Practice of autologous preoperative plasmapheresis in Germany in 1993.

Autologous preoperative plasmapheresis which is being performed at the University Hospital of Tübingen since 1984 in advance of surgical, orthopaedic or gynecologic operations, constitutes, in combination with intraoperative autotransfusion (IAT), an optimal method to compensate high losses of intravascular volume. Unlike all other procedures which also substitute lost volume (such as infusion of electrolytic solutions or plasma expanders, haemodilution, retransfusion of preoperatively donated autologous blood, transfusion of homologous plasma or foreign blood) this method grants optimal clotting as well as intravascular retention of volume and in addition to this excludes every risk of infection. Although the therapeutic advantages of autologous preoperative plasmapheresis are well known and confirmed by our statistics (about 75% of the patients do not need any foreign blood), the method is rarely practiced in Germany and mainly performed in specialized hospitals (e.g. in the orthopaedic departments of Tübingen, Ulm, Hamburg, Hannover or Essen). This unfortunate situation is obviously due to some of the following, primarily logistic problems. First of all the procedure of autologous preoperative plasmapheresis needs relatively long planning in advance of the operation (between 2 and 4 weeks) and a number of surgeons renounces the method--even if the patient's medical condition is appropriate and no higher costs are to be expected. The above mentioned alternatives of compensating blood losses are preferred, even if they are in no way comparable in their efficiency. Secondly, in Germany autologous preoperative plasmapheresis is mostly performed by an anaesthetist, who is, however, under our laws obliged to reinfuse the plasma himself, which he has taken from a patient.(ABSTRACT TRUNCATED AT 250 WORDS)

[Avoidance of homologous blood transfusions in gynecology and obstetrics]. / Zur Vermeidung von Fremdbluttransfusionen in der Gynäkologie und Geburtshilfe.

Public concern about the safety of transfusion was aroused by the discovery that the acquired immuno deficiency syndrome (AIDS) can be transmitted by blood transfusion. Patients who require transfusion are now apprehensive to the point of seeking alternatives or even refusing to receive blood. "Autologous transfusion" of the patients own blood can completely eliminate the risk of disease of transmission. Autologous transfusion can be accomplished in different ways: through intraoperative salvage and retransfusion of the patient's blood during surgery, and through donation by the patient of the required amount of blood before surgery. Intraoperative salvage is, to some degree at least, an alternative to transfusion of homologous blood for many surgical patients. Predepositing of blood is an alternative for patients whose elective surgery is scheduled far enough in advance (about 3 weeks) to permit deposit of the required amount of blood. Greater use of predonation would reduce the risk of hepatitis and other transfusion-associated illnesses. It should be noted that any transfusion in obstetrics and gynecology - autologous or homologous - may need a severe indication.

[The quality of washed autotransfused erythrocytes. The elimination of plasma hemoglobin, osmotic fragility and survival rate of retransfused erythrocytes]. / Die Qualität gewaschener autotransfundierter Erythrozyten. Untersuchungen zur Elimination von Plasmahämoglobin, osmotischen Resistenz und Uberlebensrate retransfundierter Erythrozyten.

Intraoperative transfusion has until recently been understood to mean full retransfusion of the blood removed by a suction pump without significant changes due to external influences, which considerably limited its utilization. Intraoperative transfusion can only be performed without decisive disadvantages when the blood can be suctionally removed in large amounts and immediately retransfused. In recent years, the Cell Saver has provided a system which can also prepare soiled blood for retransfusion. Extensive orthopedic surgery entails large blood losses due to oozing from expanded wound areas; only rarely does acute bleeding occur. Because of intensive tissue contact, the suctioned blood has been soiled with activated clotting factors, lytic enzymes, free haemoglobin from damaged red cells, cleaning solutions, and other undesired elements. With the Cell Saver system, it is possible to remove the plasma and recover 70-80% of the intact red cells sufficiently freed from stroma and free haemoglobin. The osmotic fragility of these cells served as a measure of integrity and membrane stability. They were compared to red cells withdrawn preoperatively and showed an identical osmotic relationship. Determining the survival rate of the retransfused cells in vivo shows that they provide a high-quality and in most cases, a sufficient replacement of blood loss. Even after 6 days, over 70% were found in the circulating blood. Premature, disproportionate elimination, which could be dangerous for the patient, does not occur.

[Autotransfusion and plasmapheresis in preparation for surgery. Behavior of coagulation]. / Autotransfusion und operationsvorbereitende Plasmapherese.

With the current day implementation of methods of autotransfusion one retransfuses if possible only washed red cell concentrates and eliminates the plasma. In the case of operations where patients undergo large blood loss, one must effect a substitution for the lost plasma volume and the lost clotting factors. In addition to electrolyte and colloidal solutions one can use a substitution of homologous and also autologous fresh frozen plasma (FFP). The effects of different substitutes on the clotting reaction has been investigated in 47 patients on whom extensive orthopaedic and also traumatologic surgical operations have been performed. By the combination of homologous blood and homologous FFP as also with autologous red cells and homologous FFP the clotting reactions remain the same. This determines the advantages of autotransfusion as compared with conventional techniques but, in addition, there is a saving in the usage of homologous blood. Where an operation can be planned in advance, the necessary FFP can be obtained from the patient. By utilisation of autologous FFP the operative and post- operative blood losses are reduced. As a result it is possible e.g. in total hip prosthesis, in approximately 90% of all cases, to operate without using homologous blood or plasma. The determined stability of AT III in autologous plasma--without AT III prophylaxis of thrombosis by Heparin is ineffective--and all other clotting factors leads to an expectancy of a not activated clotting mechanism and at the same time to low thrombosis risks.(ABSTRACT TRUNCATED AT 250 WORDS)

[Horner's syndrome in obstetrics. A rare complication of peridural regional anesthetic procedures]. / Das Hornersyndrom in der Geburtshilfe. Eine seltene Komplikation rückenmarksnaher Regionalanaesthesieverfahren.

A case of Horner's syndrome (HS) following lumbar epidural block during labor is described. 10 min after injection of the local anaesthetic the symptoms and signs of HS were recognized. They spontaneously disappeared 60 min later. It is concluded, that HS seems to be a benign complication of epidural anaesthesia which may, however, present the first sign or symptom of an extensive block of serious consequence. Pregnant women in labor receiving epidural block, seem to be predisposed to HS.