Ankstyvos pooperacinės transfuzijos po klubo sąnario endoprotezavimo operacijų

Ankstyvos pooperacinės transfuzijos po klubo sąnario endoprotezavimo operacijų: dviejų potransfuzinio hematokrito prognozės metodų retrospektyvus palyginimas Audrius Andrijauskas1, Juozas Ivaškevičius1, Jurgita Židanavičiūtė21 Vilniaus universiteto Anesteziologijos ir reanimatologijos klinika,Šiltnamių g. 29 LT-04130, Vilnius2 Matematikos ir informatikos institutas,Akademijos g. 4, LT-08663 VilniusEl paštas: [email protected] Įvadas / tikslas Klubo sąnario endoprotezavimo operacijų metu ir ankstyvuoju pooperaciniu laikotarpiu vyksta reikšmingas kraujavimas. Sudėtinga parinkti perpilamos eritrocitų masės kiekį, siekiant hematokrito padidėjimo. Buvo palyginti du metodai, kurie padeda prognozuoti potransfuzinį hematokritą: naujas homeostazinis kraujo būklių metodas, apsaugotas parengtinio JAV patento, toliau vadinamas A metodu, ir praktikoje labai dažnai naudojamas apytikslės taisyklės (Habibi et al.) metodas, arba B metodas. Ligoniai ir metodai Retrospektyviai ištirta 16 ankstyvųjų pooperacinių kraujo perpylimų, atliktų ASA-2 fizinės klasės pacientams po klubo sąnario endoprotezavimo operacijų: iš jų 5 vyrams ir 11 moterų, kurių amžiaus vidurkis 64,75±10,427 (nuo 45 iki 79 metų). Visiems buvo taikytas toks pat rutininis gydymo reglamentas: veninio kraujo hematokrito tyrimai paimti tiesiogiai prieš transfuzijos pradžią (20 min. po infuzijų sustabdymo), vėliau – 20 min. nuo transfuzijos baigimo. Aštuoniems buvo perpiltas vienas eritrocitų masės vienetas, o kitiems aštuoniems – du vienetai. Perioperaciniai infuzinės terapijos ir transfuzijų duomenys, tyrimų rezultatai, diurezė ir netekimas per drenus buvo registruojami naujo tipo apskaitos lape – HBS nomogramoje (Autorystės teisės © 2005, Audrius Andrijauskas). Naudojant abu metodus apskaičiuotas prognozuojamas potransfuzinis hematokritas. Metodu A matematiškai apskaičiuojamas hematokrito vertėms būdingas homeostazinis cirkuliuojančios eritrocitų masės tūris. Skaičiavimų korekcija atlikta tik metodo A (A-cor), atsižvelgiant į transfuzijos metu vykusį nukraujavimą per žaizdos drenus, nes antrasis metodas tokiai korekcijai nepritaikytas. Metodo B yra trys prognoziniai protokolai: B1 numato hematokrito padidėjimą trimis hematokrito procentais (3%), B2 – 4% ir B3 – 5%. Rezultatai Metodu A prognozuojama prasčiau negu B1 (p = 0,019), bet geriau negu B-2 (p = 0,04) ir B-3 (p < 0,0001), o A-cor buvo tiksliausia, lyginant su A (p < 0,0001), B-1 (p < 0,009), B-2 (p < 0,0001) ir B-3 (p < 0,0001). Metodas B neatsižvelgia į transfuzijos metu vykstantį nukraujavimą ir neturi kriterijų, kurie nurodytų, kada ir kurį prognozinį protokolą reikėtų naudoti. Dėl to ne tik modifikuotu metodu A-cor, bet ir metodu A potransfuzinis hematokritas prognozuojamas geriau negu metodu B. Išvada Naujasis metodas gali būti naudingas parenkant perpilamos eritrocitų masės kiekį, todėl tikslinga jį plačiau ištirti. Reikšminiai žodžiai: kraujavimas, kraujas, hematokritas, transfuzija, naujas metodas, nomograma Immediate postoperative transfusions after total hip arthroplasty: retrospective analysis comparing two methods of predicting post-transfusion hematocrit Audrius Andrijauskas1, Juozas Ivaškevičius1, Jurgita Židanavičiūtė21 Vilnius University Clinic of Anaesthesiology and Intensive Care,Šiltnamių str. 29 LT-04130 Vilnius, Lithuania2 Institute of Mathematics and Informatics,Akademijos str. 4, LT-08663 Vilnius, LithuaniaE-mails: [email protected], [email protected] Background / objective Total hip arthroplasty is associated with significant bleeding, which continues through early postoperative hours. Choosing the amount of packed red blood cells (PRBC) for transfusion to reach hematocrit targets is challenging. We compared two methods of predicting post-transfusion hematocrit: the new – Homeostatic Blood States’ Method, patent pending – USA, referred to as method A, and the conventional "Rule of Thumb" (Habibi et al.) referred to as method B. Patients and methods The retrospective investigation of immediate postoperative blood transfusions included sixteen adult patients who were ASA physical status II, five of them males and eleven females, mean age 64.75±10.427 (range, 45–79 yr) after total hip arthroplasty. Patients received routine procedures: venous blood samples taken just before starting transfusion (20 minutes after stopping all infusions), then 20 minutes after transfusion. Eight patients received one PRBC unit, others received two. The amount of wound drainage was measured. Perioperative infusion and transfusion data, timing, blood test results, urine output and drainage amounts were recorded using a new type of chart – HBS Nomogram (Copyright © 2005 by Audrius Andrijauskas). We calculated post-transfusion hematocrit predicted by both methods. Method A deploys mathematical formulas for calculating hematocrit-specific homeostatic circulating erythrocyte mass. Corrections for simultaneous blood loss were applied to calculations by method A protocol A-cor. Corrections are not applicable to method B, which accounts only for units transfused: protocol B1 predicts 3%, B2 4% and B3 5% hematocrit increase. Results Method B-1 (p = 0.019) predicted hematocrit better than method A, but method A did it better than B-2 (p = 0.04), B-3 (p < 0.0001) and B-1 (p < 0.009), and method A-cor was the best, predicting better than A (p < 0.0001), B-1 (p < 0.009), B-2 (p < 0.0001) and B-3 (p < 0.0001). Method B does not account for simultaneous bleeding, and there are no criteria for choosing a proper protocol – B1, B2 or B3, therefore the overall advantage was given to method A and its modification A-cor. Conclusion The new method is a promising tool for transfusion amount selection, therefore further investigations are purposeful. Key words: bleeding, blood, hematocrit, transfusion, new method, nomogra

The maintenance and monitoring of perioperative blood volume

The assessment and maintenance of perioperative blood volume is important because fluid therapy is a routine part of intraoperative care. In the past, patients undergoing major surgery were given large amounts of fluids because health-care providers were concerned about preoperative dehydration and intraoperative losses to a third space. In the last decade it has become clear that fluid therapy has to be more individualized. Because the exact determination of blood volume is not clinically possible at every timepoint, there have been different approaches to assess fluid requirements, such as goal-directed protocols guided by invasive and less invasive devices. This article focuses on laboratory volume determination, capillary dynamics, aspects of different fluids and how to clinically assess and monitor perioperative blood volume

Kristaloidai ir koloidai perioperacinei skysčių terapijai: savybės ir dozavimo ypatumai

Straipsnio tikslas yra apžvelgti kristaloidų ir koloidų savybes, šių preparatų pranašumus ir trūkumus bei derinimo ypatumus perioperacinėje skysčių terapijoje. Racionali skysčių terapija gerina gydymo baigtį po didelių chirurginių intervencijų. Perioperacinei skysčių terapijai yra vartojami kristaloidų ir koloidų tirpalai bei jų deriniai. Nė viena iš tirpalų rūšių nėra pranašesnė už kitą, o nepageidaujamas poveikis labai priklauso nuo dozės. Trumpoje apžvalgoje aprašomos išskirtinės tirpalų savybės ir atsižvelgiant į naujausius mokslinius tyrimus apibūdinamos racionalaus jų dozavimo bei derinimo galimybės. Ypatingas dėmesys skiriamas naujų individualaus skysčių skyrimo metodų ir pusiau uždaros grandinės infuzinių sistemų naudojimo perspektyvoms. Reikšminiai žodžiai: skysčių terapija, kristaloidai, koloidai, perioperacinis laikotarpis, gydymo baigtis Crystalloids and colloids: aspects of their co-administration in perioperative fluid therap

Hipotenzinė anestezija atliekant klubo ir kelio sąnarių endoprotezavimą: į tikslą nukreiptas skysčių terapijos algoritmas

Audrius Andrijauskas1, Juozas Ivaškevičius1, Manvilius Kocius2, Narūnas Porvaneckas2, Darius Činčikas1, Jeugenija Olševska11 Vilniaus universiteto Anesteziologijos ir reanimatologijos klinika,Šiltnamių g. 29 LT-04130 Vilnius2 Vilniaus universiteto Reumatologijos, ortopedijos, traumatologijos,plastinės ir rekonstrukcinės chirurgijos klinika, Šiltnamių g. 29 LT-04130 VilniusEl paštas: [email protected] Kontroliuojama hipotenzinė anestezija jau ilgą laiką taikoma siekiant sumažinti kraujo netektį ir kraujo perpylimo poreikį. Be to, sumažinus arterinį kraujo spaudimą, pagerėja operavimo sąlygos („sausas operacinis laukas“). Atsiranda galimybė sumažinti išorinį mechaninį spaudimą, taikomą operuojamos galūnės kraujotakai sustabdyti atliekant kelio sąnario endoprotezavimą, arba net visai jo netaikyti. Šiuolaikiniai metodai grindžiami įvairiais valdomą hipotenziją sukeliančiais veiksniais, kaip pavyzdžiui, tai gali būti (a) kraujagysles plečiantys vaistai, (b) centrinė simpatinė blokada ir (c) stiprų kardiodepresinį-vazopleginį poveikį turintys inhaliaciniai anestetikai. Taikant hipotenzinę anesteziją, didžiausią rūpestį kelia paciento saugumo užtikrinimas. Ypatingą pavojų kelia „nebyli“ organų išemija dėl nepakankamo jų aprūpinimo krauju, nes ji gali sutrikdyti audinių ir organų funkciją ar net sukelti žūtį. Taigi, užtikrinant metodo saugumą lemiama reikšmė tenka efektyvaus cirkuliuojančio tūrio (normovolemijos) palaikymui arterinės hipotenzijos sąlygomis. Deja, iki šiol nėra paprasto, patikimo ir veiksmingo metodo, kuris leistų užtikrinti šią ypač svarbią paciento saugumo sąlygą. Tradicinius kraujotakos optimizavimo metodus šiuo metu keičia skysčių terapijos metodai, grindžiami į tikslą nukreiptų priemonių taikymo koncepcija. Remdamiesi šia koncepcija autoriai sukūrė klinikinį TNP algoritmą, kuris skirtas normovolemijai užtikrinti, atliekant kelio ir klubo sanario planinį endoprotezavimą hipotenzinės anestezijos sąlygomis. Algoritmas pateikiamas kartu su svarbiausių hemodinamikos parametrų taikymo ir klinikinio interpretavimo ypatumų apžvalga. Reikšminiai žodžiai: hemodinamika, į tikslą nukreipta skysčių terapija, skysčiai, transfuzija, algoritmas Hypotensive anaesthesia in total hip and knee arthroplasty: algorithm for the goal-directed fluid management Audrius Andrijauskas1, Juozas Ivaškevičius1, Manvilius Kocius2, Narūnas Porvaneckas2, Darius Činčikas1, Jeugenija Olševska11 Vilnius University Clinic of Anaesthesiology and Intensive Care,Šiltnamių str. 29 LT-04130 Vilnius, Lithuania2 Vilnius University Clinic of Rheumatology, Orthopaedics, Traumatology, Plastic and Reconstructive Surgery, Šiltnamių str. 29, LT-04130 Vilnius, LithuaniaE-mail: [email protected] Hypotensive anaesthesia is a technique that deploys the controlled reduction of mean arterial pressure. It has been used for decades to reduce intraoperative blood loss and related blood transfusions, also to ensure the ‘dry operating field’ and minimize the tourniquet inflation pressure in patients undergoing total hip (THA) and knee (TKA) arthroplasty. Hypotensive anesthesia can be achieved in different ways such as (a) by decreasing cardiac output with vasodilatory agents, (b) inducing the sympathetic block by spinal and/or epidural anaesthesia, and/or (c) by using potent anesthetic gases in general anaesthesia. The major concern in the method’s clinical applicability is the patient’s safety. Inherent risks related to hypotensive anaesthesia are mainly associated with the concern of occult tissue hypoperfusion resulting from inadequately compensated relative hypovolemia. Therefore, maintaining an effective circulating volume (normovolemia) is crucial for the safe management of controlled arterial hypotension. However, the lack of a simple, reliable and effective method for the guidance of appropriate measures is an ongoing deficiency. Conventional strategies aiming to establish, monitor and maintain normovolemia are currently replaced by the goal-directed management (GDM) in fluid therapy. It has already become a standard of care in selected patients such as those undergoing major abdominal surgery. On the basis of goal-directed fluid management, authors have developed a GDM algorithm for the optimization of fluid status, aiming to secure normovolemia during hypotensive anaesthesia. The new algorithm is highlighted along with a review of related issues of its clinical application. Key words: hemodynamics, goal-directed-management, fluid, transfusion, algorith

PRE- and POST-operative Data_a+v+c_36 TKA patients.xlsx

Data set of hemoglobin readings and derived variables used in the perioperative mini volume loading test (mVLT). Obtained during RCT in 36 TKA surgery patients. <br

Data from our prospective observational clinical study using mini volume loading test (mVLT) using 2.5 ml kg-1 boluses of crystalloid for indication of perioperative changes in patient's hydration level

We prospectively collected data in 48 adult ASA II physical state patients who had elective primary total knee arthroplasty (TKA). As part of a larger RCT, with an aim to evaluate peri-operative changes in patients' hydration level, the mini volume loading test (mVLT) was applied before induction of spinal anaesthesia (pre-operative) and also 24-h later (post-operative). The mVLT protocol implied mini fluid challenges consisting of Ringer’s acetate boluses followed by 5 min periods without fluid loading. Six 2.5 ml kg^-1 boluses were infused. Haemoglobins -  invasive (aHb, arterial) and non-invasive (SpHb or cHb, capillary), cardiac stroke volume (SV) deviation (%), perfusion index (PI) and its deviation from baseline (PID) were measured before and after each mini fluid challenge and also 20 min after the last bolus. We present our data. Several variables were obtained by mathematically processing haemoglobin values: plasma dilution (PD), plasma dilution efficacy (PDE), arterio-capillary plasma dilution efficacy difference (acPED) as well as relative difference between the paired invasive and non-invasive haemoglobin measurements (RD) and absolute RD (ARD). We post the related math, too

Haemoglobin and other data from perioperative goal directed fluid protocols in total knee arthroplasty surgery patients (RCT)

We prospectively studied patients undergoing total knee arthroplasty (TKA). As part of a revised GDT (revGDT) protocol, the mini volume loading test (mVLT) was applied before induction of anaesthesia and surgery (pre-operative) and also 24-h later (post-operative). The mVLT implies mini fluid challenges consisting of acetated Ringer’s boluses followed by 5-min periods without fluids. Three 5 mL kg^-1 boluses were used in mVLT for 36 TKA patients, and six 2.5 mL kg^-1 boluses in other 48 TKA patients. Haemoglobins -  invasive (aHb, arterial; and vHb, venous) and non-invasive (SpHb, capillary), as well as stroke volume (SV) deviation from baseline (%), perfusion index (PI) and its deviation from baseline (PID), mean arterial pressure (MAP). They were measured before and after each mini fluid challenge and also 20 min after the last bolus. We present our records of raw data. Several variables were obtained by mathematically processing haemoglobin values: plasma dilution (PD), plasma dilution efficacy (PDE), arterio-capillary plasma dilution efficacy difference (acPED) as well as relative difference between the paired invasive and non-invasive haemoglobin measurements (RD) and absolute RD (ARD) and some other parameters. We post the related math

Intra-articular morphine or neostigmine does not assure better pain relief

Background and Objectives: Choice of optimal postoperative analgesia technique remains challenging. Our double - blind randomized prospective clinical study compares efficacy of end-of- surgery intra-articular application of morphine or neostigmine after anterior crutiate ligament repair. Methods: 60 adult ASA I - II patients were randomized into 3 groups: intra-articular morphine 6 mg, neostigmine 0.5 mg, placebo. All received femoral nerve block and spinal anesthesia. Numeric rating scale used for pain assessment at rest and motion during 48 postoperative hours, and 0-10 scale for evaluation of overall patient satisfaction. Adjunct analgesics were recorded. Results: The only significant difference between protocol groups was better pain relief at motion at the end of trial in neostigmine 0.5 mg group than in placebo (p=0.018). Consumption of adjuncts wasn’t different on day of surgery, postoperative Day 1 and Day 2 respectively - diclofenac (p=0.85, p=0.41, p=0.9) and tramadol (p=0.62, p=0.72, p=1). Patient satisfaction was similar (p=0.59) among groups. Conclusions: Intra-articular neostigmine provided similar pain control at motion as morphine during the trial, but it was better than placebo on the 2nd postoperative day. Similar pain control at rest, adjunct consumption and patient satisfaction recorded throughout the whole observation period in all groups

Issues of perioperative transfusion and fluid therapy in elective total hip and knee arthroplasty surgery

Fluid and red cell administration is a critical component of perioperative treatment in major surgery. It is apparent from the literature that operating a normohydrated patient is associated with fewer complications and a shorter hospital stay. However, numerous patients receive excessive fluid therapy with the resulting volume overload and organ dysfunction. Oedema contributes to tissue hypoxia, delayed wound healing and an increased risk of infection. On the other hand, inadequate fluid resuscitation promotes gut ischaemia which is one of the initiating causes of sepsis and multi-organ failure. Therefore, optimizing the patients' perioperative hydration may improve the clinical outcome. However, traditionally used haemodynamic parameters, such as arterial blood pressure, central venous or pulmonary arthery wedge pressures, are unreliable for optimizing fluid therapy. The most promising method, the "goal-directed fluid therapy", implies that cardiac output is measured before and after consequitive intravenous test-fluid loads. The procedure is repeated until no further increase in cardiac output is achieved. In such a way the circualting blood volume is optimized so that cardiac output is maximized. Similarly, in the treatment of perioperative hypotension, the blood pressure response to the test-fluid load can be monitored, suggesting that the patient will not benefit from the further fluid infusion when the haemodynamic response becomes inadequate. The transfusion decission-making continues being a never-ending debate. Acknowledging the need for surgery and patient specific strategies in perioperative fluid management and transfusion decision-making, as well as the existing variability in individual practices, in this review the authors introduced their new algorithms applicable to patients who undergo elective total hip and knee arthroplasty

Statistically biased calibration method for the real-time adjustment of noninvasive haemoglobin measurements in a semiautomated infusion system

Closed loop systems are the ultimate solution to ensure that optimal therapies are delivered in a timely manner. A concept of a semi-closed loop infusion system for perioperative semi-automated optimisation of blood pressure and haemodilution is proposed. The key variable for the latter objective is the noninvasively and continuously measured blood haemoglobin concentration. However, it lacks reliability in predicting the haemoglobin in large blood vessels. Our proposed statistically biased calibration method for the adjustment of noninvasively measured Hb enabled better prediction of arterial Hb when it was applied to data from our ongoing clinical trial