Is cell salvage safe in liver resection? A pilot study.

STUDY OBJECTIVE: To investigate the quality of cell salvaged (CS) blood in patients undergoing hemihepatectomy (study group) and compare it with CS-blood from aortic surgery (control group). DESIGN: Observational study. SETTING: Operating room in a university hospital. MEASUREMENTS: 6 patients undergoing hemihepatectomy or aortobifemoral bypass with intraoperative blood loss of more than 800 mL. Samples were drawn from the central venous catheter, from the reservoir of a CS recovery system, and from the processed blood in each patient to determine interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor (TNF), complement C3a, and the terminal complement complex C5b-9. Microbiological analysis included colony count after cultivation in aerobic and anaerobic medium as well as enrichment culture for 6 days. MAIN RESULTS: In the hemihepatectomy group, levels of IL-6, C3a, and C5b-9 were significantly higher in the reservoir than in samples obtained from the central venous catheter. After the washing procedure, levels of IL-6, C3a, and C5b-9 were lower in the liver resection group than in each patient's own plasma levels. In all patients undergoing aortobifemoral bypass and in 5 patients undergoing hemihepatectomy, blood samples were sterile or showed growth of commensal skin microflora in low numbers (coagulase-negative staphylococci or propionibacteria). In one patient in the liver resection group, we could not exclude contamination with intestinal flora. CONCLUSION: Cell salvaged blood in liver resection seems to be safe for retransfusion with respect to cytokine release and complement activation, but requires further investigation in regard to bacterial contamination.

Hemodynamic effects of cardiotomy suction blood.

OBJECTIVE: Cardiac surgery induces a systemic inflammatory activation, which in severe cases is associated with peripheral vasodilation and hypotension. Cardiotomy suction blood contains high levels of inflammatory mediators, but the effect of cardiotomy suction blood on the vasculture is unknown. We investigated the effect of cardiotomy suction blood on systemic vascular resistance in vivo and whether cell-saver processing of suction blood affects the vascular response. METHODS: Twenty-five patients undergoing coronary surgery (mean age, 68 +/- 2 years; 80% men) were included in a prospective randomized study. The patients were randomized to retransfusion of cell-saver processed (n = 13) or cell-saver unprocessed (n = 12) suction blood during full cardiopulmonary bypass. Mean arterial blood pressure was continuously registered during retransfusion, and systemic vascular resistance was calculated. Plasma concentrations of tumor necrosis factor alpha, interleukin 6, and complement factor C3a were measured in suction blood. RESULTS: Retransfusion of cardiotomy suction blood induced a transient reduction in systemic vascular resistance in all patients. The peak reduction was significantly less pronounced in the group receiving cell-saver processed blood (-12% +/- 2% vs -28% +/- 3%, P = .001). There was a significant correlation between tumor necrosis factor alpha concentration in retransfused cardiotomy suction blood and peak reduction of systemic vascular resistance (r = 0.60, P = .002). CONCLUSIONS: The results suggest cardiotomy suction blood is vasoactive and might influence vascular resistance and blood pressure during cardiac surgery. The observed vasodilation is proportional to the inflammatory activation of suction blood and can be reduced by processing suction blood with a cell-saving device before retransfusion.

Lipid transfer protein and vicilin are important walnut allergens in patients not allergic to pollen.

BACKGROUND: Walnut is the most common cause of allergic reactions to tree nuts, as reported by large population studies. Two major allergens of walnut have been identified up until now: a 2S albumin and a vicilin-like protein. OBJECTIVE: This study was designed to identify the walnut major allergens in the Italian population and to compare the walnut IgE-binding profile in patients with or without pollen allergy. METHODS: We selected 46 patients either with oral allergy syndrome confirmed by open oral challenge or with systemic symptoms after ingestion of walnut. These patients' sera were used for the immunoblotting of walnut extract; the identified allergens were purified by HPLC and sequenced. A peach-walnut cross-inhibition study was then performed. RESULTS: The only major allergen recognized by our study population was a 9-kd lipid transfer protein (LTP), recognized by 37 patients. Two other minor allergens of approximately 9-kd molecular weight, both belonging to the vicilin family, were recognized by 10 patients. IgE binding to walnut LTP was completely inhibited by peach LTP. CONCLUSION: In Italian patients with walnut allergy confirmed by documented history of severe systemic reactions or by open oral food challenge, the major allergen is an LTP. The sensitization to this protein seems to be secondary to the sensitization to peach LTP, which acts as the primary sensitizer. LTP and vicilins were able to sensitize patients not allergic to pollen.

Coronary surgery without cardiotomy suction and autotransfusion reduces the postoperative systemic inflammatory response.

BACKGROUND: Cardiotomy suction and autotransfusion of mediastinal shed blood may contribute to the inflammatory response after cardiac surgery. We compared inflammatory activation, myocardial injury, bleeding, and hemoglobin levels in patients undergoing coronary surgery with or without retransfusion of cardiotomy suction blood and mediastinal shed blood. METHODS: Twenty-nine patients were included in a prospective randomized study. Cardiotomy suction blood and mediastinal shed blood were either retransfused or discarded. Plasma concentrations of the cytokines tumor necrosis factor-alpha and interleukin-6 and complement factor C3a were measured preoperatively and 10 minutes, 2 hours, and 24 hours after cardiopulmonary bypass. C-reactive protein, erythrocyte sedimentation rate, troponin-T, and hemoglobin levels were analyzed preoperatively, and 24 and 48 hours after cardiopulmonary bypass. Postoperative bleeding the first 12 hours was registered. RESULTS: Baseline data did not differ between the groups. Plasma concentrations of tumor necrosis factor-alpha, interleukin-6, and C3a increased after surgery in both groups but significantly less in the group without cardiotomy suction and autotransfusion. The peak delta values in the no-retransfusion group was 36% (tumor necrosis factor-alpha), 47% (interleukin-6), and 75% (C3a) of the values in the retransfusion group. C-reactive protein, erythrocyte sedimentation rate, and troponin-T increased after surgery in both groups without intergroup differences. Postoperative bleeding and hemoglobin levels did not differ between the groups. No patient received homologous blood transfusion. CONCLUSIONS: Coronary surgery without retransfusion of cardiotomy suction blood and mediastinal shed blood reduces the postoperative systemic inflammatory response.

Activation of the complement system by different autologous transfusion devices: an in vitro study.

BACKGROUND: The aim of the present investigation was to study whether autologous transfusion devices activate the complement system and whether complement-activated blood is more vulnerable to further activation during processing. STUDY DESIGN AND METHODS: Forty-eight blood units were randomized to be processed by one of three different salvage systems: Group 1 underwent whole blood filtration (hemofiltration) (n=16); Group 2 underwent continuous processing, saline washing, and centrifugation (CATS, Fresenius AG ) (n=16); and Group 3 underwent saline washing and centrifugation (Cell-Saver, Haemonetics Corp.) (n=16). Eight blood units for each system were activated with cobra venom factor (CVF) at a concentration of 0.2 U per mL whole blood before processing. C activation was studied by determinations of C4d, Bb, C3a, and SC5b-9. Samples were drawn from whole blood, processed blood, and the waste bags. RESULTS: The concentrations of Bb, C3a, and SC5b-9 in whole blood after activation with CVF were significantly elevated compared to blood that was not activated (p < 0.01). Processed blood from hemofiltration contained significantly higher levels of complement-split products than techniques that use washing and centrifugation. The concentrations of SC5b-9 in blood processed by hemofiltration were higher in the experiments with CVF activation (p < 0.05). CONCLUSION: The tested autologous transfusion systems did not themselves activate the complement system, and complement-activated blood was not more vulnerable to further activation during processing. A blood-salvaging technique that used washing and centrifugation reduced elevated concentrations of complement-split products, whereas hemofiltration did not.

Predictors of allograft ischemic injury in clinical heart transplantation.

OBJECTIVES: 1. Identify clinical, biochemical and inflammatory predictors of allograft ischemic injury in clinical heart transplantation. 2. Evaluate the impact of high dose insulin (GIK) on allograft metabolism during blood cardioplegia and post-ischemic injury. DESIGN: A clinical, prospective, randomized open trial comprising 25 consecutive heart transplantations at a university hospital. Ischemic injury was evaluated from plasma levels of creatine kinase isoenzyme MB (CK-MB). Blood cardioplegic arterial and coronary sinus concentrations of C3a, IL-6, substrates, amino acids and blood gases were measured at the end of the implantation period, prior to reperfusion. Twelve patients received high dose insulin with glucose, potassium and amino acids. RESULTS: CK-MB increased from 1.9 +/- 0.2 to 161 +/- 13 microg/l (range 47-293 microg/l). The peak level of CK-MB correlated with donor age (r = 0.48, p = 0.02) and implantation time (r = 0.53, p = 0.02); and with recipient plasma IL-6 (r = 0.56, p = 0.02), allograft oxygen extraction (r = 0.56, p = 0.02), lactate release (r = 0.47, p = 0.02) and allograft arterial-coronary sinus (cs) pH (r = 0.47, p = 0.02) all during final cardioplegia before reperfusion. Seventy-two percent of the variance of CK-MB was explained by a model which included donor age, art-cs pH difference and arterial IL-6. In contrast, CK-MB was unrelated to total ischemic time (r = -0.17, p = 0.38). Insulin infusion had no effect on myocardial substrates during cardioplegia, or on post-ischemic CK-MB. CONCLUSION: Donor age, duration and quality of the implantation period are significant predictors of allograft ischemic injury in heart transplantation. High dose insulin had no detectable effects on allograft metabolism during cardioplegia, or on subsequent ischemic injury.

Hypersensitivity to mugwort (Artemisia vulgaris) in patients with peach allergy is due to a common lipid transfer protein allergen and is often without clinical expression.

BACKGROUND: The observation of mugwort-specific IgE antibodies in patients with peach allergy suggests that mugwort sensitization might play a role in sensitization to peach. OBJECTIVE: We sought to study the clinical manifestations of mugwort hypersensitivity in patients with peach allergy, identify the common allergens, and evaluate their IgE crossreactivity. METHODS: Patients with oral allergy syndrome for peach and specific IgE antibodies to mugwort were investigated for respiratory symptoms during the mugwort season. Peach and mugwort allergens were identified by means of SDS-PAGE and IgE immunoblotting. Immunoblotting inhibition experiments were done to study cross-reactivity between peach and mugwort and other pollens. RESULTS: Seventeen patients were studied, 10 with no seasonal respiratory symptoms and 7 with clear late summer respiratory symptoms. In IgE immunoblotting the 10 asymptomatic patients reacted only to a 9-kd allergen of both mugwort and peach, whereas the 7 patients with pollinosis reacted to other allergens. Ten patients with mugwort allergy, no history of allergy to peach, and negative results for peach-specific IgE antibodies were also studied. The mugwort 9-kd protein was identified as a lipid transfer protein (LTP) homologous to peach LTP. Immunoblotting inhibition showed that IgE binding to the peach 9-kd band was totally inhibited by 4 microg of peach LTP but only by 400 microg of mugwort LTP, whereas 4 microg of both mugwort and peach LTP totally inhibited the mugwort immunoblotting. The results were similar with other pollens. CONCLUSIONS: Patients sensitized only to the 9-kd LTP of mugwort do not present hay fever symptoms, and this sensitization is a consequence of the peach sensitization.

Autologous blood transfusion in radical hysterectomy with and without erythropoietin therapy.

OBJECTIVE: To investigate whether preoperative treatment with erythropoietin facilitates the collection of a sufficient amount of autologous blood in a short period of time. METHODS: Forty-one women scheduled for radical hysterectomy were randomized to preoperative autologous blood donation with or without preoperative recombinant human erythropoietin therapy. All patients were scheduled to deposit three units of blood within 2 weeks before surgery. Hemoglobin, erythrocyte volume fraction, blood cells, iron status, and hemolysis were analyzed before and after surgery. RESULTS: Hemoglobin levels decreased continuously in both groups after the first autologous donation until day 1 postoperatively. With erythropoietin therapy, the erythrocyte volume fraction and hemoglobin levels were significantly higher during precollection and day 1 after surgery. Preoperatively, the drop was 12 g/L less in the erythropoietin-treated group. The additional use of erythropoietin therapy reduced the inability of patients to predeposit blood from 17.8% to 3.4%. CONCLUSION: Most women can predeposit three units of whole blood in only 2 weeks without obtaining severe anemia. By treating women with erythropoietin, one out of seven can be prevented from a hemoglobin level below the 100 g/L limit for donation.

[Compression dressing after hip joint replacement reduces the need of allogeneic blood transfusion]. / Kompressionsförband minskar behovet av allogent blod vid höftproteskirurgi.

Allogeneic blood transfusion may increase the risk for postoperative infections, allergic reactions and transmission of diseases. The aim with the present study was to evaluate the effect on blood saving with a new type of compression dressing after hip joint replacement surgery. 50 patients undergoing after hip joint replacement surgery were prospectively allocated to postoperatively get a standard dressing (n = 24) or the new type of a compression dressing (n = 26). The peroperative bleeding was similar in both groups. The need for allogeneic blood transfusions were significantly higher in the group of patients that got standard dressing. This study indicates that the compression dressing reduces the need for allogeneic blood transfusions after after hip joint replacement surgery.