Foro de debate: seguridad de las alternativas a la transfusión alogénica en el paciente quirúrgico y/o crítico / Forum for debate: Safety of allogeneic blood transfusion alternatives in the surgical/critically ill patient

Estos últimos años han aparecido alertas de seguridad, no siempre bien sustentadas, que cuestionan el uso de algunas alternativas farmacológicas a la transfusión de sangre alogénica y/o lo restringen en indicaciones establecidas. Asistimos también a la preconización de otras alternativas, incluyendo productos hemáticos y fármacos antifibrinolíticos, sin que haya una base científica sólida que lo justifique. Por iniciativa del Grupo de Estudios Multidisciplinares sobre Autotransfusión y del Anemia Working Group España se reunió a un panel multidisciplinar de 23 expertos del área de cuidados de la salud en un foro de debate para: 1) analizar las diferentes alertas de seguridad en torno a ciertas alternativas a la transfusión; 2) estudiar los antecedentes que las han propiciado, la evidencia que las sustentan y las consecuencias que conllevan para la práctica clínica, y 3) emitir una valoración argumentada de la seguridad de cada alternativa a la transfusión cuestionada, según el uso clínico de la misma. Los integrantes del foro mantuvieron contactos por vía telemática y una reunión presencial en la que presentaron y discutieron las conclusiones sobre cada uno de los elementos examinados. Se elaboró un primer documento que fue sometido a 4 rondas de revisión y actualización hasta alcanzar un consenso, unánime en la mayoría de los casos. Presentamos la versión final del documento, aprobada por todos los miembros del panel, esperando sea de utilidad para nuestros colegas

In recent years, several safety alerts have questioned or restricted the use of some pharmacological alternatives to allogeneic blood transfusion in established indications. In contrast, there seems to be a promotion of other alternatives, based on blood products and/or antifibrinolytic drugs, which lack a solid scientific basis. The Multidisciplinary Autotransfusion Study Group and the Anemia Working Group España convened a multidisciplinary panel of 23 experts belonging to different healthcare areas in a forum for debate to: 1) analyze the different safety alerts referred to certain transfusion alternatives; 2) study the background leading to such alternatives, the evidence supporting them, and their consequences for everyday clinical practice, and 3) issue a weighted statement on the safety of each questioned transfusion alternative, according to its clinical use. The members of the forum maintained telematics contact for the exchange of information and the distribution of tasks, and a joint meeting was held where the conclusions on each of the items examined were presented and discussed. A first version of the document was drafted, and subjected to 4 rounds of review and updating until consensus was reached (unanimously in most cases). We present the final version of the document, approved by all panel members, and hope it will be useful for our colleagues

Manejo de la anemia perioperatoria en los programas de patient blood management: luces y sombras / Perioperative anemia correction in patient blood management programs: lights and shadows

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Forum for debate: Safety of allogeneic blood transfusion alternatives in the surgical/critically ill patient.

In recent years, several safety alerts have questioned or restricted the use of some pharmacological alternatives to allogeneic blood transfusion in established indications. In contrast, there seems to be a promotion of other alternatives, based on blood products and/or antifibrinolytic drugs, which lack a solid scientific basis. The Multidisciplinary Autotransfusion Study Group and the Anemia Working Group España convened a multidisciplinary panel of 23 experts belonging to different healthcare areas in a forum for debate to: 1) analyze the different safety alerts referred to certain transfusion alternatives; 2) study the background leading to such alternatives, the evidence supporting them, and their consequences for everyday clinical practice, and 3) issue a weighted statement on the safety of each questioned transfusion alternative, according to its clinical use. The members of the forum maintained telematics contact for the exchange of information and the distribution of tasks, and a joint meeting was held where the conclusions on each of the items examined were presented and discussed. A first version of the document was drafted, and subjected to 4 rounds of review and updating until consensus was reached (unanimously in most cases). We present the final version of the document, approved by all panel members, and hope it will be useful for our colleagues.

[Spanish reference values for the Breastfeeding Self-Efficacy Scale-Short Form BSES-SF]. / Valores de referencia españoles para la versión reducida de la Escala de Autoeficacia para la Lactancia Materna BSES-SF.

BACKGROUND: To describe the reference values for the Spanish version of the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF), considering the differences according to parity and previous breastfeeding experience. METHODS: Cross-sectional study in five hospitals in Valencia and one in Murcia, Spain, in a convenience sample of 949 in-hospital breastfeeding women, with no medical problems in the mothers or newborns hindering breastfeeding. Data on sociodemographic and obstetric variables, and on breastfeeding self-efficacy, were collected using the BSES-SF. Central tendency, dispersion and percentile data were calculated to generate reference values for the entire sample, and by parity and previous experience. RESULTS: The level of self-efficacy was significantly lower (p <0.001) among primiparous women (mean =47.67±11.03) or those without previous experience (mean =47.30±11.18) than among multiparas (mean =52.87±10.66) or women with previous experience (mean =53.93±9.93). The P25 and P75 percentiles for the BSES-SF were, respectively, 42 and 59 for the entire sample; 39 and 56 for women without children or without previous experience; 46 and 61 for mothers with children; and 47 and 62 for mothers with previous experience. CONCLUSIONS: The specific percentiles obtained by parity or previous experience should be considered the reference values for comparing the level of self-efficacy of a given case, and for evaluating and planning educational postpartum support interventions.

Necesidades transfusionales en la artroplastia primaria de rodilla: impacto de la utilización del recuperador de sangre postoperatorio / No disponible

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Insuficiencia cardíaca severa y anemia / Severe heart failure and anemia

No disponible

[Evaluation of the OrthoPAT autologous transfusion system by experimental models simulating intra- and postoperative blood salvage]. / Evaluación del sistema de autotransfusión orthoPat, utilizando modelos experimentales de simulación de recuperación de sangre intra y postoperatoria.

OBJECTIVE: To evaluate the efficacy of the OrthoPAT (Haemonetics) system for blood salvage and for removing chemical or cellular debris, by experimental models simulating intra- and postoperative conditions. MATERIAL AND METHODS: Blood samples (20%-25% packed red cells) were prepared for the intraoperative model (n=8) and the postoperative model (n=22). Surgical compresses were soaked in some samples (n=5). Other samples were supplemented with hemolyzed blood (n=7). From others cytokines were removed and blood activated with bacterial liposaccharides (n=10) was added. The samples were analyzed before and after processing; tests included detection of free plasma hemoglobin (FPH), potassium ions (K+), glutamic oxalic transaminase (GOT), lactate dehydrogenase (LDH), proteins, and cytokines. RESULTS: In the intraoperative model 2935 (SD 260) mL of blood was processed. The concentration of packed red cells was 63% and 80% of the red cells were recovered. In the postoperative model 652 (35) mL was processed, the packed red cell concentration was 67% and 81% of the red cells were recovered. Reductions were observed in the concentrations of white blood cells (72%), platelets (88%), GOT and LDH (75%), and proteins and K+ (>95%). Fifty percent of the red cells were recovered in the surgical compresses model. In the hemolysis model, the K+ and FPH concentrations were reduced more than 95%. In the cytokine model, up to 90% of the interleukin 1beta, interleukin 6, and tumor necrosis factor content was removed from the activated blood samples. CONCLUSIONS: These findings suggest that the OrthoPAT system washes blood and salvages content effectively, recovering 80% of red cells. Moreover, its processing capacity (800-1000 mL x h(-1)) seems adequate for blood replacement in orthopedic surgery.

Evaluación del sistema de autotransfusión OrthoPAT®, utilizando modelos experimentales de simulación de recuperación de sangre intra y postoperatoria / Evaluation of the OrthoPAT® autologous transfusion system by experimental models simulating intra- and postoperative blood salvage

OBJETIVO: Evaluar la eficacia del sistema de autotransfusión OrthoPAT® (Haemonetics) en la recuperación de hematíes y su capacidad para eliminar contaminantes químicos o celulares, utilizando diferentes modelos experimentales de recuperación de sangre intra y post-operatoria. MATERIAL Y MÉTODOS: Se prepararon mezclas de sangre (Htc=20-25%) que fueron utilizadas en los modelos de recuperación intraoperatoria (n=8), postoperatoria (n=22), y de compresas quirúrgicas (n=5), así como en los de hemólisis (suplementadas sangre hemolizada, n=7) y eliminación de citocinas (suplementadas con sangre activada con liposacárido bacteriano, n=10). Se determinaron hematimetría, hemoglobina libre en plasma (HBLP), K+, GOT, LDH, proteínas y citocinas, antes y después del procesamiento de la sangre. RESULTADOS: En modelo intraoperatorio, se procesaron 2935±260 mL de sangre, obteniéndose un concentrado de hematíes con Htc del 63% y recuperándose el 80% de los hematíes. En el postoperatorio, estos valores fueron 652±35 mL, 67% y 81%, respectivamente, y se redujo el contenido de leucocitos (72%), plaquetas (88%), GOT y LDH (75%), proteínas y potasio (>95%). En el de compresas, se recuperó el 50% de los hematíes. En el de hemólisis, hubo una reducción >95% del contenido de K+ y HBLP. En el de citocinas, se eliminó hasta el 90% del contenido de IL-1β, IL-6 y TNFα de las mezclas suplementadas con sangre activada. CONCLUSIONES: De estos resultados parece concluirse que el sistema OrthoPAT® realiza un lavado y concentración efectivos de la sangre, recuperando el 80% de los hematíes. Además, su capacidad de procesamiento (800- 1000 mL h-1) parece ser adecuada para la reposición hemática en cirugía ortopédica

OBJECTIVE: To evaluate the efficacy of the OrthoPAT® (Haemonetics) system for blood salvage and for removing chemical or cellular debris, by experimental models simulating intra- and postoperative conditions. MATERIAL AND METHODS: Blood samples (20%-25% packed red cells) were prepared for the intraoperative model (n=8) and the postoperative model (n=22). Surgical compresses were soaked in some samples (n=5). Other samples were supplemented with hemolyzed blood (n=7). From others cytokines were removed and blood activated with bacterial liposaccharides (n=10) was added. The samples were analyzed before and after processing; tests included detection of free plasma hemoglobin (FPH), potassium ions (K+), glutamic oxalic transaminase (GOT), lactate dehydrogenase (LDH), proteins, and cytokines. RESULTS: In the intraoperative model 2935 (SD 260) mL of blood was processed. The concentration of packed red cells was 63% and 80% of the red cells were recovered. In the postoperative model 652 (35) mL was processed, the packed red cell concentration was 67% and 81% of the red cells were recovered. Reductions were observed in the concentrations of white blood cells (72%), platelets (88%), GOT and LDH(75%), and proteins and K+ (>95%). Fifty percent of the red cells were recovered in the surgical compresses model. In the hemolysis model, the K+ and FPH concentrations were reduced more than 95%. In the cytokine model, up to 90% of the interleukin 1β, interleukin 6, and tumor necrosis factor content was removed from the activated blood samples. CONCLUSIONS: These findings suggest that the OrthoPAT® system washes blood and salvages content effectively, recovering 80% of red cells. Moreover, its processing capacity (800-1000 mL·h-1) seems adequate for blood replacement in orthopedic surgery

[Ability of leukocyte reduction filters to remove fat particles from blood in experimental models simulating blood salvage in orthopedic surgery]. / Capacidad de los filtros leucorreductores para la eliminación de partículas de grasa en sangre. Modelo experimental de simulación de la sangre recuperada en cirugía ortopédica.

BACKGROUND: Salvaged autologous blood in orthopedic surgery may contain tissular debris such as fat particles (FP), possibly increasing the risk of fat embolism after bone surgery. Therefore, this study was initiated to ascertain the capacity of leukocyte filters to remove FP using in vitro models. METHODS: All experiments were performed in triplicate using donor blood bags within 15 days of their donation. Five different olive oil volumes were added to blood to obtain 5 oil concentrations (1% to 5%), and blood was subsequently filtered through a PureCell (Pall Biomedical, Portsmouth, UK) leukocyte-reduction filter. In another set of experiments, 5 different oil volumes (1, 2.5, 5, 7.5 or 10 mL) were injected into the line during filtration of oil-free blood. In addition, 3 preparations of blood supplemented with 5% oil were processed in the autotransfusion device OrthoPAT (Haemonetics Corp, Braintree, MA, USA), and the obtained red cell concentrate was subsequently filtered through PureCell. We collected samples for cell counting and analysis and FP detection with a Pentra 120 Retic (ABX, Montpellier, France) flow cytometer. RESULTS: Specific signals corresponding to FP were clearly detected in the white blood cell scattergrams yielded by the cytometer for oil supplemented blood. PureCell removed FP up to an oil concentration of 3% or up to an injected oil volume of less than 10 mL. Addition of a filtration step through a PureCell filter after blood washing by the OrthoPAT device completely removed FP. CONCLUSIONS: Leukocyte filters seem to be useful for removing FP from unprocessed blood with a low degree of fat contamination (less than 10 mL) and to complete FP removal from processed blood. Therefore, using a leukocyte filter in the patient's line should contribute to improving the safety of perioperative autologous blood salvage.

Capacidad de los filtros leucorreductores para la eliminación de partículas de grasa en sangre. Modelo experimental de simulación de la sangre recuperada en cirugía ortopédica / Ability of leukocyte reduction filters to remove fat particles from blood in experimental models simulating blood salvage in orthopedic surgery

OBJETIVOS: La sangre autóloga recuperada en cirugía ortopédica puede contener detritus tisulares, como partículas grasas (PG),con riesgo de embolismo graso. Se ha estudiado la capacidad de los filtros de leucocitos en la eliminación de PG, utilizando diferentes modelos in vitro . MÉTODOS: Todos los ensayos se realizaron por triplicado utilizando bolsas de sangre con menos de 15 días de almacenamiento. Se añadieron diferentes volúmenes de aceite de oliva a la sangre, para obtener 5 concentraciones de aceite (1 a 5%),siendo posteriormente filtrada a través del filtro de leucocitos PureCell (Pall). En otra serie de experimentos, se inyectaron diferentes volúmenes de aceite (1;2,5;5;7,5 ó 10 ml)en el circuito durante la filtración de sangre sin grasa. Además, se procesaron 3 preparaciones de sangre con aceite al 5% en el autotransfusor OrthoPAT (Haemonetics)y el con- centrado de hematíes obtenido se filtró a través de PureCell.Se tomaron muestras para hematimetría y detección de PG (analizador Pentra 120 Retic,ABX). RESULTADOS: En los diagramas de dispersión de leucocitos obtenidos para la sangre que contenía aceite, se detectaron claramente las señales específicas correspondientes a PG. El filtro PureCell eliminó las PG hasta una concentración de aceite del 3%o hasta un volumen de aceite inyectado en el circuito inferior a 10 ml. Además, PureCell eliminó totalmente las PG remanentes en sangre procesada por OrthoPAT. CONCLUSIONES: Los filtros de leucocitos parecen ser útiles para eliminar las PG de sangre no procesa- da con bajo grado de contaminación grasa (inferior a 10 mL),y para completar la eliminación de PG en sangre procesada. Por tanto, su uso en la línea de infusión al paciente podría contribuir a aumentar la seguridad de la recuperación perioperatoria de sangre autóloga

BACKGROUND: Salvaged autologous blood in ortho- pedic surgery may contain tissular debris such as fat par- ticles (FP), possibly increasing the risk of fat embolism after bone surgery. Therefore, this study was initiated to ascertain the capacity of leukocyte filters to remove FP using in vitro models. METHODS: All experiments were performed in triplicate using donor blood bags within 15 days of their donation. Five different olive oil volumes were added to blood to obtain 5 oil concentrations (1%to 5%),and blood was subsequently filtered through a PureCell (Pall Biomedical,Portsmouth,UK)leukocyte-reduction filter. In another set of experiments,5 different oil volumes (1, 2.5,5,7.5 or 10 mL)were injected into the line during filtration of oil-free blood.In addition,3 preparations of blood supplemented with 5%oil were processed in the autotransfusion device OrthoPAT (Haemonetics Corp, Braintree, MA, USA),and the obtained red cell concentrate was subsequently filtered through PureCell. We collected samples for cell counting and analysis and FP detection with a Pentra 120 Retic (ABX, Montpellier, France)flow cytometer. RESULTS: Specific signals corresponding to FP were cle- arly detected in the white blood cell scattergrams yielded by the cytometer for oil supplemented blood. PureCell removed FP up to an oil concentration of 3%or up to an injected oil volume of less than 10 mL. Addition of a filtration step through a PureCell filter after blood washing by the OrthoPAT device completely removed FP. CONCLUSIONS: Leukocyte filters seem to be useful for removing FP from unprocessed blood with a low degree of fat contamination (less than 10 mL)and to complete FP removal from processed blood. Therefore, using a leukocyte filter in the patient ’s line should contribute to improving the safety of perioperative autologous blood salvage

Fisiopatología del metabolismo del hierro: implicaciones diagnósticas y terapéuticas / Fisiopathology of iron metabolism

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Transfusión en el paciente crítico / Tranfusion in the critical patient

La transfusión de sangre constituye una de las terapias más frecuentes en el paciente crítico. Aunque la transfusión puede ser útil en situaciones de pérdidas masivas de sangre y en hemodiluciones graves, su eficacia para disminuir la deuda tisular de oxígeno no ha sido documentada de manera consistente. Artículos recientes muestran una asociación entre transfusión de sangre y el aumento de la morbimortalidad en pacientes críticos. Este incremento puede deberse al efecto inmunosupresor que la sangre produce en el receptor y que está íntimamente ligado al tiempo de almacenamiento de la misma. Este artículo describe los hallazgos más recientes sobre los efectos deletéreos de la sangre y las alternativas a las transfusiones sanguíneas (AU)

[Treatment of conjunctival intraepithelial neoplasia with topical mitomycin C 0.02%]. / Tratamiento de las neoplasias conjuntivales intraepiteliales con colirio de mitomicina C al 0,02%

PURPOSE: To evaluate the efficacy of topical mitomycin C (MMC) 0.02% in treating conjunctival intraepithelial neoplasia (CIN). METHODS: Three patients with CIN were treated with topical MMC 0.02%. Our follow-up period was twelve months (range 8-18 months). RESULTS: CIN was resolved in all three cases without modifying the normal corneal and conjunctival architecture. CONCLUSIONS: Topical MMC 0.02% four times daily during two weeks is a useful alternative tool for the surgical management of CIN.

Utilidad de la eritropoyetina como alternativa a la transfusión alogénica en cirugía ortopédica mayor / Erythropoietin as an alternative to allogenic transfusion in major orthopedic surgery

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