The use of algorithms by transfusion decision makers can serve as an effective physician education intervention.
Despite published guideline and consensus conference recommendations, the role of acute preoperative hemodilution in elective surgery has not been defined. We performed a case study analysis of this technique in a large surgical program in order to estimate its degree of efficacy as practiced routinely, and to better define its role as a blood conservation strategy. Patients undergoing elective radical prostatectomy by one surgeon during a 3-yr period were analyzed retrospectively for blood loss, hematocrit levels, records of acute hemodilution, and transfusion outcomes. Patient blood volumes were determined by nomogram; final hematocrits after discrete blood volumes lost by surgery or by hemodilution were estimated. Sixteen (4.4%) of 410 total patients reviewed underwent hemodilution, representing 0 (O%), 4 (3%), and 12 (8%) of the 112,146, and 152 patients undergoing surgery in years 1, 2, and 3, respectively. Median whole blood volume and mean red blood cell (RBC) volume removed by hemodilution was 1000 mL (range, 400-1500 mL) and 338 mL (range, 156-585 mL), respectively, representing 15% of patients' admission RBC volume. Net intraoperative RBC volume "saved in losses by this technique was 95 mL (range, 25-204 mL), representing only 9.3% (range, 4%-17%) of total RBC volume lost during hospitalization. RBC volume removed by hemodilution constituted 34% (95-283 mL) of the total RBC volume transfused. We conclude that use of acute preoperative hemodilution remains in evolution and, as a single blood conservation intervention, contributes only modestly to blood conservation.(Anesth Analg 1994;78:932-7) ecent guidelines for blood transfusion in the surgical setting have emphasized that autologous blood should be procured preoperatively when possible (1'2). While the demonstrated safety and efficacy of preoperative donation in elective surgery has made this practice a standard of care in certain elective orthopedic (3) and urologic procedures (4), this practice can be time consuming and expensive (5). Several reports have also suggested that preoperative autologous blood donation may contribute to cardiovascular morbidity in geriatric patients (6,7). In contrast, acute preoperative hemodilution, in which autologous blood is procured immediately before surgery, remains an underutilized blood conservation intervention. We have therefore reviewed the experience with this technique in patients undergoing radical prostatectomy with a single surgeon at our institution, in order to analyze its efficacy as a blood conservation intervention. In addition, we define a methodology that can serve as an institutional approach in analyzing the effectiveness of blood conservation strategies. MethodsThe records of patients undergoing radical prostatectomy for Stage A or B prostate cancer by a single surgeon (WJC) during a 3-yr period were reviewed. Radical retropubic prostatectomy was performed as described previously (8) under general anesthesia. Predeposit of autologous blood and/or acute preoperative hemodilution were offered to...
We retrospectively analyzed our 2-year experience with venous access for 363 therapeutic plasma exchanges in 46 patients with neurological disease, including acute Guillain-Barré syndrome (N = 20), myasthenia gravis (N = 17), and chronic inflammatory demyelinating polyneuropathy (N = 9). Twenty-three patients (50%) completed the planned course of therapy using only peripheral venous access, and 28 central venous catheters were placed in the remaining 23 patients. Patients utilizing central venous access did not undergo a greater number of procedures, but they were more likely to have acute Guillain-Barré syndrome (P < 0.02) or to be hospitalized in a medical intensive care unit (P < 0.01). Three types of central catheters were used, and although our experience was predominantly with 1 type, differences were noted. Only 3% of procedures (3 of 96) done with a Quinton-Mahurkar catheter were associated with a catheter failure, compared to 27% (4 of 15, P < 0.01) with a Hickman catheter and 67% (2 of 3) with a triple-lumen catheter. Life-threatening complications occurred with 3 of 28 (11%) central catheters. To optimize the success of therapeutic plasma exchange using central access, it is critical that hemapheresis personnel advise each patient's primary physician regarding the type of central venous catheter required. Currently, we recommend use of a Quinton-Mahurkar or other dual-lumen hemodialysis catheter.
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