Electronic remote blood issue combined with a computer-controlled, automated refrigerator for major surgery in operating theatres at a distance from the transfusion service.

BACKGROUND: The difficulty of supplying red blood cells within an adequate time to patients undergoing surgery is a known problem for transfusion services, particularly if the operating theater is located at some distance from the blood bank. The consequences frequently are that more blood is ordered than required; several units are allocated and issued; and unused units must be returned to the blood bank. Some sparse reports have demonstrated that remote blood issue systems can improve the efficiency of issuing blood. STUDY DESIGN AND METHODS: This study describes a computer-controlled, self-service, remote blood-release system, combined with an automated refrigerator, installed in a hospital at which major surgery was performed, located 5 kilometers away from the transfusion service. With this system, red blood cell units were electronically allocated to patients immediately before release, when the units actually were needed. Two 2-year periods, before and after implementation of the system, were compared. RESULTS: After implementation of the system, the ratio of red blood cell units returned to the transfusion service was reduced from 48.9% to 1.6% of the issued units (8852 of 18,090 vs. 182 of 11,152 units; p < 0.0001), and the issue-to-transfusion ratio was reduced from 1.96 to 1.02. An increase in the number of transfused red blood cell units was observed, probably mainly due to changes in the number and complexity of surgical procedures. No transfusion errors occurred in the two periods. CONCLUSION: The current results demonstrate that the remote blood-release system is safe and useful for improving the efficiency of blood issue for patients in remote operating theatres.

Noninvasive dynamic assessment with transthoracic echocardiography of a composite arterial Y-graft achieving complete myocardial revascularization.

BACKGROUND: Composite arterial grafts are increasingly used in coronary artery bypass surgery. We assessed with transthoracic echocardiography the composite radial artery and in situ left internal thoracic artery Y-graft. METHODS: In 53 of 60 consecutive patients who underwent complete myocardial revascularization using only this composite arterial graft, good transthoracic echocardiographic images and pulsed Doppler signals of the Y-graft main stem were obtained at rest and early after standard exercise. Stress/rest 99mTc-sestamibi myocardial perfusion single-photon emission computed tomography (SPECT) was the gold standard for residual myocardial ischemia. The patients with negative SPECT were divided into groups according to the number of coronary artery systems grafted, and history of preoperative myocardial infarction. RESULTS: Diastolic peak velocity, diastolic velocity-time integral, the diastolic-to-systolic ratio of the peak velocities and velocity-time integrals, and the stress-to-rest ratio of the diastolic peak velocities and diastolic velocity-time integrals in the negative-SPECT patients were significantly greater than in the 6 positive-SPECT patients. Sensitivity and specificity for ischemia of the stress-to-rest ratio of the diastolic peak velocities less than 1.5 were 100%. The stress-to-rest ratio of the diastolic velocity-time integrals in the patients with three coronary systems grafted, and in those without preoperative myocardial infarction, were respectively greater than in the patients with two systems grafted (p < 0.0001), and in those with preoperative myocardial infarction (p = 0.0048). CONCLUSIONS: Noninvasive dynamic assessment with transthoracic echocardiography of a composite arterial graft, including in situ left internal thoracic artery, is feasible and correlates with myocardial perfusion SPECT. The Y-graft used was able to regulate its flow capacity to myocardial demand.

Weaning from ventilator after cardiac operation using the Ciaglia percutaneous tracheostomy.

OBJECTIVE: To determine the predictors of weaning from mechanical ventilation after cardiac operation with the Ciaglia percutaneous dilatational tracheostomy (PDT) in our preliminary experience in the use of this technique. METHODS: We prospectively analysed 33 consecutive patients (mean age 70.9+/-12.7 years) who underwent PDT in our intensive care unit after cardiac operation. The investigation involved preoperative and postoperative clinical status, operative procedure, indication and timing for PDT. RESULTS: PDT was performed after a mean time of 7.7+/-5.0 consecutive days of translaryngeal intubation. Twenty-four (73%) patients were weaned from ventilator after a mean time of mechanical ventilation of 15.8+/-9.1 days. Time point of PDT was the only predictor of ventilator weaning (P=0.0029): there was significant association between PDT performed before the seventh consecutive day of translaryngeal intubation (early PDT) and successful weaning from ventilator (P=0.01; odds ratio=11.2, 95% confidence interval=1.2-104.3). Among the patients weaned from ventilator, those who underwent early PDT had significantly shorter times of mechanical ventilation, and intensive care unit and hospital stays than patients with later PDT (P=0.035, 0.011 and 0.0073, respectively). Nine (27%) patients died of their underlying disease while still being mechanically ventilated; another six (18%) spontaneously breathing but still incannulated patients died afterward. No major PDT-related complications were observed. Two minor peristomal bleedings and one self-resolving subcutaneous emphysema were recorded. CONCLUSIONS: Early PDT was a safe and effective method to wean from mechanical ventilation the cardiosurgical patients of this series.

Tricuspid valve annuloplasty using a partial flexible ring: mid-term follow-up.

BACKGROUND: Tricuspid valve annuloplasty (TVA) using a complete or partial rigid or flexible ring is becoming common practice in the surgical treatment of tricuspid insufficiency (TI). This study evaluates the immediate outcome and the mid-term clinical and echocardiographic follow-up after TVA performed using the Cosgrove-Edwards partial flexible ring. METHODS: From June 1998 to March 2002, 35 consecutive adult patients with TI > 2+ underwent TVA using this annuloplasty ring. TI was secondary to right ventricular dilation and/or dysfunction (functional TI) in 32 (91.4%) patients, and due to anatomic anomalies of the tricuspid valve (organic TI) in 3 (8.6%). Pulmonary hypertension was present in 34.4% of the patients with functional TI. Thirty-two (91.4%) patients were in preoperative NYHA functional class III or IV. The mean follow-up was 28.3 +/- 14.6 months. RESULTS: There were three (8.6%) in-hospital non-valve-related cardiac deaths, and one (3.1%) non-cardiac death during follow-up. The 3-year actuarial survival was 96.5%. TI was well controlled within grade 1+ in 30 (96.8%) survivors, but one presented residual grade 2+ TI. The NYHA functional class improved to 1.3 +/- 0.5 (p = 0.035). CONCLUSIONS: TVA performed using the Cosgrove-Edwards ring is a valid option for the surgical treatment of both functional and organic TI, even in case of pulmonary hypertension and at mid-term follow-up.