Background: Cardiac surgery using cardiopulmonary bypass carries a high risk of bleeding and need for blood transfusion. Blood administration is associated with increased rates of morbidity and mortality. Perioperatively, strategies are often employed to reduce blood transfusions in high-risk patients or in situations where blood transfusion is contraindicated. Normovolemic hemodilution is a blood conservation technique used during cardiac surgery that involves replacement of blood with fluids. SANGUINATE® (PEGylated carboxyhemoglobin bovine) is a novel hemoglobin-based oxygen carrier that can deliver oxygen effectively to tissues in the presence of severe hypoxia. The use of a hemoglobin-based oxygen carrier during hemodilution may augment tissue oxygen delivery and reduce blood transfusion. Methods: Six standardized cardiopulmonary bypass runs simulating normovolemic hemodilution using varying proportions of bovine whole blood and SANGUINATE were performed. Pump speed, flow rate, line pressures, hemoglobin concentration, oxygenation, and degree of anticoagulation were assessed at regular intervals. Membrane oxygenators and arterial line filters were inspected for evidence of clotting following each run. Results: Increases in the pressure drop across the membrane oxygenator were detected during runs 5 and 6. Median activated clotting time values were able to be maintained at goal during the runs, and SANGUINATE did not appear to be thrombogenic. Hemoglobin concentration decreased following the addition of SANGUINATE. Oxygenation was maintained during all runs that included SANGUINATE. Conclusion: SANGUINATE does not impact the performance of the cardiopulmonary bypass circuit in a bovine whole blood model. The results support further evaluation of SANGUINATE in the setting of normovolemic hemodilution and cardiopulmonary bypass.

Blood transfusions in the operating room are associated with increased morbidity and mortality as well as increased cost. The technology exists for continuous noninvasive hemoglobin monitoring (SpHb), which could allow for the rapid diagnosis and treatment of acute blood loss anemia secondary to surgical bleeding. However, the accuracy of this technology has been called into question. SpHb in the operating room could reduce cost by decreasing lab draws, unnecessary transfusions, and the morbidity associated with blood transfusions. This review examines the accuracy of noninvasive hemoglobin monitoring as well as the role it may play in the operating room.

Bleeding after cardiac surgery is a common and serious complication leading to transfusion of multiple blood products and resulting in increased morbidity and mortality. Despite the publication of numerous guidelines and consensus statements for patient blood management in cardiac surgery, research has revealed that adherence to these guidelines is poor, and as a result, a significant variability in patient transfusion practices among practitioners still remains. In addition, although utilization of point-of-care (POC) coagulation monitors and the use of novel therapeutic strategies for perioperative hemostasis, such as the use of coagulation factor concentrates, have increased significantly over the last decade, they are still not widely available in every institution. Therefore, despite continuous efforts, blood transfusion in cardiac surgery has only modestly declined over the last decade, remaining at ≥50% in high-risk patients. Given these limitations, and in response to new regulatory and legislature requirements, the Society of Cardiovascular Anesthesiologists (SCA) has formed the Blood Conservation in Cardiac Surgery Working Group to organize, summarize, and disseminate the available best-practice knowledge in patient blood management in cardiac surgery. The current publication includes the summary statements and algorithms designed by the working group, after collection and review of the existing guidelines, consensus statements, and recommendations for patient blood management practices in cardiac surgery patients. The overall goal is creating a dynamic resource of easily accessible educational material that will help to increase and improve compliance with the existing evidence-based best practices of patient blood management by cardiac surgery care teams.

The authors regret that the title of Christa Boer was incorrectly stated as MD in their published article. This has been corrected to PhD above. The authors apologise for any inconvenience caused. Society of Cardiovascular Anesthesiologists Clinical Practice Improvement Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery PatientsJournal of Cardiothoracic and Vascular AnesthesiaVol. 33Issue 11PreviewBleeding after cardiac surgery is a common and serious complication leading to transfusion of multiple blood products and resulting in increased morbidity and mortality. Despite the publication of numerous guidelines and consensus statements for patient blood management in cardiac surgery, research has revealed that adherence to these guidelines is poor, and as a result, a significant variability in patient transfusion practices among practitioners still remains. In addition, although utilization of point of care coagulation monitors and the use of novel therapeutic strategies for perioperative hemostasis, such as the use of coagulation factor concentrates, has increased significantly over the last decade, they are still not widely available in every institution. Full-Text PDF

Learning Objectives: Cardiac surgery using cardiopulmonary bypass (CPB) carries a high risk of bleeding and need for perioperative blood transfusion. Blood transfusion is an expensive, resource-intensive intervention that is associated with increased rates of ICU length of stay, end-organ dysfunction, and mortality. Normovolemic hemodilution is a blood conservation strategy used to reduce transfusion rates that involves replacement of whole blood with fluid to maintain normovolemia. SANGUINATE® (PEGylated Carboxyhemoglobin Bovine) is a novel hemoglobin-based oxygen carrier that is able to deliver oxygen effectively to tissues in the presence of severe hypoxia. Its use as a component of the replacement fluid during hemodilution would provide an additional means to augment tissue oxygen delivery while avoiding perioperative RBC transfusion. In this study simulating normovolemic hemodilution, the effect of varying mixtures of bovine whole blood and SANGUINATE® on flow characteristics and oxygenation during CPB were evaluated. Methods: Six standardized 120-minute CPB runs simulating normovolemic hemodilution using varying proportions of normal saline, bovine whole blood, calcium chloride, heparin, and SANGUINATE® were performed. The first run represented a control with no addition of SANGUINATE®. The circuit was de-aired and heated to normothermia (37°C). The FiO2 was set to 0.60 and the sweep gas was set to 0.5 L/min. The blood was circulated through the CPB circuit at 5 L/min for all runs. Hemoglobin concentration, activated clotting time, and indices of CPB functionality were assessed at regular intervals following the addition of SANGUINATE®. Results: The addition of SANGUINATE® did not result in major changes in CPB flow characteristics as determined by pump RPM, flow rate, or line pressure. Adequacy of oxygenation, as determined by the post-membrane PO2 value, was maintained for all runs irrespective of the SANGUINATE® concentration. No visible clots were identified on the membrane oxygenator following the runs. Conclusions: The results of our study show that SANGUINATE® does not impact the performance of the CPB circuit in a normovolemic hemodilution model using bovine whole blood. Oxygenation remained adequate, and thrombogenicity was not observed. These results support further evaluation of SANGUINATE® as a means to reduce blood transfusion in the perioperative cardiac surgical setting.

Research into potential use of perfluorocarbons for liquid ventilation and as oxygen delivery agents in humans has been underway since the 1960s. While partial liquid ventilation with perfluorocarbons showed promise in animal models and early human investigation, randomized controlled human trials failed to show benefit and an elevated rate of adverse events. Initial approval of Fluosol-DA (Green Cross Corporation, Osaka, Japan) by the United States Food and Drug Administration as an oxygen delivery agent for use in high-risk coronary angioplasty represents the only approved application of these compounds to supplement tissue oxygenation, but the compound was rendered obsolete and removed from the market with the development of advanced angioplasty catheters in the 1990s. Second-generation perfluorocarbons were developed with a higher capacity to increase the amount of oxygen dissolved in the fluid phase of blood. Early clinical trials of perflubron emulsion in non-cardiac and cardiac surgery were promising, but dose restriction and the requirement for high inspired oxygen concentration to maximize oxygen delivery for prolonged periods of time limited the clinical utility as a replacement for the oxygen carrying capacity of red blood cells. Identification of excess serious adverse events in treated patients resulted in discontinuation of pivotal clinical trials. Continued research investigating different formulations of perfluorocarbons has shown promise in animal studies, but continued research is necessary to prove safety and efficacy in humans.

BACKGROUND: Although numerous studies have demonstrated the feasibility of cardiac surgery for blood refusal patients, few studies match to controls, and fewer examine cost. This historical cohort study aims to compare costs and outcomes after cardiac surgery in Jehovah's Witness patients who refuse blood transfusion with a group of matched patients accepting transfusion.STUDY DESIGN AND METHODS: A retrospective database review was performed to find all patients having cardiac surgery who refused blood products from January 2005 to July 2012 at Duke University Medical Center. These 45 patients were closely matched 1: 2 with controls who accepted transfusion based on characteristics likely to influence transfusion. Cost from day of surgery to hospital discharge and other outcome data (length of stay [LOS], discharge hemoglobin [Hb], acute kidney injury) were analyzed retrospectively.RESULTS: Forty-five Witnesses having cardiac surgery were temporally matched to two controls having the same surgery. Median euroSCORE was the same in both groups (6.0, p=0.9981). In the matched-pairs comparison of cost, there was no significant difference in total cost for Witnesses and controls. There was no difference in intensive care unit LOS (median, 1 day, both groups) or total LOS (median, 9 days for Witnesses vs. 7 days for controls). Mean Hb at discharge was higher in Witnesses than in controls (11.7 g/dL vs. 9.8 g/dL, p<0.001). Thirty-day mortality was zero in both groups.CONCLUSION: Utilizing applicable blood conservation measures, cardiac surgery may be performed with similar outcomes and cost from day of surgery to discharge compared to controls in select patients without blood transfusion.

Based on biblical doctrines, patients of the Jehovah's Witness faith refuse allogeneic blood transfusion. Cardiac surgery carries a high risk of blood transfusion, but has been performed in Jehovah's Witnesses for many years. The literature contains information on the outcomes of this cohort, but does not detail the perioperative care of these patients. This article describes a single institution's experience in perioperative care of Jehovah's Witnesses undergoing cardiac surgery.

BackgroundEstimates of blood loss in the operating room are typically performed as a visual assessment by providers, despite multiple studies showing this to be inaccurate. Use of a less subjective measurement of blood loss such as direct measurement of the hemoglobin (Hb) mass lost from the surgical field may better quantify surgical bleeding. The objective of this investigation was to compare anesthesiologist estimates of intraoperative blood loss with measured Hb loss.Study Design and MethodsSixty patients undergoing posterior spine surgery were enrolled in a prospective, randomized trial comparing intraoperative blood loss using unipolar cautery alone or with use of a bipolar tissue sealant device. Hb concentration and fluid volume were measured from all surgical sponges, suction canisters, and the cell salvage device. Using the volume and concentration of Hb from each solution allowed calculation of Hb mass, which was converted into volume of blood lost and compared with estimates of blood loss documented by the anesthesia team. A single‐sample t test of no difference was used to compare estimated with measured blood loss.ResultsMean estimated blood loss exceeded measured blood loss by 246 mL (860 mL vs. 614 mL, p < 0.0001).ConclusionEstimated blood loss exceeded measured blood loss by 40% on average. The likely etiology of this discrepancy relates to the inability to visually determine Hb concentration of sanguineous solutions in suction canisters and surgical sponges. Ramifications of excessive bleeding estimates include unnecessary transfusion and overadministration of intravenous fluids, both of which may have deleterious effects.

More than a decade has passed since the publication of the results of the Transfusion Requirements in Critical Care (TRICC) trial, supporting the restriction of red blood cell (RBC) transfusions in the gravest patients1. Since then, some reports are indicative of improvements in transfusion practices (mostly as regards reduced haemoglobin [Hb] thresholds at which patients are transfused2–4). Nonetheless, the overall use of allogeneic RBC transfusions in clinical practice remains relatively high and still varies widely among many centres and practitioners5–7. The latest data from the U.S. Department of Health and Human Services indicate that over 14.6 million units of RBC or whole blood were transfused in the USA in 2006, which is a 3.3% increase from the previous report8. Similarly, the Agency for Healthcare Research and Quality (AHRQ) reported that in 2007, blood transfusions were given in one in every ten hospital admissions in which a procedure was performed; this is a 140% increase from 1997, making transfusion the fastest growing common procedure in hospitals in the USA9. Allogeneic blood transfusions have historically been linked with a myriad of risks and complications. Some risks (e.g. transfusion reactions and transmission of pathogens) have been largely mitigated through advancements in blood banking (e.g. screening for antibodies and markers of infective agents), although these risks are not likely to ever be completely eliminated10,11. Some other risks and complications (e.g. immunomodulation and transfusion-related acute lung injury [TRALI]) appear to have more subtle and elusive aetiologies and are more difficult to tackle11. The presence of leukocytes, residual plasma, and the effects of blood storage have been investigated as possible causes of harmful consequences of banked allogeneic blood12–15. Notably, a number of clinical trials on the effects of storage age of blood on patients’ outcomes are underway: the results of these trials could substantially change the transfusion practice landscape, if they demonstrate that the currently accepted shelf-life of banked blood is too long and should be revised16–19. The other potential threat to safe, readily available transfusions is the aging population which could result in more recipients and fewer donors, putting more pressure on the less than 10% margin that currently exists between the number of collected and transfused blood units8. Finally, direct and indirect costs associated with transfusion have been rising steadily20, providing another motivation for improving transfusion practices.

BACKGROUND: Traditional techniques for obtaining hemostasis during orthopedic surgery, such as conventional electrocautery and sealants, have limited clinical effectiveness in reducing hemoglobin (Hb) loss and requirement for transfusion. The bipolar tissue sealant device studied in this trial combines radiofrequency energy with saline irrigation to hemostatically seal both cut bone and soft tissue, potentially aiding hemostasis.STUDY DESIGN AND METHODS: Sixty patients undergoing multilevel posterior lumbar instrumentation and fusion were randomly assigned to unipolar cautery alone (control group) or unipolar cautery plus use of the bipolar tissue sealant device (treatment group). Hb loss from the surgical field was measured (rather than estimated) and compared between the two groups. The primary hypothesis was that the treatment group would lose significantly less Hb than the control group.RESULTS: The control group experienced a mean Hb loss of 102.4 g while the treatment group showed a significantly lower mean Hb loss of 66.2 g (p = 0.0004). No significant difference was found between groups with respect to secondary endpoints including length of surgery, number of red blood cell units transfused, number of total blood component units transfused, transfusion avoidance, length of stay, or serious adverse events.CONCLUSION: Use of a bipolar tissue sealant device in addition to unipolar cautery significantly decreased Hb loss during multilevel, posterior lumbar spinal instrumentation and fusion when compared with unipolar cautery alone.

BACKGROUND: This retrospective study compares the safety and efficacy of hepatic parenchymal transection using vascular staplers (VS) and the crush-clamp (CC) technique.METHODS: Demographics, clinicopathologic data, treatments, and postoperative outcomes from patients who underwent VS or CC hepatic parenchymal transection were compared.RESULTS: From 1996-2006, 99 and 112 patients underwent hepatic transection with VS and CC, respectively. Compared to CC, VS transection was associated with less operative time (median 210 vs 275 minutes), blood loss (median 250 vs 500 mL), and postoperative red blood cell (RBC) transfusion (29% vs 44%), all P .05. VS transection was not associated with RBC transfusion on multivariate analysis. There were no differences in rates of positive resection margins (9% vs 13%), postoperative mortality (2% vs 4%), overall morbidity (32% vs 29%), and severe morbidity (20% vs. 23%), all P >.05.CONCLUSION: Hepatic parenchymal transection with VS can be accomplished with similar safety and efficacy as CC transection. (C) 2008 Elsevier Inc. All fights reserved.

Background\r\nThis retrospective study compares the safety and efficacy of hepatic parenchymal transection using vascular staplers (VS) and the crush-clamp (CC) technique.

Background. A minority of patients having cardiac procedures (15% to 20%) consume more than 80% of the blood products transfused at operation. Blood must be viewed as a scarce resource that carries risks and benefits. A careful review of available evidence can provide guidelines to allocate this valuable resource and improve patient outcomes.Methods. We reviewed all available published evidence related to blood conservation during cardiac operations, including randomized controlled trials, published observational information, and case reports. Conventional methods identified the level of evidence available for each of the blood conservation interventions. After considering the level of evidence, recommendations were made regarding each intervention using the American Heart Association/ American College of Cardiology classification scheme.Results. Review of published reports identified a high-risk profile associated with increased postoperative blood transfusion. Six variables stand out as important indicators of risk: ( 1) advanced age, ( 2) low preoperative red blood cell volume ( preoperative anemia or small body size), ( 3) preoperative antiplatelet or antithrombotic drugs, ( 4) reoperative or complex procedures, ( 5) emergency operations, and ( 6) noncardiac patient comorbidities. Careful review revealed preoperative and perioperative interventions that are likely to reduce bleeding and postoperative blood transfusion. Preoperative interventions that are likely to reduce blood transfusion include identification of high-risk patients who should receive all available preoperative and perioperative blood conservation interventions and limitation of antithrombotic drugs. Perioperative blood conservation interventions include use of antifibrinolytic drugs, selective use of off- pump coronary artery bypass graft surgery, routine use of a cell-saving device, and implementation of appropriate transfusion indications. An important intervention is application of a multimodality blood conservation program that is institution based, accepted by all health care providers, and that involves well thought out transfusion algorithms to guide transfusion decisions.Conclusions. Based on available evidence, institution-specific protocols should screen for high- risk patients, as blood conservation interventions are likely to be most productive for this high- risk subset. Available evidence-based blood conservation techniques include ( 1) drugs that increase preoperative blood volume ( eg, erythropoietin) or decrease postoperative bleeding ( eg, antifibrinolytics), ( 2) devices that conserve blood ( eg, intraoperative blood salvage and blood sparing interventions), ( 3) interventions that protect the patient's own blood from the stress of operation ( eg, autologous predonation and normovolemic hemodilution), ( 4) consensus, institution-specific blood transfusion algorithms supplemented with point-of-care testing, and most importantly, ( 5) a multimodality approach to blood conservation combining all of the above.