Impact of reservoir hematocrit and processing parameters on the quality of processed blood product.
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Algorithms↗
Biomedical subjects
G Shulman
Publications and source records attributed to G Shulman.
Intraoperative autotransfusion in hip arthroplasty.
Two groups of patients having primary or revision total hip replacement were studied during a period of 11 months. The first group of 40 consecutive patients consented to have whole blood collected coincident with acute normovolemic hemodilution. An inventory of autologous red blood cells, plasma, and platelets was prepared in the operating room as a preliminary to surgery. Subsequently, the same supplies and equipment were used for autotransfusion intraoperatively. In a case-control study, another 40 patients having total hip replacements were matched for age, gender, and weight. The second group of patients refused hemodilution and received autotransfusion alone. The perioperative transfusion requirements of the two groups were compared. The total blood product donor exposure rate of the first group was 1/4 of the controls (0.6 and 2.4 donor units per patient, respectively). The average length of stay in the hospital after surgery for the first group was shortened significantly (6.2 versus 8.4 days), possibly from less immunogenic insult associated with increased transfusions of autologous blood products. Hemodilution, followed by autotransfusion, was cost effective in primary and revision total hip replacements, autotransfusion alone was cost effective only in revision arthroplasty.
Adult↗
Safety and efficacy of a heparin removal device: a prospective randomized preclinical outcomes study.
BACKGROUND: Systemic protamine sulfate for heparin reversal after cardiopulmonary bypass (CPB) is associated with uncommon, but life-threatening adverse reactions. METHODS: In a prospective randomized 3-day outcomes study, a heparin removal device (HRD) group (n = 12; 60-, 80-, 100-kg subgroups) was compared with a matched systemic Protamine group (Protamine; n = 6) for safety and efficacy using an adult swine model of CPB (60 minutes, 28 degrees C). RESULTS: HRD run time was 25 to 38 minutes depending on weight without complications. After HRD, heparin concentration decreased from 4.77 +/- 0.17 to 0.45 +/- 0.06 U/mL (activated clotting time [ACT] 776 +/- 83 to 180 +/- 12 seconds), and in Protamine, 3.94 +/- 0.63 to 0.13 +/- 0.02 U/mL (ACT 694 +/- 132 to 101 +/- 5 seconds) (p = 0.01 between groups, but no significant differences 60 minutes later). No significant difference between HRD and Protamine to 72 hours was seen in plasma-free hemoglobin C3a, heparin concentration, thromboelastogram index, platelet count, activated partial thromboplastin time, anti-thrombin III, fibrinogen, ACT, and tissue histology. CONCLUSIONS: In a prospective randomized outcomes study, HRD achieved predictable reversal of systemic heparinization after CPB with no difference in safety or outcomes compared with protamine.
Adsorption↗
Quality of processed blood for autotransfusion.
Centrifugal red blood cell washers for intraoperative autotransfusion process shed blood during surgery. In this study, the quality of processed fresh, human bank blood was assessed in a standardized laboratory setting during standard, medium, and high flow processing. Red cell recovery rates and plasma washout efficiencies were compared using three different devices. The accurate parameters measuring effectiveness and product quality were red cell mass (RCM) flow rate and the plasma washout efficiency. Cobe BRAT 2, a system with discontinuous flow (DF) and a cylindrical centrifuge bowl, permitted processing in standard and medium flow of 26 and 35 mL RCM/min, respectively, with washout of residual plasma albumin of 93.2 and 91.2%. The Medtronic Sequestra 1000, a DF system with a conical centrifuge bowl processed blood at 15 and 23 mL RCM/min and eliminated plasma albumin with 98.4 and 96.8% washout during standard and medium flow, respectively, with significant red cell loss occurring during medium flow. The respective speeds of high-flow programs with BRAT 2 and Sequestra 1000 were 15 and 22 mL RCM/min, related to a hematocrit in the holding bag, less than that of the incoming blood from the reservoir. Washout was 58.2 and 58.3%, respectively. Fresenius CATS, a continuous flow (CF) device, produced flow rates of 19, 24, and 43 mL RCM/min and plasma albumin elimination of 97.8, 94.4, and 93.3% in standard, medium, and high-flow, respectively. Holding bag hematocrits with CF exceeded that of DF. Standard, medium, and high-flow programs of CATS may be used without restriction.
Blood Transfusion, Autologous↗
Augmented autologous transfusions in major reconstructive spine surgery.
Intraoperative autologous transfusion during major reconstructive spine surgery decreased allogeneic red blood cell transfusions, but patients were exposed to significant numbers of allogeneic blood products. This study reports a prospective study of 160 randomized patients undergoing major reconstructive spine surgery. Without delaying start of surgery, 80 patients underwent hemapheresis with coincidental normovolemic hemodilution in the operating room to sequester autologous blood components. A therapeutic dose plateletpheresis product and an average of 2 U each of freshly collected autologous red cells and fresh plasma were prepared prior to surgical incision. The same supplies and equipment were used subsequently to carry out intraoperative autologous transfusion (IAT). Autologous plasma and platelets were transfused to Sequestration patients, contributing to a significant decrease of total allogeneic donor exposures. One or more autologous red blood cell unit equivalents were cost effectively salvaged and retransfused to 78% of the Sequestration patients. Altogether, autologous red cells comprised 87% of the total red cells transfused. During the same time period, 80 age-, sex-, and weight-matched controls, who received IAT only, were accrued for comparison with Sequestration patients. Of all red cells transfused to control patients, autologous units comprised 47%. Both patient groups received the same total perioperative red blood cell support. The per patient cost for IAT, with or without sequestration, was competitive with supplying one unit of cross-matched allogeneic red cells. IAT only patients had greater allogeneic blood donor exposures than Sequestration patients, in whom the numbers of allogeneic red cells, plasma and platelet transfusions were decreased. Compared with IAT alone, the hospital post-operative stay of Sequestration patients was 23% less than IAT only patients.
Adult↗
Audit of autotransfusion in spine surgery.
A prospective evaluation has been undertaken of 382 patients undergoing reconstructive spine surgery during a thirty-six month period. Acute normovolaemic haemodilution and haemapheresis for blood component sequestration was used in 80 patients in the operating theatre. An average of two units each of freshly collected autologous red cells and fresh plasma together with a therapeutic dose of a plateletpheresis product were prepared for each patient prior to surgical incision. The same supplies and equipment were subsequently used for conventional blood salvage and autotransfusion. The other 302 patients received salvaged blood only. Of the total blood transfused, autologous red cells comprised 87% of sequestration and 49% of autotransfusion-only patients. Each group received the same total perioperative red blood cell support. The cost for one red cell equivalent by intraoperative autologous transfusion was competitive with that of providing one unit of cross-matched allogeneic red cells. As compared with salvage alone, sequestration combined with salvage was even more cost effective and decreased reliance on allogenic products and preoperative autologous blood donations. The rate of transfusing autologous blood products was markedly increased.
Adult↗
Acute normovolemic red cell exchange for cardiopulmonary bypass in sickle cell disease.
A patient with sickle cell disease (hematocrit, 28.5%; hemoglobin S fraction, 79%), required mitral valve repair. Partial red cell removal and blood component sequestration with an autotransfusion device before cardiopulmonary bypass initially decreased the sickle red cell mass. This was followed by an acute one-volume whole blood exchange transfusion performed upon the initiation of cardiopulmonary bypass, resulting in a further reduction. Both techniques yielded fresh autologous plasma for use; sequestration yielded a platelet-pheresis product. Adequate postbypass hemostasis was demonstrated.
Adolescent↗
Efficacy of autotransfusion in spine surgery: comparison of autotransfusion alone and with hemodilution and apheresis.
STUDY DESIGN: Two prospective groups of patients received intraoperative autologous transfusion during reconstructive spine surgery. Before intraoperative autologous transfusion, one group underwent normovolemic hemodilution and apheresis of blood components in the operating room while being prepared for surgery. The allogeneic blood products needed for transfusion by each group were studied and compared with those of a retrospective group of patients receiving conventional transfusion therapy. OBJECTIVES: To determine if a combination of intraoperative autologous transfusion and hemodilution and apheresis decreases reliance on allogeneic blood products and increases autologous transfusions. SUMMARY OF BACKGROUND DATA: Transfusion rates of allogeneic red blood cells, which were unchanged by intraoperative autologous transfusion alone, were lowered when treatment included transfusion of these cells and preoperative autologous deposit. However, donor exposures from transfusions of allogeneic platelets and fresh frozen plasma have not been addressed. METHOD: Preoperative hemodilution and apheresis of autologous red blood cells, fresh plasma, and platelets, performed during induction of anesthesia for spine surgery was followed by intraoperative autologous transfusion using the same supplies. Intra- and postoperative transfusion of blood products to each group were evaluated and compared; allogeneic transfusions were given to a retrospective cohort of patients who received conventional transfusion therapy. RESULTS: Hemodilution and apheresis followed by intraoperative autologous transfusion reduced exposures to individual blood donor products resulting in fewer transfusions and in transfusion of significantly fewer blood products. Intraoperative autologous transfusion alone decreased the number of red blood cells transfused, but required the same donor exposures for fresh frozen plasma and platelet support as the cohort of patients who received conventional transfusion therapy. CONCLUSIONS: A combination of hemodilution and apheresis and intraoperative autologous transfusion significantly decreased transfusion of allogeneic blood products and reliance on preoperative autologous deposit. Autologous transfusion of all blood products was significantly increased.
Adolescent↗
Adverse effects of postoperative infusion of shed mediastinal blood.
BACKGROUND: Postoperative infusion of shed mediastinal blood has been used in an effort to decrease blood usage after cardiac operations. Recent experience has suggested that this practice may actually lead to a delayed increase in bleeding. METHODS: In a prospective, randomized study, 40 patients undergoing coronary artery bypass grafting with shed mediastinal blood collected in a cardiotomy reservoir were divided into two equal groups and studied during their first 4 hours in the intensive care unit. Shed mediastinal blood was directly infused in group I (n = 20), whereas in group II (n = 20), it was not. In group II, if a sufficient volume of red cells was present to allow processing (n = 5), washed red cells were infused. Variables studied before and after infusion were the amount of blood lost and infused, homologous blood transfused, complete blood count and differential, serum fibrinogen, fibrin split products, D-dimers, clotting factors, prothrombin time, activated partial thromboplastin time, thromboelastograms, plasma-free hemoglobin, complement factors C3 and C4, creatine kinase and its MB isoenzyme, and body temperature. RESULTS: After infusion of shed mediastinal blood, elevated levels of fibrin split products and D-dimers were found in significantly more patients in group I. The thromboelastogram index was normal in 76% of patients in group II but in only 12.5% in group I. Group I also had an increase in band neutrophils, a greater number of febrile patients, higher serum levels of creatine kinase, its MB isoenzyme, and plasma-free hemoglobin, and greater blood loss during hours 3, 4, and 5 in the intensive care unit. The volume of red cells in shed mediastinal blood (hematocrit, 9% to 10%) was small, resulting in clinically insignificant autotransfusion when infused directly, and insufficient for cell processing in most patients. CONCLUSIONS: These data support those in previous studies that direct infusion of shed mediastinal blood does not save substantial amounts of autologous red cells and can cause a delayed coagulopathy and other adverse effects that may be harmful to patients postoperatively.
Adult↗
Central adiposity and its metabolic correlates in obese adolescent girls.
To establish whether alterations in insulin action and secretion and their relationship to body fat distribution occur early in the course of developing obesity, we studied 14 obese adolescent girls [13.2 +/- 0.7 yr, body mass index (BMI) 32 +/- 1.4], 16 nonobese young women (24.0 +/- 0.6 yr, BMI 21.0 +/- 0.9). Insulin action was assessed by a sequential two-step (8 and 40 mU,m-2.min-1) euglycemic insulin clamp in combination with [1-13C]glucose and indirect calorimetry. Insulin secretion was determined by the hyperglycemic clamp technique (6.9 mmol/l). Magnetic resonance imaging was used to quantify visceral and subcutaneous abdominal fat depots. In obese girls, an impairment in glucose disposal was present with both insulin doses; at the higher dose, rates of glucose uptake were reduced by 30% in nonobese girls (240 +/- 30 vs. 340 +/- 19 mg.m-2.min-1, P < 0.05) and by an additional 29% (170 +/- 17 mg.m-2.min-1, P < 0.05) in obese girls. Insulin infusion failed to stimulate glucose oxidation and to suppress lipid oxidation only in obese girls. Suppression of free fatty acid levels, but not hepatic glucose production, was decreased in obese girls compared with controls. Fasting and glucose-stimulated insulin responses were greater in obese than in nonobese adolescents, who, in turn, had greater responses than lean women. In obese girls, visceral fat, but neither waist-to-hip circumference ratio nor subcutaneous fat, was highly correlated with basal insulin secretion (r = 0.89, P < 0.001), stimulated insulin secretion (r = 0.61, P < 0.05), and insulin resistance (r = -0.87, P < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)
Adipose Tissue↗
[Preliminary evaluation of composite materials for the repair of incisional hernias].
Recent investigations have shown that direct exposure of the intestines to currently available absorbable and nonabsorbable biomaterials can result in their adhesion to the bowel. This can then lead to bowel obstruction or migration of the mesh into the intestinal lumen and formation of intestinal fistula. It has been suggested by some authors that an absorbable covering of the peritoneal side of a nonabsorbable mesh would prevent adhesions and biomaterial related intestinal fistula formation. However, the effectiveness of such a combination has not been substantiated by recent experimental and clinical studies. This preliminary report examines the feasibility of combining porous and non-porous biomaterials for the creation of a composite that would incorporate with the abdominal wall without adhering to the intestines.
Animals↗
Progesterone administration induced impairment of insulin suppression of hepatic glucose production.
OBJECTIVE: To assess whether P administration impairs insulin-mediated glucose uptake. DESIGN: Two-step euglycemic hyperinsulinemic clamp studies. SETTING: Rats studied with (n = 11) or without (n = 10) P treatment. PARTICIPANTS: Conscious, unstressed, oophorectomized female rats. MAIN OUTCOME MEASURES: Plasma glucose and insulin levels and the rates of glucose turnover results. RESULTS: Fasting glucose (115 +/- 5 versus 109 +/- 4 mg/dL; conversion factor to SI units 0.05551) and insulin (1.67 +/- 0.24 versus 1.51 +/- 0.22 ng/mL; conversion factor to SI units 174.5) levels were not significantly different in the control and P treated groups, respectively. However, the basal rate of glucose turnover was significantly higher in P-treated rats (8.38 +/- 0.50 versus 6.59 +/- 0.35 mg/kg per minute in controls. During low-dose insulin infusion (2 mU/kg per minute), there was no difference in glucose or insulin levels, or the rate of glucose utilization; however, residual hepatic glucose production was significantly greater in the P group (5.34 +/- 0.68 versus 2.57 +/- 1.00 mg/kg per minute) in controls. At high-dose insulin infusion (10 mU/kg per minute), hepatic glucose production was completely suppressed in both groups; there was no difference in insulin sensitivity as assessed by the glucose utilization rate or the ratio of glucose uptake to insulin level. CONCLUSIONS: Chronic P therapy does not alter insulin-mediated glucose utilization in peripheral tissues but does reduce the ability of insulin to suppress endogenous hepatic glucose production.
Animals↗
Comparative effects of monomethylsuccinate and glucose on insulin secretion from perifused rat islets.
In the absence of any other exogenously added fuel, monomethylsuccinate, the methyl ester of succinic acid, at 10-20 mM stimulates insulin release in a biphasic pattern. In quantitative terms, first-phase release evoked by 20 mM MMSucc was comparable to that observed with 20 mM glucose but second-phase release was only 20% of the glucose-induced response. Secretion to both MMSucc and glucose was virtually abolished by the calcium channel antagonist nitrendipine (0.5 microM). In islets that had phosphoinositide pools labeled with [3H]inositol for 2 h, subsequent stimulation with 20 mM MMSucc results in dramatic and sustained increases in [3H]inositol efflux rates. Inositol phosphate levels are also increased. In contrast to secretion, the increase in phosphoinositide hydrolysis caused by MMSucc was largely resistant to nitrendipine, whereas significant reductions in glucose-induced phosphoinositide hydrolysis were observed in the presence of the calcium channel antagonist. MMSucc (2.75-10 mM) substitutes for glucose in that MMSucc supported the insulinotropic effects of the sulfonylurea tolbutamide (200 microM) and the gut hormone cholecystokinin (200 nM). A prior 15-min exposure to 20 mM MMSucc also sensitized islets to the stimulatory effects of 7.5 mM glucose. Finally, a 2-h exposure to 20 mM MMSucc desensitized the islet, in terms of both phosphoinositide hydrolysis and insulin secretion, to a subsequent exposure to 10 mM glucose. Thus, appropriate concentrations of MMSucc can cause qualitatively many of the effects induced by glucose.(ABSTRACT TRUNCATED AT 250 WORDS)
Analysis of Variance↗
A survey of hepatitis B surface antigen-positive blood donors: degree of understanding and action taken after notification.
All blood donors in the United States are tested for hepatitis B surface antigen (HBsAg) upon donation; if the test result is positive, the primary method of notification is by letter. To assess the effectiveness of this notification methods in stimulating HBsAg-positive donors to seek medical care and take preventive measures, 54 donors who tested HBsAg-positive on donation at the American Red Cross Blood Services. Atlanta Region, from January 1987 to July 1989 were interviewed. Thirty-nine donors (72%) had sought medical care after notification; the only motivating factor was that the letter told the donor to consult with his or her physician. Compared with donors who did not seek medical care, donors who did so were more likely to understand that the blood test was abnormal or that they were infected, and they were more likely to understand how hepatitis B virus is transmitted and that a vaccine is available. The differences were not significant, however. Of those donors who sought medical care, less than half received appropriate recommendations for protection of contacts, and of those who did, only one-third received prophylaxis. In-person and telephone interviews with donors, revision of the notification letter, and hepatitis B education programs targeted at medical care providers are suggested.
Blood Donors↗
Indeterminate HTLV serologic results in U.S. blood donors: are they due to HTLV-I or HTLV-II?
Current screening tests to detect human T-lymphotropic virus type I (HTLV-I) in volunteer blood donors commonly yield indeterminate HTLV serologic results (mostly isolated gag reactors). To assess the significance of indeterminate HTLV serologic results in U.S. blood donors, we compared 56 persons who had such serologic patterns with 30 HTLV seropositive blood donors and with HTLV seronegative controls. Polymerase chain reaction assays showed that none of the 56 individuals with indeterminate HTLV serologic results were infected with HTLV-I or HTLV-II, while all 30 HTLV seropositive blood donors were infected with either HTLV-I (in 15) or HTLV-II (in the other 15). The seroindeterminate blood donors were also different from the HTLV seropositive blood donors and more like HTLV seronegative controls in their demographic characteristics and the presence of HTLV risk factors. These results are evidence that volunteer blood donors with isolated and persistent gag seroreactivity in the United States are unlikely to be infected with HTLV-I or HTLV-II.
Adolescent↗
Seroprevalence and epidemiological correlates of HTLV-I infection in U.S. blood donors.
Screening for human T-lymphotropic virus type I (HTLV-I) antibodies was performed on sera from 39,898 blood donors at eight blood centers in geographically distinct areas of the United States. Ten donors (0.025 percent) showed evidence of HTLV-I seropositivity by enzyme immunoassays; this was confirmed by protein immunoblot and radioimmunoprecipitation. Seroprevalence rates ranged from 0 to 0.10 percent at the locations sampled, with HTLV-I antibodies found predominantly in donors from the southeastern and southwestern United States. Matched case-control interviews and laboratory studies were performed on five seropositive women and two seropositive men who participated in an identity-linked collection of sera from a subset of 33,893 donors at six of the eight blood centers. Four of the women and both men are black; one woman is Caucasian. Four of the seven seropositive individuals admitted to prior intravenous drug abuse or sexual contact with an intravenous drug user. Sexual contact with native inhabitants of an HTLV-I endemic area was the only identified risk factor for one male. The distribution of HTLV-I antibodies in this U.S. blood donor sample corroborates the previously reported epidemiology of this agent and suggests that additional donor screening measures, including the testing of donated blood for HTLV-I markers, may be necessary to prevent the spread of HTLV-I to transfusion recipients.
Adult↗
Double contrast arthrography of the knee. A comparison to clinical diagnosis and arthroscopic findings.
The accuracy of pre-arthroscopic double contrast arthrography was evaluated in 100 consecutive patients. Meniscal tears were correctly diagnosed arthrographically in 76% of cases, and clinically in 85% of cases. Although reasonably accurate in determining the location of the meniscal tear, arthrography was significantly inaccurate in the evaluation of the type of tear. The status of the anterior cruciate ligament was correctly interpreted by arthrogram in 76% of cases; the integrity of the ligament was correctly assessed in 94% of cases by clinical examination without anesthesia. It appears, therefore, when compared to initial clinical examination, double contrast arthrography is of limited usefulness as a pre-surgical aid to the diagnosis of intra-articular knee pathology.
Arthrography↗
Acute bacterial arthritis in the adult.
Suppurative arthritis can be a complex and vexing problem. Formal arthrotomy is among the many successful approaches for the treatment of septic joints in the adult, however, it is not without morbidity and may not always be required. The clinical features, pathophysiology, and treatment of this disorder are reviewed.
Acute Disease↗