Avoiding homologous blood and blood products in the perisurgical setting.
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Blood Transfusion↗
Biomedical subjects
H Gombotz
Publications and source records attributed to H Gombotz.
[Autologous blood donation with preliminary erythropoietin stimulation].
Low basal hemoglobin and functional iron deficiency are the limiting factors in autologous blood donation program. Treatment with recombinant human erythropoietin can increase the volume of autologous blood and makes donation of > or = 3 units possible-even in patients with low basal hemoglobin. Best results are obtained if stimulation begins already one week before first donation.
Anemia, Iron-Deficiency↗
[Reduction in the use of donated blood in surgical medicine].
After rapid changes in transfusion practice over the past few years, blood conservation techniques have become standard in modern perioperative management. As a result, the amount of homologous blood products transfused has been markedly reduced in some types of surgical procedures. Provided that skillful surgical technique is applied and the use of blood products is restricted, autologous transfusion techniques (predonation of autologous blood, preoperative plasmapheresis, acute normovolaemic haemodilution, and intra- and postoperative blood salvage) can be performed with an acceptable risk for patients. In addition, stimulation of erythropoiesis with recombinant human erythropoietin, supplemental iron therapy, and improving haemostasis by aprotinin may further reduce homologous blood requirements. All patients undergoing elective surgery have to be informed about the side effects of transfusion of homologous blood products and the possibility of blood-saving methods. An individual blood conservation plan, based on the patient's status and surgery, the equipment available, and personal experience should be worked out by the responsible anaesthesiologist, whereby a combination of different methods may be most effective. If storage is necessary, autologous blood products should be preparated like homologous products. The feasibility of predonation and retransfusion of autologous blood in patients with infectious diseases like hepatitis or acquired immune deficiency syndrome and the amount of labaratomy testing are still under discussion. Although blood conservation programs are time-consuming and more expensive, they reduce the various risks of using homologous blood products.
Adolescent↗
Neuromonitoring during hypothermic cardiopulmonary bypass.
To reduce the incidence of neurological and neuropsychological dysfunction following hypothermic cardiopulmonary bypass (CPB), central nervous system (CNS) monitoring before, during, and after CPB seems to be necessary. Compared to the total scope of hemodynamic monitoring CNS monitoring, however, is mostly investigational and infrequently used in clinical routine, and the impact on postoperative outcome is still being discussed. An optimal CNS monitoring would have to include continuous objective measurement of brain function, perfusion, and metabolism with regard to patients' disease and would also have to be adapted to the technique applied and the period of CPB. Over the past few years a number of monitoring devices (computer-processed electroencephalogram, jugular bulb saturation, Doppler flow measurement, near infrared spectroscopy) have been evaluated. Each of them has a specific diagnostic power so that a combination of only two or more devices will meet the criteria for effective brain monitoring. In addition, the impact on outcome and the applicability and cost-effectiveness of these tools will have to be investigated in the future.
Cardiopulmonary Bypass↗
Troponin T as a marker of perioperative myocardial cell damage.
Unstable angina in patients undergoing CABG surgery is associated with a higher morbidity and mortality compared to patients with stable angina. Mortality ranges between 2 and 10% (20, 21). The importance of the preoperative status is only clear and well documented for patients with unstable angina who are unresponsive to medical treatment, patients who undergo emergency revascularization, and for patients with failed angioplasty. The adverse outcome in elective patients with unstable angina was statistically not significantly different from those with stable angina. Therefore, we may assume that in stabilized patients with unstable angina and minor myocardial cell damage intraoperative determinants like the duration of the aortic clamping period or the degree of revascularization are more relevant than the preoperative ones. These determinants may also be reflected by a marked and significant increase of troponin T in both groups during and after surgery. As for other cardiac enzymes, this increase of troponin T beginning immediately after reperfusion of the cardioplegic heart may limit its diagnostic value after cardiac surgery (6,22). On the other hand, troponin T may serve as a marker in assessing the effectiveness of different cardioprotective measures. Nevertheless, preoperatively elevated troponin T levels may indicate a jeopardized myocardium with an ongoing process of myocardial cell damage and may be of prognostic value. Antianginal and antiischemic therapy, therefore, has to be continued and completed until the day of surgery in these high-risk patients.
Angina, Unstable↗
Preoperative myocardial cell damage in patients with unstable angina undergoing coronary artery bypass graft surgery.
BACKGROUND: Troponin-T is one of the contractile proteins of the myocardium. Its release into the circulation indicates various degrees of myocardial cell damage. Troponin-T may be measured in serum with a recently developed enzyme immunoassay. This immunoassay was used to evaluate the preoperative myocardial cell damage in patients with stable and unstable angina undergoing elective coronary artery bypass graft surgery, and it was compared with conventional assays of creatine kinase (CK) MB isoenzyme activity and mass. METHODS: Twenty-one patients with unstable angina and 31 with stable angina were studied. Troponin-T, CK-MB activity, and CK-MB mass were measured 24 h before anesthesia and surgery, immediately before induction of anesthesia, before and after cardiopulmonary bypass, at the end of surgery, and 24 h afterward. RESULTS: In 90% (19 of 21) of the patients with unstable angina, troponin-T was increased 24 h before anesthesia (median 0.33 microgram/l, range 0.15-5.2 micrograms/l), whereas only 3% (1 of 31) of the patients with stable angina had increased values (median 0.0 microgram/l, range 0.0-0.53 microgram/l). The difference was statistically significant (P < 0.001). The same profile was found in patients with and without unstable angina immediately before induction of anesthesia (86% [18 of 21] and 0%, respectively) and before cardiopulmonary bypass (62% [13 of 21] and 0%, respectively). In contrast to troponin-T, CK-MB activity was increased in only 0-14% of patients with unstable angina, and CK-MB mass was increased in only 9-24%. After bypass troponin-T increased in both groups (P < 0.01), but there was no longer a statistically significant difference between the groups. Twelve percent (4 of 31) of the patients in the stable angina group and 28% (6 of 21) in the unstable group had major cardiac events (P not significant). CONCLUSIONS: The study data suggest that many patients with unstable angina undergoing elective coronary artery bypass graft surgery have already increased troponin-T levels preoperatively, although conventional biochemical markers such as CK-MB activity and mass are at a normal range. Increased troponin-T and normal CK-MB concentrations may reflect some degree of ischemic myocardial cell damage. Because of the small number of patients in the study, the influence of preoperative myocardial injury on perioperative outcome could not be clarified.
Adult↗
Erythropoietin in patients undergoing coronary artery bypass graft surgery.
Recombinant human erythropoietin (rHuEPO) has proved to be a useful drug that can aid in protecting patients from possible hazards of homologous blood. Use of rHuEPO for patients scheduled for coronary artery bypass graft (CABG) surgery can enhance the benefit of a preoperative autologous blood donation program while simultaneously minimizing its risks. The main objective are to decrease homologous transfusion requirements by increasing the amount of collected autologous blood and to maximize safety by ameliorating a pre- or postoperative anemia. The goal of this review is to assess the possible benefits of perioperative use of rHuEPO during CABG surgery. Furthermore, we evaluate its ability to augment the quality of collected blood and to lower the risk of autologous blood donation. Side effects, dosages, manner of administration, concomitant iron therapy and suggestions for special patient groups will be discussed.
Blood Transfusion, Autologous↗
Subcutaneous recombinant human erythropoietin and autologous blood donation before coronary artery bypass surgery.
Conventional therapies with recombinant human erythropoietin (rHuEPO) to sustain preoperative autologous blood collection entail high doses of the drug at short intervals. To evaluate the efficacy of a single weekly dose of rHuEPO for autologous blood collection, we randomly assigned 24 male patients scheduled for coronary artery bypass surgery to receive 400 IU/kg rHuEPO subcutaneously once a week or iron only. Patients were examined weekly and a total of up to 4 units of autologous blood were obtained if the hemoglobin level exceeded 12 g/dL. Patients receiving rHuEPO had consistently higher hemoglobin values than those receiving iron only (P < 0.001). Consequently, more autologous red cells were obtained from this group (776 +/- 49 mL vs 682 +/- 91 mL; P < 0.05). One patient receiving rHuEPO and eight in the control group required homologous blood at surgery (P < 0.01). These results suggest that 400 IU/kg rHuEPO administered subcutaneously once a week efficiently stimulates erythropoiesis and compensates the hemoglobin decrease after autologous blood donation.
Blood Transfusion, Autologous↗
[Right ventricular assist device (RVAD) in septic, fulminating pulmonary artery embolism].
We describe a 34-year-old male with pulmonary embolism. The patient had been admitted to a peripheral hospital for incision and drainage of a very large ischio-rectal abscess. Four days after successful surgical intervention and during a change of dressings he developed a massive pulmonary artery embolism. The patient was transferred to the Department of Cardiac Surgery in Graz; on arrival he had a cardiac arrest. Resuscitation was initiated and the patient was transferred to the operating theatre where emergency sternotomy and embolectomy revealed large thrombotic masses in the pulmonary circulation. Extracorporeal circulation was initiated, but despite aggressive medical measures (dopamine, dobutamine, isoproterenol, enoximone, and prostaglandin E1 in maximum therapeutic doses) and a long reperfusion time weaning was not possible. Despite the septic state, a right ventricular assist device (RVAD; ABIOMED BVS 5000) was installed. Weaning was finally accomplished with a pump flow of 2.2 l/min m2 and the patient transferred to the intensive care unit. On post-operative day 3 the pump flow was reduced to 2 l/min. The patient's condition remained stable, which made removal of the RVAD possible on postoperative day 5. The further course was uneventful, with secondary ischio-rectal wound closure. His initial psychomotor impairment had nearly disappeared and he was discharged 2 months later.
Adult↗
Preoperative prostaglandin E1 treatment to prevent right ventricular failure after orthotopic heart transplantation.
Elevated pulmonary vascular resistance (PVR) and pulmonary hypertension (PH) are high risk factors for early graft failure in orthotopic heart transplantation (oHTx). The need for an oversized donor in patients with elevated PVR aggravates the shortage of suitable donor organs. To decrease the elevated PVR to values suitable for orthotopic heart transplantation prostaglandin E1 (PGE1) was administered in 11 patients (11 male, mean age 49.2 years, mean dosage 35 ng/kg per min over 6-8 days). Ten days after the discontinuation of the PGE1 therapy, recatheterization was done. All haemodynamic data were determined by right heart catheterization using a Swan Ganz catheter and thermodilution technique before, and 10 days after, PGE1 treatment. The Wilcoxon signed ranks test was used for statistics. PVR significantly decreased in all patients (5.5 to 2.8 Wood units, P < 0.005). All patients were considered to be suitable for oHTX and put on the waiting list. At the time of writing, in eight of these patients (eight male, mean age 49.6 years; four ischemic, four dilatative CMP) oHTX had been successfully performed. No right ventricular failure occurred in the postoperative phase. These results sugest that long-term moderation of elevated PVR by PGE1 therapy weeks or months before transplantation enables oHTX in patients with elevated PVR.
Adult↗
Transoesophageal echocardiography during removal of a caval filter in a patient at high risk of massive pulmonary thromboembolism.
A new type of vena caval filter was to be removed from a woman who had a high risk of massive pulmonary thromboembolism because of extensive thrombus in the iliac vein incorporating the filter. The removal was performed under general anaesthesia in the cardiac operating theatre using transoesophageal echocardiography to monitor the right heart and the pulmonary artery during the critical phase of removal. The manoeuvre succeeded with only insignificant embolisation occurring, and that was identified by transoesophageal echocardiography.
Echocardiography↗
Open heart surgery in children of Jehovah's Witnesses: extreme hemodilution on cardiopulmonary bypass.
Between January 1979 and July 1989, 15 children of Jehovah's Witnesses underwent corrective open surgery for congenital heart disease (CHD) on cardiopulmonary bypass (CPB). Ages ranged from 1.5-17 years and body weight from 9.1-63 kg, with five patients weighing less than 15 kg. Eight children were cyanotic, and two of them had had previous thoracic operations. All operations were performed in moderate to deep hypothermia using a modified version of isovolemic hemodilution with bloodless priming technique of extracorporeal circulation. Mean hematocrit levels decreased from 47.3% (36.9-70%) to 34.6% (27.2-49.1%) after hemodilution, and then to 17.9% (10.5-25.6%) during bypass. They increased again to 34.1% (24.4-50%) at the end of the operation and to 33.4% (25.1-40%) on day 12. All intra- and postoperative hematocrit levels were significantly lower (p less than 0.001). There was one postoperative death, not related to the technique. Our results demonstrate that bloodless cardiac surgery on bypass is feasible in children as shown in this special group of children of Jehovah's Witnesses. Knowing the risks of homologous blood transfusion this technique should be used more extensively in the future.
Adolescent↗
[The child with heart surgery. Current developments, early and late results of corrective surgery in cyanotic heart defects in childhood].
Present state of operative techniques in children with congenital cyanotic heart defects is described as well as the early and late results after open heart operations-based on own experiences of many years.
Adolescent↗
[Sinus node inhibitors in coronary surgery].
In patients with coronary artery disease, rapid ventricular rates require adequate treatment since disturbed oxygen balance and ischemia may be incurred. By virtue of their isolated action on the sinus node, "specific bradycardic substances" have only negligible hemodynamic side effects and, accordingly, represent an alternative to other available rate-slowing drugs. The clonidine derivative, alinidine (N-allyl-clonidine) was used primarily as the specific bradycardic substance in our studies in patients at the time of aortocoronary bypass surgery. In addition to its rate-slowing properties, this substance also elicits an analgetic and anti-ischemic effect and, in a small percentage, it is metabolized to clonidine. The purpose of this study was to assess the effectiveness and hemodynamic actions of alinidine in the treatment of intraoperative heart rate acceleration and, in combination with the calcium channel blocker nifedipine, to evaluate its use for postoperative hypertension. The first study was performed in nine patients in whom, during aortocoronary bypass surgery, there was a heart rate increase in excess of 20% above the preoperative control value. Patients were excluded with impaired ventricular function, absence of sinus rhythm, concomitant increase in arterial mean pressure greater than 30%, hypovolemia, pulmonary capillary wedge pressure in excess of 15 mmHg as well as those with ECG changes precluding exact assessment of myocardial ischemia. In addition to the ECG, the following parameters were registered: heart rate, arterial pressure, central venous pressure and, with a semi-floating balloon-tipped catheter, pulmonary artery pressure as well as pulmonary wedge pressure. Cardiac output was determined with thermodilution.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
[The preoperative outpatient clinic--possible use of a personal computer].
Since 1977, the Department of Anesthesiology of the University of Graz has had a preoperative clinic. Since August 1988 we have processed current data using a personal computer (PC). We have adapted an IBM-compatible PC and a commercial data-processing program (dBase III plus) for the special requirements of the preoperative clinic. The procedure is directed by menus and is also easy to learn for non-professionals. Important functions have been executed automatically by the current program, such as loading the software or securing the data on a floppy disk. No additional work is necessary for data input. Every test result can be supplied immediately by a printer, whereby important parameters are denoted as such. After 13 months of testing, we could see that the use of a PC offers an inexpensive possibility for processing medical data with the help of electronics. The installation was not destined to remain a short trial, but will become a permanent system at our clinic.
Anesthesiology↗
[10 years' experience with heart surgery in Jehovah's witnesses].
UNLABELLED: As a result of their interpretation of the Bible, members of Jehovah's Witnesses do not accept blood transfusions under any circumstances. Consequently, they present moral and ethical problems to surgeons and anesthetists, especially in cardiac surgery. PATIENTS and METHODS. From November 1978 to November 1988, 66 members Jehovah's Witnesses were scheduled for cardiac surgery; 57 patients were operated upon (mean age 33.3 years, 14 days to 70.4 years; mean body weight 51 kg, 0.7 to 95.5 kg); 21 were younger than 14 years. Patients with hematocrit (Hct) less than 35%, expected high intra- and postoperative blood loss, compromised left ventricular function, ST-segment alterations, critical aortic stenosis, severe unstable angina pectoris, complex heart defects, especially in children, extreme body weight, severe diabetes, renal insufficiency, coagulopathies, severe pulmonary disease, and heavy smokers were excluded from operation. Whereas in nonbypass patients no special blood-saving techniques were used, in bypass patients a modified version of isovolemic hemodilution, with a hypothermic, bloodless priming technique of extracorporeal circulation (ECC) was performed after induction of anesthesia. At the end of the ECC all blood collected in the pericardial and pleural cavities was returned to the oxygenator and the entire content of the extracorporeal circuit was infused into the patient through the aortic cannula. All patients receiving ECC were ventilated for 24 h postoperatively and received dopamine (2-5 micrograms/kg) and antibiotics routinely. RESULTS: Due to the above mentioned contraindications, 9 patients were not accepted for surgery, 10 were operated upon without cardiopulmonary bypass or blood-saving techniques. In 47 patients open heart surgery with ECC and moderate or deep hypothermia was performed. In the adult patients (n = 36) Hct values decreased from 44.4% (35-70%) preoperatively to 32.1% (21-46%) after hemodilution, reached their lowest levels during cardiopulmonary bypass at 17.9% (9.9-43%), and increased to 33.7% (22%-43%) at the end of the operation. Hct averaged 28.2% (20%-39%) on the 3rd and 33.2% (23%-46%) on the 12th postoperative day. In children (n = 11) Hct decreased from 47.2% (36.9%-70%) to 33.6% (27.2%-49.1%) after hemodilution, during bypass to 16.1% (10.5%-25.5%) and increased to 32.1% (24.4%-37.4%) at the end of the operation. On the 3rd postoperative day Hct was 25% (21.4%-39%) and increased to 29.4% (25.1%-40%) on the 12th postoperative day. No statistical differences in Hct values were found between both groups. (ABSTRACT TRUNCATED AT 400 WORDS)
Adolescent↗
Intraoperative heart rate reduction--alinidine versus metoprolol.
In a double-blind randomized protocol the effectiveness of the specific bradycardic agent alinidine (0.6 mg.kg-1 i.v.) was compared to that of the betablocker metoprolol (0.035 mg.kg-1 i.v.). Twenty-four coronary artery disease patients undergoing a bypass procedure with an intraoperative heart rate increase of more than 20% were included. Patients with a concomitant intraoperative mean arterial pressure increase of more than 30% or with an intraoperative wedge pressure higher than 15 mmHg (2.0 kPa) were excluded. After application of alinidine and metoprolol, heart rate decreased significantly (P less than 0.01) in the alinidine group from 88 +/- 19 beats per min to 72 +/- 13 and in the metoprolol group from 82 +/- 16 to 72 +/- 12. Baseline values were not obtained. Compared to the hemodynamic changes in the metoprolol group, the alterations of pulmonary capillary wedge pressure (PCWP) (P less than 0.05), stroke volume index (SVI) (P less than 0.05), left ventricular stroke work index (LVSWI) (P less than 0.01) and right ventricular stroke work index (RVSWI) (P less than 0.05) in the alinidine group were statistically significantly different. PCWP remained unchanged after alinidine and increased in the metoprolol group (1.4 +/- 0.4 to 1.6 +/- 0.4 kPa). In the alinidine group LVSWI (43.1 +/- 15 to 49.2 +/- 18 g-m.m-2), RVSWI (5.1 +/- 4 to 6.6 +/- 3 g-m.m-2) and SVI (37.2 +/- 12.2 to 42.5 +/- 12.8 ml.m-2) increased.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
[Quantifying pulmonary artery hypertension by Doppler echocardiography measurement of tricuspid valve insufficiency].
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Blood Flow Velocity↗