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Objectives: Recent data show that up to 50% of heart procedures require blood transfusion, which can have adverse long- and short-term outcomes for the patient. This led to the updated 2011 Society of Thoracic Surgery (STS)/Society of Cardiovascular Anesthesiologists (SCA) guidelines in an attempt to adopt more effective blood conservation techniques. We present our results after the implementation of a more aggressive strategy for intraoperative blood conservation in cardiac surgery., Methods: Our cardiac surgery database was reviewed retrospectively, comparing outcomes from two different time periods, after the implementation of a more effective two-way blood conservation strategy beginning in March 2012: more aggressive intraoperative autologous donation (IAD) based on a newly constructed nomogram, and the use of a shorter length circuit of the cardiopulmonary bypass (CPB) which allowed for lower fluid volume as a prime. The method of retrograde autologous priming (RAP) was the same for both time periods., Results: A total of 1126 patients (Group 1) were studied in a 12-month period (March 2012-February 2013) after the implementation of the new strategy, and compared with 3758 patients (Group 2) of the previous 36-month period (March 2009-February 2012). There was a significant reduction in the percent change of the intraoperative haematocrit between Groups 1 and 2 (14 vs 28%, P = 0.01), with an increase in the mean IAD volume (655 vs 390 ml, P = 0.02) and a reduction in the CPB priming volume (1000 vs 1600 ml, P = 0.03). Group 1 required significantly less blood transfusions in the perioperative period (29 vs 49%, P = 0.02) and had significantly reduced postoperative rates of respiratory failure (3 vs 7%, P = 0.03), pneumonia (1 vs 3.1%, P = 0.01), chest tube output (350 vs 730 ml, P = 0.01), reoperation for bleeding (1.2 vs 2.5%, P = 0.04) and length of stay (6.1 vs 8.2 days, P = 0.05)., Conclusions: Blood conservation is safe and effective in reducing transfusions in cardiac surgery, minimizing perioperative morbidity and mortality. Aggressive IAD and low CPB prime, along with effective RAP, is the three-way blood conservation strategy that leads to improved outcomes in cardiac surgery., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Total knee arthroplasty (TKA) can be associated with substantial blood loss, leading to increased morbidity and transfusion rates. The study objective was to evaluate routine use of a thrombin-based topical hemostatic matrix in reducing blood loss and transfusion requirements in primary TKA. 108 patients were enrolled in a prospective, randomized, single-center trial. Patients receiving the hemostatic agent demonstrated a lower mean calculated blood loss (1325.2±464.8mL vs. control, 1509.3±432.8mL; P=0.02), drain output (415.6±202.0mL vs. control, 579.9±306.7mL; P=0.008), and length of stay (3.3±0.8days vs. control, 3.7±1.1days; P=0.03), without a statistically significant difference in mean hemoglobin loss or transfusion requirements. The clinical utility of this hemostatic agent to reduce transfusions after uncomplicated, primary TKA continues to remain unclear., (Published by Elsevier Inc.)

Perioperative anaemia and allogenic blood transfusion (ABT) are known to increase the risk of adverse clinical outcomes. The quality, cost and availability of blood components are also major limitations with regard to ABT. Perioperative patient blood management (PBM) strategies should be aimed at minimizing and improving utilization of blood components. The goals of PBM are adequate preoperative evaluation and optimization of haemoglobin and bleeding parameters, techniques to minimize blood loss, blood conservation technologies and use of transfusion guidelines with targeted therapy. Attention to these details can help in cost reduction and improved patient outcome.

Background: There are little published data on outcomes of blood conservation (BC) patients after noncardiac surgery. The objective of this study was to compare the surgical outcomes of patients enrolled in our BC program with that of the general population of surgical patients., Methods: BC patients at our institution undergoing various surgical procedures were identified from the 2007-2009 National Surgical Quality Improvement Program database and compared with a cohort of conventional care (CC) patients matched by age, gender, and surgical procedure. Univariate and multiple logistic regression analyses were performed to evaluate 30-d postoperative outcomes., Results: One hundred twenty BC patients were compared with 238 CC patients. The two groups were similar for all preoperative variables except smoking, which was lower in the BC group. On univariate analysis, BC patients had similar mean operating time (148 versus 155 min; P = 0.5), length of stay (5.9 versus 5.5 d; P = 0.7), and rate of return to the operating room (7.5% versus 5.5%; P = 0.4) compared with CC patients. BC and CC patients had similar 30-d morbidity (18% versus 14%; P = 0.3) and mortality rates (1.6% versus 1.3%; P = 1.0), respectively. On multivariable analysis, enrollment in the BC program had no impact on postoperative 30-d morbidity (odds ratio, 1.78; 95% confidence interval, 0.71-4.47) or 30-d mortality (unadjusted odds ratio, 1.33; 95% confidence interval, 0.22-8.05)., Conclusions: Short-term postoperative outcomes in BC patients are similar to the general population, and these patients should not be denied surgical treatment based on their unwillingness to receive blood products., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Blood conservation, or Patient Blood Management (PBM), is a paradigm shift in transfusion practice. Recognizing the potential adverse effects associated with blood transfusion, PBM emphasises the use of alternatives to transfusion in order to minimize unnecessary or inappropriate blood transfusion. The ONTraC program is a network of transfusion coordinators in 25 Ontario hospitals with the focus of implementing PBM. The program has been highly successful in reducing transfusion rates and improving clinical outcomes, and has proven very cost-effective. This paper summarizes results of the program from its inception in 2002-2011., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

The past is prologue. Reviewing the history of transfusion tells us how far we have come, but also where we need to go. The past has been filled with innovation and important discoveries, but is also fraught with stumbling blocks and unintended side effects. Although much has been achieved and transfusion is safer today than ever, nonetheless we are recognizing new potential concerns with transfusion and we are undergoing a paradigm shift in our attitudes, approach and patient management in regard to blood transfusion., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Allogenic blood is a finite resource, with associated risks. Previous studies show intraoperative cell salvage (ICS) can reduce allogenic transfusion rates in orthopaedic surgery. However, there are concerns regarding efficacy and cost-effectiveness of ICS. This study was carried out to review ICS use in revision hip arthroplasty. All patients who underwent ICS and re-infusion between 2008 and 2010 in the Southern General Hospital (SGH) were audited. The fall in haemoglobin (Hb), volume of blood re-infused and postoperative allogenic transfusion rates were recorded. This group was compared to a similar SGH cohort who underwent surgery by the same surgeons between 2006 and 2008, and a pre-2005 control group where no ICS was used. The proportion of patients receiving a postoperative allogenic transfusion fell by 55% in the 2008-2010 ICS cohort compared with the control, and by 40% compared with the previous ICS group. In both instances, there was a statistically significant (p < 0.001) reduction in mean units transfused per patient; in the 2008-2010 ICS cohort, a mean of 0.8 units was used per patient, while 1.4 were used in the 2006-2008 cohort. 3.5 units were used in the control group. There was no statistically significant difference in age or preoperative Hb between the groups, or in length of hospital stay. In this study, ICS has been shown to be effective in reducing rates and volume of postoperative allogenic transfusion in patients undergoing revision hip surgery at the SGH. However, further work is needed to establish the effect of changing anaesthetic technique on postoperative allogenic transfusion rates.

In orthopedics management of surgical blood loss is an important aspect which has evolved along with modern surgeries. Replacement of lost blood by transfusion alone is not the answer as was considered earlier. Complications like infection and immune reaction due to blood transfusion are a major concern. Today numerous techniques are available in place of allogenic blood transfusion which can be employed safely and effectively. In this article we have reviewed these techniques, their merits and demerits.

Introduction: Ascending and aortic arch surgery is associated with higher levels of blood loss and subsequent need for allogeneic blood transfusions. We hypothesized that aggressive, comprehensive blood conservation strategies may limit the need for transfusions and, subsequently, improve postoperative outcomes., Methods: Over a five-year period, 189 patients underwent proximal aortic surgery at our institution. Fifty-one patients underwent surgery using a comprehensive blood conservation strategy (BCS), including preoperative hemoglobin optimization, antifibrinolytic therapy, intraoperative acute normovolemic hemodilution, cell salvage and meticulous surgical technique. The remaining 138 patients underwent surgery using conventional techniques (CONV)., Results: Patients in the BCS group required fewer transfusions during their hospital stay compared to the conventional group (56.9% vs. 72.5%, p=0.041). When examining elective cases, this trend widens, with 40.0% of BCS patients requiring any transfusions compared to 72.9% patients in the conventional group (p=0.001). Red cell (47.1% vs. 62.3%, p=0.06), plasma (43.1% vs. 61.6%, p=0.02) and platelets (27.5% vs. 47.8%, p=0.01) were also less frequently required in the BCS group than the conventional group, respectively. When a transfusion was required, patients in the BCS group received significantly fewer units of red blood cells (2.8 ± 7.0 units) than the conventional group (5.81 ± 9.5 units; p=0.039). Mortality was similar in both groups (BCS 7.8%, conventional 10.9%, p=0.54); however, there was significantly less morbidity in the BCS group, using a composite of any of 10 major postoperative complications (23.5% vs. 39.1%; p=0.046). Median intensive care unit (ICU) and hospital lengths of stay were 2 and 7 days in the BCS group and 2 and 8 days in the CONV group (p=0.15), respectively., Conclusions: The aggressive use of a comprehensive blood conservation strategy in ascending and aortic arch surgery can significantly reduce the need for blood transfusions and is associated with less postoperative morbidity. Further evaluation with a randomized, controlled trial is warranted.

Neonates and infants undergoing cardiac surgery with cardiopulmonary bypass are exposed to multiple blood products from different donors. The volume of the bypass circuit is often as large as the patient's total blood volume and asanguineous bypass primes are unusual. As a result, blood products are required for the cardiopulmonary bypass prime and are often used to treat the postbypass dilutional coagulopathy. We review clot formation and strength, cardiopulmonary bypass prime considerations, assessment of postbypass coagulopathy, component therapy use, ultrafiltration techniques, and use of antifibrinolytic medications. A combined approach including techniques to minimize the prime volume, utilization of ultrafiltration, administration of antifibrinolytics during surgery, and the proper treatment of the dilutional coagulopathy can limit the transfusion requirements.

Unlabelled: GENERAL OBJECTIVE: To assess the practice of blood conservation., Specific Objectives: To determine the methods of blood conservation in use, to assess the lower limit for hemoglobin for elective procedures, to determine transfusion trigger point in practice, to find out limitations in practice and ways to improve clinical practice., Materials and Methods: This was conducted in February 2009. Self-administered questionnaires were distributed among the surgeons and anesthetists in practice at the University of Nigeria Teaching Hospital, Enugu State University Teaching Hospital, Ebonyi State University Teaching Hospital and National Orthopaedic Hospital, Enugu. The data gathered was analyzed using the SPSS software., Results: : Of participants who agreed to fill the questionnaires, more than 50% were males. The most prevalent specialty was general surgery (24.2%), followed by orthopedics (22.6%), obstetrics and gynecology (20.7%), and anesthesia (17.7%). The lowest hemoglobin limit before the patient was allowed into the theatre for elective procedures was 10 g/dl while individual transfusion trigger points ranged from hemoglobin of 6 to 10 g/dl. Majority of the doctors would avoid homologous blood transfusion in order to avoid transfusion-related diseases and reaction. Regarding knowledge of blood conservation methods and means of avoiding homologous blood, the use of diathermy was highest (12.33%), followed by preoperative blood donation (11.87%), use of hematinics (10.96%), and tourniquet 10.5%. Also, in practice, diathermy was the most frequently used (18.69%), followed by preoperative blood donation (16.16%), use of tourniquet (15.15%), while the Ovadje cell saver was least with 0.01%. Suggestions from respondents on the ways of limiting transfusion-related problems included optimization of patients (24.5%), improvement of standard of living (17.7%), and personnel training (13.3%)., Conclusion: There is an agreement with the global trend geared toward minimizing the use of homologous blood by doctors in these hospitals. However, our practice must continually be refined by continuing medical education in order to keep everyone informed of changes in practice. The Government must improve the quality of service by the provision of unavailable infrastructure.

There is increasing concern about the safety of homologous blood transfusion during cardiac surgery, and a restrictive transfusion practice is associated with improved outcome. Transfusion-free pediatric cardiac surgery is unrealistic for the vast majority of procedures in neonates or small infants; however, considerable progress has been made by using techniques that decrease the need for homologous blood products or even allow bloodless surgery in older infants and children. These techniques involve a decrease in prime volume by downsizing the bypass circuit with the help of vacuum-assisted venous drainage, microplegia, autologous blood predonation with or without infusion of recombinant (erythropoietin), cell salvaging, ultrafiltration and retrograde autologous priming. The three major techniques which are simple, safe, efficient, and cost-effective are: a prime volume as small as possible, cardioplegia with negligible hydric balance and circuit residual blood salvaged without any alteration. Furthermore, these three techniques can be used for all the patients, including emergencies and small babies. In every pediatric surgical unit, a strategy to decrease or avoid blood bank transfusion must be implemented. A strategy to minimize transfusion requirement requires a combined effort involving the entire surgical team with pre-, peri-, and postoperative planning and management.