Structure of delay in carotid surgery--an observational study.

OBJECTIVES AND DESIGN: Undelayed investigation and surgical treatment of symptomatic carotid artery stenosis are recommended as per guidelines on stroke prevention. We evaluated patient referral pathways and delays from symptom to surgery in Helsinki University Central Hospital (HUCH) region. MATERIALS AND METHODS: One hundred consecutive symptomatic patients scheduled for carotid endarterectomy (CEA) between August 2007 and September 2008 were identified and the delay between ischaemic index symptom and CEA was analysed. RESULTS: The median time from the index symptom to surgery was 47 days (range: 3-688 days). The longest delay was surgery related with a median of 25 days (range: 2-202 days) from the consultation of the vascular surgeon to the operation. Only 11% of the patients were operated within the recommended 2 weeks' time. It was more likely that CEA was performed within 2 weeks if an emergent consultation to Meilahti Hospital neurologist on call did take place (odds ratio (OR) 12.6, 95% confidence interval (CI) 1.5-104, p = 0.019). CONCLUSION: Delays from symptom to surgery were generally too long and the in-hospital door-to-knife time (DKT) was long mostly due to waiting for the operation theatre. The investigation of all stroke, amaurosis fugax and transient ischaemic attack patients should be performed on an emergency basis and most optimally centralised to hospitals were carotid surgery is performed.

Platelet transfusions in adult patients with particular reference to patients undergoing surgery.

Descriptive information on platelet (PLT) recipients, particularly during surgery, is limited. A description of the current epidemiology of PLT-transfused patients is required to optimize platelet transfusion care and to follow trends in PLT use. In 2004 and 2005, information was combined from several computerized medical systems. Participating hospitals (9 hospital districts of 21) handled approximately 64% of annual Finnish hospital admissions. A total of 6321 adult patients were transfused with 37,761 PLT products. Most PLT products (43.1%) were transfused to patients suffering from haematological malignancies. Only 1.0% of all surgical patients received PLTs (53.8% of PLT recipients and 35.8% of transfused PLTs). The most common single operation connected with PLT transfusion was coronary artery bypass while 27.1% of surgery-related PLTs were given to patients having an operation involving the digestive system or spleen. Only 36.4% of all PLT-transfused (operated and conservatively treated) patients were discharged directly home; in-hospital mortality was 9.5%. PLTs were given 40 products per 1000 hospital admissions requiring an operation in 2004, and 38 products in 2005. Perioperative PLT use is slightly decreasing in adult patients. As a single-operation type, coronary artery bypass patients receive most of the PLT products and have experienced no decline in PLT use over the years. Overall, PLT recipients have high in-hospital mortality.

Advances in cardiac surgical transfusion practices during the 1990s in a Finnish university hospital.

BACKGROUND AND OBJECTIVES: Recent transfusion practices in coronary artery bypass (CABG) operations in a Finnish university hospital were evaluated, utilizing the data stored automatically in hospital registers. MATERIALS AND METHODS: The register-based transfusion data on all 2363 CABG patients operated on during a 2.5-year period, from 1997 to 1999, were analysed and compared with a review of surgical transfusion practices in Finland from 1993 to 1994. RESULTS: The rate of allogeneic transfusion showed a decrease from 76% in 1993-94 to 48% in the time-period January to June 1999, and the mean number of donor exposures decreased from 3.3 to 2.0 units per patient. The mean blood product purchase costs per patient almost halved from 1993-94 to 1997-99. CONCLUSION: Hospital registers provide a good means for prompt evaluation and reporting of large-scale transfusion data. Since 1993, transfusion rates and costs in CABG operations have decreased markedly. Further development of transfusion registers is warranted.

On-site coagulation monitoring does not affect hemostatic outcome after cardiac surgery.

BACKGROUND: Rapid coagulation tests are now available for monitoring of bleeding patients after cardiac surgery. As inappropriate blood use in these patients may be due to lack of timely coagulation data, we studied the effect of an algorithm with on-line coagulation monitoring on transfusions in these patients. METHODS: Prospectively, patients bleeding (>1.5 ml kg(-1) 15 min(-1)) after cardiac surgery were randomly assigned to two groups: in group A (n=28), hemostatic treatment during the immediate recovery period (1 h after surgery) was based on an algorithm with on-site hemostasis monitoring, whereas during the same period group B patients (n=30) were managed solely according to the clinician's judgement; laboratory tests other than activated clotting time after heparin neutralization were prohibited. RESULTS: Cumulative chest tube drainage up to 16 h and total transfusion requirements did not differ between the groups. Using a platelet transfusion trigger of 100x10(9)/l, significantly more patients received platelets during the immediate recovery period in the algorithm group than in the control group (14 vs. 3 patients, P=0.001). Desmopressin acetate was administered more often in group A than in group B (8 vs. 2 patients, P=0.04). CONCLUSIONS: Algorithm-based therapy increased utilization of hemostatic interventions during the immediate recovery period without any obvious benefit to the hemostatic outcome. Re-evaluation of the platelet transfusion trigger seems warranted.

Transfusion thresholds in common elective surgical procedures in Finland.

BACKGROUND AND OBJECTIVES: Transfusion practices and thresholds in common elective surgical procedures were investigated in a nationwide multicenter survey in Finland. MATERIALS AND METHODS: The records of 764 total hip replacement (THR), 397 total knee replacement (TKR) and 343 transurethral resection of the prostate (TURP) patients were reviewed by four anesthesiologists. RESULTS: The allogeneic red cell (RBC) transfusion rates in THR, TKR and TURP operations were 92, 84 and 18%, respectively. In THR and TKR, 74% of patients who lost 20% or less of their blood volume during hospitalization were transfused with RBCs. Postoperatively, the median pretransfusion hemoglobin values were 9.6 g/dl in orthopedic operations and 10.7 g/dl in TURP. In some hospitals, the median transfusion threshold in TURP patients was as high as 11.2 g/dl. CONCLUSION: The transfusion thresholds in all operations were liberal compared to recent international recommendations. Inappropriate thresholds were reflected in the high transfusion rates. This study accentuates the need for continuous discussion and educational measures to find optimal indications for transfusion in surgery, and to rationalize the transfusion policy in Finland.

Transfusion practices in primary total joint replacements in Finland.

BACKGROUND AND OBJECTIVES: A multicenter survey was carried out in 11 Finnish hospitals to determine the prevailing transfusion practices in orthopedic surgery. MATERIALS AND METHODS: The records of 1,161 patients who had undergone primary total hip (THR) or knee replacement (TKR) were reviewed. RESULTS: Allogeneic red cells (RBC) were administered to 92% of the THR patients and to 84% of the patients undergoing TKR. Significant interhospital variation in RBC transfusion, from 2.4 to 4.1 units per patient in THR and from 1.8 to 2.8 units in TKR, was detected after adjustment for clinical and laboratory findings. CONCLUSION: The use of RBCs in orthopedic surgery was generous compared with reports from other European countries and the US. Each hospital's individual transfusion policy seemed to be a strong determinant of allogeneic blood use.