American journal of surgery
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The orthopedic surgeon has several options available for blood conservation. Preoperative autologous donation (PAD) of blood is a cost-effective measure when the cost of managing transfusion-transmitted infectious disease is considered; overuse and underuse are expensive problems, however. Hemodilution, while used successfully in prostate surgery, is logistically impractical in joint replacement centers. ⋯ Studies are under way to determine whether this method of blood conservation alters transfusion requirements. Recombinant human erythropoietin (Epoetin alfa) has a role in elective procedures with significant blood loss, including complex revision joint replacement, bilateral joint arthroplasty, and spinal fusion. Preoperative Epoetin alfa administration enhances preoperative autologous blood collection and increases perioperative red blood cell mass.
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Acute normovolemic hemodilution (ANH) is a common blood conservation strategy in elective surgical procedures. Moderate ANH is safe in patients > 60 years of age; ANH is not recommended for patients who have coronary artery disease, significant anemia, renal disease, severe hepatic disease, pulmonary emphysema, or obstructive lung disease. ⋯ Preoperative autologous donation (PAD) as a blood conservation strategy has the advantage of protecting the patient from risks associated with allogenic transfusion, but it is expensive and time consuming. No protocols have established a preference for either ANH or PAD; an early study suggested that ANH is less expensive and more effectively preserves blood components, but other researchers warn that the methodology for ANH remains unresolved.
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Conservative use of allogeneic red blood cell (RBC) transfusion is a growing trend in cardiovascular surgery. Recent advances in blood conservation measures have reduced, and in some cases eliminated, the need for allogeneic RBC transfusions in some of these patients. ⋯ Meticulous surgical technique, moderate hemodilution, aprotinin, hemostatic techniques, blood salvage, and autotransfusion are intraoperative measures that can reduce blood loss. Postoperatively, even severe blood deficits can often be restored with adequate diet and rest and the use of actinics.
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Practice Guideline Guideline
Surgical red blood cell transfusion practice policies. Blood Management Practice Guidelines Conference.
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The technique of lymphoscintigraphy may allow a more selective approach to the management of clinically negative neck nodes among patients with cutaneous head and neck melanoma. ⋯ Lymphoscintigraphy and sentinel node biopsy are more difficult to perform in the head and neck than in other parts of the body. The reliability of sentinel node biopsy based on lymphoscintigraphy may be improved by identifying and marking all nodes that are considered to receive direct lymphatic drainage from the primary melanoma, and by use of a gamma probe intraoperatively.