Allogeneic red blood cell transfusions: efficacy, risks, alternatives and indications

Careful assessment of risks and benefits has to precede each decision on allogeneic red blood cell (RBC) transfusion. Currently, a number of key issues in transfusion medicine are highly controversial, most importantly the influence of different transfusion thresholds on clinical outcome. The aim of this article is to review current evidence on blood transfusions, to highlight ‘hot topics' with respect to efficacy, outcome and risks, and to provide the reader with transfusion guidelines. In addition, a brief synopsis of transfusion alternatives will be given. Based on up-to-date information of current evidence, together with clinical knowledge and experience, the physician will be able to make transfusion decisions that bear the lowest risk for the patien

Perioperative Bluttransfusion: Nutzen, Risiken und Richtlinien

Zusammenfassung: Chirurgisch und traumatisch bedingte Blutverluste sind die häufigsten Ursachen von allogenen Bluttransfusionen, welche nach wie vor mit beträchtlichen Risiken verbunden sind. Nach Korrektur der Hypovolämie ist der Anästhesist häufig mit einer normovolämischen Anämie konfrontiert. Die klinische Relevanz dieses isolierten Hämoglobinabfalls besteht darin, dass die globale und/oder regionale Sauerstoffversorgung über eine kritische Schwelle hinaus beeinträchtigt sein kann, wonach sich eine Gewebshypoxie einstellt. Diese kritische Schwelle ist von Patient zu Patient verschieden und abhängig von dessen Kapazität, den Abfall des Sauerstoffgehaltes zu kompensieren. Aus diesem Grunde sollten primär physiologische Transfusionskriterien angewandt werden und nicht rigide nummerische Transfusionskriterien wie die Hämoglobinkonzentration, welche die individuelle Reserve eines Patienten weitgehend außer Acht lasse

Allogeneic red blood cell transfusions: efficacy, risks, alternatives and indications

Careful assessment of risks and benefits has to precede each decision on allogeneic red blood cell (RBC) transfusion. Currently, a number of key issues in transfusion medicine are highly controversial, most importantly the influence of different transfusion thresholds on clinical outcome. The aim of this article is to review current evidence on blood transfusions, to highlight 'hot topics' with respect to efficacy, outcome and risks, and to provide the reader with transfusion guidelines. In addition, a brief synopsis of transfusion alternatives will be given. Based on up-to-date information of current evidence, together with clinical knowledge and experience, the physician will be able to make transfusion decisions that bear the lowest risk for the patient

Segment-specific expression of sodium-phosphate cotransporters NaPi-IIa and -IIc and interacting proteins in mouse renal proximal tubules

Sodium-dependent phosphate cotransport in renal proximal tubules (PTs) is heterogeneous with respect to proximal tubular segmentation (S1 vs. S3) and nephron generation (superficial vs. juxtamedullary). In the present study, S1 and S3 segments of superficial and juxtamedullary nephrons were laser-microdissected and mRNA and protein expression of the Na/Pi-cotransporters NaPi-IIa and NaPi-IIc and the PDZ proteins NHERF-1 and PDZK1 determined. Expression of NaPi-IIa mRNA decreased axially in juxtamedullary nephrons. There was no effect of dietary Pi content on NaPi-lla mRNA expression in any proximal tubular segment. The abundance of the NaPi-IIa cotransporter in the brush-border membrane showed inter- and intranephron heterogeneity and increased in response to a low-Pi diet (5days), suggesting that up-regulation of NaPi-lla occurs via post-transcriptional mechanisms. In contrast, NaPi-IIc mRNA and protein was up-regulated by the low-Pi diet in all nephron generations analysed. NHERF-1 and PDZK1, at both mRNA and protein levels, were distributed evenly along the PTs and did not change after a low-Pi die

Rapid pressure compensation by automated cuff pressure controllers worsens sealing in tracheal tubes

Background Cyclic redistribution of air within the cuff during respiratory pressure changes creates a self-sealing mechanism which allows tracheal sealing, despite tracheal airway pressure being above baseline cuff inflation pressure. The aim of the present study was to investigate the effect of continuous automated cuff pressure regulation on tracheal sealing during cyclic respiratory pressure changes. Methods In vitro tracheal sealing was studied in four different high volume-low pressure (HVLP) tracheal tube cuffs size internal diameter 8.0 and 5.0 mm in combination with a conventional pressure manometer and two different automated pressure controllers (VBM Cuff Controller; Cuff Pressure Control Tracoe™). Experiments were performed at 10, 15, 20, and 25 cm H2O cuff pressure during intermittent positive pressure ventilation with peak inspiratory pressures of 20 and 25 cm H2O. Air leakage was assessed spirometrically. Experiments were performed four times with each tube brand and size with two exemplars of each of the three cuff pressure controllers. Results Owing to immediate cuff pressure correction, tracheal sealing at cuff pressure below inspiratory pressure was reduced in most of the tracheal tube cuffs, except in those with reduced sealing characteristics when using the Pressure Control Tracoe™ compared with the conventional pressure manometer and the VBM Cuff Controller. Tracheal sealing with the Pressure Control Tracoe™ comparable with the other two devices was only achieved at cuff pressures of 20 and 25 cm H2O. Conclusions Automated cuff pressure controllers with rapid pressure correction interfere with the self-sealing mechanism of high sealing HVLP tube cuffs and reduce their improved sealing characteristic

Effect of tracheal tube cuff shape on fluid leakage across the cuff: an in vitro study

Background This study compared the fluid leakage in the new ‘tapered' shaped against the classic ‘cylindrical' shaped tracheal tube cuffs when placed in different sized tracheas. Methods The 7.5 mm internal diameter (ID) tracheal tube cuffs—Tapered Seal Guard (TSG), Standard Seal Guard (SSG), Hi-Lo, Microcuff, Ruesch, and Portex Profile—were compared in an in vitro apparatus. Vertical artificial tracheas with 16, 20, and 22 mm ID were intubated, 5 ml clear water was applied above the unlubricated tube cuffs, and fluid leakage was measured up to 60 min. Data of tapered vs non-tapered tube cuffs (16 observations) were compared for each tracheal diameter using the Mann-Whitney test. Results Median (range) fluid leakage (ml) at 60 min was 2.14 (0.05-4.88), 1.14 (0.00-4.84), and 0.13 (0.00-1.32), respectively, for 16, 20, and 22 mm tracheas in the TSG tube studies when compared with 4.58 (0.44-4.88), 2.21 (0.00-4.81), and 0.00 (0.00-4.81) in the SSG tube and 4.54 (1.54-4.82), 0.90 (0.00-4.49), and 4.85 (4.40-4.99) in the Microcuff tube studies. Leakage in all polyvinylchloride (PVC) tube cuffs was almost complete (5 ml) within 5 min (P<0.001). Conclusions The tapered PU tube cuff was as effective as the cylindrical PU cuffs in smaller tracheal diameters and was more efficient than the cylindrical Microcuff PU tube cuff in larger tracheal diameter in preventing subglottic fluid leakage across the tube cuff tested in this in vitro study. PVC tube cuffs leaked much more and faster than PU cuff

Allogeneic blood transfusions: benefit, risks and clinical indications in countries with a low or high human development index.

The risks associated with allogeneic red blood cell (RBC) transfusions differ significantly between countries with low and high human development indexes (HDIs). In countries with a low HDI, the risk of infection (HIV, HBV, HCV and malaria) is elevated. In contrast, in countries with a high HDI, immunological reactions (haemolytic transfusion reactions, alloimmunization and immunosuppression) are predominant. Therefore the overall risk associated with RBC transfusions in low HDI countries is much more significant than that in high HDI countries. In view of these risks, the limited efficacy of RBC transfusion and its high costs, this procedure should be used sparingly and rationally. Therefore RBC transfusion protocols adapted to the local situation are essential. Such protocols should distinguish between physiological and haemoglobin-based transfusion triggers. In countries with a high HDI, relative tachycardia and hypotension, despite normovolaemia, ST-segment changes suggestive of myocardial ischaemia and an Hb level &lt;6 g/dl can serve as general guidelines for transfusion. Higher haemoglobin transfusion triggers should be used for patients aged &gt;80 years and those with coronary artery or cerebrovascular disease. In countries with a low HDI, clinical signs of circulatory failure or myocardial ischaemia and an Hb level &lt;5 g/dl can serve as transfusion guidelines

Comparison of thromboelastometry (ROTEM®) with standard plasmatic coagulation testing in paediatric surgery

Background Thromboelastometry (ROTEM®) might be useful to detect intraoperative coagulation disorders early in major paediatric surgery. This observational trial compares this technique to standard coagulation tests. Methods Intraoperative blood sampling was obtained in children undergoing elective major surgery. At each time point, standard coagulation tests [activated partial thromboplastin time (aPTT), prothrombin time (PT), and fibrinogen level] and ROTEM® analyses (InTEM, ExTEM, and FibTEM) were performed simultaneously by trained hospital laboratory staff. Results A total of 288 blood samples from 50 subjects were analysed. While there was a poor correlation between PT and aPTT to ExTEM clotting time (CT) and InTEM CT, respectively, a good correlation was detected between PT and aPTT to clot formation time, and a very good correlation between fibrinogen level and FibTEM assay (r=0.882, P<0.001). Notably, 64% of PT and 94% of aPTT measurements were outside the reference range, while impaired CT was observed in 13% and 6.3%, respectively. Standard coagulation test results were available after a median of 53 min [inter-quartile range (IQR): 45-63 min], whereas 10 min values of ROTEM® results were available online after 23 min (IQR: 21-24 min). Conclusions PT and aPTT cannot be interchangeably used with ROTEM® CT. Based on the results of ROTEM®, recommended thresholds for PT and aPTT might overestimate the need for coagulation therapy. A good correlation was found between the fibrinogen level and the FibTEM assay. In addition, ROTEM® offered faster turnaround time

Perioperative Bluttransfusion Nutzen, Risiken und Richtlinien. [Perioperative blood transfusions. Value, risks, and guidelines]

Surgical blood loss and trauma are the major causes of allogeneic blood transfusions, which still bear considerable risks. After the correction of hypovolemia, the anesthesiologist often has to deal with normovolemic anemia. The clinical relevance of this isolated decrease in hemoglobin concentration consists in an eventually compromised global or regional oxygen supply with the development of tissue hypoxia below a critical threshold. This is an individual threshold for each patient and depends on his or her capacity to compensate the decrease in blood oxygen content. Therefore, physiologic transfusion triggers should primarily be applied and not rigid numeric transfusion triggers, such as hemoglobin concentration, which do not take into account each patient's individual reserve

Electrocardiographic changes during continuous intravenous application of bupivacaine in neonatal pigs

Background It is controversial as to whether T-wave elevation is caused by local anaesthetics, epinephrine, or their combination. It has been shown that T-elevation after intravascular injection of a small bupivacaine test dose is caused by epinephrine and not by bupivacaine. The aim of this study was to investigate ECG changes with higher doses of i.v. bupivacaine. Methods Thirty neonatal pigs were anaesthetized with sevoflurane and their tracheas intubated and artificially ventilated. Under steady-state conditions, bupivacaine was continuously infused (flow rate 3.2 ml kg−1 min−1) by a syringe infusion pump through a central venous catheter. Group 1 received bupivacaine 0.125%, Group 2 bupivacaine 0.5%. The ECG was continuously printed and subsequently analysed for alterations in heart rate, ventricular de- and repolarization, and arrhythmias at 1.25, 2.5, and 5 mg kg−1 bupivacaine infused. Results Sinus rhythm persisted in all pigs. Heart rate decreased progressively in both groups, but this was significantly more pronounced in Group 1. T-wave elevation occurred in 40% and 0% (Groups 1 and 2) at 1.25 mg kg−1, in 80% and 0% at 2.5 mg kg−1, and in 93% and 80% at 5 mg kg−1 bupivacaine infused. There were significant differences between the two groups at 1.25 and 2.5 mg kg−1 infused. Conclusions Higher doses of i.v. infused bupivacaine can cause T-elevation. With slower injection technique, T-elevation can already be detected at lower bupivacaine doses administere