Elective aortic surgery with minimal banked blood.

It has been a historical supposition that aortic surgery, even in an elective setting, has been associated with the transfusion of large amounts of blood products. We feel that this assumption is now dated, and in fact far fewer patients now receive allogenic blood products. To assess this assumption, we carried out a retrospective chart review of all patients who underwent elective aortic surgery over an 18-month period from April 1994 to October 1995. Factors analyzed included type of procedure, blood loss, amount of Cell Saver blood replaced, need for autologous blood transfusion, and need for allogenic blood transfusion. Sixty-seven patients underwent elective aortic surgery with either an aortic tube graft (23), an aortobiiliac graft (25), or an aortobifemoral graft (19). The male:female ratio was 48:19, with a mean age of 67 years (range, 42-85 years). Mortality and morbidity were 4.4 per cent and 8.9 per cent, respectively. The average blood loss per patient was 770 cc. Cell saver was used in 65 patients, with the average amount of blood returned being 542 cc. Overall, 73 per cent of patients did not require allogenic blood transfusion, and 58 per cent did not need any type of transfusion. Of those who stored autologous blood prior to operation, none required allogenic blood perioperatively. With the new advances in autologous blood transfusion both by predeposit and salvage transfusion, we have greatly reduced the need for transfusion of allogenic blood products in patients undergoing major aortic surgery. This is reassuring, and although increasing short-term cost, will reduce the morbidity-infectious, noninfectious, and immunologic-associated in prior decades with allogenic blood transfusions. We strongly recommend the use of Cell Saver techniques, and also, where possible, patients should be encouraged to donate their own blood prior to major aortic procedures for future transfusion.

Hereditary protein S deficiency in a large New Jersey kindred.

PURPOSE: Protein S is a vitamin K-dependent anticoagulant protein that serves as a cofactor for activated protein C. Deficiency of protein S has been associated with recurrent thrombotic events. To characterize better the risks of thrombosis in protein S deficiency, we studied 62 members in a large kindred. METHOD: All members were evaluated by a thorough clinical history. Plasma samples were assayed for total protein S antigen and protein S activity. Upper and lower extremity venous duplex examinations were performed in the majority of adult members. RESULT: Twenty-six (40%) of the 62 family members were classified as deficient on the basis of either low total protein S antigen levels or low protein S functional activity. Five members deficient in protein S had 16 venous thrombotic events. In all members the onset of thrombotic events occurred after 19 years of age, with a tendency for recurrence. Three lower extremity deep venous thromboses that had been occult previously were first diagnosed on surveillance duplex scanning. Only one member whose protein S level was not deficient had a single episode of superficial thrombophlebitis. CONCLUSION: Our findings in this large kindred confirm an autosomal-dominant inheritance pattern. Thrombotic events occurred after the age of 19 years in affected individuals and tended to be recurrent. The diagnosis of protein S deficiency is based on functional and immunologic plasma assays. In this study venous duplex scanning proved to be a useful diagnostic adjuvant.

Evaluation of autotransfusion in elective aortic reconstruction.

A new intraoperative autotransfusion system was prospectively evaluated in 30 major aortic reconstructions. After systemic heparinization of the patient, blood is collected in a cardiotomy reservoir and immediately reinfused (up to 500 ml/min). The amount of autotransfused or banked blood necessary to maintain the hemoglobin at 100 g/L during and for 24 hours after surgery was monitored and coagulation profiles, renal function and complications were recorded. The amount of autotransfused blood averaged 1414 ml and the number of packed red blood cells transfused over 24 hours averaged 1.9 units. Of the 30 patients, 24 required 2 units of homologous blood or less over 24 hours; 8 patients received no homologous transfusions and another 8 only 1 unit. There was no significant change postoperatively in serum creatinine or fibrinogen levels or in the prothrombin and partial thromboplastin times; the platelet count fell from 264 x 10(9)/L preoperatively to 182 x 10(9)/L postoperatively (p less than 0.05), but this was not clinically relevant. The free plasma hemoglobin level rose substantially, but perioperative urine output was good. There were no complications attributable to autotransfusion. The use of the autotransfuser during major vascular surgery provides a safe, effective means to minimize the loss of clotting factors, preserve blood-bank resources and eliminate the risk of disease transmission from homologous blood. By allowing rapid reinfusion when blood loss is excessive, this system can prevent prolonged hypotension in patients at increased cardiac risk.