Overcoming challenges in managing a high-risk pregnancy with placenta previa and newly diagnosed Bombay phenotype.

BACKGROUND: Bombay phenotype is rare and characterized by a lack of H antigen on the surface of red blood cells (RBCs) with naturally occurring anti-H antibodies. The presence of anti-H necessitates the exclusive use of Bombay phenotype RBCs for transfusion. We present a case of a pregnant woman with Bombay phenotype who required urgent cesarean section delivery due to high-risk placenta previa. CASE DESCRIPTION: A 36-year-old G1P0 woman of Indian origin presented at 36 weeks and 4 days gestation for management of a high-risk pregnancy with complete placenta previa. Bombay phenotype was unexpectedly identified on routine testing. Given the rarity of the blood, advanced gestation, and risk of post-partum hemorrhage associated with complete placenta previa and spontaneous labor, prompt strategic planning commenced for a successful delivery. Two frozen allogeneic Bombay phenotype RBCs were available as part of a concise transfusion plan. Intraoperative cell salvage was successfully employed and allogeneic transfusion was not required. CONCLUSION: Management of patients with rare blood types can be extremely challenging and guidance for those presenting later in pregnancy is scarce. Our patient's gestational age precluded the use of well-known effective strategies, including hemoglobin optimization, autologous and directed donation, and procurement of large quantities of rare blood. Rather, our approach utilized multidisciplinary expertise and strategic planning to yield a successful outcome.

Retrograde Autologous Priming in Cardiac Surgery: Results From a Systematic Review and Meta-analysis.

BACKGROUND: Retrograde autologous priming (RAP) before cardiopulmonary bypass (CPB) may minimize allogeneic red cell transfusion. We conducted a systematic review of the literature to examine the impact of RAP on perioperative allogeneic red cell transfusions in cardiac surgical patients. METHODS: This study involved a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies evaluating the use of RAP in cardiac surgery involving CPB. The primary outcome was intraoperative allogeneic red cell transfusion. Secondary outcomes included whole hospital allogeneic transfusions and adverse events such as acute kidney injury (AKI) and stroke. RESULTS: A total of 11 RCTs (n = 1337 patients) were included, comparing RAP patients (n = 674) to control (n = 663). In addition, 10 observational studies (n = 2327) were included, comparing RAP patients (n = 1257) to control (n = 1070). Overall, RAP was associated with a significantly reduced incidence of intraoperative red cell transfusion (n = 18 studies; odds ratio [OR] = 0.34; 95% confidence interval [CI], 0.22-0.55, P < .001) compared to controls. This effect was seen among RCTs (n = 10 studies; OR = 0.19; 95% CI, 0.08-0.45, P < .001) and observational studies (n = 8 studies; OR = 0.66; 95% CI, 0.50-0.87, P = .004) in isolation. RAP was also associated with a significantly reduced incidence of whole hospital red cell transfusion (n = 5 studies; OR = 0.28; 95% CI, 0.19-0.41, P < .001). Among the studies that reported AKI and stroke outcomes, there was no statistically significant increased odds of AKI or stroke in either RAP or control patients. CONCLUSIONS: Based on the pooled results of the available literature, RAP is associated with a significant reduction in intraoperative and whole hospital allogeneic red cell transfusion. Use of RAP may prevent hemodilution of cardiac surgical patients and thus, lessen transfusions. Additional high-quality prospective studies are necessary to determine the ideal priming volume necessary to confer the greatest benefit without incurring organ injury.

Impact of Preoperative Erythropoietin on Allogeneic Blood Transfusions in Surgical Patients: Results From a Systematic Review and Meta-analysis.

BACKGROUND: Erythropoietic-stimulating agents such as erythropoietin have been used as part of patient blood management programs to reduce or even avoid the use of allogeneic blood transfusions. We review the literature to evaluate the effect of preoperative erythropoietin use on the risk of exposure to perioperative allogeneic blood transfusions. METHODS: The study involved a systematic review and meta-analysis of randomized controlled trials evaluating the use of preoperative erythropoietin. The primary outcome was the reported incidence of allogeneic red blood cell transfusions during inpatient hospitalizations. Secondary outcomes included phase-specific allogeneic red blood cell transfusions (ie, intraoperative, postoperative), intraoperative estimated blood loss, perioperative hemoglobin levels, length of stay, and thromboembolic events. RESULTS: A total of 32 randomized controlled trials (n = 4750 patients) were included, comparing preoperative erythropoietin (n = 2482 patients) to placebo (n = 2268 patients). Preoperative erythropoietin is associated with a significant decrease in incidence of allogeneic blood transfusions among all patients (n = 28 studies; risk ratio, 0.59; 95% CI, 0.47-0.73; P < .001) as well as patients undergoing cardiac (n = 9 studies; risk ratio, 0.55; 95% CI, 0.37-0.81; P = .003) and elective orthopedic (n = 5 studies; risk ratio, 0.36; 95% CI, 0.28-0.46; P < .001) surgery compared to placebo, respectively. Preoperative erythropoietin was also associated with fewer phase-specific red blood cell transfusions. There was no difference between groups in incidence of thromboembolic events (n = 28 studies; risk ratio, 1.02; 95% CI, 0.78-1.33; P = .68). CONCLUSIONS: Preoperative erythropoietin is associated with a significant reduction in perioperative allogeneic blood transfusions. This finding is also confirmed among the subset of patients undergoing cardiac and orthopedic surgery. Furthermore, our study demonstrates no significant increase in risk of thromboembolic complications with preoperative erythropoietin administration.

Risk factors and prediction model for inpatient surgical site infection after major abdominal surgery.

BACKGROUND: Surgical site infections (SSIs) are a common source of postoperative morbidity and a marker of surgical quality. The ability to predict the incidence of SSIs is limited and most models have poor predictive value. We sought to identify risk factors associated with SSIs and develop a prediction model for SSIs after major abdominal surgery. METHODS: A total of 1744 patients undergoing pancreatic, hepatobiliary, and colorectal resections between January 1, 2010 and August 31, 2013 at Johns Hopkins Hospital were identified. Risk factors for any inpatient SSI (superficial and deep) were evaluated using multivariable logistic regression. RESULTS: Median patient age was 58 y (interquartile range 47, 68); surgical procedures included colorectal (59.0%), liver (26.2%), and pancreas (14.8%) resections. SSI occurred in 7.6% (n = 132) of patients. Factors associated with SSI included preoperative weight loss >4.5 kg (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.06-4.25), emergency operations (OR, 2.05; 95% CI, 1.32-3.17), and colorectal resections (OR, 1.65; 95% CI, 1.13-2.43) (all P ≤ 0.003). Intraoperative and postoperative risk factors included estimated blood loss (EBL) >600 mL (OR, 2.23; 95% CI, 1.54-3.25), maximum respiratory rate (tachypnea) >20 breaths/min (OR, 1.74; 95% CI, 1.19-2.54), and perioperative transfusion (OR, 2.01; 95% CI, 1.33-3.04) (all P = 0.001). Intraoperative hypothermia, hyperthermia, bradycardia, tachycardia, hypotension, and hypertension were not associated with SSIs (all P > 0.05). After controlling competing risk factors, transfusion, EBL >600 mL, tachypnea, and colorectal resection were independently associated with SSIs (all P < 0.003). On the basis of the beta-coefficients in the multivariable model, an SSI scoring system was created by assigning 2 points for EBL >600 mL, 2 points for a colorectal resection, 3 points for tachypnea, and 3 points for a transfusion. The model showed good discriminatory ability to predict SSI (c-statistic = 0.7232; Akaike information criterion 875.37). CONCLUSIONS: A novel, simple 10-point SSI scoring system that incorporated perioperative risk factors such as blood transfusion, EBL, tachypnea, and the type of surgical procedure accurately stratifies patients according to SSI risk.

Anesthetic Management of Pheochromocytoma Resection in Adults with Single Ventricle Physiology.

Survival rates for patients with palliated congenital heart disease are increasing, and an increasing number of adults with cyanotic congenital heart disease (CCHD) might require surgical resection of pheochromocytoma-paraganglioma (PHEO-PGL). A recent study supports the idea that patients with a history of CCHD and current or historical cyanosis might be at increased risk for developing PHEO-PGL. We review the anesthetic management of two adults with single-ventricle physiology following Fontan palliation presenting for PHEO-PGL resection and review prior published case reports. We found the use of epidural analgesia to be safe and effective in the operative and postoperative management of our patients.