Efficacy of preoperative autologous blood donation in free TRAM flap breast reconstruction.

BACKGROUND: The authors critically evaluated the use of autologous blood donation in patients who had surgical breast reconstruction using the free transverse rectus abdominis musculocutaneous (fTRAM) flap technique following mastectomy. METHODS: A retrospective chart review of 201 patients was performed. Patients were operated on at one community hospital and one university hospital. Cohorts of 101 blood donors and 100 control nondonors were established. Demographic and premorbid factors and primary outcome variables were evaluated. RESULTS: The autologous donor and nondonor groups were not statistically different in any demographic categories, and there were no significant differences in premorbid factors between the two groups. Total surgical complications were more common in the autologous donor group (48 percent versus 28 percent; p < 0.004). The autologous donor group was also more likely to receive a transfusion intraoperatively (13 percent versus 0 percent, p < 0.001) or postoperatively (28 percent versus 5 percent, p < 0.001) compared with the nondonor group. CONCLUSIONS: Few patients in the nondonor group required perioperative transfusion, and fewer than half of the donors received their blood back. There was a statistically significant higher rate of surgical complications associated with autologous blood donation, most likely due to relative preoperative anemia. Autologous donation was associated with a significantly higher rate of transfusion intraoperatively and postoperatively. The authors do not recommend autologous blood donation before free TRAM flap autogenous breast reconstruction.

Nonsynostotic occipital plagiocephaly: factors impacting onset, treatment, and outcomes.

BACKGROUND: Nonsynostotic occipital plagiocephaly remains a diagnosis of concern in infancy. This study evaluates factors affecting the onset, treatment, and outcomes of nonsynostotic occipital plagiocephaly. METHODS: A retrospective chart review and telephone survey were performed. A posterior occipital deformation severity score was used. Factors such as demographics, behavioral and helmet therapy, feeding patterns, torticollis, multiple gestation pregnancies, prematurity, and congenital nonsynostotic occipital plagiocephaly were evaluated. RESULTS: One hundred five infants were identified. Of these, 95 percent were Caucasian, 93 percent were from two-parent households, and 70 percent were from households earning more than $50,000. Repositioning was attempted in 95 percent, and 45 percent progressed to helmet therapy. When comparing change in posterior occipital deformation severity score with helmet therapy to repositioning, a difference was found (p < 0.05). Forty-nine percent of patients were breast-fed, and when compared with the general population, a difference was found (p < 0.05). Twenty percent of infants had torticollis, and when compared with population norms, a difference was found (p < 0.05). Twelve percent of patients were twins, and when compared with population norms, more twinning occurred (p < 0.05). Congenital nonsynostotic occipital plagiocephaly was found in 10 percent of patients and did not result in an increased risk of progression to helmet therapy. CONCLUSIONS: This study demonstrates trends that may predict additional risks for developing nonsynostotic occipital plagiocephaly, including torticollis, plural births, and increased socioeconomic affluence. In addition, the nonsynostotic occipital plagiocephaly cohort was breast-fed less than the general population, demonstrating that breast-feeding may be preventative, as breast-fed infants are repositioned more frequently and sleep for shorter periods. As in other studies, cranial molding helmet therapy was more effective in correcting nonsynostotic occipital plagiocephaly than repositioning alone.

Transfusion-free pediatric burn surgery: techniques and strategies.

More than 1.3 million children sustain burns each year, resulting in 40,000 admissions and more than 3000 pediatric deaths. Pediatric burn surgery has been described as excessively bloody. Strategies to reduce intraoperative blood loss include the use of topical thrombin and epinephrine, extremity tourniquets, acute normovolemic hemodilution, and hypotensive anesthesia. This study reviews the single surgeon pediatric burn experience at a children's hospital and describes a comprehensive blood conservation protocol to achieve transfusion-free pediatric burn surgery. A retrospective chart review of consecutive pediatric burn surgeries from July 2000 to April 2002 was performed. Patient demographics, burn characteristics, treatment, blood loss, laboratory values, transfusion history, and complications were reviewed. Blood loss per percent total body surface area (TBSA) treated as well as percent total blood volume (TBV) loss divided by percent TBSA treated were calculated. A total 31 burn surgeries in 23 patients were reviewed. The average age was 7 years (range, 9 months-17 years). There were 17 extremity, 6 trunk, and 2 head/neck burns. The average TBSA burned was 15% (range, 1-55%). The protocol to reduce intraoperative blood loss consisted of the debridement of full-thickness burns with electrocautery and partial-thickness burns with dermabrasion. All debrided or harvested surgical sites were treated immediately with epinephrine solution-soaked pads. All graft harvest sites were injected with an epinephrine solution before harvesting split-thickness skin grafts. The average TBSA treated per surgery was 7% (range, 1-29%). The average blood loss per percent TBSA treated was 15 mL (range, 0.7-37 mL). The average percent TBV/percent TBSA was 0.76% (range, 0.04-3.6%). All 20 patients underwent surgical debridement, 7 patients were treated with AlloDerm and ultrathin split-thickness skin grafts, 2 with full-thickness skin grafts, and 17 with split-thickness skin grafts alone. Five children required blood transfusions. These burns averaged 32% TBSA (range, 20-55%). All 5 children receiving transfusions had anemia of thermal injury and demonstrated an average preoperative drop in hematocrit of 12% (range, 10-14%). There was a 29% complication rate, with 7 patients experiencing partial graft loss, and 1 patient who developed a postgraft contracture that required revisional surgery. There was a single mortality secondary to systemic inflammatory response syndrome and acute respiratory distress syndrome. After the proposed pediatric burn treatment protocol, intraoperative blood loss requiring transfusion can be minimized or eliminated. Large TBSA burns must be surveilled for burn wound anemia that may ultimately require blood transfusion.