Anemia is common in elective surgery and is an independent risk factor for morbidity and mortality. Historical management of anemia has focused on the use of allogeneic blood transfusion but this in itself is not without risk. It too has been independently associated with morbidity and mortality, let alone the costs and relative shortage of this resource. In recognition of this, patient blood management (PBM) shifts the focus from the product to the patient and views the patient's own blood as a resource that should be conserved and managed appropriately as a standard of care. It consists of 3 pillars: the optimization of red blood cell mass; reduction of blood loss and bleeding; and optimization of the patient's physiological tolerance toward anemia. Integration of these 3 pillars in the form of multimodal care bundles and strategies into perioperative pathways should improve care processes and patient outcome. Preoperative anemia is most commonly caused by functional iron deficiency and should be treated with oral iron, intravenous iron, and/or recombinant erythropoietin. An individualized assessment of the thrombotic risk of discontinuing anticoagulant and antiplatelet medication should be balanced against the risk of perioperative bleeding. Neuraxial anesthetic techniques should be considered and minimally invasive surgery undertaken where appropriate. Cell salvage should be used if significant blood loss is anticipated and pharmacological treatments such as tranexamic acid and fibrin sealants have been shown to reduce blood loss. Point of care tests can guide the perioperative management of dynamic coagulopathy. Blood testing sampling should be performed only when indicated and when taken, sample volume and waste should be minimized. Restrictive blood transfusion thresholds and reassessment after single unit transfusion should be incorporated into clinical practice where appropriate. For PBM to become standard practice in routine surgical care, national health care quality change initiatives must set the agenda for change but the patient-centered approach to PBM should be delivered in a way that is also hospital centered. Characterization of the current practice of PBM at each hospital is crucial to facilitate the benchmarking of performance. Barriers to effective implementation such as lack of knowledge should be identified and acted on. Continuous audit of practice with a focus on transfusion rates and patient outcomes can identify areas in need of improvement and provide iterative feedback to motivate and inspire the main stakeholders.
Concern about the side effects of various anaesthetic agents in newborn infants has led to the widespread use of anaesthesia with unsupplemented nitrous oxide and oxygen with muscle relaxants in such patients. To investigate the efficacy of such a regimen 36 neonates undergoing operations were randomised to two groups: one group received anaesthesia with nitrous oxide and curare alone and the other was additionally given halothane. Concentrations of metabolites and hormones were measured before and at the end of operation and at six, 12, and 24 hours after operation and the values compared between the two groups. Neonates given halothane anaesthesia showed decreased hormonal responses to operation, with significant differences between the two groups in the changes in adrenaline, noradrenaline, and cortisol concentrations and the ratio of insulin to glucagon concentration. Changes in blood concentrations of glucose and total ketone bodies and plasma concentrations of non-esterified fatty acids were also decreased in neonates receiving halothane anaesthesia. Neonates given anaesthesia with unsupplemented nitrous oxide showed significantly greater increases in the urinary ratio of 3-methylhistidine to creatinine concentration and their clinical condition was also more unstable during and after operation. Unless specifically contraindicated potent anaesthesia with halothane or other anaesthetic agents should be given to all neonates undergoing surgical operations as it decreases their stress responses and improves their clinical stability during and after operation.
The aims of this study were to determine whether the withdrawal of aprotinin (APRO) led to an increased bleeding risk in patients undergoing orthotopic liver transplantation (OLT). A retrospective analysis compared consecutive patients undergoing OLT and treated with aprotinin (APRO group; n 5 100) with a group in which aprotinin was not used (no-APRO group; n 5 100). Propensity score matching was then performed for each group to identify 2 matched cohorts. Patients were matched by their primary diagnoses and Model for End-Stage Liver Disease scores. This resulted in 2 matched cohorts with 55 patients in each group. None of the patients in the APRO group had significant fibrinolysis. In the no-APRO group, 23.6% of the patients developed fibrinolysis (P < 0.003). Tranexamic acid was used in 61.5% of the patients (n 5 8) in the no-APRO group in whom lysis was present, and this resolved the fibrinolysis in all but 1 of these patients. There were no differences in red blood cell, fresh frozen plasma, platelet concentrate, or cryoprecipitate transfusions between the 2 groups. In conclusion, we have shown a significant increase in the prevalence of fibrinolysis during OLT since the withdrawal of APRO. However, there has been no increase in transfusion requirements. Liver Transpl 20:584-590, 2014. V C 2014 AASLD.
Background: Liver transplant centers vary in approach to intraoperative vascular accesses, monitoring of cardiac function and temperature management. Evidence is limited regarding impact of selected modalities on postoperative outcomes. Objectives:To review the literature and provide expert panel recommendations on optimal intraoperative arterial blood pressure (BP), central venous pressure (CVP), and vascular accesses, monitoring of cardiac function and intraoperative temperature management regarding immediate and short-term outcomes after orthotopic liver transplant (OLT).Methods: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Recommendations made for: (1) Vascular accesses, arterial BP and CVP monitoring,(2) cardiac function monitoring, and (3) Intraoperative temperature management (CRD42021239908).
Background: Perioperative goal directed fluid therapy (GDFT) has been shown to reduce postoperative complications following major surgery; this intervention has not been formally evaluated in the setting of liver transplantation. Methods:We conducted a prospective trial of GDFT following liver transplantation randomising patients with liver cirrhosis to either 12 h of GDFT using non-invasive cardiac output monitoring or standard care (SC). The primary outcome was feasibility. Secondary outcomes included survival, postoperative complications (Clavien-Dindo), quality of life (by EQ-5D-5L) and resource use. Trial specific follow up occurred at 90 and 180 days after surgery. Results:The study was feasible. Of 224 eligible patients, 122 were approached, 114 consented to participate and 60 were enrolled into the trial. The mean (SD) volume of IV crystalloid administered to the GDFT group during the 12-h study period was 3968 (2073) ml for the GDFT group and 2510 (1026) ml for the SC group. As regards secondary outcomes there was no difference in survival or overall complication rates. There was no significant difference in quality of life scores and resource use between the groups. Conclusion:A randomised study of GDFT following liver transplantation is feasible. A post-trial stakeholder meeting supported proceeding with a full multi-centre trial.
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