Guidelines for the transfusion of red cells.

The following recommendations, which aim at standardising and rationalising clinical indications for the transfusion of red cells in Belgium, were drawn up by a working group of the Superior Health Council. To this end, the Superior Health Council organised an expert meeting devoted to "Guidelines for the transfusion of red cells" in collaboration with the Belgian Hematological Society. The experts discussed the indications for red cell transfusions, the ideal red cell concentrate, the practical issues of administering red cells, and red cell transfusions in patients in a critical condition. The recommendations formulated by the experts were validated by the working group with the purpose of harmonising red cell transfusion in Belgian hospitals.

Autologous blood donation before myocardial revascularization: a Holter-electrocardiographic analysis.

The influence of preoperative autologous blood donation on myocardial ischemia and arrhythmias was evaluated in 24 patients scheduled for coronary artery bypass grafting (CABG). All had a Holter recorder placed 24 hours before predonation (day 1), the cassette was changed prior to donation, and the recording continued for 24 hours thereafter (day 2). Each patient served as his or her own control, and observations made on day 2 were compared with those of day 1. Ischemia was quantitated by calculating the duration (C.Dur.) and the area (C. Area) of ischemic ST segment depressions, and ventricular premature beats (VPB) were classified according to the Lown grading system. Twenty-one men and 3 women were monitored. On day 1, 9 patients had 20 ischemic events, 3 being symptomatic. Nine patients demonstrated ischemia on day 2, representing a total of 3 symptomatic and 26 silent events. When comparing the two monitoring periods, 7 patients had longer or more severe ST segment depression whereas 6 other patients presented with more severe VPBs on day 2. Three patients had less ischemia on day 2, one remained stable, and 13 had no ischemia throughout the study. Silent ischemia was significantly more prolonged (C.Dur.Sil 316 v 152 sec, P < 0.05) and more intense (C. Area Sil 8 v 3.8 mm.min, P < 0.05) on day 2. Moreover, on top of a normal circadian distribution of ischemic events in the morning and in the evening, 40% of events were related to the donation or to a trip to the hospital. No preoperative characteristic helped to detect patients at risk.(ABSTRACT TRUNCATED AT 250 WORDS)

The SANGUIS Study in Belgium: an overview of methods and results. Safe and good use of blood in surgery.

SANGUIS was multicentric European study involving more than 7,000 patients in 43 teaching hospitals during a one year period. The goal of the study was to describe current transfusion practice for elective surgery in adult. The present paper summarizes the data collected on the 1,193 patients enrolled in Belgium. It also introduces the final report of the SANGUIS study in Belgium, which will be published as a special issue of the Acta Chirurgica Belgica.

Bedside transfusion errors. A prospective survey by the Belgium SAnGUIS Group.

The true incidence of bedside transfusion errors, i.e. those happening when blood products have left the blood bank, is underestimated because published figures rely on reporting of clinically relevant events or on indirect methods. The SAnGUIS project assessing blood practice in a prospective and randomized fashion for 6 elective surgical procedures gave the opportunity to trace all transfused units and to identify steps at risk during blood delivery in surgery. We considered transfusion of a wrong unit as a major error and poor execution or documentation as a recording error. Over 15 months, 808 patients out of 1,448 were transfused with 3,485 units. A total of 165 errors were found after blood products had left the blood banks. Seven were misidentifications (0.74% of patients, 0.2% of units). Eight other major errors occurred in 4 (0.5%) patients. Major errors occurred during nonemergency situations, in wards or intensive care units. The remaining ('recording') 150 errors consisted of misrecordings (61), mislabellings (6), or failures to document transfusions in the medical records (83). All errors were uneventful except one misidentification which induced a transient, yet unreported, reaction. The 'descending' inquiry method used for this study showed that most errors pass unnoticed and are therefore not reported. Measurement of error rates may constitute an important quality indicator. Retrospective information of this survey to the concerned staff people provided an impetus to take adequate measures to reduce these bedside errors.

Systematic use of aprotinin in cardiac surgery: influence on total homologous exposure and hospital cost.

To assess the impact of systematic use of aprotinin, 115 consecutive adults undergoing cardiac surgery were randomly allocated with a sealed envelope technique. Treated (T) patients (n = 58) received 2.10(6) Kallikrein Inactivating Units (KIU) before incision, 2.10(6) prior to bypass, and 5.10(5) KIU.hr-1 for 5 hrs, whereas control (C) cases (n = 57) received nothing. Surgeons, perfusionists, ICU and ward physicians were blinded. Postoperative blood loss decreased from 1198 ml (C) to 698 ml (T) (p less than 0.001). Total transfusional needs were 7.25 (C) and 4.9 (T) units (p less than 0.01), where from 65% were autologous in group T, versus 51% in group C (p less than 0.02). Total homologous exposure decreased from 4.5 (C) to 2.7 (T) units on the average, from 3 to 1 units as a median (p less than 0.01). Multiple Stepwise Regression Analysis showed treatment as the most important variable influencing postoperative blood loss, but duration and type of procedures were more important to explain transfusion needs. Both groups were comparable for other pre- and intra-operative variables. For coronary operations (n = 75), aprotinin showed the strongest negative association with blood loss, the number of arterial conduits being the second influencing variable. No evidence was found for increased early graft thrombosis. The average hospital bill was 9% lower in the treated group, an unexplained finding needing independent confirmation.

Mortality and morbidity conferences in a teaching anesthesia department.

In our anesthesia department, Morbidity and Mortality conferences (M & M's) evolved from a well established system of voluntary reporting of anesthesia related incidents. They were however not restricted to accidents solely attributable to anesthesia. Between May 1983 and December 1989, 160 cases were presented, usually by the resident or consultant in charge of the patient at the time of event. The format of conferences is described in detail in this paper. Despite an active selection process, the case mix of presentations closely reflected that of major epidemiological surveys of complications in anesthesia. Residents attending regularly M & M's during the five years of their specialty training got an accurate picture of anesthesia-related mishaps, their mechanisms of onset and their outcome. In particular, the important role played by human intervention was clearly underlined. Due to the selection process, interaction with other physicians or health professionals were described with great frequency in the genesis of accidents anesthetists had to deal with. M & M's proved a valuable teaching tool, but also contributed to improve patient care by revealing faulty routines.

Dissecting aneurysm of the ascending aorta with aorto-caval fistula. Fiberoptic oximetric findings and surgical management.

A patient presented the rare complication of a dissecting aneurysm of the ascending aorta ruptured into the superior vena cava producing a left-right fistula. Continuous oximetric measurements by a fiberoptic pulmonary artery floated catheter was used to localize the site of the shunt. Emergency surgical repair was successfully performed.

Insertion of pulmonary artery catheters--a comparison of fiberoptic and nonfiberoptic catheters.

Fiberoptic (FO) pulmonary artery catheters were compared prospectively to the conventional type to observe the degree of insertion difficulty, the rate of complications, and the amount of technical faults. The inclusion of fiberoptic bundles in pulmonary artery catheters potentially altered their stiffness, thus influencing their passage from the central venous system to the pulmonary artery. Records were kept on the insertion of 287 consecutive pulmonary artery catheters, 44 of which contained fiberoptics for the continuous measurement of mixed-venous oxygen saturation ( SvO2 ). Results showed that the FO catheter was similar to the nonfiberoptic ( NFO ) model and could thus serve as an alternative to the conventional catheter when continuous monitoring of SvO2 was indicated.

Continuous monitoring of mixed venous oxygen saturation in critically ill patients.

A new pulmonary artery balloon flow-directed catheter combines a fiberoptic photometric system for continuous display of mixed venous blood oxygen saturation (SvO2) with the capacity for hemodynamic measurements including thermodilution cardiac output estimation. This oximetry system was studied to determine its accuracy, reliability, and usefulness in the surgical intensive care unit (ICU). Twenty-two catheters were tested, but only 17 were successfully placed in 16 patients. There were technical problems associated with 10 catheters and on six occasions these necessitated the use of another catheter. The catheter values for SvO2 were closely related (r = 0.9516) to those obtained from a laboratory Co-oximeter. Continuous monitoring of SvO2 is accurate and valuable as a warning system for deterioration in cardiopulmonary function and as an indicator of the effects of various therapeutic maneuvers in critically ill patients.

Central neurogenic hyperventilation in an awake patient with brainstem astrocytoma.

A patient had the rare combination of central neurogenic hyperventilation (PaCO2 of 9 torr) and a normal level of consciousness for eight days. Morphine attenuated but never corrected the hyperventilation. Experimental effects of hypocapnia, which decreases both cerebral blood flow and metabolism in humans, are at odds with the normal mentation initially seen in this patient despite her marked and persistent hypocapnia. Death occurred after progressive brainstem dysfunction. Pathological study showed a well-differentiated astrocytoma involving primarily the medulla and pons, with scattered tumor foci throughout the entire neuraxis. Possible mechanisms for central neurogenic hyperventilation are discussed briefly in relation to the pathological findings and the observed response to morphine.