Impact of intraoperative high-volume autologous blood collection on allogeneic transfusion during and after cardiac surgery: a propensity score matched analysis.

BACKGROUND: Perioperative use of allogeneic blood products is associated with higher morbidity, mortality, and hospital costs after cardiac surgery. Blood conservation techniques such as acute normovolemic hemodilution (ANH) report variable success. We hypothesized that large-volume ANH with limited hemodilution would reduce allogeneic blood transfusion compared to the standard practice. STUDY DESIGN AND METHODS: Retrospective observational study of cardiac surgery patients at the University of Maryland Medical Center between January 2014 and September 2017. Using the institutional Society of Thoracic Surgeons database 91 autologous and 981 control patients who underwent coronary artery bypass grafting, aortic valve replacement, or both were identified. After propensity matching of 13 preoperative characteristics, 84 autologous and 84 control patients were evaluated. Our primary endpoint was avoidance of blood transfusion during index hospitalization, and secondary endpoints were postoperative bleeding and major adverse outcomes. RESULTS: The median harvest volumes in the ANH and control groups were 1100 mL and 400 mL, respectively. Of the ANH group, 25% received any transfusion versus 45.2% of the control group after propensity score matching (p < 0.006). When controlling for preoperative platelet count, the transfusion rate ratios for ANH were 0.58 (95% confidence interval, 0.39-0.88) for RBCs and 0.63 (0.44-0.89) for non-RBC components, which were both found to be statistically significant. There was no difference found in major adverse events. CONCLUSION: These results suggest that large-volume ANH is beneficial in reducing both RBC and non-RBC component usage in cardiac surgery. A further prospective validation is warranted.

Improvements in blood transfusion management: cross-sectional data analysis from nine hospitals in Zhejiang, China.

BACKGROUND: Since 2008, updated perioperative blood management (PoBM) guidelines have been implemented in Zhejiang, China. These guidelines ensure that the limited blood resources meet increasing clinical needs and patient safety requirements. We assessed the effects of implementing updated PoBM guidelines in hospitals in Zhejiang, China. METHODS: We performed a retrospective multicenter study that included adult patients who received blood transfusions during surgical care in the years 2007 and 2011. The volume of allogeneic red blood cells or autologous blood transfusions (cell salvage and acute normovolemic hemodilution [ANH]) for each case was recorded. The rates of performing appropriate pre-transfusion assessments during and after surgery were calculated and compared between the 2 years. RESULTS: We reviewed 270,421 cases from nine hospitals. A total of 15,739 patients received blood transfusions during the perioperative period. The rates of intraoperative allogeneic transfusion (74.8% vs. 49.9%, p <  0.001) and postoperative transfusion (51.9% vs. 44.2%, p <  0.001) both decreased from 2007 to 2011; the rates of appropriate assessment increased significantly during (63.0% vs. 78.0%, p <  0.001) and after surgery (70.6% vs. 78.4%, p <  0.001). The number of patients who received cell salvage or ANH was higher in 2011 (27.6% cell salvage; 9.3% ANH) than in 2007 (6.3% cell salvage; 0.1% ANH). CONCLUSION: Continuing education and implementation of updated PoBM guidelines resulted in significant improvements in the quality of blood transfusion management in hospitals in Zhejiang, China.

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.

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.

Impact of peri-operative blood transfusion on the outcomes of patients undergoing radical cystectomy for urothelial carcinoma of the bladder.

OBJECTIVE: To determine the association between peri-operative blood transfusion (PBT) and oncological outcomes in a large multi-institutional cohort of patients undergoing radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB). PATIENTS AND METHODS: We conducted a retrospective analysis of 2895 patients treated with RC for UCB. Univariable and multivariable Cox regression models were used to analyse the effect of PBT administration on disease recurrence, cancer-specific mortality, and any-cause mortality. RESULTS: Patients' median (interquartile range [IQR]) age was 67 (60, 73) years and the median (IQR) follow-up was 36.1 (15, 84) months. Patients who received PBT were more likely to have advanced disease (P < 0.001), high grade tumours (P = 0.047) and nodal metastasis (P = 0.004). PBT was associated with a higher risk of disease recurrence (P = 0.003), cancer-specific mortality (P = 0.017), and any-cause mortality (P = 0.010) in univariable, but not multivariable, analyses (P > 0.05). In multivariable analyses, pathological tumour stage, pathological nodal stage, soft tissue surgical margin, lymphovascular invasion and administration of adjuvant chemotherapy were independent predictors of disease recurrence, cancer-specific mortality and any-cause mortality (all P values <0.002). CONCLUSIONS: Patients with UCB who underwent RC and received PBT had a greater risk of disease recurrence, cancer-specific mortality and any-cause mortality in univariable, but not multivariable, analysis. Although the greater need for PBT with more advanced disease is probably caused by a number of factors, including surgical and cancer-related factors, the present analysis showed that the disease characteristics rather than need for PBT led to worse outcomes.

Comparison of results of autologous versus homologous blood transfusion in open-heart surgery.

BACKGROUND: The aim of this study was to determine a method to decrease the use of homologous blood during openheart surgery using a simple blood-conservation protocol. We removed autologous blood from the patient before bypass and used isovolumetric substitution. We present the results of this protocol on morbidity and mortality of surgery patients from two distinct time periods. METHODS: Patients from the two surgical phases were enrolled in this retrospective study in order to compare the outcomes using autologous or homologous blood in open-heart surgery. A total of 323 patients were included in the study. The autologous transfusion group (group 1) comprised 163 patients and the homologous transfusion group (group 2) 160 patients. In group 1, autologous bloods were prepared via a central venous catheter that was inserted into the right internal jugular vein in all patients, using the isovolumetric replacement technique. The primary outcome was postoperative In-hospital mortality and mortality at 30 days. Secondary outcomes included the length of stay in hospital and in intensive care unit (ICU), time for extubation, re-intubations, pulmonary infections, pneumothorax, pleural effusions, atrial fibrillation, other arrhythmias, renal disease, allergic reactions, mediastinitis and sternal dehiscence, need for inotropic support, and low cardiac-output syndrome (LCOS). RESULTS: The mean ages of patients in groups 1 and 2 were 64.2 ± 10.3 and 61.5 ± 11.6 years, respectively. Thirty-eight of the patients in group 1 and 30 in group 2 were female. There was no in-hospital or 30-day mortality in either group. The mean extubation time, and ICU and hospital stays were significantly shorter in group 1. Furthermore, postoperative drainage amounts were less in group 1. There were significantly fewer patients with postoperative pulmonary complications, pneumonia, atrial fibrillation and renal disease. The number of patients who needed postoperative inotropic support and those with low cardiac output was also significantly less in group 1. CONCLUSION: Autologous blood transfusion is a safe and effective method in carefully selected patients undergoing cardiac surgery. It not only prevents transfusion-related co-morbidities and complications but also enables early extubation time and shorter ICU and hospital stay. Furthermore, it reduces the cost of surgery.

Reduction in allogeneic blood products with routine use of autotransfusion in open elective infrarenal abdominal aortic aneurysm repair.

BACKGROUND AND OBJECTIVES: Concern about allogeneic blood product cost and complications has prompted interest in blood conservation techniques. Intraoperative autotransfusion (IAT) is currently not used routinely by vascular surgeons in open elective infrareanl abdominal aortic aneurysm (AAA) repair. The objective of this study is to review our experience with IAT and its impact on blood transfusion. METHODS: We retrospectively reviewed the medical records of consecutive patients treated electively over a 4-year period and compared 2 strategy related to IAT, routine use IAT (rIAT) versus on-demand IAT (oIAT). Outcomes measured were number of units of allogeneic red blood cells and autologous red blood cells transfused intraoperatively and postoperatively, preoperative, postoperative, and discharge hemoglobin levels; postoperative infections; length of postoperative intensive care stay; and length of hospital stay. T-independent and Fisher exact test were used. RESULTS: A total of 212 patients were included, 38 (18%) in the rIAT and 174 (82%) in the oIAT. Groups were similar except for an inferior creatinine and a superior mean aneurysm diameter for the rIAT group. Patients in the rIAT group had a lower rate of transfusion (26% vs 54%, P = .002) and a lower mean number of blood unit transfused (0.8 vs 1.8, P = .048). These findings were still more significant for AAA larger than 60 mm (18% rIAT vs 62% oIAT, P = .0001). Postoperative hemoglobin was superior in the rIAT group (107 vs 101 g/L, P = .01). Mean postoperative intensive care length of stay was shorter for the rIAT group (1.1 vs 1.8 days, P = .01). No difference was noted for infection, mortality, or hospital length of stay. CONCLUSION: The rIAT reduced the exposure to allogeneic blood products by more than 50%, in particular for patients with AAA larger than 60 mm. These results support the use of rIAT for open elective infrarenal AAA repair.

Effect of autotransfusion system on tumor recurrence and survival in hepatocellular carcinoma patients.

AIM: To investigate the therapeutic efficacy and safety of continuous autotransfusion system (CATS) during liver transplantation of hepatocellular carcinoma patients. METHODS: Eighty-three hepatocellular carcinoma (HCC) patients who underwent liver transplantation with intraoperative CATS (n = 24, CATS group) and without (n = 59, non-CATS group) between April 2006 and November 2011 at the Liver Transplant Institute of Inonu University were analyzed retrospectively. Postoperative HCC recurrence was monitored by measuring alpha-fetoprotein (AFP) levels at 3-mo intervals and performing imaging analysis by thoracoabdominal multidetector computed tomography at 6-month intervals. Inter-group differences in recurrence and correlations between demographic, clinical, and pathological data were assessed by ANOVA and χ(2) tests. Overall and disease-free survivals were calculated by the univariate Kaplan-Meier method. RESULTS: Of the 83 liver transplanted HCC patients, 89.2% were male and the overall mean age was 51.3 ± 8.9 years (range: 18-69 years). The CATS and non-CATS groups showed no statistically significant differences in age, sex ratio, body mass index, underlying disease, donor type, graft-to-recipient weight ratio, Child-Pugh and Model for End-Stage Liver Disease scores, number of tumors, tumor size, AFP level, Milan and University of California San Francisco selection criteria, tumor differentiation, macrovascular invasion, median hospital stay, recurrence rate, recurrence site, or mortality rate. The mean follow-up time of the non-CATS group was 17.9 ± 12.8 mo, during which systemic metastasis and/or locoregional recurrence developed in 25.4% of the patients. The mean follow-up time for the CATS group was 25.8 ± 15.1 mo, during which systemic metastasis and/or locoregional recurrence was detected in 29.2% of the patients. There was no significant difference between the CATS and non-CATS groups in recurrence rate or site. Additionally, no significant differences existed between the groups in overall or disease-free survival. CONCLUSION: CATS is a safe procedure and may decrease the risk of tumor recurrence in HCC patients.

Erythrocyte storage duration is not associated with increased mortality in noncardiac surgical patients: a retrospective analysis of 6,994 patients.

BACKGROUND: More than 5 million patients receive erythrocyte transfusions in the United States every year. Previous studies linked the storage duration of allogeneic erythrocytes to the risk of severe postoperative complications, especially after cardiac or trauma surgery. Limited data are available for noncardiac surgical patients. We therefore evaluated the association between storage duration of transfused erythrocytes and postoperative all-cause mortality among general surgery patients. METHODS: Perioperative data corresponding to 63,319 adult, general surgery patients were obtained from our registry and merged with blood product data. Patients receiving solely leukocyte-reduced, allogeneic erythrocyte transfusions were included. Multivariable Cox proportional hazards regression was used to characterize the relationship between median erythrocyte storage duration and postoperative mortality rate, adjusting for characteristics plausibly influencing the storage duration of erythrocytes. RESULTS: Of the 6,994 patients included in the final analysis, 23, 44, 11, 9, and 13% received 1, 2, 3, 4, and ≥5 erythrocyte units, respectively. The authors found no evidence that increasing median storage duration was associated with a difference in the risk of postoperative mortality (hazard ratio, 0.99 [0.94-1.04]; P = 0.64). Analyzing the mean storage duration of erythrocyte units as a function of year of transfusion, the authors demonstrate a relevant decrease in utilization of the oldest blood units, whereas young blood storage duration remains nearly unchanged. CONCLUSION: The authors' study supports the recent literature in surgical and medical patients and underlines the importance of sufficiently powered randomized trials to finally resolve the erythrocyte storage duration debate.

Blood transfusion after on-pump coronary artery bypass grafting: focus on modifiable risk factors.

OBJECTIVES: Perioperative transfusions are known to increase morbidity and mortality after coronary artery bypass grafting (CABG). The aims of the study were (1) to identify the clinical profile of the patient subset at highest risk from transfusion and (2) to disclose causative relationship and dose-dependency of transfusion on hospital mortality. METHODS: A prospective observational design was employed on a cohort of 1047 consecutive patients (median age 63.2 ± 9.3, 18.8% female, 30.6% diabetics, 31.9% urgent/emergent, 15.3% with low preoperative left ventricular ejection fraction (LVEF)) who underwent on-pump isolated CABG between January 2004 and December 2007. Univariate and multivariate regression analysis and post-hoc risk stratification, by means of propensity scoring and binary segmentation, were adopted. RESULTS: The following independent risk factors were identified: age, body surface area (BSA), preoperative glomerular filtration rate, preoperative haemoglobin, surgical priority, length of cardiopulmonary bypass, intraoperative haemodilution and early postoperative blood loss. The patient population was stratified in quintiles of transfusional risk, by means of propensity scoring. As to modifiable risk factors, patients in the highest quintiles of risk were those with BSA ( < 1.73, preoperative haemoglobin < 12 g/dl, intraoperative haemoglobin < 8.0 g/dl and those undergoing cardiopulmonary bypass > 90'). Binary segmentation was performed to avoid any association between red cell transfusion and worse outcomes being causative and dose-dependent. A dose-dependent pattern was disclosed, with patients receiving > 5 units being at highest risk. CONCLUSIONS: High exposure to blood transfusions may be prevented by preoperative patient stratification and by the close tailoring of management strategies on planning and implementing surgical timing, as well as by cardiopulmonary bypass technique.

Should intraoperative cell-salvaged blood be used in patients with suspected or known malignancy?

PURPOSE: Intraoperative cell salvage (ICS) is used as an alternative to allogeneic blood transfusion in an attempt to avoid or minimize the risks associated with allogeneic blood. Intraoperative cell salvage is generally avoided in surgeries where malignancy is confirmed or suspected due to concern for potential metastasis or cancer recurrence. The application of post-processing methods for ICS is hypothesized to eliminate this potential risk. The purpose of this narrative review is to examine the in vitro experimental evidence as it pertains to the removal of tumour cells from ICS blood and to review the clinical studies where ICS blood has been used in patients with malignancy. SOURCE: A search of the English literature for relevant articles published from 1973 to 2012 was undertaken using MEDLINE and Cochrane databases. Bibliographies were cross-referenced to locate further studies. PRINCIPAL FINDINGS: Leukoreduction filters are an effective method for removal of malignant cells from ICS blood. Small non-randomized clinical studies to date do not show evidence of an increased rate of metastasis or cancer recurrence. Although a theoretical risk of disease recurrence persists, the decision to use autologous ICS blood must be weighed against the known risks of allogeneic blood transfusion. CONCLUSION: Transfusion of autologous blood harvested via ICS should be considered a viable option for reduction or avoidance of allogeneic product during many oncologic surgeries and may be a lifesaving option for those patients who refuse allogeneic blood products.

[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).

Intraoperative cell salvage in radical prostatectomy does not appear to increase long-term biochemical recurrence, metastases, or mortality.

BACKGROUND: Blood management strategies help to conserve allogeneic red blood cells, a finite resource. Intraoperative cell salvage (ICS) is an effective method of allogeneic avoidance. However, concerns persist about the safety of ICS in surgical oncology cases, including radical prostatectomy (RP). Previous findings do not support these concerns. We hypothesized that ICS would not increase rates of long-term prostate cancer recurrence characterized by biochemical failure, disease dissemination, or mortality. STUDY DESIGN AND METHODS: Consecutive patients undergoing RP by a single urologist over two 3-month periods 1 year apart were analyzed retrospectively. Patients in the first period had preoperative autologous donation (PAD) but not ICS (PAD group), whereas those in the second period had ICS only (ICS group). Variables assessed included patient demographics, prostate-specific antigen levels at surgery and end of follow-up, clinical stage, operative time, surgical margin status, pathologic stage and grade, Gleason score sum, length of hospital stay, biochemical recurrence, metastases, and mortality. RESULTS: A total of 116 consecutive patients were analyzed. Of these, 32 patients in the PAD group and 42 patients in the ICS group had follow-up of at least 4.75 years. There was a significantly higher rate of biochemical failure (34.4% vs. 9.5%; p = 0.02) and metastases (12.5% vs. 0%; p = 0.03) in the PAD group versus the ICS group; there was no significant difference in mortality (9.4% vs. 0%; p = 0.08). CONCLUSION: ICS appears to be a safe and effective method of allogeneic blood conservation in patients undergoing RP. The findings suggest that there is no increased risk of biochemical failure, disease dissemination, or mortality at 5 years post-RP as a result of ICS use.

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.

Post-transfusion mortality among recipients of ABO-compatible but non-identical plasma.

BACKGROUND AND OBJECTIVES: The consequences of ABO-compatible non-identical plasma for patient outcome have not been studied in randomized clinical trials or large cohort studies and use varies widely in the absence of evidence-based policies. We investigated if transfusion with compatible instead of identical plasma confers any short-term survival disadvantage on the recipients. MATERIALS AND METHODS: The cohort of all 86 082 Swedish patients who received their first plasma transfusion between 1990 and 2002 was followed for 14 days and the risk of death in patients exposed to compatible non-identical plasma compared to recipients of only identical plasma. RESULTS: After adjustment for potential confounding factors, there was an increased mortality associated with exposure to ABO-compatible non-identical plasma, with the excess risk mostly confined to those receiving 5 or more units (relative risk, 1.15; 95% confidence interval, 1.02-1.29). Stratification by blood group indicated higher risks in group O recipients, especially when the compatible plasma was from a group AB donor. CONCLUSIONS: This study suggests that ABO-compatible non-identical plasma is less safe than identical plasma. Subanalyses by blood group suggest a role for circulating immune complexes. Our findings may have policy implications for improving transfusion safety.

Pleurodesis using autologous blood: a new concept in the management of persistent air leak in acute respiratory distress syndrome.

OBJECTIVE: Pneumothorax is present as a frequent complication in acute respiratory distress syndrome (ARDS). Persistent air leak (PAL) prolongs pneumothorax in 2% of cases of ARDS, increasing the rate of mortality by 26%. Pleurodesis using autologous blood (PAB) is an effective method in cases of oncological pulmonary surgery. The goal of this study was to compare PAB with the conventional drain and water seal in the management of PAL in patients with ARDS and pneumothorax. DESIGN: The study was a case-control, prospective, nonrandomized one comparing 2 groups subjected to artificial pairing (1:1). SETTING: The study took place at the Torrecardenas Hospital (Andalusian Health Service, Almería, Spain). PATIENTS: Participants were 2 groups of 27 patients, all with ARDS, pneumothorax, and PAL. INTERVENTIONS: One group received conventional treatment whereas the other received PAB. MAIN RESULTS: The severity of the conditions of both groups is homogeneous, shown by sex; age; Murray, Marshall, and Acute Physiology and Chronic Health Evaluation II scores; and etiology of ARDS. The patients in the PAB group had a shorter stay in the ICU, shorter weaning time (WT), and lower death rate. The average differences between the groups were 11 days less WT (adjusted odds ratio [OR] = 0.1) and 9 days less on average time spent in the ICU (adjusted OR = 0.24). The death rates in the PAB group and the control group were 3.7% and 29.6%, respectively (adjusted OR = 0.6). CONCLUSIONS: The use of PAB makes possible a decrease in ventilator WT and a shorter stay in the ICU, with a resulting increase in functional recuperation and decrease in patient mortality.