Platelet-rich plasma sequestration, with therapeutic platelet yields, reduces allogeneic transfusion in complex cardiac surgery.

UNLABELLED: Platelet dysfunction is the most common cause of nonsurgical bleeding after cardiopulmonary bypass (CPB). We hypothesized that reinfusion of a therapeutic quantity of platelets sequestered before CPB would decrease the need for allogeneic platelet transfusion, as well as decrease bleeding and total allogeneic transfusion, in cardiac surgery patients at moderately high risk for bleeding. Fifty-five patients undergoing either reoperative coronary artery bypass (CABG) or combined CABG and valve replacement were randomized to control or platelet-rich plasma sequestration (pheresis) groups. All patients received intraoperative epsilon-aminocaproic acid infusions. There was no significant difference between groups with respect to preoperative characteristics, duration of CPB, or target postoperative hematocrit. Mean platelet yields were 6.2 +/- 2.1 units (3.1 x 10(11) platelets). Mean pheresis time was 44 min. Allogeneic platelets (range = 6-12 units) were transfused to 28% of control patients, compared with 0% of pheresis patients (P < 0.01). Allogeneic packed red blood cells were transfused to 45% of control patients (1.2 units per patient) versus 31% of pheresis patients (0. 7 unit per patient) (P = 0.35). Total allogeneic units transfused were significantly reduced in the pheresis group (P < 0.02). Mediastinal chest tube drainage was not significantly decreased in the pheresis group. In this prospective, randomized study, therapeutic platelet yields were obtained before CPB. In contrast with recent studies with low platelet yields, these data support the conclusion that platelet-rich plasma sequestration is effective in reducing allogeneic platelet transfusions and total allogeneic units transfused in cardiac surgery patients at moderately high risk for post-CPB coagulopathy and bleeding. IMPLICATIONS: Transfusion of allogeneic blood products, including platelets, is common during complex cardiac surgical procedures. In the present prospective, randomized study, a significant reduction in allogeneic platelet transfusion and total allogeneic units transfused was observed after the reinfusion of a therapeutic quantity of autologous platelets sequestered before cardiopulmonary bypass.

Pharmacy-initiated introduction of patient-controlled analgesia to a 400-bed community hospital.

The pharmacist's role in the implementation of patient-controlled analgesia (PCA) in a 400-bed community hospital is described. PCA for postoperative patients was introduced on the recommendation of the pharmacy and therapeutics committee. A subcommittee selected a PCA pump, developed a physician order form and patient monitoring sheet, and in March 1987 initiated a two-month pilot study of PCA therapy in orthopedic-surgery patients. An orthopedic-service pharmacist developed an inservice-education program for the physicians, anesthesiologists, and nurses involved in the care of these patients. Because of the support of anesthesiologists for this program, PCA use during the two-month period rapidly expanded beyond orthopedics to include general and genitourinary-gynecologic patients. Nursing staff demand for PCA inservice education became so great that all staff pharmacists participated in the teaching. Pharmacists in the decentralized areas also provided one-on-one instruction to physicians, nurses, and patients. Positive evaluations of PCA therapy by patients and nurses and favorable patient pain assessment scores, in addition to the hospital-wide acceptance and use of PCA by medical staff, indicated that the program was a success. Active pharmacist participation was a major factor in PCA being well accepted by physicians, nurses, and patients as an effective alternative method of narcotic administration.