia de fêmur transtrocantérica e de quadril.

Medicina y Cirugía sin Sangre La Experiencia de Solca Guayaquil / Medicine and Surgery without Blood The Experience of Solca Guayaquil

Introducción: Los riesgos asociados con las Transfusiones de Sangre Alogénicas (TSA) son ampliamente conocidos y han contribuido a nuevos paradigmas de tratamiento para la medicina y cirugía sin sangre. Por tanto, es importante contar con estrategias terapéuticas efectivas y prácticas que sirvan como alternativas al uso de TSA. Este informe describirá las estrategias aplicadas a los pacientes de este reporte. Métodos: Estudio retrospectivo descriptivo de alternativas a la TSA utilizadas en SOLCA Guayaquil con pacientes que no aceptaron TSA bajo ninguna circunstancia, entre los años 2011 y 2017. La estrategia terapéutica se basó en un diagnóstico temprano y un tratamiento agresivo de la anemia y cualquier tipo de sangrado activo. Se utilizó eritropoyetina, hierro y folato, según requerimientos del paciente. Todos los pacientes quirúrgicos recibieron ácido tranexámico y otros hemostáticos tópicos según necesidad. Resultados: De 73 pacientes oncológicos, el 68.5 % eran no quirúrgicos, de este grupo el 62 % recibió quimioterapia. La hemoglobina aumentó hasta 12.6 g/dL. Por tratamiento global por paciente se administraron hasta 3000 mg de hierro, 140.000 unds de eritropoyetina y megadosis de vitamina C fue aplicada con una media de 24 gramos. Todos los pacientes aumentaron sus niveles de hemoglobina en un promedio de 25 días. Conclusión: Es esencial iniciar un tratamiento temprano, preventivo y coordinado con un equipo multidisciplinario comprometido a estos esquemas. Los pacientes respondieron bien a los medicamentos y las dosis recibidas y no se informaron efectos secundarios. También podemos ver que estas estrategias son efectivas y factibles de aplicar.

Introduction: Risks associated with the Allogeneic Blood Transfusions (ABT) are widely known and have contributed to new treatment paradigms for bloodless medicine and surgery. Therefore, it is essential to have effective therapeutic strategies that serve as alternatives to ABTs. This report describes the strategies applied to patients in this paper. Methods: A Retrospective descriptive study of ABT alternatives used in SOLCA Guayaquil with patients who did not accept ABTs under any circumstances, between 2011 and 2017. The therapeutic strategy was an early diagnosis and an aggressive treatment of anemia and any active bleeding. Erythropoietin, iron, and folate were applied, according to the patient's requirements. All surgical patients received tranexamic acid and other hemostatics as needed. Results: Of 73 cancer patients, 68.5% were non-surgical, 62% of the group received chemotherapy. For global treatment per patient, up to 3000 mg of iron was administered, 140,000 units of erythropoietin and megadoses of vitamin C were applied with an average of 24 grams. All patients increased their hemoglobin levels by an average of 25 days. All patients increased their hemoglobin levels by an average of 25 days. Conclusion: It is essential to start early treatment, prevent and coordinate with a multidisciplinary team committed to these schemes. The patients responded well to the medications, and the doses received, and no side effects were reported. We can also see that these strategies are practical and feasible to apply.

Clinical Efficacy of Intra-Operative Cell Salvage System in Major Spinal Deformity Surgery

OBJECTIVE: The purpose of this study was to determine the efficacy of intra-operative cell salvage system (ICS) to decrease the need for allogeneic transfusions in patients undergoing major spinal deformity surgeries.METHODS: A total of 113 consecutive patients undergoing long level posterior spinal segmental instrumented fusion (≥5 levels) for spinal deformity correction were enrolled. Data including the osteotomy status, the number of fused segments, estimated blood loss, intra-operative transfusion amount by ICS (Cell Saver®, Haemonetics©, Baltimore, MA, USA) or allogeneic blood, postoperative transfusion amount, and operative time were collected and analyzed.RESULTS: The number of patients was 81 in ICS group and 32 in non-ICS group. There were no significant differences in demographic data and comorbidities between the groups. Autotransfusion by ICS system was performed in 53 patients out of 81 in the ICS group (65.4%) and the amount of transfused blood by ICS was 226.7 mL in ICS group. The mean intra-operative allogeneic blood transfusion requirement was significantly lower in the ICS group than non-ICS group (2.0 vs. 2.9 units, p=0.033). The regression coefficient of ICS use was -1.036.CONCLUSION: ICS use could decrease the need for intra-operative allogeneic blood transfusion. Specifically, the use of ICS may reduce about one unit amount of allogeneic transfusion in major spinal deformity surgery.

Clinical Efficacy of Intra-Operative Cell Salvage System in Major Spinal Deformity Surgery

OBJECTIVE: The purpose of this study was to determine the efficacy of intra-operative cell salvage system (ICS) to decrease the need for allogeneic transfusions in patients undergoing major spinal deformity surgeries. METHODS: A total of 113 consecutive patients undergoing long level posterior spinal segmental instrumented fusion (≥5 levels) for spinal deformity correction were enrolled. Data including the osteotomy status, the number of fused segments, estimated blood loss, intra-operative transfusion amount by ICS (Cell Saver®, Haemonetics©, Baltimore, MA, USA) or allogeneic blood, postoperative transfusion amount, and operative time were collected and analyzed.

Impact of autologous whole blood administration upon experimental mouse models of acute Trypanosoma cruzi infection

Background: Autologous whole blood (AWB) administration is described as alternative/complementary medical practice widely employed in medical and veterinary therapy against infections, chronic pathologies and neoplasias. Our aim is to investigate in vivo biological effect of AWB using healthy murine models under the course of Trypanosoma cruzi acute infection. Methods: The first set of studies consisted of injecting different volumes of AWB and saline (SAL) into the posterior region of quadriceps muscle of healthy male Swiss mice under distinct therapeutic schemes evaluating: animal behavior, body and organ weight, hemogram, plasmatic biochemical markers for tissue damage and inflammatory cytokine levels and profile. To assess the impact on the experimental T. cruzi infection, different schemes (prior and post infection) and periods of AWB administration (from one up to 10 days) were conducted, also employing heterologous whole blood (HWB) and evaluating plasma cytokine profile. Results: No major adverse events were observed in healthy AWB-treated mice, except gait impairment in animals that received three doses of 20 L AWB in the same hind limb. AWB and SAL triggered an immediate polymorphonuclear response followed by mononuclear infiltrate. Although SAL triggered an inflammatory response, the kinetics and intensity of the histological profile and humoral mediator levels were different from AWB, the latter occurring earlier and more intensely with concomitant elevation of plasma IL-6. Inflammatory peak response of SAL, mainly composed of mononuclear cells with IL-10, was increased at 24 h. According to the mouse model of acute T. cruzi infection, only minor decreases ( 30%) in the parasitemia levels were produced by AWB and HWB given before and after infection, without protecting against mortality. Rises in IFN-gamma, TNF-alpha and...

El recuperador celular y necesidad transfusional en pacientes intervenidos de cirugía cardíaca / The cell saver and the transfusional need in patients undergoing cardiac surgery

Resumen Objetivo Los pacientes intervenidos de cirugía cardíaca presentan riesgo elevado de ser transfundidos con sangre durante el postoperatorio, debido al descenso de sus cifras de hemoglobina y hematocrito. Una de las alternativas a la transfusión sanguínea es el uso del recuperador celular intraquirúrgico. El objetivo de este estudio fue identificar si el uso del recuperador celular intraquirúgico disminuye la tasa transfusional durante el postoperatorio inmediato. También se ven las complicaciones postquirúrgicas inmediatas en ambos grupos. Material y Métodos Estudio analítico, prospectivo con dos cohortes de pacientes distribuidos en grupo control (162) y grupo intervención (162). Se analizarón variables sociodemográficas, de sus diagnósticos y tratamientos quirúrgicos, tiempos de isquemia cardíaca, hemoglobina, hematocrito, transfusión sanguínea y hemorragias, así como variables propias del recuperador celular. Las complicaciones estudiadas fueron; hemoglobinuria, fiebre, náuseas y vómitos. Se obtuvo el consentimiento informado de todos los pacientes y se sometió los datos al paquete estadístico SPSS versión 22.0. Resultados Las cifras de hemoglobina y hematocrito de los pacientes después de ser intervenido quirúrgicamente, fueron diferentes entre los grupos respectivamente (GC, 8,3 g/dL, 22,8%. GI,10,4 g/dL, 31,1%). Coincidiendo que los mayores transfundidos fueron los del grupo control (18,2%) frente al grupo intervención (3,9%). El grupo que presentó mayor complicación fue el grupo intervención (13,6%) que eran los que utilizaron el recuperador celular. Siendo la hemoglobinuria (82%) la mayor complicación. Conclusiones Los pacientes que utilizaron el recuperador celular disminuyeron la necesidad transfusional, sin embargo, fueron los que mayor incidencia de hemoglobinuria padecieron.

Objetive Patients undergoing cardiac surgery are at high risk of being transfused with blood during the postoperative period, due to the decrease in haemoglobin and haematocrit levels. One of the alternatives to blood transfusion is the use of the intraoperative cell saver. The objective of this study was to identify whether the use of the intra-uremic cell saver decreases the transfusional rate during the immediate postoperative period. The immediate postoperative complications were also demonstrated in both groups. Material and Methods Analytical, prospective study with two cohorts of patients distributed in control group (162) and intervention group (162). Sociodemographic variables, their diagnoses and surgical treatments, time of cardiac ischemia, haemoglobin, haematocrit, blood transfusion and haemorrhages, as well as variables specific to the cell saver were analyzed. The complications studied were; haemoglobinuria, fever, nausea and vomiting. The informed consent of all the patients was obtained and the data was submitted to the statistical package SPSS version 22.0. Results The haemoglobin and haematocrit values of patients after surgery were different between groups (GC, 8.3 g/dl, 22.8%, GI, 10.4 g/dl, 31.1 g %). Coinciding that the major transfused were those of the control group (18.2%) versus the intervention group (3.9%). The group that presented the greatest complication was the intervention group (13.6%) who were those who used the cell saver. Hemoglobinuria (82%) being the major complication. Conclusions Patients who used the cell saver decreased the need for transfusion, but were the ones with the highest incidence of hemoglobinuria.

Impact of autologous whole blood administration upon experimental mouse models of acute Trypanosoma cruzi infection

Autologous whole blood (AWB) administration is described as alternative/complementary medical practice widely employed in medical and veterinary therapy against infections, chronic pathologies and neoplasias. Our aim is to investigate in vivo biological effect of AWB using healthy murine models under the course of Trypanosoma cruzi acute infection. Methods: The first set of studies consisted of injecting different volumes of AWB and saline (SAL) into the posterior region of quadriceps muscle of healthy male Swiss mice under distinct therapeutic schemes evaluating: animal behavior, body and organ weight, hemogram, plasmatic biochemical markers for tissue damage and inflammatory cytokine levels and profile. To assess the impact on the experimental T. cruzi infection, different schemes (prior and post infection) and periods of AWB administration (from one up to 10 days) were conducted, also employing heterologous whole blood (HWB) and evaluating plasma cytokine profile. Results: No major adverse events were observed in healthy AWB-treated mice, except gait impairment in animals that received three doses of 20 µL AWB in the same hind limb. AWB and SAL triggered an immediate polymorphonuclear response followed by mononuclear infiltrate. Although SAL triggered an inflammatory response, the kinetics and intensity of the histological profile and humoral mediator levels were different from AWB, the latter occurring earlier and more intensely with concomitant elevation of plasma IL-6. Inflammatory peak response of SAL, mainly composed of mononuclear cells with IL-10, was increased at 24 h. According to the mouse model of acute T. cruzi infection, only minor decreases (< 30%) in the parasitemia levels were produced by AWB and HWB given before and after infection, without protecting against mortality. Rises in IFN-gamma, TNF-alpha and IL-6 were detected at 9 dpi in all infected animals as compared to uninfected mice but only Bz displayed a statistically significant diminution (p= 0.02) in TNF-alpha levels than infected and untreated mice. Conclusions: This study revealed that the use of autologous whole blood (AWB) in the acute model employed was unable to reduce the parasitic load of infected mice, providing only a minor decrease in parasitemia levels (up to 30%) but without protecting against animal mortality. Further in vivo studies will be necessary to elucidate the effective impact of this procedure.(AU)

Perioperative Blood Management: Pros and Cons of ANH and Cell Salvage / 한양의대학술지

Increasingly, autologous blood transfusion has been arousing concern owing to awareness of adverse effects of allogenic blood transfusion, blood shortage and patients, having religious or personal issues. With the development of medicine, Cell Salvage and Acute normovolemic hemodilution (ANH) has been proposed as an alternative to allogenic blood transfusion. This review looked at the use of ANH and cell salvage and evaluated the benefits and usefulness based on the strengths and indications. Although not consistent with all cases of ANH, there were benefits in the amount of hemorrhage and transfusion, and no supplementary plasma or platelet transfusion was needed after surgery when employing ANH. But, it showed a cutoff value only for massive bleeding surgery (at least 500 mL). In the case of cell salvage, the amount of blood transfusion was reduced in most cases and platelet or plasma transfusion was not required in most cases. When the Leukoreduction filter (LDF) was utilized, it showed the effect of removing bacterial infection or tumor cells. Nonetheless, the effectiveness and benefits for patients in certain condition of cell salvage and ANH is ambiguous with discrepancies among studies or patients. Therefore, the aim of this study is to provide clinical knowledge relative to the procedure, measure the efficacy and usefulness of peri-operative blood management mentioned above and discuss the forthcoming prospects and challenges.

Effect of autologous blood transfusion device on preventing blood loss in primary total knee arthroplasty using comprehensive hemostatic methods / 北京大学学报(医学版)

OBJECTIVE@#To analyze the conventional application of using comprehensive hemostatic methods during the perioperative period, and the effect of autologous blood transfusion (ABT) device compared with non-negative pressure drainage on preventing blood loss and allogenic blood transfusion after primary total knee arthroplasty (TKA).@*METHODS@#A total of 131 patients (131 knees) with severe knee osteoarthritis who underwent unilateral primary TKA by the same surgeon in Peking University Third Hospital from June 2014 to June 2015 were enrolled in this study. The patients were divided into ABT group (64 patients) and control group (67 patients). ABT devices were used for drainage and blood transfusion in the ABT group while the control group used the non-negative pressure drainage only. The results of the drainage fluid volume, the decrease of hemoglobin, the total blood loss, the hidden blood loss and blood transfusion after TKA were compared between the two groups.@*RESULTS@#The drainage fluid volume in ABT group was significantly higher than that in control group [515 mL (80-1 610 mL) vs. 260 mL (40-670 mL), P<0.001]. The autologous blood transfusion in ABT group was 245 mL (60-1 070 mL). There were no significant differences between the two groups in the value of hemoglobin decrease 1 day after surgery (P=0.340) and 3 days after surgery (P=0.524). There were no significant differences in the total blood loss (P=0.101) and the hidden blood loss (P=0.062) between the two groups either. There were 9 patients in the 131 patients who received allogeneic blood transfusion, of whom 5 in the ABT group (5/64, the blood transfusion rate was 7.8%) and 4 in the control group (4/67, the blood transfusion rate was 6.0%), and no significant differences in the blood transfusion rate between the two groups (P=0.943).@*CONCLUSION@#With the conventional application of using comprehensive hemostatic methods during perioperative period, the ABT device did not show the effective result of controlling postoperative blood loss and failed to reduce the rate of allogeneic blood transfusion in patients with unilateral primary TKA. However, the ABT device could increase the drainage fluid volume and improve the patient's hospitalization expenses. Therefore, there is no need for routine application of ABT device in unilateral primary TKA.

Efecto del sistema de recuperación de sangre autóloga y transfusiones homólogas en pacientes quirúrgicos de alta complejidad / Effect of homologous transfusions and the autologous blood recovery system in highly complex surgical patients

Introducción: la transfusión autóloga presenta tres modalidades: transfusión autóloga con predepósito, hemodilución preoperatoria (normovolémica o hipervolémica) y el sistema de recuperación de sangre autóloga (cell saver) intraoperatoria o posoperatoria. Objetivo: demostrar la efectividad del uso del sistema de recuperación de sangre autóloga en pacientes quirúrgicos de alta complejidad en el Hospital Alcívar. Método: estudio retrospectivo, no experimental, de observación indirecta, con análisis correlacional. La muestra fue de 112 pacientes intervenidos por afecciones cardiovasculares, ortopédicas y traumatológicas, incluidos según criterios de inclusión y exclusión. Se utilizó cell saver en 56 pacientes, y 56 pacientes utilizaron transfusiones de sangre homóloga. Resultados. el cell saver fue beneficioso en 93 por ciento de los pacientes; la morbilidad y la mortalidad disminuyeron, principalmente en los pacientes intervenidos de cualquier afección cardiovascular y aumentó el índice costo/beneficio, debido a que se priorizaron los recursos económicos. En traumatología y ortopedia no fue muy beneficioso, pues la cantidad de sangre recuperada fluctuó entre 300 y 500 mL en intervenciones convencionales, lo que motivó el uso de hemoderivados y aumentó el costo. En resecciones tumorales e instrumentaciones en diferentes segmentos de la columna vertebral se recuperó hasta 800 mL de sangre, lo que resultó significativo. La tasa de complicaciones fue menor en pacientes que utilizaron cell saver (7 por ciento) frente a los pacientes que utilizaron hemoderivados homólogos (32 por ciento). Se constató una menor estancia hospitalaria en el grupo cell saver (1-20 días) en comparación con los que usaron hemoderivados homólogos (> 10 días, en 5 casos fue mayor 21 días). Conclusiones: el uso de sistema de recuperación de sangre autóloga constituye un procedimiento efectivo para infundir hemoderivados con mayor seguridad(AU)

Introduction: Autologous transfusion has three modalities: autologous transfusion with predeposit, preoperative hemodilution (normovolemic or hypervolemic), and the system for autologous blood recovery (cell saver), whether intraoperative or postoperative. Objective: To show the effectiveness of the use of the autologous blood recovery system in highly complex surgical patients at Alcívar Hospital. Method: Nonexperimental, retrospective study, of indirect observation and with correlational analysis. The sample consisted of 112 patients who underwent surgery for cardiovascular, orthopedic and traumatological conditions, chosen based on inclusion and exclusion criteria. The cell saver system was used in 56 patients and 56 patients used homologous blood transfusions. Results: The cell saver system was beneficial in 93 percent of patients; morbidity and mortality decreased, mainly in patients operated for any cardiovascular condition, while the cost-benefit ratio increased, due to the fact prioritization of economic resources. In traumatology and orthopedics, it was not so beneficial, since the amount of blood recovered fluctuated between 300 and 500 mL in conventional interventions, which motivated the use of blood products and increased the cost. In tumor resections and instrumentation of different spine segments, up to 800 mL of blood were recovered, which was significant. The complication rate was lower in patients who used the cell saver system (7 percent), compared to patients who used homologous blood products (32 percent). A shorter hospital stay was observed in the cell saver group (1-20 days), compared to those who used homologous blood products (over 10 days, while in 5 cases it was over 21 days). Conclusions: The use of the autologous blood recovery system is an effective procedure to infuse blood products with greater safety(AU)

Influence of intraoperative blood salvage on surgery for scoliosis / Influência da recuperação intraoperatória de sangue em cirurgias para escoliose / Influencia de la recuperación intraoperatoria de la sangre en cirugía para la escoliosis

ABSTRACT Objective: To evaluate the effectiveness of intraoperative blood salvage (IBS) in reducing allogeneic transfusion in patients undergoing surgery for scoliosis. Methods: Retrospective case-control study with 69 patients who underwent surgical treatment for scoliosis correction from August 2008 to December 2014 in a teaching hospital. We used the IBS in 43 patients and it was not used in 26. The groups were compared according to the medical records, and the data were processed on SPSS 20.0. For the associations between the variable IBS and non-IBS and the independent variables we applied the χ 2 and the likelihood ratio tests, and the strength of which was calculated by their 95% CI. The means were compared by Student's t and Mann-Whitney tests. The confidence level was 0.05. Results: There were no significant differences between groups with the variables age, sex, preoperative weight, postoperative blood drainage and surgical time. There was a significant reduction of intraoperative allogeneic transfusion in the IBS group submitted to posterior arthrodesis compared with the control group, with no difference in the transfusion of red blood cells between the two groups postoperatively. In the 24 patients who underwent combined arthrodesis, there was no significant difference in allogeneic transfusion in the intra- and postoperative periods between the groups. Conclusion: The system proved to be effective in reducing allogeneic transfusion during surgery in patients undergoing posterior arthrodesis for scoliosis, but it was not effective in reducing allogeneic transfusion in the intra- and postoperative periods of those undergoing combined arthrodesis.

RESUMO Objetivo: Avaliar a eficácia da recuperação intraoperatória de sangue (RIOS) na redução da transfusão alogênica em pacientes submetidos à cirurgia para escoliose. Métodos: Estudo retrospectivo de caso-controle, com 69 pacientes submetidos a tratamento cirúrgico corretivo para escoliose, de agosto de 2008 a dezembro de 2014, em hospital-escola. Utilizou-se a RIOS em 43 pacientes e não foi usada em 26. Os grupos foram comparados conforme os prontuários, e os dados foram processados no SPSS 20.0. Nas associações entre a variável RIOS e não-RIOS e as variáveis independentes aplicaram-se os testes do χ2 e de razão de verossimilhança, sendo a força dessas calculada pelo seu IC de 95%. As médias foram comparadas pelos testes t de Student e de Mann-Whitney. O nível de confiança foi 0,05. Resultados: Não houve diferenças significativas entre os grupos com as variáveis idade, sexo, peso pré-operatório, drenagem sanguínea pós-operatória e tempo cirúrgico. Evidenciou-se redução significativa da transfusão alogênica intraoperatória no grupo RIOS submetido à artrodese posterior em comparação com o grupo-controle, sem diferença na transfusão de concentrado de hemácias entre os dois grupos no pós-operatório. Nos 24 pacientes submetidos à artrodese combinada, não houve diferença significativa na transfusão alogênica no intra e no pós-operatório entre os grupos. Conclusão: O sistema revelou-se eficaz em reduzir a transfusão alogênica no intraoperatório de pacientes submetidos à artrodese posterior para escoliose, mas não foi eficaz em reduzir a transfusão alogênica no intra e no pós-operatório daqueles submetidos à artrodese por via combinada.

RESUMEN Objetivo: Evaluar la eficacia de la recuperación de sangre intraoperatoria (RSI) en la reducción de la transfusión alogénica en pacientes sometidos a cirugía para la escoliosis. Métodos: Estudio retrospectivo de casos y controles, con 69 pacientes sometidos a cirugía correctora de la escoliosis, entre agosto de 2008 y diciembre de 2014 en un hospital universitario. Se utilizó la RSI en 43 pacientes y no se utilizó en 26. Los grupos se compararon según los datos de los registros médicos y los datos fueron procesados en el programa SPSS 20.0. En las asociaciones entre la variable RSI y no-RSI y las variables independientes se aplicaron las pruebas de χ2 y la razón de verosimilitud, siendo la fuerza de éstas calculada por su IC de 95%. Los promedios se compararon mediante la pruebas de la t de Student y de Mann-Whitney. El nivel de confianza fue de 0,05. Resultados: No se observaron diferencias significativas entre los grupos en las variables edad, sexo, peso preoperatorio, drenaje de sangre postoperatoria y tiempo quirúrgico. Se mostró una reducción significativa de la transfusión alogénica durante la cirugía en el grupo RSI sometido a la artrodesis posterior en comparación con el grupo de control, sin diferencia en la transfusión de células rojas de la sangre entre los dos grupos después de la operación. En los 24 pacientes que se sometieron a la artrodesis combinada, no hubo diferencia significativa en la transfusión alogénica en el intra y postoperatorio entre los grupos. Conclusión: El sistema ha demostrado su eficacia en la reducción de la transfusión alogénica durante la cirugía en pacientes sometidos a artrodesis posterior para la escoliosis, pero no fue efectivo en la reducción de la transfusión alogénica en el intra y postoperatorio en los que se sometieron a la artrodesis por vía combinada.