[Mortality after high-risk surgery in Jehovah's Witness patients]. / Letalität nach operativen Risikoeingriffen bei Zeugen Jehovas.

BACKGROUND: Jehovah's Witness (JW) patients strictly refuse allogeneic blood transfusion for religious reasons. Nevertheless, JW also wish to benefit from modern therapeutic concepts including major surgical procedures without facing an excessive risk of death. The Northwest Hospital in Frankfurt am Main Germany is a confidential clinic of JW and performs approximately 100 surgical interventions per year on this patient group. MATERIAL AND METHODS: A retrospective analysis of closed medical cases performed in the years 2008-2018 at the Northwest Hospital aimed to clarify (1) the frequency of surgical procedures in JW patients associated with a statistical allogeneic transfusion risk (presence of preoperative anemia and/or in-house transfusion probability >10%) during this time period, (2) the degree of acceptance of strategies avoiding blood transfusion by JW and (3) the anemia-related postoperative mortality rate in JW patients. RESULTS: In the 11- year observation period 123 surgical procedures with a relevant allogeneic transfusion risk were performed in 105 JW patients. Anemia according to World Health Organization (WHO) criteria was present in 44% of cases on the day of surgery. Synthetic and recombinant drugs (tranexamic acid, desmopressin, erythropoetin, rFVIIa) were generally accepted, acute normovolemic hemodilution (ANH) in 92% and cell salvage in 96%. Coagulation factor concentrates extracted from human plasma and therefore generally refused by JW so far, were accepted by 83% of patients following detailed elucidation. Out of 105 JW patients 7 (6.6%) died during the postoperative hospital stay. In 4 of the 7 fatal cases the cause of death could be traced back to severe postoperative anemia. CONCLUSION: Given optimal management JW patients can undergo major surgery without an excessive risk of death. The 6.6% in-hospital mortality observed in this institution was in the range of the 4% generally observed after surgery in Europe. The majority of JW patients accepted a variety of blood conservation strategies following appropriate elucidation. This also included coagulation factor concentrates extracted from human plasma enabling an effective treatment of even severe bleeding complications. In this analysis postoperative hemoglobin concentrations below 6 g/dl in older JW patients were associated with a high mortality risk due to anemia.

Vascular surgery: An essential hospital resource in modern health care.

OBJECTIVE: In modern health care, vascular surgeons frequently serve as a unique resource to other surgical specialties for vascular exposure, repair, reconstruction, or control. These services occur both in planned and unplanned clinical settings. We analyzed the frequency, outcomes, and value of vascular services in this setting to other surgical specialties and the hospital. METHODS: Intraoperative planned and unplanned vascular surgery operative consultations were reviewed over a 3-year period (2013-2016). Patient demographics, requesting surgical specialty, indication and type of vascular intervention, and work relative value units generated were recorded. Univariate and multivariate analysis of factors affecting a composite outcome of in-hospital and 30-day mortality or morbidity, or both, was performed. RESULTS: Seventy-six vascular surgery intraoperative consultations were performed, of which 56% of the consultations were unplanned. The most common unplanned consultation was for bleeding (33%). The aorta and lower extremity were the most common vascular beds requiring vascular services. The mean work relative value units generated per vascular surgery intervention was 23.8. In-hospital and 30-day mortality was 9.2%. No difference in mortality and morbidity was found between planned and unplanned consultations. Factors associated with the composite mortality/morbidity outcome were coronary artery disease (P = .002), heart failure (P = .02), total operative blood loss (P = .009), consultation for limb ischemia (P = .013), and vascular consultation for the lower extremity (P = .01). On multivariate analysis, high operative blood loss (>5000 mL) remained significant (P = .04), and coronary artery disease approached significance (P = .06). CONCLUSIONS: The need for vascular surgery services is frequent, involves diverse vascular beds, and occurs commonly in an unplanned setting. When requested, vascular surgery services effectively facilitate the completion of the nonvascular procedure, even those associated with significant intraoperative blood loss. Vascular surgery services are essential to other surgical specialties and the hospital in today's modern health care environment.

Perioperative bleeding management in pediatric patients.

PURPOSE OF REVIEW: Managing the bleeding pediatric patient perioperatively can be extremely challenging. The primary goals include avoiding hypotension, maintaining adequate tissue perfusion and oxygenation, and maintaining hemostasis. Traditional bleeding management has consisted of transfusion of autologous blood products, however, there is strong evidence that transfusion-related side-effects are associated with increased morbidity and mortality in children. Especially concerning is the increased reported incidence of noninfectious adverse events such as transfusion-related acute lung injury, transfusion-related circulatory overload and transfusion-related immunomodulation. The current approach in perioperative bleeding management of the pediatric patient should focus on the diagnosis and treatment of anemia and coagulopathy with the transfusion of blood products only when clinically indicated and guided by goal-directed strategies. RECENT FINDINGS: Current guidelines recommend that a comprehensive multimodal patient blood management strategy is critical in optimizing patient care, avoiding unnecessary transfusion of blood and blood product and limiting transfusion-related side-effects. SUMMARY: This article will highlight current guidelines in perioperative bleeding management for our most vulnerable pediatric patients with emphasis on individualized targeted intervention using point-of-care testing and specific coagulation products.

Propensity score analysis of outcomes following minimal access versus conventional aortic valve replacement.

OBJECTIVES: Minimal access aortic valve replacement has become routine in many institutions. Aim of this study was to compare the clinical outcomes between conventional and minimal access aortic valve replacement. METHODS: We retrospectively analysed the data of 2103 patients who underwent primary, isolated aortic valve replacement (AVR) in our institution between January 2001 and May 2012 with a minimal access AVR (MAAVR) via the upper partial ministernotomy approach (n = 936) or conventional AVR (CAVR) via the full sternotomy approach (n = 1167). After propensity score matching considering potential confounders [age, sex (female), weight, height, preoperative serum creatinine level, previous myocardial infarction, LV-EF and aortic valve pathology (isolated AS)], 585 matched patients were included in each group. RESULTS: Mean age (65 ± 10.5 vs 65.7 ± 11.5 years, P = 0.23), gender (females 37.2%, P = 0.9), aortic cross-clamp time (65.6 ± 18.4 vs 64.3 ± 19.8 min, P = 0.25) and postoperative blood loss [median (IQR) 400 (224-683) vs 400 (250-610) ml, P = 0.83) were similar in MAAVR and CAVR group. Thirty-day mortality was also not significantly different (1.5 vs 1.7%, P = 0.74, respectively). In contrast, CPB times were significantly longer in MAAVR (93.5 ± 25 vs 88 ± 28 min, P < 0.001). Intraoperative and postoperative autologous blood transfusions were significantly lower in MAAVR (927.2 ± 425.6 vs 1036.4 ± 599.6 ml, P < 0.001 and 170.2 ± 47.6 vs 243.5 ± 89.3 ml, P < 0.001, respectively). Intubation time was significantly shorter in MAAVR [median (IQR) 7 (5-11) vs 8 (6-14) h, P = 0.01). The incidence of renal insufficiency (creatinine ≥1.5 mg/dl) and respiratory insufficiency (need for non-invasive ventilation, reintubation or tracheotomy) was significantly lower in MAAVR (9 vs 16%, P < 0.001 and 8.5 vs 11.8%, P = 0.03, respectively). CONCLUSIONS: In comparison with CAVR, our study shows that MAAVR is a safe and effective procedure associated with low mortality rate and good long-term survival rates. In addition to that, MAAVR was associated with shorter ventilation times, lower rate of autologous blood transfusion, as well as a lower rate of postoperative respiratory and renal insufficiency. Because of the superior cosmetic results, we therefore advocate MAAVR as the procedure of choice for primary isolated AVR.

Can Transfusions Be Eliminated in Major Abdominal Surgery? Analysis of a Five-Year Experience of Blood Conservation in Patients Undergoing Pancreaticoduodenectomy.

Pancreaticoduodenectomy (PD) has historically required perioperative blood transfusion in 40 to 60 per cent of cases. Growing data suggest that transfusions may be deleterious in the surgical patient. We recently initiated a minimal transfusion approach to PD consisting of limited postoperative blood draws, early iron supplementation, changes in surgical technique, and elimination of hemoglobin transfusion triggers. Predictors of perioperative transfusion were analyzed in 130 consecutive patients undergoing PD by a single surgeon between 2008 and 2013, divided into two eras with 65 patients each. Patients in each era were similar with respect to age, comorbidities, American Society of Anesthesiologists class, body mass index, and diagnosis. The transfusion rate for the entire group was 22 per cent. Nonsignificant predictors of perioperative transfusion include American Society of Anesthesiologists class ≥3 (P = 0.41), vascular resections (P = 0.56), body mass index ≥30 (P = 0.72), and intraoperative blood loss (P = 0.89). Significant predictors of transfusion include PD performed in Era 1 as well as preoperative hemoglobin levels <10 g/dL. In Era 1, 38 per cent of patients required transfusion compared with 6 per cent in Era 2 (P < 0.01). Shorter length of stay and a trend toward decreased pancreatic fistulae were seen in Era 2. Transfusions can be almost completely eliminated in PD and this may contribute to improved outcomes.

Cell salvage during coronary artery bypass surgery and allogenic blood exposure.

AIM: Our primary aim was to assess the impact of intraoperative cell saver usage on patient exposure to allogenic blood transfusion during elective coronary artery bypass. The secondary endpoint was the impact of cell savage on the units of blood and blood products transfused perioperatively. METHODS: A prospective observational cohort study with a historical cohort as a control group was performed in a single tertiary care center. One hundred and twenty-four patients undergoing primary on-pump coronary artery bypass grafting were included. Intraoperative cell salvage was performed in 60 patients (study group) but not in the control group (n = 64). Transfusion data, intensive care unit stay, hospital stay, and postoperative complications were evaluated in the cell saver and control groups. RESULTS: The number of patients exposed to allogenic red blood cell transfusion was significantly less in the study group (55% vs. 82.8%; p = 0.001) and the units per patient was also less in the study group (1.10 ± 1.7 vs. 2.25 ± 2.289 units; p = 0.002). However, there was no significant difference in terms of units of purified plasma fraction, platelets, or cryoprecipitate transfused. Intensive care unit stay, total hospital stay, number of reexplorations, complications, readmissions, and 28-day mortality were similar in both groups. CONCLUSIONS: Intraoperative cell salvage with a cell saver in patients undergoing primary elective coronary artery bypass decreases the proportion of patients exposed to allogenic red cell transfusions and the number of units of red blood cells transfused.

Efficacy of cell saver use in living-donor liver transplant.

OBJECTIVES: Liver transplant currently is the best treatment option for end-stage liver disease. During liver transplant, there is major blood loss due to surgery and primary disease. By using a cell saver, the need for blood transfusion is markedly reduced. In this study, we aimed to evaluate the efficacy of cell saver use on morbidity and mortality in living-donor liver transplant. MATERIALS AND METHODS: We retrospectively evaluated 178 living-donor liver transplants, performed from 2005 to 2013 in our center. Child-Turcotte-Pugh A patients, deceased-donor liver transplants, and liver transplants performed for fulminant hepatic failure were not included in this study. Intraoperative blood transfusion was done in all patients to keep hemoglobin level between 10 and 12 g/dL. Cell saver was used in all liver transplants except in patients with malignancy, hepatitis B, and hepatitis C. RESULTS: We included 126 patients in the study. Cell saver was used in 84 liver transplants (66%). In 42 patients (34%), liver transplant was performed without a cell saver. In living-donor liver transplant with cell saver use, 10 mL/kg blood (range, 2-50 mL/kg blood) was transfused from the cell saver; in addition, 5 to 10 mL/kg allogeneic blood was transfused. In living-donor liver transplant without cell saver, 20 to 25 mL/kg allogeneic blood was transfused. CONCLUSIONS: During liver transplant, major blood transfusion is needed because of surgery and primary disease. Cell saver use markedly decreases the need for allogeneic blood transfusion and avoids adverse events of massive transfusion.

[The intraoperative auto- and allohemotransfusion by massive bleeding in emergency abdominal surgery].

The results of intraoperative hemotransfusion of 112 patients with abdominal injuries, complicated with bleeding and the loss of more then 70% of the circulating blood. The aim of the study was to compare the efficacy of auto- and allohemotransfusion. The first method allowed to decrease both the overall lethality (p=0.039) and postoperative lethality (p=0.018). The odds ratio by the predominate autohemotransfusion was 1.385 (95% 1.101-1.741), where as the odds ratio by the predominate allohemotransfusion was 0.403 (95% 0.183-0.885; p=0.011).

Refusal of blood transfusion by Jehovah's Witness women: a survey of current management in obstetric and gynaecological practice in the U.K.

BACKGROUND: Refusal of blood transfusion by Jehovah's Witness (JW) women poses potential problems for obstetrics worldwide as haemorrhage remains a major cause of maternal morbidity and mortality. There is a general consensus that morbidity and mortality rates in association with childbirth and gynaecological interventions are higher in these women than in the general population. We conducted a postal questionnaire survey of current practice among U.K. consultant obstetricians and gynaecologists to establish the practices that could contribute to poor outcomes in these women. MATERIALS AND METHODS: The main variables of interest were: use of a multi-disciplinary approach; the acceptable minimum haemoglobin (Hb) concentration before vaginal delivery and abdominal hysterectomy as low to medium risk scenarios and open myomectomy as a high risk scenario for haemorrhage; Hb concentration thresholds for iron supplementation; and the use of oral iron, intravenous iron, erythropoietin and cell salvage as potential management tools. RESULTS: The response rate was 28%. Sixty percent of gynaecologists and 85% of obstetricians reported having a protocol for the management of JW women. Forty-six percent of consultants adopt a multi-disciplinary approach which include anaesthetists and haematologists. A Hb concentration of >11-12 g/dL is considered the minimum acceptable level by a majority (47%) prior to normal delivery and by 42% of gynaecologists prior to abdominal hysterectomy. For open myomectomy 28% of gynaecologists prefer a minimum level of 11-12 g/dL but a further 31% of gynaecologists prefer a minimum level of 12-13 g/dL. DISCUSSION: A small but substantial proportion of consultants do not have protocols, operate on JW women with low Hb concentrations, do not use a lower Hb concentration threshold for supplementation, and do not adopt a multi-disciplinary approach, all of which could contribute to the reported poor outcomes in these women.

Intraoperative blood product resuscitation and mortality in ruptured abdominal aortic aneurysm.

OBJECTIVES: The resuscitation of patients with ruptured abdominal aortic aneurysms (RAAAs) has not been well studied, and the potential benefit of autotransfusion (AT) is unknown. The increased use of fresh-frozen plasma (FFP) has been associated with decreased mortality rates in trauma patients and may also improve RAAA survival. We explored the influence of intraoperative AT and FFP resuscitation on mortality rates in massively transfused RAAA patients. METHODS: A single-center review of RAAA patient records from April 1989 to October 2009 was undertaken. Clinical data and outcomes were studied. Operative and anesthesia records were queried for intraoperative transfusion totals. Massive transfusion was defined as ≥10 units of red blood cells (RBCs) inclusive of AT units. RESULTS: We identified 151 RAAA patients, of which 89 (60%) received a massive transfusion and comprised the study population. These 89 patients had an in-hospital mortality rate of 44%. Univariate predictors of mortality included increased age, preoperative hypotension, operative blood loss, and crystalloid, RBCs, and FFP volume. AT was used in 85 patients, with an increased ratio of AT:RBC units associated with survival. Mortality was 34% with AT:packed RBCs (PRBC) ≥1 (high AT) and 55% with AT:PRBC of <1 (low AT; P = .04). On multivariate analysis, age > 74 years (P = .03), lowest preoperative systolic blood pressure (SBP) <90 mm Hg (P = .06), blood loss >6 liters (P = .06), and low AT (P = .02) independently predicted mortality. The mean RBC:FFP ratio was similar in those that died (2.7) and in those that lived (2.9; P = .66). RBC:FFP ≤2 (high FFP) was present in 38 (43%) patients, with mortality of 49%. RBC:FFP >2 (low FFP) had 40% mortality (P = .39). RBC:FFP ratios decreased over time from 3.6 (years 1989 to 1999) to 2.2 (years 2000 to 2009; P < .001), but more liberal use of FFP was not associated with decreased mortality (47% vs 41%; P = .56). AT:PRBC ratios were stable over time (range, 1.4-1.2; P = .18). CONCLUSIONS: Greater use of AT but not of FFP was associated with survival in massively transfused RAAA patients. No mortality benefit was seen with increased FFP, but few patients had high FFP transfusion ratios. Further study to identify RAAA patients at risk for massive transfusion should be undertaken and a potentially greater role for AT in RAAA resuscitation investigated.

Intraoperative autotransfusion for repair of unruptured aneurysms of the infrarenal abdominal aorta. A multicenter study of 203 patients. Association Universitaire de Recherche en Chirurgie (AURC).

BACKGROUND: The goals of this study were to evaluate the costs and savings of intra- and postoperative blood transfusions as well as the potential biological modifications associated with the use of intraoperative blood salvage. METHODS: Intraoperative autotransfusion (IOAT) with wash-out was prospectively studied during the repair of unruptured aneurysms of infrarenal abdominal aorta in 203 patients operated on in 13 institutions. RESULTS: The mean quantity of blood retrieved was 688+/-468 mL The mean quantity of blood derivatives and intraoperative solutes used for repletion was 4,261 ml, ranging from 1,723 ml between days 0 to D2 to 562 ml from D3 to D8. Ninety-eight patients did not receive any blood derivatives at all. Thirty-five patients received plasma to correct coagulation factors. The quantity of autotransfused globular concentrate was less than 500 ml in 89 patients. CONCLUSIONS: IOAT precluded the need for transfusion of homologous globular concentrates, particularly in those patients who had bled most. On average, more than two globular concentrates were recuperated. Use of IOAT led to financial savings. Perioperative bleeding is not the only factor that intervenes in the decision to transfuse globular concentrates. Postoperative dilution is the most important factor as attested by the amount of protides and the hematocrit. Coagulation factors are modified but remain compatible with normal hematosis in 83% of patients undergoing operation.

Vascular complications of transsphenoidal surgery.

Vascular complication of transsphenoidal surgery can lead to mortality and serious morbidity. In a series of 3,061 transsphenoidal operations for pituitary disease, 24 such complications were encountered, seven of which were fatal. The anatomic substrate for such complications is discussed, along with technical aspects of surgery and other methods for the avoidance of vascular complications.