Autotransfusion in the postoperative orthopedic patient.

Transfusion of autologous blood has become increasingly important as an alternative to the use of conventional allogeneic products. Some areas of autotransfusion, like predeposit and intraoperative salvage, are well standardized and generally recommended by physicians. In many orthopedic surgical procedures, the postoperative drainage constitutes a significant percentage of the total perioperative blood loss. Recently, reinfusion of this salvaged, unprocessed autologous blood has been widely advocated; however, reports on its quality are infrequent in the literature. This pilot study, based on sophisticated laboratory testing, describes an efficient method whereby postoperatively shed blood can be appropriately processed and returned to the patient as a relatively safe product.

Priapism associated with asplenic state.

Priapism may be primary (idiopathic) or secondary to sickle cell anemia, trauma, leukemia, drugs, venous thromboembolic diseases, and other less common disorders. This study concerns 21 patients with priapism treated during a period of ten years. Nine patients (43%) had sickle cell anemia. Of the 12 individuals (57%) classified as idiopathic, 3 (25%) had previously undergone surgical splenectomy for benign conditions. Considering the propensity for this unusual condition to develop in patients with hemoglobinopathy-induced hyposplenism, the possibility of a relationship between the asplenic state and priapism is considered.

Hb Mizuho or alpha 2 beta (2)68(E12)Leu----Pro in a Caucasian boy with high levels of Hb F; identification by sequencing of amplified DNA.

Hb Mizuho, an unstable beta chain variant with a Leu----Pro substitution at position beta 68, was observed in a young Caucasian boy from Kentucky. Identification was made by sequence analyses of amplified DNA and by hybridization of amplified DNA with specific probes. The patient had high Hb F levels up to the present age of nearly 5 years; this high Hb F might in part be responsible for his condition which was considerably milder than that seen in the two patients described in earlier reports. The increased gamma chain synthesis may be due to special characteristics of the beta-globin gene cistron which are comparable to those observed in sickle cell anemia patients with a relatively mild disease.

Hemoglobin C in association with hereditary persistence of fetal hemoglobin.

Hemoglobin C and hereditary persistence of fetal hemoglobin (HPFH) are an uncommon combination of hemoglobinopathies. Several tests are needed to verify this condition, among them hemoglobin electrophoresis and Kleihauer-Betke staining of a peripheral blood smear. Family studies are useful in delineating the genetics of the hemoglobinopathy but could not be performed in our case. In more confusing cases or with an unusual subtype, more extensive testing may be required. HPFH, by itself, is without clinical manifestations. It may be confused with other conditions; therefore, its presence in patients with hematologic symptoms requires more precise definition of the hemoglobin abnormality.

Value of the preoperative history as an indicator of hemostatic disorders.

Eighty-three general surgical patients completed the standardized bleeding history questionnaire, and screening tests of platelet counts, prothrombin times, partial thromboplastin times, and Ivy bleeding times were done on these patients. Fifty-two per cent had undergone previous operation; 25% described symptoms of potential hemostatic disorders and seven per cent had positive family histories. Laboratory results indicated abnormalities in five patients (6%). The bleeding history is an important part of the preoperative evaluation of a patient, but it can have serious false-negative results. This history should guide the selection of laboratory tests. Such testing can yield an unexpectedly high rate of abnormalities. When identified, these abnormalities require further investigation.

Intraoperative autotransfusion. Experience in 725 consecutive cases.

Autologous intraoperative transfusion employing the Haemonetics Cell Saver is reported in 725 patients from a general hospital population, of which 75% were cardiovascular patients. The remaining cases included various orthopedic procedures, splenectomy, craniotomy, ectopic pregnancies, Caesarian sections, and exploratory laparotomy. On occasion, this method was utilized in trauma and in pediatric surgery. The product of washed red blood cells gave an average yield of 573 cc per case with an average hematocrit of 55 cc/dl available for autologous infusion. In 100 consecutive open heart procedures operated prior to the Cell Saver period, an average of 1.97 units of bank blood was utilized during operation, as compared with 0.75 units in 100 consecutive cases studied employing the Cell Saver (p less than 0.0001). Homologous blood utilization during cardiac surgery declined more than 50% with the use of the Cell Saver. Quality control was monitored scrupulously and included special precautions against air embolism, abnormal coagulation, and sepsis. The overall mortality rate was 2.8%, and in no instance was mortality or morbidity ascribable to the autologous transfusion. Numerous advantages offered by autotransfusion include prevention of sensitization of the recipient to various antigens in donor erythrocytes, leucocytes, platelets, and plasma, and avoidance of transfusion-transmitted diseases, especially viral hepatitis. Additionally, autologous blood, the only perfectly compatible product, provided immediate availability while conserving blood bank resources. In circumstances in which the intraoperative blood loss exceeded 1000 cc in the adult, its use was observed to be cost-effective. In the present study, autotransfusion proved safe, efficient, and in some instances life saving.

Clinical assessment of three hemoglobin screening programs on a selected population.

Through three related programs, 9,675 individuals were screened for hemoglobinopathy. The studied population was predominantly black (58%) and male (91%). Identified were 333 variants (3.4%), 90.7% of them in blacks. Two hundred occurred in hospitalized patients. Laboratory results were entered in medical charts in all but three instances. Annotation of the abnormality by a physician in the progress notes, discharge summary, or final coded diagnosis was made in 14.4% of the reviewed records. This included 46.7% of 15 patients with clinically manifested disease related to the hemoglobinopathy.

Red cell exchange in the pregnancy complicated by a major hemoglobinopathy.

A new method of partial erythrocyte exchange for pregnancies complicated by a major hemoglobinopathy is described. The Haemonetics 30 Cell Separator allows efficient withdrawal and discard of the patient's erythrocytes. The patient's leukocytes, platelets, and plasma are conserved and returned with washed, compatible donor red cells which contain Hb AA. Three pregnant black women with significant hemoglobinopathies were treated by this modality during their pregnancies. Vaginal term deliveries were accomplished in each case. The method offers advantages in the efficiency of blood quantity displacement, patient comfort, adaptability to the patient with severe anemia, and the use of outpatient facilities. The method is suggested for use whenever a patient with an obstetrically significant hemoglobin variant needs transfusions of erythocytes.

Immunoglobulins and hyposensitization for allergy.

The premise that protracted stimulation of the human immune system might be involved in the induction of malignant immunocytopathies is scrutinized. Studies of the serum immunoglobulins of 313 patients who had been hyposensitized for allergy are compared with those of 138 nonallergic and 189 allergic individuals not subjected to this therapy. Critical historical data in all groups are also evaluated. The investigators concluded that, as far as the parameters studied, there were significant differences in the mean total immunoglobulin G levels in allergic hyposensitized persons compared with the non-allergic control group. It involved a depression of the serum IgG concentration and related to the length of the desensitization program and to whether it was continuous or interrupted. One evolving monoclonal immunocytopathy, etiology of which has not been established, was encountered during the period of study.

The bone marrow biopsy, osteoscan, and peripheral blood in non-hematopoietic cancer.

Bone marrow biopsies were obtained from the iliac crests of 101 male patients with unresectable cancers of non-hematopoietic origin. Tumor cells were identified in 31% of the biopsies. Bone scintophotography studies were performed on 67 patients with positive or suspicious scans reported in 67%. Abnormal peripheral blood smears were encountered in 51% of 100 patients. Histologically established marrow metastases associated with a positive osteoscan and an abnormal peripheral smear occurred in 8% of the patients. The association of either one of the latter two with a positive histologic specimen was observed in about one-half of the patients. The significance of these associations is discussed.

Hemoglobin Louisville (beta-42 (CD1) phe-leu): an unstable variant causing mild hemolytic anemia.

An unstable hemoglobin variant termed Hb Louisville, was found in four members of a Caucasian family, who were suffering from a mild hemolytic anemia. The variant showed a decreased stability upon warming at 65 degrees C and an increased tendency to dissociate in the presence of sulfhydryl group-blocking agents. The structural abnormality was identified as a replacement of phenylalanyl residue in position 42 (CD1) by a leucyl residue. Substitution of this phenylalanyl residue, which participates in the contact with heme, by a nonpolar leucyl residue has apparently less severe consequences than a replacement of the same residue by a polar seryl residue as in Hb Hammersmith. Oxygen equilibrium studies of total hemolysate from one Hb Louisville heterozygote indicated a decreased oxygen affinity, a marked decrease in heme-heme interaction, and a normal Bohr effect. Studies with isolated Hb Louisville were not made because it was not possible to separate the variant from normal Hb A.