The use of intraoperative cell salvage and autologous blood transfusion has become an important method of blood conservation. The main aim of autologous transfusion is to reduce the need for allogeneic blood transfusion and its associated complications. Allogeneic blood transfusion has been associated with increased risk of tumour recurrence, postoperative infection, acute lung injury, perioperative myocardial infarction, postoperative low-output cardiac failure, and increased mortality. We have reviewed the current evidence for cell salvage in modern surgical practice and examined the controversial issues, such as the use of cell salvage in obstetrics, and in patients with malignancy, or intra-abdominal or systemic sepsis. Cell salvage has been demonstrated to be safe and effective at reducing allogeneic blood transfusion requirements in adult elective surgery, with stronger evidence in cardiac and orthopaedic surgery. Prolonged use of cell salvage with large-volume autotransfusion may be associated with dilution of clotting factors and thrombocytopenia, and regular laboratory or near-patient monitoring is required, along with appropriate blood product use. Cell salvage should be considered in all cases where significant blood loss (>1000 ml) is expected or possible, where patients refuse allogeneic blood products or they are anaemic. The use of cell salvage in combination with a leucocyte depletion filter appears to be safe in obstetrics and cases of malignancy; however, further trials are required before definitive guidance may be provided. The only absolute contraindication to the use of cell salvage and autologous blood transfusion is patient refusal.

SUMMARY A review was made of 88 adult institutionalized patients with spastic cerebral palsy and contractural deformity of the hips. 21 were untreated for dislocated hip, and 11 of these suffered from hip pain. The degrée of pain was directly related to neurological maturity and to the coexistence of athetosis and spasticity. Decubitus ulcers and perineal care problems were more associated with contractures than with dislocation alone. It is concluded that dislocation and subluxation should be prevented by surgical means, but that surgical treatment of the already dislocated hip should be reserved for the neurologically mature and athetoid patient. RÉSUMÉ Histoire naturelle de la luxation de handle dans l'infirmité motrice cérébrate Une revue a été faite de 88 cas d'adultes en placement avec infirmité motrice cérébrale, déformation de la hanche sous contracture. 21 n'avaient pas été traités pour luxation de hanche et parmi eux 11 souffraient de leur hanche. Le degré de la douleur était directement reliéà la maturité neurologique et à la coexistence d'athétose et de spasticité. Les escarres de décubitus et les problè mes de soins périnéaux étaient plus souvent associés aux contractures quà la seule luxation. Les auteurs concluent que la luxation et la sub‐luxation devraient ectre prévenues par intervention chirurgicale mais que le traitement chirurgical d'une hanche déja luxée devrait être réservé aux sujets neurologiquement matures et athétosiques. ZUSAMMENFASSUNG Klinischer Verlauf der Hüftluxation bei spastischer Cerebralparese 88 erwachsene Heimpatienten mit spastischer Cerebralparese und Kontrakturen der Hüftgelenke wurden in einer Übersichtsstudie zusammengefaßt. Bei 21 war die Hüftluxation unbehandelt und 11 davon litten unter Schmerzen in den Hüftgelenken. Der Schweregrad der Beschwerden stand direkt in Relation zum neurologischen Bild und zum gleichzeitigen Auftrétén von Athetose und Spastik. Decubitalulcera und Probleme bei der Analhygiene traten bei Kontrakturen häufiger als bei Luxationen auf. Man hat die Schlußfolgerung gezogen, daß Dislokation und Subluxation durch chirurgische Maßnahmen vermindert werden sollten; die chirurgische Behandlung der Hüftluxation jedoch sollte erst bei Patienten vorgenommen werden, die das voile neurologische Bild und eine Athetose haben. RESUMEN Historia natural de la luxación de cadera en la parálisis cerebral espástica Se hizo una revisión de 88 adultos ingresados en una Institución afectos de parálisis cerebral y con deformidad por contractura de las caderas. 21 fueron tratados por luxación de cadera, y 11 sufrían de dolor a este nivel. El grado de dolor estaba en relación directa con la madurez neurológica y con la persistencia de atetosis y espasticidad. Las úlceras de decubito y los problemás del cuidado perineal estaban má asociadas con las contracturas que con la luxación sola. Se concluye que la, luxación y la subluxación deberían ser prevenidas por medios quinirgicos pero el tratamiento quirúrgico de la dislocaci6n ya establecida debería estar reservado para l...

SummaryPlatelet dysfunction after cardiopulmonary bypass contributes to microvascular bleeding and is associated with blood transfusion and resternotomy. Platelet count can be readily performed, but currently there are no standardised, reproducible, rapidly available platelet function tests. We studied platelet function as measured by multiple electrode platelet aggregometery (multiplate) and light transmission aggregometry in 44 patients undergoing routine coronary artery surgery. Platelet aggregation as measured by multiplate was reduced during and after cardiopulmonary bypass compared with baseline with evidence of partial recovery by the time of transfer to ITU. In patients transfused blood, platelet aggregation measured by multiplate was reduced during chest closure with adenosine diphosphate (18 U vs 29 U, p = 0.01) and thrombin receptor agonist peptide-6 agonist (65 U vs 88 U, p = 0.01) compared with patients not transfused. This suggests that multiplate, a new point of care analyser, can detect platelet dysfunction in this setting. Platelet dysfunction after cardiopulmonary bypass (CPB) is a major contributor to microvascular bleeding, and associated with excessive blood loss, perioperative blood transfusion and surgical re-exploration. The effects of CPB include dilution (and reduced concentration of platelets) and alteration in platelet structure and function [1,2]. In addition, use of platelet inhibitors in the peri-operative period is associated with platelet inactivation.Administration of blood products during excessive bleeding is commonly required, but is associated with significant morbidity and mortality, including lung injury, immunomodulation, fluid overload and infection [3]. Transfusion algorithms in common use include established laboratory and near patient testing to guide clinicians in use of blood products. Reduced platelet count is a universal trigger for platelet concentrate administration. Thromboelastography is also commonly performed, and maximum amplitude is used by some as a surrogate for clot strength and consequently, platelet activity and fibrinogen level [4]. Platelet function per se is, however, not routinely assessed, mainly because of difficulty with testing and a lack of agreement between different modalities [5,6].

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To identify the incidence, risk factors and impact on long-term survival of invasive pulmonary aspergillosis (IPA) and Aspergillus colonisation in patients receiving vv-extracorporeal membrane oxygenation (ECMO). A retrospective evaluation was performed of patients receiving vv-ECMO at a tertiary hospital in Manchester (UK) between January 2012 and December 2016. Data collected included epidemiological data, microbiological cultures, radiographic findings and outcomes. Cases were classified as proven IPA, putative IPA or Aspergillus colonisation according to a validated clinical algorithm. One hundred thirty-four patients were supported with vv-ECMO, median age of 45.5 years (range 16.4–73.4). Ten (7%) patients had putative IPA and nine (7%) had Aspergillus colonisation. Half of the patients with putative IPA lacked classical host risk factors for IPA. The median number of days on ECMO prior to Aspergillus isolation was 5 days. Immunosuppression and influenza A infection were significantly associated with developing IPA in a logistic regression model. Cox regression model demonstrates a three times greater hazard of death associated with IPA. Overall 6-month mortality rate was 38%. Patients with putative IPA and colonised patients had a 6-month mortality rate of 80 and 11%, respectively. Immunosuppression and influenza A infection are independent risk factors for IPA. IPA, but not Aspergillus colonisation, is associated with high long-term mortality in patients supported with vv-ECMO.

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Only a small number of English hospitals provide postcardiotomy venoarterial extracorporeal membrane oxygenation (VA‐ECMO) and there are doubts about its efficacy and safety. The aim of this service evaluation was to determine local survival rates and report on patient demographics. This was a retrospective service evaluation of prospectively recorded routine clinical data from a tertiary cardiothoracic center in the United Kingdom offering services including cardiac and thoracic surgery, heart and lung transplantation, venovenous extracorporeal membrane oxygenation (VV‐ECMO) for respiratory failure, and all types of mechanical circulatory support. In six years, 39 patients were supported with VA‐ECMO for refractory postcardiotomy cardiogenic shock (PCCS). We analyzed survival data and looked for associations between survival rates and patient characteristics. The intervention was venoarterial‐ECMO in patients with PCCS either following weaning from cardiopulmonary bypass or following a trial of inotropes and intra‐aortic balloon counterpulsation on the intensive care unit. 30‐day, hospital discharge, 1‐year and 2‐year survivals were 51.3%, 41%, 37.5%, and 38.5%, respectively. The median (IQR [range]) duration of support was 6 (4‐9 [1‐35]) days. Nonsurvival was associated with advanced age, shorter intensive care length of stay, and the requirement for postoperative hemofiltration. Reasonable survival rates can be achieved in selected patients who may have been expected to have a worse mortality without VA‐ECMO. We suggest postoperative VA‐ECMO should be available to all patients undergoing cardiac surgery be it in their own center or through an established pathway to a specialist center.

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