Masui. The Japanese journal of anesthesiology
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The "Guideline for Management of Critical Bleeding in Obstetrics" was implemented by five obstetrics-related societies in April 2010 to improve management strategies and outcomes of massive bleeding in obstetrics. Besides emergency transfusion replacing acute blood loss, the Guideline contains a flow chart of instructions for autologous blood transfusion in obstetric patients with rare blood types, irregular antibodies, or with an increased risk and/or history of massive bleeding. In this chapter, based on the characteristics of bleeding in the field of obstetrics, indication, contraindication, patient selection, preparation, and pitfalls regarding actual practices of autologous blood transfusion are detailed in terms of efficacy and limitations. The pros and cons of autologous blood transfusion are discussed together with the feasibility of intra/post-operative blood salvage and hemodilutional autologous blood transfusion during bleeding to reduce the total amount of transfusion and thereby improve the outcome of critical bleeding in obstetrics.
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"Identification error between patient and blood product" is the main cause of ABO-incompatible blood transfusion, but "Phlebotomy error" also has serious consequences. In order to prevent ABO-incompatible transfusion, it is important to establish a management system of blood transfusion in the hospital, including a hospital transfusion committee and a responsible medical doctor. In addition, in large hospitals routinely carrying out a considerable number of blood transfusions, it is important to employ specialists in blood banking. ⋯ Because there is little residual plasma in leukocyte-reduced red cell concentrate (RCC-LR), acute hemolysis is not detected on minor ABO mismatch blood transfusion. In the case of emergent blood transfusion, concerning the risk of acute hemolytic reaction, type-O RCC-LR blood transfusion is safer than ABO-identical RCC-LR when the blood of the patient is tested only once. When red cell antibody screening is not performed, there is a risk of hemolysis due to incompatible blood transfusion irrespective of the ABO blood group system, including a delayed hemolytic transfusion reaction.
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Rapid and massive bleeding has to be counteracted by efficient volume restoration against rapid loss of intravascular volume. There are two phases of volume management for massive bleeding, uncontrolled phase and controlled phase. During initial uncontrolled phase, rapid infusion of crystalloid with RCC (red cell concentrate) is the first choice of volume management to prevent shock and profound decline of hemoglobin level. ⋯ A new generation of hydroxyethyl starch is a promising blood substitute, designed with minimum side effect. Although renal damage especially in septic patient and coagulation disorder are theoretically suspected, beneficial effect as volume expansion overwhelms these stochastic side effects. Since the side effect depends on the dose and how much it remains in the body, a purposeful use during volume expansion phase should be recommended.
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Among all drugs used for general anesthesia, neuromuscular blocking agents (NMBAs) seem to play a predominant role in the incidence of severe adverse reactions. The overall incidence of perioperative anaphylaxis is estimated at 1 in 10,000-20,000 anesthetic procedures, whereas it is estimated at 1 in 6,500 administrations of NMBAs. ⋯ Prick testing is advised for the diagnosis of the NMBAs responsible for an anaphylactic reaction, and intradermal testing is preferred when investing cross-reaction. The choice of the safest possible anesthetic agents should be based on the result of a rigorously performed allergologic assessment.
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Both Japan Society of Blood Transfusion and Cell Therapy and Japan Society of Anesthesiologists have made a "Guideline of Management at Critical Bleeding in the Operating Room" in 2007. Since 2008, Japan Red Cross Blood Center (JRC) introduced leuko-reduction filter and diversion technique to prevent bacterial contamination. This improvement can easily introduce ABO compatible transfusion at critical situation. ⋯ When such mismatch transfusion necessarily performed, hydration therapy to protect kidney function should be applied immediately after hemostasis. 4) Red Cell Volume in a PC bag: PC in Japan have processed by single donor apheresis alone since 2004. Our results showed that each PC bag contains less than 5 mm(-3) of RBCs. If this level of RBCs caused hemolysis in ABO mismatch patient, it is too small to cause DIC or renal failure.