Cost of red blood cell transfusion; evaluation in a French academic hospital.

OBJECTIVES: The economic impact of Patient blood management (PBM) must be assessed beyond the acquisition cost of blood products alone. The estimate of indirect costs may vary depending on the organization and the elements taken into account. The transposition of data from the literature into a specific local context is therefore delicate. The objective of this work was to evaluate the overall cost of red blood cell concentrate (RBC) transfusion from a French healthcare establishment point of view. METHODS: We carried out an activity based costing analysis in our hospital for the year 2018. The steps of the transfusion process and additional costs were detailed and cumulated (resource consumption, labor time, frequency) to populate the ABC model. Several scenarios were developed focusing either on RBC, all blood products or the surgical activity, and a univariate sensitivity analysis was conducted. RESULTS: The average total cost of transfusion, including acquisition cost, was 339,64 euros per RBC transfused. The cost of administration was 138.41 euros/RBC. Focusing only on surgical activities increased this cost (152.43 euros) while taking all blood products into account reduced it (92.49 euros). CONCLUSION: The difference in our results with the literature confirms the local variability in the cost of transfusion, which may affect the economic impact of PBM. Our study related to the specific context of a single French institution has limitations that a multicenter study would clarify in order to carry out economic modelling of transfusion optimization and alternatives and to guide the choice of PBM strategies at the national level.

[High-flow nasal oxygen for severe hypoxemia after cardiac surgery]. / Oxygénation nasale à haut débit pour hypoxémie après chirurgie cardiaque.

OBJECTIVES: High-flow nasal oxygen (Optiflow™) is validated in paediatric intensive care but not in adults' patients for severe hypoxemia. The aim of this study was to evaluate this oxygen system delivery in adults' patients for postoperative hypoxemia after cardiac surgery. STUDY DESIGN: Prospective, open study for evaluation of medical practice. PATIENTS AND METHODS: Patients operated upon for cardiac surgery with immediate postoperative hypoxemia characterized by SpO(2) <0.96 with 50% oxygen with a Venturi mask were treated with the high-flow nasal oxygen system (O group) when it was available or with the classical high-flow oxygen face mask (M group). Gas exchanges were measured at the end of the surgery, at the beginning of the treatment and 1 hour, 6 hours after the inclusion and at day 1 and 2 post-treatment. Parameters studied were: duration of hypoxemia, duration of ICU stay, postoperative pneumonia occurrence, requirement of re-intubation, non invasive ventilation and catecholamine. Tolerance was evaluated with measurement of pain (visual scale), satisfaction (visual scale), and dryness of mouth. RESULTS: Forty patients were included, 19 in group O, 21 in group M. Patient's characteristics did not differ between the two groups before treatment. There were no significant differences between groups for duration of hypoxemia (3.8±2.2 days in O group versus 4.3±2.3 days in M group), duration of hypoxemia, duration of ICU stay, postoperative pneumonia occurrence, requirement of re-intubation, non invasive ventilation and catecholamine. Pain was not significantly different between groups, satisfaction was better (P<0.001) and mouth drier (P<0.001) in group O than in group M. CONCLUSION: These results give good arguments for an improvement in gas exchange and better tolerance of high-flow nasal oxygen (Optiflow™) versus classical high-flow oxygen face mask in postoperative cardiac patients. These results must be confirmed by a randomised study with a larger population.

[Intra-aortic balloon pumping and heparin-induced thrombocytopenia]. / Contre-pulsion par ballonnet intra-aortique et thrombopénie induite par l'héparine non fractionnée.

Thrombocytopenia is frequently reported in the presence of intra-aortic balloon pumping (IABP) after cardiac surgery and in cardiology, but heparin-induced thrombocytopenia (HIT) is rarely responsible of it in this circumstance. A case-report if HIT in a patient with IABP is presented. This case emphasised the difficulty in diagnosis of HIT in this situation. An acute decrease in platelet count lasting after removal of IABP could suggest the diagnosis of HIT when other origins for thrombocytopenia are excluded.

[Body mass index and albuminemia in patients under mechanical circulatory assistance before cardiac transplantation]. / Indice de masse corporelle et albuminémie péri-implantatoires de patients sous assistance circulatoire mécanique (ACM) en attente d'une transplantation cardiaque.

OBJECTIVE: To evaluate the prognostic influence of peri-implantation nutritional status of patients under mechanical circulatory assist (MCA) prior to cardiac transplantation (CT). STUDY DESIGN: Retrospective analysis of patients with cardiogenic shock included from June 1997 to December 2002. PATIENTS AND METHODS: Evaluation at MCA's implantation, at day (D) 30 and at CT or patient's death (D) of body mass index (BMI=body weight (kg)/size (m(2)), albuminemia (Alb g/l), expressed as median values (med) and range (min-max). Odds ratio (OR) and CI 95%) were calculated. A multivariate analysis was performed to determine variables related to D or CT success. RESULTS: Thirty-four patients (30 men), median age 40.5 years (10-63), were included. MCA types were cardiac pumps (N=3); pneumatic (N=18) or electric (N=5) ventricular assist devices and artificial heart (N=8). Global mortality was 56% (19 over 34 patients) and at implantation in the global population (N=34) BMI was 19.4 (9.3-28.1) and Alb 24.6 g/l (15-37.5). At MCA's implantation and D30 respectively, 38 and 42% of the patients had a severe hypoAlb (Alb<30 g/l) and a BMI<19 attesting of a seriously deteriorated nutritional status. No significant statistical difference was observed on median BMI of transplanted patients T (N=15) and expired patients D (N=19). Alb was significantly different (p<10(-4)) between T and D patients: median Alb: 30 g/l (20-37.5) in T patients, 20 g/l (15-31) in D patients. HypoAlb<21 g/l was an independent prognostic factor of death (p=0.004; OR: 0.541; IC95% : 0.36-0.82) and Alb>33 g/l an independent prognostic factor of CT success (p=0.003; OR:1.38; IC95% : 1.12-1.71). CONCLUSION: These results seem to demonstrate that at MCA implantation, a seriously deteriorated albuminemia level (<30 g/l) negatively impacts patients overall survival after CT.

[Posterior reversible encephalopathy syndrome: about 2 cases related to the cyclosporine]. / Syndrome d'encéphalopathie postérieure réversible: à propos de 2 cas liés à la ciclosporine.

Following a pulmonary transplantation for cystic fibrosis, 2 patients exhibited a syndrome associating arterial hypertension, headache, visual trouble and generalized seizures. Cerebral magnetic resonance imaging revealed diffuse cortical and subcortical lesions predominantly in posterior regions. The exclusion of alternate diagnoses and the disappearance of the symptoms when the cyclosporine treatment was stopped confirmed the diagnosis of cyclosporine-related reversible posterior encephalopathy syndrome (PRES). Immediate appropriate management resulted in symptom disappearance and regression of radiological images.

[Effects of plasma substitutes on hemostasis]. / Effets des solutés de remplissage vasculaire sur l'hémostase.

OBJECTIVE: Data synthesis on haemostasis effects of cristalloids and colloids and clinical implications for their use for plasma volume replacement. DATA SOURCES: Data were searched in the Medline database from 1954 to 2000 using the following key-words: cristalloids, colloids, albumin, gelatin, dextran, hydroxyethyl starch, haemostasis, von Willebrand disease, haemodilution. DATA EXTRACTION: Publications from 1954 to 1990 were selected depending on the quality of their methodology. Most of articles published after 1990 and all types including case report were accepted. DATA SYNTHESIS: Cristalloids induces a moderate hypercoagulable state with 10 to 30% haemodilution. Hypocoagulation is observed above 50% haemodilution. Albumin does not impair hemostasis except with a 50% or more haemodilution where hypocoagulation is observed. Dextran dramatically impairs haemostasis and fibrinolysis. With increasing dose, a progressive decrease of all von Willebrand multimers, mostly the largest, is observed. Till 50% haemodilution, gelatin has a moderate impact on hemostasis, but platelet aggregation is moderately modified. However this moderate impairment of haemostasis may potentiate the haemostatic effect of other colloids when used in association with gelatin. More than 30% haemodilution with hydroxyethyl starch (HES) has a serious effect in vitro on platelet function and fibrinoformation. In most studies in human, less than 20 ml.kg-1 plasma volume replacement has no clinical impact, but in some evaluations postoperative bleeding is more important with HES, particularly HES 450, in comparison to other colloids. With HES 450 and HES 200 highly substituted (0.6 of degree of substitution) intravascular cumulation of large molecules leads to type I von Willebrand syndrome when doses overtake 80 ml.kg-1. Dextran and HES are prohibited in patients with impaired haemostasis due to congenital disease (haemophilia and von Willebrand disease) or acquired defect (thrombocytopenia). Caution is required in patients with renal failure or receiving antithrombotic or non-steroidal anti-inflammatory agents. Patients without a haemorrhagic diathesis must not received more than 1.5 g.kg-1.j-1 of dextran and restrictive conditions of use must be respected with HES. CONCLUSION: Except isotonic cristalloids, all colloids induce haemostastic changes particularly for haemodilution over 30%. Effects are more pronounced with HES and dextran.

[Hyperchloremic acidosis druing plasma volume replacement]. / Acidose hyperchlorémique lors du remplissage vasculaire.

OBJECTIVES: Review of the physiological and clinical consequences of hyperchloraemic acidosis observed during plasma volume replacement using crystalloids and colloids. DATA SOURCES: Data were searched in the Medline database after 1990 using the following key words: metabolic acidosis, crystalloids, colloids, albumin, gelatin, hydroxyethyl starch. DATA EXTRACTION: Publications before 1990 were selected for their historical value. Most of articles published after 1990 and all types including case report were accepted. DATA SYNTHESIS: Large volume infusion of isotonic solution can cause hyperchloraemic acidosis. Colloid plasma substitutes using saline solvent may be responsible for the same kind of acidosis with acidaemia. The anion gap is not modified in this case because of chloride increase. Physiological mechanism may be described using the Henderson-Hasselbach equation or the strong ion difference decrease (Stewart concept). Excessive chloride infusion is a major factor in this acid-base disorder and the term hyperchloraemic acidosis should be preferred to dilutional acidosis. When perioperative acidosis occurs, careful and complete analysis of acid-base disturbance should be made. The association of a normal anion gap, normal lactatemia, hyperchloraemia and acidaemia does not need specific treatment. Acidosis corrects spontaneously and slowly following chloride normalization. But any factor that may increase acidosis should be avoided. CONCLUSION: The use of balanced solution like lactated-Ringer solution instead of isotonic saline solution for fluid resuscitation, except for specific contra-indication as intracranial hypertension, may avoid hyperchloraemic acidosis. Potential risk of this acidosis led to the conception of a new colloid using balanced crystalloids solution as the solvent (Hextend).

Transesophageal echocardiography diagnosis of tricuspid obstruction by a vena cava tumour.

PURPOSE: To present the anesthetic management for excision of a primary tumour of the inferior vena cava. CLINICAL FEATURES: Resection of a primary tumour of the inferior vena cava without extension to the right atrium was scheduled without extra-corporeal circulation (ECC). The operation consisted of tumour excision with transtumoral clamping. During the immediate postoperative period, tricuspid obstruction was suspected when a "cannon a wave" was recorded from the right atrial pressure curve. Transesophageal echocardiography confirmed the diagnosis of tumour obstruction of the tricuspid valve. CONCLUSION: Tricuspid obstruction due to postoperative mobilization of a primary tumour of the inferior vena cava was diagnosed by transesophageal echocardiography. Perioperative management particularities of the primary tumour of the vena cava are discussed.

Postoperative analgesia by epidural methylprednisolone after posterolateral thoracotomy.

The aim of this study was to evaluate the potential analgesic effect of epidural methylprednisolone (MP) after posterolateral thoracotomy (PLT). Adult male patients undergoing PLT for lung surgery were included in a prospective, randomized, double blind study. Peroperative analgesia (bupivacaine plus sufentanil) was given by a thoracic epidural catheter associated with general anaesthesia. After surgery, patients received either MP 1 mg kg(-1) followed by a continuous epidural infusion of MP 1.5 mg kg(-1) during 48 h (MP group) or 0.9% saline as a bolus injection and continuous epidural infusion (P group). Additional morphine analgesia was administered by i.v. patient-controlled analgesia. Pain was assessed at rest and with mobilization every 4 h after operation during 48 h with a visual analogue scale (VAS). The primary end-point was the total morphine requirements during the 48 first postoperative hour. Twenty-four patients were allocated to MP (n=12) and P (n=12) groups. Characteristics of the two groups were similar. There were no differences between groups for morphine requirements (median and interquartile range) during the 48 h: 59 mg (40-78) in MP group vs 65 mg (59-93) in P group. There were no differences between groups for morphine requirements every 4 h during the 48 h and VAS for pain at rest and evoked pain. No side effects were reported. It was concluded in this small study that these results did not support the use of epidural steroids for postoperative analgesia after PLT.

[Post-traumatic hematoma of the esophagus]. / Hématome post-traumatique de l'oesophage.

A 20-year-old man was admitted after a traffic accident for a closed chest trauma. Initial evaluation showed a sternal fracture with a minor pneumomediastinum. Twenty-four hours later be experienced an acute respiratory failure, due to total left pulmonary atelectasis from indirect compression of the left main stem bronchus. Mediastinal widening at the postero-superior level was visualized by CT scan. The aortogram was normal. Thoracotomy showed a moderate left haemothorax, associated with an intramural haematoma of the low thoracic oesophagus which was respected. The time course was uneventful, except repetitive atelectases treated by fibrescopic aspiration. Oesophageal haematoma secondary to chest trauma is a rare injury, with around 10 cases reported in the literature. Compression of tracheobronchial axis is exceptional. Because of the delayed occurrence of such a complication after chest trauma, with sternal fracture, close clinical surveillance and CT scans are essential.