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Intraoperative cell salvage with autologous transfusion in liver transplantation

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World Journal of Gastrointestinal Surgery 2019年第1期11卷 11-18页

作者： Marcelo A Pinto Marcio F Chedid Leo Sekine Andre P Schmidt Rodrigo P Capra Carolina Prediger Jo?o E Prediger Tomaz JM Grezzana-Filho Cleber RP Kruel Division of Gastrointestinal Surgery and Liver Transplantation Hospital de Clínicas de Porto Alegre Medical School of UFRGS Division of Hematology Hospital de Clínicas de Porto Alegre Medical School of UFRGS Division of Anesthesia and Perioperative Medicine Hospital de Clínicas de Porto Alegre Medical School of UFRGS

Liver transplant(LT) is the primary treatment for patients with end-stage liver disease. About 25000 LTs are performed annually in the world. The potential for intraoperative bleeding is quite variable. However, massive bleeding is common and requires blood transfusion. Allogeneic blood transfusion has an immunosuppressive effect and an impact on recipient survival, in addition to the risk of transmission of viral infections and transfusion errors, among others.Techniques to prevent excessive bleeding or to use autologous blood have been proposed to minimize the negative effects of allogeneic blood transfusion.Intraoperative reinfusion of autologous blood is possible through previous selfdonation or blood collected during the operation. However, LT does not normally allow autologous transfusion by prior self-donation. Hence, using autologous blood collected intraoperatively is the most feasible option. The use of intraoperative blood salvage autotransfusion(IBSA) minimizes the perioperative use of allogeneic blood, preventing negative transfusion effects without negatively impacting other clinical outcomes. The use of IBSA in patients with cancer is still a matter of debate due to the theoretical risk of reinfusion of tumor cells. However, studies have demonstrated the safety of IBSA in several surgical procedures, including LT for hepatocellular carcinoma. Considering the literature available to date, we can state that IBSA should be routinely used in LT, both in patients with cancer and in patients with benign diseases.

关键词： Liver transplantation Cell saver Hepatocellular carcinoma Blood transfusion Cell salvage

Impact of perioperative transfusion in patients undergoing resection of colorectal cancer liver metastases: A population-based study

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World Journal of Clinical Cases 2019年第10期7卷 1093-1102页

作者： Bo Long Zhen-Nan Xiao Li-Hua Shang Bo-Yan Pan Jun Chai Department of Anesthesiology Shengjing HospitalChina Medical UniversityShenyang 110004Liaoning ProvinceChina Department of Anesthesiology Shenyang Women’s and Children’s HospitalShenyang 110011Liaoning ProvinceChina

BACKGROUND Perioperative allogeneic blood transfusion is associated with poorer outcomes.AIM To identify the factors that were associated with perioperative transfusion and to examine the impact of perioperative transfusion in patients undergoing resection of colorectal cancer(CRC)liver metastases.METHODS The United States National Inpatient Sample(NIS)database was searched for patients with CRC who received surgery for liver metastasis.Linear and logistic regression analyses were performed.RESULTS A total of 2018 patients were included,and 480 had a perioperative transfusion.Emergency admission(adjusted odds ratio[aOR]=1.42;95%CI:1.07-1.87),hepatic lobectomy(aOR=1.76;95%CI:1.42-2.19),and chronic anemia(aOR=2.62;95%CI:2.04-3.35)were associated with increased chances of receiving a transfusion,but receiving surgery at a teaching hospital(aOR=0.75;95%CI:0.58-0.98)was associated with a decreased chance of receiving a transfusion.Receiving a perioperative transfusion was significantly associated with increased in-hospital mortality(aOR=3.38;95%CI:1.57-7.25),and increased overall postoperative complications(aOR=1.67;95%CI:1.31-2.13),as well as longer length of hospital stay CONCLUSION Patients with an emergency admission,hepatic lobectomy,chronic anemia,and who have surgery at a non-teaching hospital are more likely to receive a perioperative transfusion.Patients with CRC undergoing surgery for hepatic metastases who receive a perioperative transfusion are at a higher risk of inhospital mortality,postoperative complications,and longer length of hospital stay.

关键词： Colorectal cancer Liver metastasis Perioperative blood transfusion Intraoperative blood loss National inpatient sample

Prediction of massive transfusion in trauma patients in the surgical intensive care units (THAI-SICU study)

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Chinese Journal of Traumatology 2019年第4期22卷 219-222页

作者： Osaree Akaraborworn Onuma Chaiwat Sunisa Chatmongkolchart Chanatthee Kitsiripant Kaweesak Chittawatanarat Sunthiti Morakul Thammasak Thawitsri Petch Wacharasintg Sujaree Poopipatpab Waraporn Chau-In Chaiyapruk Kusumaphanyo Division of Trauma and Critical Care Department of Surgery Faculty of Medicine Prince of Songkla University Hat Yai Songkhla Thailand Department of Anesthesiology Faculty of Medicine Srinakharinwirot University Nakhon Nayok Thailand Department of Anesthesiology. Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand Department of Anesthesiology Faculty of Medicine Prince of Songkla University Hat Yai Songkhla Thailand Department of Surgery Faculty of Medicine Chiang Mai University Chiang Mai Thailand Department of Anesthesiology Faculty of Medicine Ramathibodi Hospital Mahidol University Bangkok Thailand Department of Anesthesiology Faculty of Medicine King Chulalongkorn Memorial Hospital Bangkok Chulalongkorn University Thailand Department of Anesthesiology Phramongkutklao Hospital Bangkok Thailand Department of Anesthesiology Navamindradhiraj University Bangkok Thailand Department of Anesthesiology Khon Kaen University Khon Kaen Thailand

Purpose: After damage control surgery, trauma patients are transferred to intensive care units to restore the physiology. During this period, massive transfusion might be required for ongoing bleeding and coagulopathy. This research aimed to identify predictors of massive blood transfusion in the surgical intensive care units (SICUs). Methods: This is an analysis of the THAI-SICU study which was a prospective cohort that was done in the 9-university-based SICUs in Thailand. The study included only patients admitted due to trauma mechanisms. Massive transfusion was defined as received >10 units of packed red blood cells on the first day of admission. Patient characteristics and physiologic data were analyzed to identify the potential factors. A multivariable regression was then performed to identify the significant model. Results: Three hundred and seventy patients were enrolled. Sixteen patients (5%) received massive transfusion in the SICUs. The factors that significantly predicted massive transfusion were an initial sequential organ failure assessment (SOFA)>9 (risk difference (RD) 0.13, 95% confidence interval (CI): 0.03—0.22, p = 0.01);intra-operative blood loss > 4900 mL (RD 0.33, 95% CI: 0.04—0.62, p = 0.02) and intra-operative blood transfusion > 10 units (RD 0.45, 95% Cl: 0.06 to 0.84, p = 0.02). The probability to have massive transfusion was 0.976 in patients who had these 3 factors. Conclusion: Massive blood transfusion in the SICUs occurred in 5%. An initial SOFA >9, intra-operative blood loss >4900 mL, and intra-operative blood transfusion >10 units were the significant factors to predict massive transfusion in the SICUs.

关键词： Massive transfusion Massive bleeding Surgical intensive care Multiple trauma

Children are not little adults:blood transfusion in children with burn injury

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Burns & Trauma 2017年第3期5卷 158-163页

作者： Tina L. Palmieri Shriners Hospital for Children Northern California and the University of California Davis 2425 Stockton Blvd Suite 718 Sacramento CA 95817 USA

Blood transfusion in burns larger than 20%total body surface area (TBSA) are frequent due to operative procedures, blood sampling, and physiologic response to burn injury. Optimizing the use of blood transfusions requires an understanding of the physiology of burn injury, the risks and benefits of blood transfusion, and the indications for transfusion. Age also plays a role in determining blood transfusion requirements. Children in particular have a different physiology than adults, which needs to be considered prior to transfusing blood and blood products. This article describes the physiologic differences between children and adults in general and after burn injury and describes how these differences impact blood transfusion practices in children.

关键词： Blood transfusion Pediatric Burn injury

Development and validation of a predictive score for perioperative transfusion in patients with hepatocellular carcinoma undergoing liver resection

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Hepatobiliary & Pancreatic Diseases International 2015年第4期14卷 394-400页

作者： Hai-Qing Wang Jian Yang Jia-Yin Yang Wen-Tao Wang Lu-Nan Yan Department of Liver Surgery West China Hospital Sichuan University

Liver resection is a major surgery requiring perioperative blood transfusion. Predicting the need for blood transfusion for patients undergoing liver resection is of great importance. The present study aimed to develop and validate a model for predicting transfusion requirement in HBV-related hepatocellular carcinoma patients undergoing liver resection. METHODS： A total of 1543 consecutive liver resections were included in the study. Randomly selected sample set of 1080 cases （70% of the study cohort） were used to develop a predic- tive score for transfusion requirement and the remaining 30% （n=463） was used to validate the score. Based on the preopera- tive and predictable intraoperative parameters, logistic regres- sion was used to identify risk factors and to create an integer score for the prediction of transfusion requirement. RESULTS： Extrahepatic procedure, major liver resection, hemoglobin level and platelets count were identified as inde- pendent predictors for transfusion requirement by logistic regression analysis. A score system integrating these 4 factors was stratified into three groups which could predict the risk of transfusion, with a rate of 11.4%, 24.7% and 57.4% for low, moderate and high risk, respectively. The prediction model appeared accurate with good discriminatory abilities, generat- ing an area under the receiver operating characteristic curve of 0.736 in the development set and 0.709 in the validation set. CONCLUSIONS： We have developed and validated an integer- based risk score to predict perioperative transfusion for pa- tients undergoing liver resection in a high-volume surgicalcenter. This score allows identifying patients at a high risk and may alter transfusion practices.

关键词： liver resection transfusion hepatocellular carcinoma

静脉丙种球蛋白联合血小板输注、利伐沙班治疗肝素诱导的危重血小板减少症1例（英文）

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Chinese Medical Sciences Journal 2019年第1期34卷 60-64页

作者：黄河林颖姚荣欣何牧卿林晓骥温州医科大学附属第二医院育英儿童医院血液科浙江温州325027

肝素诱导血小板减少症是指应用肝素过程中,以血小板减少,常合并静脉血栓发生为主要表现的疾病,是临床上肝素少见而严重的不良反应。我们使用静脉丙种球蛋白、血小板输注及口服抗凝药利伐沙班成功治疗了1例同时存在血栓与出血表现,肝素... 详细信息

肝素诱导血小板减少症是指应用肝素过程中,以血小板减少,常合并静脉血栓发生为主要表现的疾病,是临床上肝素少见而严重的不良反应。我们使用静脉丙种球蛋白、血小板输注及口服抗凝药利伐沙班成功治疗了1例同时存在血栓与出血表现,肝素诱导的血小板减少症患者。通过对此病例的治疗,我们认为静脉丙种球蛋白输注对危急重肝素诱导的血小板减少症的转归起到关键作用,一方面它避免了血栓的进一步形成;另一方面保证了血小板输注与利伐沙班治疗的有效性。因此,对于危急重肝素诱导的血小板减少症患者,静脉丙种球蛋白输注是一种有效而较优的治疗措施。

关键词： heparin-induced thrombocytopenia thrombosis intravenous immunoglobulin platelet transfusion rivaroxaban

Coagulopathy and transfusion therapy in pediatric livertransplantation

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World Journal of Gastroenterology 2016年第6期22卷 2005-2023页

作者： Mirco Nacoti Davide Corbella Francesco Fazzi Francesca Rapido Ezio Bonanomi Pediatric Intensive Care Unit Ospedale Papa Giovanni XXIII Piazza OMS24127 BergamoItaly Department of Anesthesia Ospedale Papa Giovanni XXIII24127 BergamoItaly Faculty of Medicine UniversitàStatale di Milano20122 MilanoItaly

Bleeding and coagulopathy are critical issues complicating pediatric liver transplantation and contributing to morbidity and mortality in the cirrhotic child. The complexity of coagulopathy in the pediatric patient is illustrated by the interaction between three basic models. The first model, "developmental hemostasis", demonstrates how a different balance between pro- and anticoagulation factors leads to a normal hemostatic capacity in the pediatric patient at various ages. The second, the "cell based model of coagulation", takes into account the interaction between plasma proteins and cells. In the last, the concept of "rebalanced coagulation" highlights how the reduction of both pro- and anticoagulation factors leads to a normal, although unstable, coagulation profile. This new concept has led to the development of novel techniques used to analyze the coagulation capacity of whole blood for all patients. For example, viscoelastic methodologies are increasingly used on adult patients to test hemostatic capacity and to guide transfusion protocols. However, results are often confounding or have limited impact on morbidity and mortality. Moreover, data from pediatric patients remain inadequate. In addition, several interventions have been proposed to limit blood loss during transplantation, including the use of antifibrinolytic drugs and surgical techniques, such as the piggyback and lowering the central venous pressure during the hepatic dissection phase. The rationale for the use of these interventions is quite solid and has led to their incorporation into clinical practice; yet few of them have been rigorously tested in adults, let alone in children. Finally, the postoperative period in pediatric cohorts of patients has been characterized by an enhanced risk of hepatic vessel thrombosis. Thrombosis in fact remains the primary cause of early graft failure and re-transplantation within the first 30 d following surgery, and it occurs despite prolongation of standard coagulation assays. Data, however, are currently

关键词： Children Coagulation Thrombosis Liverdisease transfusion Transplantation Point of carecoagulation

Microvascular response to transfusion in elective spine surgery

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世界骨科杂志：英文版 2017年第1期8卷 49-56页

作者： J Matthias Walz Ottokar Stundner Federico P Girardi Bruce A Barton Aimee R Koll-Desrosiers Stephen O Heard Stavros G Memtsoudis Department of Anesthesi-ology and Perioperative Medicine UMass Memorial Healthcare Department of Anesthesiology Hospital for Special SurgeryWeill Cornell Medical Center Department of Anesthesiology PerioperativeMedicine and Intensive Care MedicineParacelsus Medical University Department of Orthopedic Surgery Hospital for Special SurgeryWeill Cornell Medical Center Department of Quantitative Health Sciences University of Massachusetts Medical School

AIM To investigate the microvascular(skeletal muscle tissue oxygenation; SmO_2) response to transfusion in patients undergoing elective complex spine surgery.METHODS After IRB approval and written informed consent, 20 patients aged 18 to 85 years of age undergoing > 3level anterior and posterior spine fusion surgery were enrolled in the study. Patients were followed throughout the operative procedure, and for 12 h postoperatively. In addition to standard American Society of Anesthesiologists monitors, invasive measurements including central venous pressure, continual analysis of stroke volume(SV), cardiac output(CO), cardiac index(CI), and stroke volume variability(SVV) was performed. To measure skeletal muscle oxygen saturation(SmO_2) during the study period, a non-invasive adhesive skin sensor based on Near Infrared Spectroscopy was placed over the deltoid muscle for continuous recording of optical spectra. All administration of fluids and blood products followed standard procedures at the Hospital for Special Surgery, without deviation from usual standards of care at the discretion of the Attending Anesthesiologist based on individual patient comorbidities, hemodynamic status, and laboratory data. Time stamps were collected for administration of colloids and blood products, to allow for analysis of SmO_2 immediately before, during, and after administration of these fluids, and to allow for analysis of hemodynamic data around the same time points. Hemodynamic and oxygenation variables were collected continuously throughout the surgery, including heart rate, blood pressure, mean arterial pressure, SV, CO, CI, SVV, and SmO_2. Bivariate analyses were conducted to examine the potential associations between the outcome of interest, SmO_2, and each hemodynamic parameter measured using Pearson's correlation coeffi-cient, both for the overall cohort and within-patients individually. The association between receipt of packed red blood cells and SmO_2 was performed by running an interrupted time series model, with SmO_2

关键词： transfusion Complex spine surgery Near infrared spectroscopy Microvascular blood flow Hemodynamic monitoring

Up-regulation of NKG2A Inhibitory Receptor on Circulating NK Cells Contributes to transfusion-induced Immunodepression in Patients with β-thalassemia Major

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Journal of Huazhong University of Science and Technology(Medical Sciences) 2016年第4期36卷 509-513页

作者：邹勇宋志兴陆英梁晓莉袁青廖思红鲍俊杰 Department of Blood transfusion the Third Affiliated Hospital of Sun Yat-sen UniversityGuangzhou 510630 China Department of Clinical Laboratory the Third Affiliated Hospital of Sun Yat-sen UniversityGuangzhou 510630 China Reproductive Medicine Unit Department of Obstetrics & Gynecology the First People's Hospital of Foshan Foshan 528000 China Preterm Birth Prevention and Treatment Research Unit Department of Obstetrics Guangzhou Women and Children's Medical Center GuangZhou Medical University Guangzhou 510180 China

Accumulating evidence has shown that allogeneic blood transfusions can induce significant immunosuppression in recipients, and thereby increase the risk of postoperative infection and/or tumor relapse. Although it is well known that natural killer（NK） cells are responsible for the immunodepression effects of transfusion, the underlying mechanisms remain obscure. In this study, we investigated the role of NK cells in transfusion-induced immunodepression in β-thalassemia major. The proportion of circulating NK cells and the expression of NK receptors（NKG2A, CD158 a, NKP30, NKP46 and NKG2D） as well as CD107 a were detected by multicolor flow cytometry. IFN-γ production by circulating NK cells was detected by intracellular cytokine staining. Our results showed that the proportion and cytotoxicity（CD107a expression） of circulating NK cells in transfusion-dependent β-thalassemia major patients were remarkably lower than those of β-thalassemia minor patients or healthy volunteers. Expression of NKG2 A inhibitory receptor on circulating NK cells in patients with β-thalassemia major was remarkably up-regulated, but there were no significant differences in the expression levels of NKP30, NKP46, NKG2 D, CD158 a and IFN-γ. These results indicate NKG2 A inhibitory receptor may play a key role in transfusion-induced immunodepression of NK cells in patients with β-thalassemia major.

关键词： natural killer cells NKG2A thalassemia transfusion immunodepression