This document summarizes a research article about developing a strategy for performing heart surgery on patients who refuse blood transfusions for religious reasons. The strategy involves four parts: administering high doses of erythropoietin preoperatively to increase red blood cell counts; optimizing platelet and coagulation levels; reinfusing lost blood intraoperatively and postoperatively; and restricting fluid administration to minimize dilution. This multimodal strategy has allowed over 200 heart surgeries to be performed at one hospital on patients refusing transfusions, with no transfusions required and mortality lower than expected.
Outcome After Procedures for Retained Blood Syndrome in Coronary SurgeryPaul Molloy
OBJECTIVES:
Incomplete drainage of blood from around the heart and lungs can lead to retained blood syndrome (RBS) after cardiac sur-
gery. The aim of this study was to assess the incidence of and the outcome after procedures for RBS in patients undergoing isolated coronary artery bypass grafting (CABG)-
Outcome After Procedures for Retained Blood Syndrome in Coronary SurgeryPaul Molloy
OBJECTIVES:
Incomplete drainage of blood from around the heart and lungs can lead to retained blood syndrome (RBS) after cardiac sur-
gery. The aim of this study was to assess the incidence of and the outcome after procedures for RBS in patients undergoing isolated coronary artery bypass grafting (CABG)-
Management of Takotsubo Syndrome: A Comprehensive ReviewNicolas Ugarte
Takotsubo syndrome (TTS), also known as Takotsubo cardiomyopathy, is a transient left
ventricular wall dysfunction that is often triggered by physical or emotional stressors. Although
TTS is a rare disease with a prevalence of only 0.5% to 0.9% in the general population, it is
often misdiagnosed as acute coronary syndrome. A diagnosis of TTS can be made using Mayo
diagnostic criteria. The initial management of TTS includes dual antiplatelet therapy,
anticoagulants, beta-blockers, angiotensin-converting enzyme inhibitors or aldosterone
receptor blockers, and statins. Treatment is usually provided for up to three months and has a
good safety profile. For TTS with complications such as cardiogenic shock, management
depends on left ventricular outflow tract obstruction (LVOTO). In patients without LVOTO,
inotropic agents can be used to maintain pressure, while inotropic agents are contraindicated
in patients with LVOTO. In TTS with thromboembolism, heparin should be started, and
patients should be bridged to warfarin for up to three months to prevent systemic emboli. Our
comprehensive review discussed the management in detail, derived from the most recent
literature from observational studies, systematic review, and meta-analyses.
These guidelines are very important in cardiac surgery. Tranfusion triggers, perfusion interventions,blood salvage,blood products all are described in great detail.
Jehowah's witnesses and blood conservation strategies by Dr.Minnu M. PanditraoMinnu Panditrao
dr. Mrs. Minnu M. Panditrao explains the problems faced by anesthesiologists in anesthetising the Jehowah's Witness patients because of their beliefs. Ina ddition she also discribes various strategies of Blood conservation.
Intraoperative aortic dissection during cardiac surgery is infrequent, complicating surgical intervention in 0.04 - 1% of cases. Dissections can occur anywhere, most often as a result of direct mechanical damage at the location of the side clamp, site of cannulation of the aorta, or at the site of proximal anastomosis and may manifest as hematoma, bleeding at the cannulation site or bleeding from the proximal anastomoses or aortic suture lines. Delayed diagnosis and treatment can lead to extremely (23-41%) high mortality rate.
Transfusion support in Surgery- elective surgery, cardiac surgery, MSBOS, Tra...DrShinyKajal
AABB indications
Elective surgeries- Maximum surgical blood ordering schedule
Anemia and surgery- including Transfusion Trigger
Surgery and coagulation disorders- including factor replacement
Transfusion in cardiac surgeries- including autologous transfusion
Patient Blood management in surgery
Allogenic Transfusion
Autologous Transfusion- Intra And Postoperative Red Cell Salvage, Haemodilution
Blood Substitutes
Haematopoietic Factors
Antifibrinolytics
Fibrin Sealants
Conjugated Oestrogens.
AABB pretransfusion testing schemes
Type and screen
Maximum surgical blood ordering schedule
transfusion trigger for surgery
factor replacement in surgery
autologous transfusion
cell salvage
perioperative
massive transfusion protocol
Management of Takotsubo Syndrome: A Comprehensive ReviewNicolas Ugarte
Takotsubo syndrome (TTS), also known as Takotsubo cardiomyopathy, is a transient left
ventricular wall dysfunction that is often triggered by physical or emotional stressors. Although
TTS is a rare disease with a prevalence of only 0.5% to 0.9% in the general population, it is
often misdiagnosed as acute coronary syndrome. A diagnosis of TTS can be made using Mayo
diagnostic criteria. The initial management of TTS includes dual antiplatelet therapy,
anticoagulants, beta-blockers, angiotensin-converting enzyme inhibitors or aldosterone
receptor blockers, and statins. Treatment is usually provided for up to three months and has a
good safety profile. For TTS with complications such as cardiogenic shock, management
depends on left ventricular outflow tract obstruction (LVOTO). In patients without LVOTO,
inotropic agents can be used to maintain pressure, while inotropic agents are contraindicated
in patients with LVOTO. In TTS with thromboembolism, heparin should be started, and
patients should be bridged to warfarin for up to three months to prevent systemic emboli. Our
comprehensive review discussed the management in detail, derived from the most recent
literature from observational studies, systematic review, and meta-analyses.
These guidelines are very important in cardiac surgery. Tranfusion triggers, perfusion interventions,blood salvage,blood products all are described in great detail.
Jehowah's witnesses and blood conservation strategies by Dr.Minnu M. PanditraoMinnu Panditrao
dr. Mrs. Minnu M. Panditrao explains the problems faced by anesthesiologists in anesthetising the Jehowah's Witness patients because of their beliefs. Ina ddition she also discribes various strategies of Blood conservation.
Intraoperative aortic dissection during cardiac surgery is infrequent, complicating surgical intervention in 0.04 - 1% of cases. Dissections can occur anywhere, most often as a result of direct mechanical damage at the location of the side clamp, site of cannulation of the aorta, or at the site of proximal anastomosis and may manifest as hematoma, bleeding at the cannulation site or bleeding from the proximal anastomoses or aortic suture lines. Delayed diagnosis and treatment can lead to extremely (23-41%) high mortality rate.
Transfusion support in Surgery- elective surgery, cardiac surgery, MSBOS, Tra...DrShinyKajal
AABB indications
Elective surgeries- Maximum surgical blood ordering schedule
Anemia and surgery- including Transfusion Trigger
Surgery and coagulation disorders- including factor replacement
Transfusion in cardiac surgeries- including autologous transfusion
Patient Blood management in surgery
Allogenic Transfusion
Autologous Transfusion- Intra And Postoperative Red Cell Salvage, Haemodilution
Blood Substitutes
Haematopoietic Factors
Antifibrinolytics
Fibrin Sealants
Conjugated Oestrogens.
AABB pretransfusion testing schemes
Type and screen
Maximum surgical blood ordering schedule
transfusion trigger for surgery
factor replacement in surgery
autologous transfusion
cell salvage
perioperative
massive transfusion protocol
Major surgery is a considerable physiologic insult that can be
associated with significant morbidity and mortality. The prevention of perioperative morbidity is a determining factor in providing high-quality in health care, since the occurrence of postoperative complications adversely affects postoperative survival and increase healthcare costs
Austin Spine is an open access, peer reviewed, scholarly journal dedicated to publish articles covering all areas of Spine.
The journal aims to promote latest information and provide a forum for doctors, researchers, physicians, and healthcare professionals to find most recent advances in the areas of Spine. Austin Spine accepts research articles, reviews, mini reviews, case reports and rapid communication covering all aspects of Spine.
Austin Spine strongly supports the scientific up gradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing.
Identify the etiology of perioperative hypertension.
Outline the appropriate evaluation of perioperative hypertension.
Review the management options available for perioperative hypertension
Blood transfusion is a complex activity in healthcare, constitutes an important part of various treatment protocols. Thus the indications for ordering blood must be fully justified to avoid over or misusage of this resource. In a 5 year retrospective study, details of patient’s diagnosis and indications for transfusion are correlated with whole blood and components transfused from the blood bank data base in SAQR Hospital, in Ras Al Khaimah UAE. It was found that 7,045 blood units which were transfused, maximum blood was supplied to surgical wards; most common indications for transfusion were injuries during road traffic accidents, orthopedic surgeries and cardiovascular surgeries. Nearly half (52%) of all blood was given to female recipients. UAE nationals received the maximum units of blood; most prevalent blood group among blood transfusion recipients was O +ve. Major usage of blood products transfused were packed RBC’s. The study concludes that regular assessment of blood component usage followed by academic sessions for clinicians is recommended for effective and efficient use of available blood to patients in a life-threatening situation.
With the growing number of individuals prescribed anti-coagulants, a dilemma exists whether to discontinue the medication few days before the dental innervation or to keep continuing it to prevent the chances of stroke. This presentation covers in detail the pros an cons of discontinuing the anti-platelet medication.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
2. Citation: Weltert L (2012) Blood-Sparing Heart Surgery in Critically Anaemic Patients Refusing Red Blood Cell Transfusions. J Blood Disord Transfus
S1:009. doi:10.4172/2155-9864.S1-009
Page 2 of 5
ISSN: 2155-9864 JBDT, an open access journal Hematologic Oncology: Diagnosis & Therapeutics J Blood Disord Transfus
reduced the haemoglobin content and the density of the blood [10].
Encouraged by this first study we began a second study, which is still
ongoing, using a single administration of 80,000 IU erythropoietin
with the expectation of achieving saturation of the receptor. The
preliminary results seem even better. The second element of the
strategy is assessment and correction of the patient’s aggregation and
coagulation status [11]. In addition to a history of drug administration
and withdrawal from coumadin, heparin, aspirin and clopidogrel, we
routinely evaluate antithrombin and INR and, when in doubt, perform
thromboelastography and aggregometry. All suboptimal results
undergo complete pharmacological correction. The third element
of this strategy is the recovery of intra- and postoperative blood
loss. The Cell Saver System and in particular the Cardiopat system, a
centrifugal pump which concentrates red blood cells extracted from
the haemorrhagic fluid, are used for salvage and recovery in the first 6
hours after the operation [12-14].
A randomized study currently in press has shown that this method
leads to a saving of almost 0.5 units of blood per patient (1.37 units
transfused in controls vs 0.94 in the Cardiopat group). The system is
versatile and can be used for any operation, but is still difficult for nurses
to manage and inadequate to handle heavy intraoperative bleeding.
Active collaboration with the developers will lead to the creation of a
second-generation product that bridges earlier defects.
The fourth element of the strategy is a restrictive policy on fluid
dilution. A simple checklist designed to check the rate of infusion
of all the venous accesses can significantly reduce intraoperative
haemodilution. The simultaneous use of these four strategies is our gold
standard, to which it is crucial to add respect for transfusion triggers in
patients who agree. For example, lowering the transfusion trigger from
8.5 g/dl to 8.0 g/dl in the absence of poor organ perfusion can further
reduce the use of transfusion in the absence of additional risks.
Material and Methods
Although in the general population the notion of transfusion is
totally acceptable, for Jehovah’s Witnesses it is not.
Italian Law has established that the refusal to be transfused, when
expressed by a patient with self-awareness and mental clarity and
collected by a medical officer at the beginning of the inpatient episode
cannot be transgressed, even when immediate survival depends on
transfusion. This legal provision makes Jehovah’s Witnesses extremely
difficult to treat in cardiac surgery. In many cases interventions are
impossible to postpone and the need to avoid anaemia is paramount
in order to minimize organ ischaemia, primarily in the heart. Our
particular attention to blood transfusion has made our hospital the
referral centre for Jehovah’s Witnesses in Italy. In this subgroup we
apply the above-mentioned protocol with meticulous care, knowing
that in case of failure of the strategy transfusion cannot be used. Since
January 2006, 202 patients have categorically refused transfusion
despite consenting to the intervention and its risks. This subset
represents approximately 4% of the total population undergoing
heart surgery at the European Hospital. The type of operation ranged
from myocardial revascularization, mitral plasty and aortic valve
replacement to replacement of the ascending aorta, as shown in Table 1.
Only one patient needed reoperation after previous surgery. We chose
to compare this population to a cohort of 4700 patients operated on
in the same timeframe. We therefore conducted a retrospective cohort
study, focused on mortality and adverse events. All patients’ risk factors
for ischaemic heart disease (family history, the presence of diabetes,
hypercholesterolemia, smoking, obesity, hypertension) as well as factors
included in the EUROScore analysis (age, gender, chronic pulmonary
obstructive disease, the presence of extracardiac arteriopathy,
neurological dysfunction, previous cardiac surgery, serum creatinine,
active endocarditis, critical preoperative state, unstable angina,
left ventricular dysfunction, recent myocardial infarct, pulmonary
hypertension, emergency conditions, post-infarct septal rupture)
and biometric parameters (height, weight and BSA) were collected
and stored in the database before running a custom randomization
application working in Windows XP. All deaths were recorded and
categorized according to the principal initial cause and adverse events
and postoperative findings were all recorded in the central database.
Transfusion-Refus-ing
Population
Transfusion-Ac-cepting
Population p Value
Isolated CABG 35, 20% 33, 20% 0.34
Ascending aorta
replacement 19, 80% 19, 60% 0.98
Aortic valve
replacement 20, 40% 22, 40% 0.44
Mitral valve repair 15, 30% 14, 90% 0.85
Mitral valve re-placement
4, 10% 3, 40% 0.34
Other 5, 20% 6, 50% 0.26
Table 1: Distribution by type of operation in the subpopulation analysed.
Transfusion- Re-fusing
Population
Transfusion- Ac-cepting
Population
p Value at
ANOVA
No. of patients 202 4700
Family history of cardio-vascular
disease 53.6% 48.1% 0.25
Obesity 26.6% 24.9% 0.31
Diabetes 42.6% 38.5% 0.12
Hypercholesterolemia 54.3% 51.7% 0.47
Smoking habit 37.1% 41.1% 0.33
Hypertension 72.8% 74.7% 0.37
Logistic EUROScore 8.1±7.27 9.2±9.7 0.25
Age 68,7±9.2 66.4±9.8 0.12
Gender 71% Male 70% Male 0.37
Chronic pulmonary
obstructive disease 26.1% 27.5% 0.15
Presence of extracar-diac
arteriopathy 22.1% 23.8% 0.22
Neurological dysfunc-tion
disease 3.4% 4.1% 0.31
Previous cardiac
surgery 4.9% 5.4% 0.24
Serum creatinine 1.24±0.9 1.33±0.4 0.23
Severe renal impair-ment
3.2% 3.9% 0.17
Presence of active
endocarditis 2.1% 2.6% 0.25
Critical preoperative
state 2.2% 2.4% 0.16
Unstable angina 19.1% 21.6% 0.09
Ejection fraction 48.5±9.2 52.7±8.3 0.09
Recent myocardial
infarct 12.7% 13.6% 0.21
Pulmonary hypertension 5.9% 6.3% 0.17
Postinfarct septal
rupture 0.3% 0.2% 0.16
Height 163±7. 165±9 0.24
Weight 74±15 76±12 0.31
Baseline haemoglobin
g/dl 13.5±1.4 12.8±1.2 0.16
Table 2: Baseline characteristics.
3. Citation: Weltert L (2012) Blood-Sparing Heart Surgery in Critically Anaemic Patients Refusing Red Blood Cell Transfusions. J Blood Disord Transfus
S1:009. doi:10.4172/2155-9864.S1-009
Page 3 of 5
ISSN: 2155-9864 JBDT, an open access journal Hematologic Oncology: Diagnosis & Therapeutics J Blood Disord Transfus
After discharge patients returned for a 30-day postoperative check and
the follow-up file was then closed and reported for analysis.
Statistical Analysis
All data were processed by IBM SPSS version 17, including Analysis
of Variance (ANOVA) and risk analysis.
The first step was to ascertain whether the two populations were
comparable in terms of baseline characteristics. ANOVA of the
dependent variables ‘Accepting transfusion’ or ‘Refusing transfusion’
was performed (ANOVA and UniANOVA as needed, CI 95%, p = 0.05)
on all preoperative data, namely general cardiovascular risk parameters,
EUROScore risk parameters and biometric parameters. The second step
was to verify whether the two groups differed in terms of adverse events
in general and mortality. Every comparison was tested with several
statistical techniques (Student’s t-test, Yates’ continuity-corrected chi-
squared test), as appropriate.
Results
ANOVA confirmed the comparability of the two cohorts, as all
variables analysed proved to have no statistically significant difference
between the two groups, including primary disease characteristics. The
baseline demographic and clinical characteristics of each group are
summarized in Table 2. Table 3 shows the adverse events analysis, with
differences in terms of 30-day mortality, in-hospital complications and
mid-term morbidity. Briefly, the two populations did not differ for the
parameters considered, except in terms of atrial fibrillation and deep
vein thrombosis, which seemed to occur more frequently in the control
group (29.2% vs 33.4%, p 0.04; 1.7% vs 2.4%, p=0.03, respectively) and
of transfusions, which did not occur at all in the transfusion-refusing
population; on the other hand, the control group required 1.1 units
of blood per patient (p<0.001). Overall mortality was subdivided
according the recorded initial cause, as shown in Table 4.Within
the overall mortality in the no-transfusion subgroup we identified,
albeit with a certain degree of arbitrariness, those patients in whom
inability to correct the anaemia was the primary cause of a potentially
preventable death. To distinguish these conditions we used blood lactate
under conditions of sufficient flow measured by the thermodilution
Swan–Ganz. In these cases, the presence of anaemia < 7.0 g/dl was
considered an inducer of major organ distress. This corresponds to
about 1.6% of the subgroup, i.e. almost half the deaths in this category.
The comparison group had no occurrences in this category, as would
be expected and the inconsistency of absolute numbers (just 3 cases) in
the remaining categories clearly makes statistical inference unreliable.
Overall mortality was also analyzed with regard to the type of operation
(Table 5), although extreme fragmentation of the reports owing to the
increasing number of categories again makes any kind of statistical
inference unreliable. The expected mortality in the transfusion-refusing
group, calculated according to the EUROScore parameters, was 8.1%
and in the comparison population was 9.2%. The observed mortality
rate in the transfusion-refusing group was 3.1%. For comparison, in
the general population mortality in the same period amounted to 2.7%.
The difference was not statistically significant (p= 0. 10). Results are
shown in Figure 1.
Transfusions
Refusing
Population
Transfusions
Accepting
Population
p value
No. of patients 202 4700
Blood loss at 24 h (ml) 600±450 660±380 0.17
Intraoperative blood salvage (ml) 370±250 390±230 0.11
Postoperative blood salvage (ml) 350±370 330±340 0.12
Allogenic RBC transfusion (units) 0.0 1.11±1.9 0.02
Fresh frozen plasma transfusion
(units) 0.0 0.94±1.3 0.01
Platelet transfusion (units) 0.0 0.12±0.9 0.02
ICU stay (days) 2.45±1.7 2.63±1.9 0.31
Perioperative MI (%) 2.8% 2.6% 0.21
Peak troponin level (nmol/l) 5.6±7.2 4.7±6.5 0.16
Epileptic syndrome (%) 3.9% 3.5% 0.17
Focal neurological damage (%) 2.4% 2.1% 0.10
Generalized neurological damage
(%) 1.4% 1.9% 0.13
Bleeding at 6 h (ml) 360±370 330±400 0.11
Bleeding at 12 h (ml) 480±390 510±410 0.09
Bleeding at 24 h (ml) 620±450 640±360 0.11
Revision for haemostasis (%) 3.2% 4.5% 0.07
Cardiac tamponade (%) 2.9% 3.2% 0.19
Atrial fibrillation (%) 29.2% 33.4% 0.04
Acute respiratory distress syndrome
(%) 7.7% 5.9% 0.23
Acute pulmonary edema (%) 3.8% 4.6% 0.13
Pneumonia (%) 5.9% 6.5% 0.14
Need for reintubation (%) 5.6% 5.4% 0.13
Increase in liver enzymes (%) 6.5% 6.9% 0.17
Bowel ischaemia (%) 2.9% 2.5% 0.20
Creatinine level before surgery
(mmol/l) 1.22±0.8 1.29±0.7 0.19
Maximum creatinine level (mmol/l) 1.94±0.6 2.27±0.9 0.19
First 24-h urine output (ml) 1820±700 1740±800 0.21
Use of fenoldopam (%) 7.90% 6.70% 0.18
Need for haemo-dia-filtration (%) 6.6% 4.10% 0.11
Need for insulin infusion (%) 19.0% 17.0% 0.10
Fluid balance on discharge from
ICU (ml) 540±350 590±340 0.11
Central venous pressure on
discharge from ICU (mmHg) 11±3 12±3 0.27
Length of stay after operation (days) 6.7±2.1 7.2±3.0 0.10
Neurological complications at 30
days (%) 2.3% 2.2% 0.26
Long-term wound infection (%) 5.5% 5.7% 0.09
Deep vein thrombosis (%) 1.7% 2.4% 0.03
Renal failure (%) 3.3% 3.6% 0.15
30-day overall mortality (%) 3.1% 2.7% 0.23
Table 3: Postoperative occurrences.
Cause of Death
Transfusion-
Refusing
Population
Transfusion-
Accepting
Population
n % n % p Value
Refractory myocardial insuf-ficiency
0 0.00% 12 0.26% 0.001
Multiorgan failure( initial cause
bowel ischaemia) 1 0.45% 34 0.72% 0.07
Multiorgan failure (initial cause
respiratory distress syndrome) 2 0.91% 65 1.38% 0.05
Multiorgan failure (initial cause
irreversible ischaemic cerebral
damage)
0 0.00% 16 0.34% 0.001
Multiorgan failure (initial cause
severe and untreated anaemia) 3 1.60% 0 0.00% 0.001
Any cause 6 3.10% 127 2.70% 0.1
Table 4: Causes of death in the two populations.
4. Citation: Weltert L (2012) Blood-Sparing Heart Surgery in Critically Anaemic Patients Refusing Red Blood Cell Transfusions. J Blood Disord Transfus
S1:009. doi:10.4172/2155-9864.S1-009
Page 4 of 5
J Blood Disord Transfus Hematologic Oncology: Diagnosis & Therapeutics ISSN: 2155-9864 JBDT, an open access journal
Discussion
The focus of this study was to assess whether the impossibility of
transfusing red blood cells in the setting of major surgery determines
an increase in risk of death and postoperative complications despite
a modern and tested approach using blood-saving techniques.
Blood-conservation techniques are of paramount importance in
cardiac surgery, as postoperative bleeding is common and allogenic
RBC transfusion carries the risks of clerical errors, immunological
reactions and transmission of blood borne pathogens, both familiar
and unrecognized. Moreover, allogenic blood products are quite
expensive in their production process and represent a limited resource
worldwide. Nowadays, despite all efforts, a proportion of patients
undergoing cardiac surgery require allogenic RBC transfusion. The
design of this study was simple and adequately powered. All patients
presenting for heart surgery at our institution were eligible for the study
and no exclusion criteria were applied. All variables analysed showed
no statistically significant differences between the two groups. The key
findings were that observed postoperative occurrences did not differ
substantially and no difference could be established in terms of mortality.
Despite a consistent number of studies regarding each separate aspect
of blood conservation, in both general heart surgery patients and those
refusing transfusion, we could find no relevant publications with regard
Transfusion-
Refusing
Population
Refractory Myocar-dial
Insufficiency
Multiorgan Failure (Initial
Cause Bowel Ischaemia)
Multiorgan Failure (Inital
Cause Respiratory Dis-tress
Syndrome)
Multiorgan Failure (Initial
Cause Irreversible Isch-aemic
Cerebral Damage)
Multiorgan Failure (Initial
Cause Severe and Un-treated
Anaemia)
Any Cause
n of % n of % n of % n of % n of % n of %
Isolated CABG 0 71 0,00% 1 71 1,41% 0 71 0,00% 0 71 0,00% 0 71 0,00% 1 71 1,41%
Ascending
aorta replace-ment
0 40 0,00% 0 40 0,00% 0 40 0,00% 1 40 2,50% 0 40 0,00% 1 40 2,50%
Aortic valve
replacement 0 41 0,00% 0 41 0,00% 0 41 0,00% 0 41 0,00% 2 41 4,85% 2 41 4,88%
Mitral valve
repair 0 31 0,00% 0 31 0,00% 1 31 3,24% 0 31 0,00% 0 31 0,00% 1 31 3,23%
Mitral valve
replacement 0 8 0,00% 0 8 0,00% 0 8 0,00% 0 8 0,00% 1 8 12,07% 1 8 12,50%
Other 0 11 0,00% 0 11 0,00% 0 11 0,00% 0 11 0,00% 0 11 0,00% 0 11 0,00%
Total 0 202 0,00% 1 202 0,50% 1 202 0,50% 1 202 0,50% 3 202 1,49% 6 202 3,06%
Isolated CABG 4 1560 0.26% 19 1560 1.22% 13 1560 0.83% 2 1560 0.13% 0 1560 0.00% 38 1560 2.44%
Ascending
aorta replace-ment
0 921 0.00% 2 921 0.22% 6 921 0.65% 7 921 0.76% 0 921 0.00% 15 921 1.63%
Aortic valve
replacement 4 1053 0.38% 9 1053 0.85% 19 1053 1.80% 2 1053 0.19% 0 1053 0.00% 34 1053 3.23%
Mitral valve
repair 1 700 0.14% 1 700 0.14% 15 700 2.14% 1 700 0.14% 0 700 0.00% 18 700 2.57%
Mitral valve
replacement 1 160 0.63% 1 160 0.63% 9 160 5.63% 2 160 1.25% 0 160 0.00% 13 160 8.14%
Other 2 306 0.65% 2 306 0.65% 3 306 0.98% 2 306 0.65% 0 306 0.00% 9 306 2.95%
Total 12 4700 0.26% 34 4700 0.72% 65 4700 1.38% 16 4700 0.34% 0 4700 0.00% 127 4700 2.70%
Table 5: Causes of death in relation to type of operation.
Jehow a's Witnesses General Population
0,00%
1,00%
2,00%
3,00%
4,00%
5,00%
6,00%
7,00%
8,00%
9,00%
10,00%
8,10%
9,20%
3,10% 2,70%
Expected Mortality
Observed Mortality
Figure 1: Observed overall mortality, no-transfusion group vs global population, compared to predicted mortality as calculated by EUROSCore. P 0.11.
5. Citation: Weltert L (2012) Blood-Sparing Heart Surgery in Critically Anaemic Patients Refusing Red Blood Cell Transfusions. J Blood Disord Transfus
S1:009. doi:10.4172/2155-9864.S1-009
Page 5 of 5
J Blood Disord Transfus Hematologic Oncology: Diagnosis & Therapeutics ISSN: 2155-9864 JBDT, an open access journal
to an integrated strategy such as ours and this led us to disclose our
method. The ability to recruit a relatively large number of heart surgery
patients within a short period also yields interesting findings, as this
is intrinsically the best way to control for confounding factors due to
changes in approaches, drugs and techniques over time. The study lacks
the power of prospective and randomized studies, but randomization
with regard to this topic could easily be illegal and hence impossible to
realize. Another possible weakness is the lack of blindness: despite the
strict observance of internal protocols, the awareness of not being able
to transfuse can lead individuals to multiply their efforts at all times,
thereby biasing the ‘equal strategy’ assumption.
Conclusion
This observational study shows that it is possible to perform cardiac
surgery without allogenic transfusion, with a mortality rate that is
acceptable and comparable to that of the general population. The results
obtained in the specific subpopulation of those who refused blood
transfusions might in the future be of benefit to the entire population,
avoiding the detrimental effect of transfusion and bringing cardiac
surgery closer to the goal of not requiring blood.
References
1. Koch CG, Khandwala F, Li L, Estafanous FG, Loop FD, et al. (2006) Persistent
effect of red cell transfusion on health-related quality of life after cardiac
surgery. Ann Thorac Surg 82: 13-20.
2. Koch CG, Li L, Duncan AI, Mihaljevic T, Loop FD, et al. (2006) Transfusion in
coronary artery bypass grafting is associated with reduced long-term survival.
Ann Thorac Surg 81: 1650-1657.
3. Koch CG, Li L, Van Wagoner DR, Duncan AI, Gillinov AM, et al. (2006) Red
cell transfusion is associated with an increased risk for postoperative atrial
fibrillation. Ann Thorac Surg 82: 1747-1756.
4. Saving and improving lives-National Blood Service. Annual report 2004.
5. Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP (1999) Transfusion
medicine. First of two parts--blood transfusion. N Engl J Med 340: 438-447.
6. Karkouti K, Wijeysundera DN, Yau TM, Beattie WS, Abdelnaem E, et al. (2004)
The independent association of massive blood loss with mortality in cardiac
surgery. Transfusion 44: 1453-1462.
7. Price S, Pepper JR, Jaggar SI (2005) Recombinant human erythropoietin use
in a critically ill Jehovah’s Witness after cardiac surgery. Anesth Analg 101:
325-327.
8. Alghamdi AA, Albanna MJ, Guru V, Brister SJ (2006) Does the Use of
Erythropoietin Reduce the Risk of Exposure to Allogeneic Blood Transfusion
in Cardiac Surgery? A Systematic Review and Meta-Analysis. J Card Surg 21:
320-326.
9. Monk TG (2004) Preoperative recombinant human erythropoietin in anaemic
surgical patients. Crit Care 8: 45-48.
10. Weltert L, D’Alessandro S, Nardella S, Girola F, Bellisario A, et al. (2010)
Preoperative very short-term, high-dose erythropoietin administration
diminishes blood transfusion rate in off-pump coronary artery bypass: a
randomized blind controlled study. J Thorac Cardiovasc Surg 139: 621-626.
11. Diprose P, Herbertson MJ, O’Shaughnessy D, Deakin CD, Gill RS (2005)
Reducing allogeneic transfusion in cardiac surgery: a randomized double-blind
placebo-controlled trial of antifibrinolytic therapies used in addition to intra-operative
CS. Br J Anaesth 94: 271-278.
12. Murphy GJ, Allen SM, Unsworth-White J, Lewis CT, Dalrymple-Hay MJ (2004)
Safety and Efficacy of Perioperative CS and Autotransfusion After Coronary
Artery Bypass Grafting: A Randomized Trial. Ann Thorac Surg 77: 1553-1559.
13. Carless PA, Henry DA, Moxey AJ, O’Connell D, Brown T, et al. (2006) Cell
salvage for minimizing perioperative allogeneic blood transfusion. Cochrane
Database Syst Rev 17: CD001888.
14. Klein AA, Nashef SA, Sharples L, Bottrill F, Dyer M, et al. (2008) A randomized
controlled trial of cell salvage in routine cardiac surgery. Anesth Analg 107:
1487-1495.
This article was originally published in a special issue, Hematologic Oncol-ogy:
Diagnosis & Therapeutics handled by Editor(s). Dr. Ulrich Mahlknecht,
Saarland University, Germany
Submit your next manuscript and get advantages of OMICS
Group submissions
Unique features:
• User friendly/feasible website-translation of your paper to 50 world’s leading languages
• Audio Version of published paper
• Digital articles to share and explore
Special features:
• 200 Open Access Journals
• 15,000 editorial team
• 21 days rapid review process
• Quality and quick editorial, review and publication processing
• Indexing at PubMed (partial), Scopus, DOAJ, EBSCO, Index Copernicus and Google Scholar etc
• Sharing Option: Social Networking Enabled
• Authors, Reviewers and Editors rewarded with online Scientific Credits
• Better discount for your subsequent articles
Submit your manuscript at: http://www.omicsonline.org/submission