4 th nata asian symposium jointly organized by nata and the chinese society of anesthesiology july...

44thth NATA NATA ASIAN ASIAN SYMPOSIUMSYMPOSIUM

Jointly organized by NATA and the Chinese Society of Anesthesiology

July 28-29, 2007 Beijing, China

Welcome to the 4th Asian NATA Symposium• After very successful meetings in Singapore, Honk Kong and After very successful meetings in Singapore, Honk Kong and

Jakarta, the organizers wish to welcome you to the 4th Asian SJakarta, the organizers wish to welcome you to the 4th Asian Symposium of the Network for Advancement of Transfusion Alymposium of the Network for Advancement of Transfusion Alternatives (NATA), organized in collaboration with the Chinesternatives (NATA), organized in collaboration with the Chinese Society of Anesthesiology. The principal objective of this me Society of Anesthesiology. The principal objective of this meeting is to contribute to the education of participants in the meeting is to contribute to the education of participants in the more effective use of blood products, blood conservation and traore effective use of blood products, blood conservation and transfusion alternatives in everyday clinical practice. During this nsfusion alternatives in everyday clinical practice. During this symposium, international and local specialists will present and symposium, international and local specialists will present and discuss the most recent developments and strategies concernindiscuss the most recent developments and strategies concerning avoidance of blood transfusions and efficient alternatives to g avoidance of blood transfusions and efficient alternatives to transfusion of allogeneic blood. All of the speakers and presiditransfusion of allogeneic blood. All of the speakers and presiding members are recognized experts in the field, who work witng members are recognized experts in the field, who work with or conduct research concerning the better use of blood produh or conduct research concerning the better use of blood products and transfusion alternatives. cts and transfusion alternatives.

Welcome to the 4th Asian NATA Symposium

• Thus, for those with a special interest in transfusion medicine, Thus, for those with a special interest in transfusion medicine, the NATA Symposium is a unique opportunity to meet the the NATA Symposium is a unique opportunity to meet the specialists and discuss topics of importance during the two specialists and discuss topics of importance during the two days of the meeting. We trust you will find the meeting days of the meeting. We trust you will find the meeting informative, stimulating and that it will answer your needs informative, stimulating and that it will answer your needs regarding the advancement of transfusion practices.regarding the advancement of transfusion practices.

Philippe Van der Linden, MD, PhDPresident-Elect, NATAProfessor, ChairmanDepartment of AnesthesiologyCHU Brugmann-HuderfBrussels, Belgium

Xinmin Wu, MDPresident, Chinese Society of AnesthesiologyProfessor, ChairmanDepartment of AnesthesiologyPeking University First HospitalBeijing, China

Saturday, July 28,2007

Morning

Moderator Time Content Sperker

08:30-08:45 Welcome Address Prof. Xinmin Wu, President of the Chinese Society of Anesthesiology

08:45-09:00 Opening Address Prof. Konrad Messmer, NATA Past Chair

Efficacy of TransfusionBuweiYu, Shanghai,ChniaPhilippe Van Der Linden,Brussels,Belgium

09:00-09:20 Tolerance of Anemia in Surgical Patients

Konrad Messmer, Munich, Germany

09:20-09:40 Hemodilution and Neuroprotection Xiaomei Feng, Nanjing, China

09:40-10:00 Efficacy of Red Blood Cell Transfusion Philippe Van der Linden, Brussels, Belgium

10:00-10:30 Questions and Answers

10:30-11:00 Break

Transfusion ComplicationsNi Daoming,Beijing, ChinaDiana Teo,Singapore

11:00-11:20 Complications of Blood Transfusion Feng Gao, Shanghai, China

11:20-11:40 Measures to Assure the Quality and Safety of the Blood Supply in China

Yan Qiu, Beijing, China

11:40-12:00 Hemovilance Systems in Asia Diana Teo, Singapore


12:30-14:00 B.Braun Satellite Symposium

Afternon

Moderator Time Content Speaker

ReplacementJin Liu,Chengdu, ChinaIdit Matot,Jerusalem, Israel

14:00-14:20 Is Oncotic Pressure Everything? Reconsidering the Use of Albumin in Critically Ill Patients

ZhanggangXue,Shanghai, China

14:20-14:40 The Colloid/Colloid Controversy: Does It Matter?

Idit Matot, Jerusalem, Israel

14:40-15:00 Volume Replacement and Inflammatory Response

Yuguang Huang, Beijing, China


15:30-16:00 Break

ThrombosisAnd HemostasisYuke Tian,Wuhan, ChinaDonat R. Spahn,Zurich, Switzerland

16:00-16:20 Bedside Coagulation Monitoring: Useful or Not?

Charles-MarcSamama, Paris, France

16:20-16:40 Recombinant Activated Factor VII: Efficacy and Safety

Sylvain Bélisle,Montreal,QC,Canada

16:40-17:00 Perioperative Management of Antiplatelet Agents

Charles-Marc Samama, Paris, France


Pro and Con Discussion:

Perioperative Fluid Management

Zhanggang Xue,Shanghai, ChinaKonrad Messmer,Munich,Germany

17:30-17:50 Restrictive Fluid Therapy Improves Postoperative Outcomes: Pro

Idit Matot, Jerusalem, Israel

17:50-18:10 Restrictive Fluid Therapy Improves Postoperative Outcomes: Con

Donat R. Spahn, Zurich,Switzerland


Sunday, July 29,2007

Morning

Moderator Time Content Speaker

Transfusion Strategies

in TraumaYun Yue,Beijing, ChinaSylvain Bélisle,Montreal, QC,Canada

09:00-09:20 Prehospital Care: To Fill or Not to Fill?

Ernest E. Moore,Denver, CO, USA

09:20-09:40 Management of Severe Coagulopathy

Donat R.Spahn, Zurich, Switzerland

09:40-10:00 The Potential Role of Blood Substitutes in Trauma

Ernest E. Moore,Denver, CO, USA


10:30-11:00 Break

Transfusion Alternatives in Cardiothoracic Surgery

Tiehu Ye,Beijing, ChinaCharles-Marc Sama

ma,Paris, France

11:00-11:20 Acute Normovolemic Hemodilution

Konrad Messmer, Munich, Germany

11:20-11:40 Pharmacological Alternatives Sylvain Bélisle,Montreal, QC, Canada

11:40-12:00 Blood Conservation Strategies in Cardiac Surgery

Philippe Van der Linden, Brussels,

Belgium


12:30 End of day two program

Welcome Address Welcome Address • Prof. Xinmin Wu, Prof. Xinmin Wu,

President of the CPresident of the Chinese Society of hinese Society of AnesthesiologyAnesthesiology

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Opening Address Opening Address

• Prof. Konrad Messmer, NProf. Konrad Messmer, NATA Past ChairATA Past Chair

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Efficacy of Transfusion

Tolerance of Anemia in Surgical PatientsTolerance of Anemia in Surgical Patients

• Konrad Messmer, MD,1 and Konrad Messmer, MD,1 and Oliver Habler, MD, PhD2Oliver Habler, MD, PhD2

• 1Emeritus Professor, Universi1Emeritus Professor, University of Munich, Munich, Germaty of Munich, Munich, Germanyny

• 2Professor of Anesthesiology 2Professor of Anesthesiology and Intensive Care Medicine,and Intensive Care Medicine,

• Clinic of Anesthesiology, InteClinic of Anesthesiology, Intensive Care and Pain Control,nsive Care and Pain Control,

• Johann Wolfgang Goethe UniJohann Wolfgang Goethe University, Frankfurt am Main,versity, Frankfurt am Main,

• GermanyGermany

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• The availability of homologous blood and blood products has resulted in the liberal use of blood transfusions, although the use of donor blood is still associated with serious risks for the recipient, including hemolysis, infection, immunosuppresion and transfusion-related acute lung injury. Several prospective studies, in particular the multicenter study of Hebert et al. (the TRICC trial),1 have clearly shown that liberal transfusion policies in fact worsen patient outcome. Therefore, it appears necessary to reconsider the indications of blood transfusion.2 In addition, there is an increasing discrepancy between the need for blood (due to demographic changes and surgeries in the elderly population) and the willingness to donate blood. Last but not least, due to the ever increasing tests for blood safety, the secondary costs per unit of red cells or other blood products are continuously rising. To cope with these problems, allogeneic transfusions need to be reduced or avoided whenever possible. Based on the studies of intentional intraand perioperative hemodilution in patients undergoing elective surgical procedures and from data obtained from intensive care patients, hemoglobin (Hb) concentrations between 6 and 8 g/dL are acceptable, provided oxygen transport is not impaired by reduced saturation of arterial blood or inadequate tissue perfusion, in particular of the myocardium.



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• The basic mechanism that compensates for the reduced oxygen content of the arterial blood is a rise in stroke volume and cardiac output, both depending on adequate venous return and myocardial function. Hence, it is evident that patients with cardiac risks, in particular coronary disease, will need a higher hemoglobin concentration, as do intensive care patients (Hb 8-9 g/dL). The study by Hebert et al. has clearly demonstrated that a liberal transfusion policy with Hb values of 10-12 g/dL significantly reduced the survival rate in ICU patients as compared to those with a target hemoglobin concentration of 7-9 g/dL.1 The hemoglobin setpoint has to be determined for the individual patient with regard to the underlying disease, his actual blood volume, the amount of blood loss expected and the actual oxygen needs. By accepting dilutional anemia (Hb 6-8 g/dL) during and after elective surgery, the number of transfusions of allogeneic blood can be reduced and the risks and side effects can be safely avoided.



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Volume therapy with HESVolume therapy with HES 130/0.4 130/0.4 during sepsisduring sepsis

• Xiaomei Feng, JiaXiaomei Feng, Jianguo Xunguo Xu

• Nanjing General Nanjing General Hospital of NanjiHospital of Nanjing Military Commng Military Command, School of Meand, School of Medicine, Nanjing Udicine, Nanjing University, Nanjing,niversity, Nanjing, China China


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Efficacy of Red Blood Cell TransfusionEfficacy of Red Blood Cell Transfusion


• Philippe Van der LindPhilippe Van der Linden, MD, PhDen, MD, PhD

• Department of AnesthesiDepartment of Anesthesiolgy, CHU Brugmann – olgy, CHU Brugmann – HUDERF,HUDERF,

• Free University of BrussFree University of Brussels, Brussels, Belgiumels, Brussels, Belgium

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• The aims of allogeneic blood transfusion in critically ill patients are to rThe aims of allogeneic blood transfusion in critically ill patients are to reduce the risks associated with anaemia and/or to increase oxygen deliveduce the risks associated with anaemia and/or to increase oxygen delivery in an attempt to improve survival in these high risk patients. In an every in an attempt to improve survival in these high risk patients. In an evaluation of transfusion practice in tertiary-level intensive care units, Hebaluation of transfusion practice in tertiary-level intensive care units, Hebert et al. reported that the most frequent reasons for administering red blert et al. reported that the most frequent reasons for administering red blood cells were bleeding and the need to augment oxygen delivery. ood cells were bleeding and the need to augment oxygen delivery.

• Eighteen clinical studies for a total of 359 patients attempted to determiEighteen clinical studies for a total of 359 patients attempted to determine the effect of red blood cell (RBC) transfusion on the oxygen uptake ne the effect of red blood cell (RBC) transfusion on the oxygen uptake (VO(VO22)–oxygen delivery (DO)–oxygen delivery (DO22) relationship. All measured VO) relationship. All measured VO22 and DO and DO22 before and after the transfusion of a specified number of allogeneic RBbefore and after the transfusion of a specified number of allogeneic RBC units. The results of these trials are inconsistent. C units. The results of these trials are inconsistent.

• Although hemoglobin concentration increased significantly in all the stuAlthough hemoglobin concentration increased significantly in all the studies, DOdies, DO22 did not increase in four of them. Despite the administration of did not increase in four of them. Despite the administration of 1 to 3 RBC units, cardiac filling pressures did not increase, and cardiac 1 to 3 RBC units, cardiac filling pressures did not increase, and cardiac output did not change or even tended to decrease.output did not change or even tended to decrease.


Efficacy of Red Blood Cell TransfusionEfficacy of Red Blood Cell Transfusion

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• Indeed, acute hemoconcentration will be associated with an exponential Indeed, acute hemoconcentration will be associated with an exponential increase in blood viscosity at all shear rates, particularly at the lowest onincrease in blood viscosity at all shear rates, particularly at the lowest one prevalent in the postcapillary veinules. This phenomenon will result in e prevalent in the postcapillary veinules. This phenomenon will result in a decrease in venous return at the systemic level as well as a reduction ia decrease in venous return at the systemic level as well as a reduction in bulk flow. At the microcirculatory level, it translates into a reduction n bulk flow. At the microcirculatory level, it translates into a reduction of mean red blood cell velocity and an increased number of capillaries cof mean red blood cell velocity and an increased number of capillaries containing stationary RBCs. Therefore, in the studies reporting an increasontaining stationary RBCs. Therefore, in the studies reporting an increase in DOe in DO22 with blood transfusion, this elevation was essentially related to with blood transfusion, this elevation was essentially related to a rise in arterial blood oxygen content.a rise in arterial blood oxygen content.

• In the 14 studies that showed an increase in systemic DOIn the 14 studies that showed an increase in systemic DO22, only five reported a, only five reported an increase in systemic VOn increase in systemic VO22. In addition, the studies that demonstrated an increa. In addition, the studies that demonstrated an increase in VOse in VO22 should be interpreted with caution since in all of them VO should be interpreted with caution since in all of them VO22 was calcu was calculated using the Fick equation. Calculating both VOlated using the Fick equation. Calculating both VO22 and DO and DO22 from the same val from the same values of cardiac output, arterial saturation and hemoglobin concentration may indues of cardiac output, arterial saturation and hemoglobin concentration may indeed introduce a problem of mathematical coupling of the data. This phenomenoeed introduce a problem of mathematical coupling of the data. This phenomenon is more likely to occur when DOn is more likely to occur when DO22 variations associated with therapeutic inter variations associated with therapeutic interventions are of small amplitude. The three studies that directly measured VOventions are of small amplitude. The three studies that directly measured VO22 d did not report an increase in VOid not report an increase in VO22 associated with blood transfusion, although tw associated with blood transfusion, although two of them did show a significant increase in calculated VOo of them did show a significant increase in calculated VO22..

Efficacy of Transfusion RETURN

• The lack of a VOThe lack of a VO22 change in the presence of a significant increase in DO change in the presence of a significant increase in DO22 i is most likely explained by the fact that there was probably not underlying ts most likely explained by the fact that there was probably not underlying tissue hypoxia in these patients. Indeed, tissue hypoxia is not likely to exist issue hypoxia in these patients. Indeed, tissue hypoxia is not likely to exist in the absence of circulatory shock, and the dependency of VOin the absence of circulatory shock, and the dependency of VO22 on DO on DO22 is is a hallmark of shock. Consistent with this hypothesis, Fenwick et al. showea hallmark of shock. Consistent with this hypothesis, Fenwick et al. showed that VOd that VO22 increased with DO increased with DO22 in patients with hyperlactatemia but not in p in patients with hyperlactatemia but not in patients without it. The absence of VOatients without it. The absence of VO22 increase in the presence of a signific increase in the presence of a significant increase in DOant increase in DO22 might also be attributed to the inability of RBC transfu might also be attributed to the inability of RBC transfusion to correct a tissue oxygen debt. The inability of old transfused red blosion to correct a tissue oxygen debt. The inability of old transfused red blood cells to acutely augment systemic VOod cells to acutely augment systemic VO22 from a supply-dependent positio from a supply-dependent position can be explained by the structural and functional changes in the RBC pron can be explained by the structural and functional changes in the RBC product occurring with storage. However, even though the storage lesion has bduct occurring with storage. However, even though the storage lesion has been well demonstrated ex vivo, its influence on cellular oxygenation has noeen well demonstrated ex vivo, its influence on cellular oxygenation has not been convincingly demonstrated.The effects of RBC on tissue oxygenatiot been convincingly demonstrated.The effects of RBC on tissue oxygenation are not an “on/off” mechanism, and it is still possible that although less en are not an “on/off” mechanism, and it is still possible that although less efficient, transfusion of stored RBCs may still be sufficient to correct a smalfficient, transfusion of stored RBCs may still be sufficient to correct a small oxygen deficit.l oxygen deficit.

• Although RBC transfusion is clearly life-saving in some clinical situations, Although RBC transfusion is clearly life-saving in some clinical situations, its efficacy remains poorly demonstrated in clinical studies. With the excepits efficacy remains poorly demonstrated in clinical studies. With the exception of life-threatening situations, the decision to transfuse a given patient stion of life-threatening situations, the decision to transfuse a given patient should still rely on clinical judgment taking into account the benefit-risk ratihould still rely on clinical judgment taking into account the benefit-risk ratio of transfusion versus the known risks associated with anemia.o of transfusion versus the known risks associated with anemia.

Efficacy of Transfusion RETURN

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Efficacy of Transfusion• Questions and AnswersQuestions and Answers

• Konrad MessmerKonrad Messmer

• Xiaomei FengXiaomei Feng

• Philippe Van der LindenPhilippe Van der Linden

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Complications of Blood Transfusion

• Feng Gao, MDFeng Gao, MD

• Shanghai Blood CShanghai Blood Center, Shanghai, Center, Shanghai, Chinahina

Transfusion Complications

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• Blood transfusion plays an important role in clinical practice. However, it is also Blood transfusion plays an important role in clinical practice. However, it is also possible, on certain conditions, for transfusion to bring about adverse reactions apossible, on certain conditions, for transfusion to bring about adverse reactions and complications. Transfusion reactions can be divided into two groups: noninfend complications. Transfusion reactions can be divided into two groups: noninfectious reactions and transfusion-transmitted diseases. Non-infectious reactions inctious reactions and transfusion-transmitted diseases. Non-infectious reactions include immunological and nonimmunological reactions.clude immunological and nonimmunological reactions.

• Non-infectious transfusion reactionsNon-infectious transfusion reactions• Acute non-infectious reactionsAcute non-infectious reactions• Acute non-infectious immunological reactions include hemolytic, febrile non-heAcute non-infectious immunological reactions include hemolytic, febrile non-he

molytic, urticarial, anaphylactic reactions and transfusion-related acute lung injumolytic, urticarial, anaphylactic reactions and transfusion-related acute lung injury (TRALI). Febrile non-hemolytic transfusion reactions (FNHTRs) are the most ry (TRALI). Febrile non-hemolytic transfusion reactions (FNHTRs) are the most frequent reactions and the reported incidence varies (0.5–6% for red blood cells frequent reactions and the reported incidence varies (0.5–6% for red blood cells and 1–38% for platelets). Acute hemolytic reactions are the most serious and can and 1–38% for platelets). Acute hemolytic reactions are the most serious and can bebe

• fatal. TRALI is a serious reaction that has recently attracted increasing attention.fatal. TRALI is a serious reaction that has recently attracted increasing attention.• Acute non-infectious non-immunological reactions include hypotension with AAcute non-infectious non-immunological reactions include hypotension with A

CE inhibition, circulatory overload, air embolus, non-immune hemolysis and hyCE inhibition, circulatory overload, air embolus, non-immune hemolysis and hypocalcemia. The incidence of circulatory overload is less than 1%, but the outcopocalcemia. The incidence of circulatory overload is less than 1%, but the outcome may be serious. Usually it is due to unreasonable transfusion of whole blood me may be serious. Usually it is due to unreasonable transfusion of whole blood or plasma, and it is avoidable.or plasma, and it is avoidable.


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• Delayed non-infectious reactionsDelayed non-infectious reactions• Alloimmunization of RBC antigens or HLA antigens, hemolytic reactions aAlloimmunization of RBC antigens or HLA antigens, hemolytic reactions a

nd transfusion-associated graft-versushost disease (TA-GvHD) are the maind transfusion-associated graft-versushost disease (TA-GvHD) are the main delayed immunological reactions. Although the mechanism of immune mn delayed immunological reactions. Although the mechanism of immune modulation of transfusion is not completely known, it may be the reason for iodulation of transfusion is not completely known, it may be the reason for increased infection rate and post-resection tumor recurrence rate after transfncreased infection rate and post-resection tumor recurrence rate after transfusion. Iron overload is the main delayed nonimmunological reaction and ususion. Iron overload is the main delayed nonimmunological reaction and usually happens after transfusion of over 100 red blood cell units.ually happens after transfusion of over 100 red blood cell units.

• Transfusion-transmitted diseasesTransfusion-transmitted diseases• Transfusion-transmitted diseases include infections caused by viruses, bactTransfusion-transmitted diseases include infections caused by viruses, bact

eria, spirochete (main syphilis) and parasite (malaria and Chagas’ disease). eria, spirochete (main syphilis) and parasite (malaria and Chagas’ disease). HIV, HBV and HCV are the main transfusion-transmitted viruses and there HIV, HBV and HCV are the main transfusion-transmitted viruses and there are new emerging transfusion-transmitted agents, such as West Nile virus aare new emerging transfusion-transmitted agents, such as West Nile virus and prions (variant Creutzfeldt-Jakob disease). Although great progress in ind prions (variant Creutzfeldt-Jakob disease). Although great progress in improvement of blood safety has been made, there are still residual risks of tmprovement of blood safety has been made, there are still residual risks of transfusiontransmitted infections, mainly viruses, and other transfusion adveransfusiontransmitted infections, mainly viruses, and other transfusion adverse reactions and complications. Therefore, it is necessary and important to rse reactions and complications. Therefore, it is necessary and important to take measures to further reduce the risks of transfusion-associated adverse rtake measures to further reduce the risks of transfusion-associated adverse reactions and complications, including the use of alternatives to blood transfeactions and complications, including the use of alternatives to blood transfusion as much as possible.usion as much as possible.

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Measures to Assure the Quality and safetyof the Blood Supply in China

• Yan Qiu PhD,Yan Qiu PhD,• Vice Director Vice Director • Beijing Red CrBeijing Red Cr

oss Blood Centoss Blood Center, Chinaer, China


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Hemovigilance Systems in Asia

• Diana Teo, MDDiana Teo, MD

• Centre for TransCentre for Transfusion Medicine, fusion Medicine, Health Sciences Health Sciences Authority,Authority,

• SingaporeSingapore


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• Hemovigilance is defined as a set of surveillance procedures covering the whole transHemovigilance is defined as a set of surveillance procedures covering the whole transfusion chain (from the collection of blood and its components to the follow up of its rfusion chain (from the collection of blood and its components to the follow up of its recipients), intended to collect and assess information on unexpected or undesirable evecipients), intended to collect and assess information on unexpected or undesirable events resulting from the therapeutic use of labile blood products, and to prevent their oents resulting from the therapeutic use of labile blood products, and to prevent their occurrence and recurrence. It is increasingly used worldwide as an important tool for stccurrence and recurrence. It is increasingly used worldwide as an important tool for strengthening blood transfusion safety. In general, hemovigilance can be divided into threngthening blood transfusion safety. In general, hemovigilance can be divided into three broad categories: 1) recipient hemovigilance; 2) process hemovigilance; and 3) doree broad categories: 1) recipient hemovigilance; 2) process hemovigilance; and 3) donor hemovigilance.nor hemovigilance.

• Recipient hemovigilance covers the adverse reactions that may occur in the transfusioRecipient hemovigilance covers the adverse reactions that may occur in the transfusion recipient, including the identification of transfusion-transmitted infections. Different n recipient, including the identification of transfusion-transmitted infections. Different models of recipient hemovigilance systems exist, differing in the type of notification models of recipient hemovigilance systems exist, differing in the type of notification (voluntary versus mandatory approach), the range of reactions reported (all reactions (voluntary versus mandatory approach), the range of reactions reported (all reactions versus only serious reactions), and the body to which the reports are made (governmeversus only serious reactions), and the body to which the reports are made (government, blood transfusion service, or private organization). When comparing hemovigilancnt, blood transfusion service, or private organization). When comparing hemovigilance data, it is important to take these differences into consideration. Each country shoule data, it is important to take these differences into consideration. Each country should determine which model best suits their local environment and needs.d determine which model best suits their local environment and needs.

• Process hemovigilance involves errors that occur either in the process of production oProcess hemovigilance involves errors that occur either in the process of production or transfusion of blood and blood components. This includes surveillance of errors and r transfusion of blood and blood components. This includes surveillance of errors and near misses, monitoring of traceability of blood products, and blood utilization. Donor near misses, monitoring of traceability of blood products, and blood utilization. Donor hemovigilance includes untoward events occurring during blood donation, data relatehemovigilance includes untoward events occurring during blood donation, data related to donor selection, and epidemiological data on donors found positive in infectious d to donor selection, and epidemiological data on donors found positive in infectious marker screening. Both process and donor hemovigilance are relatively new areas and marker screening. Both process and donor hemovigilance are relatively new areas and therefore less well developed within hemovigilance systems.therefore less well developed within hemovigilance systems.


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• Hemovigilance systems within Asia vary. While some countries have centrally-coordinated Hemovigilance systems within Asia vary. While some countries have centrally-coordinated national systems in place, many others either do not have any hemovigilance programs yet national systems in place, many others either do not have any hemovigilance programs yet or have it as detached programs within individual hospitals. Where they exist, national hemor have it as detached programs within individual hospitals. Where they exist, national hemovigilance systems are usually coordinated by the blood service working in collaboration wovigilance systems are usually coordinated by the blood service working in collaboration with hospital transfusion committees. Most of these systems are voluntary.ith hospital transfusion committees. Most of these systems are voluntary.

• The introduction of hemovigilance programs has helped to increase awareness of transfusioThe introduction of hemovigilance programs has helped to increase awareness of transfusion safety both within the blood service and at the hospitals. Availability of hemovigilance dan safety both within the blood service and at the hospitals. Availability of hemovigilance data enables informed decisions about blood safety and transfusion safety based on real risks ta enables informed decisions about blood safety and transfusion safety based on real risks as opposed to perceived risks. For example, it has provided significant insight into the relatias opposed to perceived risks. For example, it has provided significant insight into the relative frequency of complications previously thought to occur only rarely, such as transfusion-rve frequency of complications previously thought to occur only rarely, such as transfusion-related acute lung injury.elated acute lung injury.

• Information management systems are now being used to enhance data gathering and analysInformation management systems are now being used to enhance data gathering and analysis. This will facilitate the introduction of Rapid Alert Systems, which will enable a more pris. This will facilitate the introduction of Rapid Alert Systems, which will enable a more proactive approach to be adopted in dealing with potential hazards. Hemovigilance networks oactive approach to be adopted in dealing with potential hazards. Hemovigilance networks will continue to expand beyond national and regional borders, and this will turn allow pooliwill continue to expand beyond national and regional borders, and this will turn allow pooling of data and identification of risks too small to be recognized in a single blood service or ng of data and identification of risks too small to be recognized in a single blood service or country. Common issues of concern can be identified and joint efforts taken to address thecountry. Common issues of concern can be identified and joint efforts taken to address them.m.

• Improved and more consistent definitions for event reporting are being developed by the IntImproved and more consistent definitions for event reporting are being developed by the International Society of Blood Transfusion and the European Hemovigilance Network. This wernational Society of Blood Transfusion and the European Hemovigilance Network. This will improve data sharing efforts between hemovigilance systems, leading to the real possibilill improve data sharing efforts between hemovigilance systems, leading to the real possibility of a global hemovigilance network in the near future. The inclusion of cells and tissues ity of a global hemovigilance network in the near future. The inclusion of cells and tissues will eventually lead to the replacement of the concept of hemovigilance with that of biovigiwill eventually lead to the replacement of the concept of hemovigilance with that of biovigilance. Biovigilance systems could also be linked with pharmacovigilance systems to providlance. Biovigilance systems could also be linked with pharmacovigilance systems to provide truly comprehensive systems that will benefit not only donor and patient safety, but enhane truly comprehensive systems that will benefit not only donor and patient safety, but enhance public health safety.ce public health safety.

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Transfusion Complications• Questions and AnswersQuestions and Answers

• Feng GaoFeng Gao

• Yan QiuYan Qiu

• Diana TeoDiana Teo

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Is Oncotic Pressure Everything? Reconsideringthe Use of Albumin in Critically Ill Patients

• Zhanggang Xue, MDZhanggang Xue, MD

• Department of AnestheDepartment of Anesthesia & SICU, Zhongshasia & SICU, Zhongshan Hospital,n Hospital,

• Fudan University, ShaFudan University, Shanghai, Chinanghai, China

Perioperative Volume Replacement

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• Albumin administration in the critically ill is controversial Albumin administration in the critically ill is controversial and hotly debated, despite having been accepted and wideland hotly debated, despite having been accepted and widely used for more than 50 years. Traditional use of albumin iy used for more than 50 years. Traditional use of albumin in critically ill patients includes the use of 20% albumin ann critically ill patients includes the use of 20% albumin and furosemide to reduce edema in SIRS, administration of ad furosemide to reduce edema in SIRS, administration of albumin following paracentesis for ascites, and use of replalbumin following paracentesis for ascites, and use of replacement albumin in nephrotic syndrome. The aims are to mcement albumin in nephrotic syndrome. The aims are to maintain blood volume in vessels to stabilize the hemodynaaintain blood volume in vessels to stabilize the hemodynamic situation, increase COPcap, prevent edema, and impromic situation, increase COPcap, prevent edema, and improve nutritional status. However, a Cochrane report by Offrinve nutritional status. However, a Cochrane report by Offringa et al. suggested that treatment with albumin was related ga et al. suggested that treatment with albumin was related to a 6% excess of deaths above control, which fussed the wto a 6% excess of deaths above control, which fussed the world.orld.


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• Why give the guilty to an “old man of achievement”? We think that mortalWhy give the guilty to an “old man of achievement”? We think that mortality may not be the most appropriate an endpoint to evaluate albumin adminity may not be the most appropriate an endpoint to evaluate albumin administration. The result from Offringa’s report is not reliable because cause the istration. The result from Offringa’s report is not reliable because cause the result came out not all from randomized controlled trials and the primary dresult came out not all from randomized controlled trials and the primary disease that cause the hypoalbuminemia is not balanced. By this lecture, we isease that cause the hypoalbuminemia is not balanced. By this lecture, we would like to reevaluate the effects of albumin from four aspects, which arwould like to reevaluate the effects of albumin from four aspects, which are the main reasons why we use albumin: volume resuscitation, edema corre the main reasons why we use albumin: volume resuscitation, edema correction, wound healing and protection of immune function.ection, wound healing and protection of immune function.

• We also draw a conclusion from two recent randomized controlled trials: dWe also draw a conclusion from two recent randomized controlled trials: different primary disease complexity, different skill and management in one ifferent primary disease complexity, different skill and management in one special disease cause the different out come for usage of albumin; the simpspecial disease cause the different out come for usage of albumin; the simpler the primary disease, the more obvious superiority the albumin shows.ler the primary disease, the more obvious superiority the albumin shows.

• As mentioned above, we believe that more standard protocol need to be imAs mentioned above, we believe that more standard protocol need to be implemented to evaluate the safety of albumin use in critical patients: more dplemented to evaluate the safety of albumin use in critical patients: more detailed subgroups, more reasonable scoring system to balance the basic situetailed subgroups, more reasonable scoring system to balance the basic situation, as well as protocols based on objective monitoring, not empirical judation, as well as protocols based on objective monitoring, not empirical judgment.gment.

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The Colloid–Colloid Controversy:Does It Matter?


• Idit Matot, MDIdit Matot, MD

• Associate Professor, Associate Professor, Department of AnestDepartment of Anesthesiology and Criticahesiology and Criticall

• Care Medicine, HadCare Medicine, Hadassah Hebrew Univeassah Hebrew University Medical Center,rsity Medical Center,

• Jerusalem, IsraelJerusalem, Israel

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Volume Replacement and Inflammatory Response

• Yuguang Huang, MDYuguang Huang, MD

• Department of AnestheDepartment of Anesthesiology, Peking Union siology, Peking Union Medical CollegeMedical College

• Hospital, Chinese AcaHospital, Chinese Academy of Medical Sciendemy of Medical Sciences and Pekingces and Peking

• Union Medical College,Union Medical College, Beijing, China Beijing, China

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• Although the effect of resuscitation fluids has been studied extensively for the effect on the red cell and intravascular volume restoration, not enough attention has been focused on the role played by the choice of resuscitation fluids in the inflammatory response. Recent work demonstrated that infusion of different fluids can have widely divergent impact on the immune response, neutrophil activation, upregulation of adhesion molecules, and induction of cell death by apoptosis and tissue injury. We will review the recently published literature about the relationship between different fluid replacement solutions and inflammatory response, aid to illustrate the mechanisms involved in this inflammatory response and conclude about what would be an ideal solution for volume replacement. Optimization of the patient’s intravascular volume status may generally have important effects on immune response, endothelial activation and injury, but the definite influence of resuscitation fluids on immune function, inflammatory response, and endothelial activation and injury is not clear. An ideal solution for volume replacement is not apparent at this time. There should be more well-designed randomized clinical and laboratory studies focusing on the prevention of immune activation with better fluids.


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• Questions and AnswersQuestions and Answers

• Zhanggang XueZhanggang Xue

• Idit MatotIdit Matot

• Yuguang HuangYuguang Huang

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Bedside Coagulation Monitoring: Useful or Not?

Thrombosis and Hemostasis

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• Charles Marc Samama, Charles Marc Samama, MD, PhD, FCCPMD, PhD, FCCP

• Professor and Chairman, Professor and Chairman, Department of AnesthesiDepartment of Anesthesiology andology and

• Intensive Care, Hotel-DiIntensive Care, Hotel-Dieu University Hospital, Peu University Hospital, Paris, Francearis, France

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Bedside Coagulation Monitoring: Useful or Not?

• Intraoperative bleeding can be related to: surgery, the surgical setting, emergency, inexperience, acquired or constitutional hemostasis disorders, uncontrolled fluid loading (highmolecular- weight hydroxyethyl starches, dextrans, dilution), anticoagulant agents, antiplatelet agents, hypothermia, acidosis, hypocalcemia, low hematocrit, etc. Hemorrhagic manifestations related to defects of primary hemostasis (thrombocytopenia, drop in hematocrit, von Willebrand disease, antiplatelet agents) are:

• - classically diffuse• - visually assessed at mucocutaneous sites• - spontaneous• - occur immediately after surgical incision…• Manifestations related to coagulation defects (drop in• coagulation factors and fibrinogen, DIC, hemophilia,• anticoagulant treatments) are:

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• - often delayed

• - associated with bleeding into deeper tissues

• - not spontaneous (induced)

• - could be more difficult to assess visually…

• Although clinical assessment remains an important element in the decision-making process, it alone is insufficient as an indication for transfusion. Biological tests are to be performed. Among usual laboratory tests, the most relevant test is the platelet count. Bedside tests are of course useful but not yet validated by the International Society on Thrombosis and Haemostasis. However, times are changing and either the CoaguchekPro DM® (Roche – On Site Prothrombin time and Activated Partial Thromboplastin Time) and the ROTEM® (thrombelastography) are now being extensively studied and could be finally validated as helpful bedside tests in the operating room (and maybe elsewhere). Only a close collaboration with the hemostasis (hematology) laboratory will allow further developments of these monitors.

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Recombinant Activated Factor VII: Efficacy and Safety

• Sylvain Bélisle, MD, Sylvain Bélisle, MD, FRCPCFRCPC

• Department of AnestDepartment of Anesthesiology, University hesiology, University of Montreal,of Montreal,

• Montreal, Quebec, CMontreal, Quebec, Canadaanada


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Recombinant Activated Factor VII: Efficacy and Safety• Recombinant activated factor VII (rFVIIa) is approved for the treatment of bleeding in hemophiliac pati

ents. Case reports and case series suggest that rFVIIa is effective in the management of uncontrolled bleeding of diverse origins in patients with a (baseline) normal hemostatic system. While such results are interesting and suggest possible efficacy, the gold standard in establishing benefits and harms of an intervention is the randomized controlled trial (RCT). In this presentation, we review all published RCTs that have evaluated the hemostatic efficacy and safety of rFVIIa in non-hemophiliac patients.

• In total, at the time of writing, RCTs had been published on the use of rFVIIa to control bleeding in patients either with (6 RCTs) or without (7 RCTs) a hemostatic defect at the time of administration of the drug. Results of studies in patients with a known hemostatic defect at the time of administration of the drug showed either no benefit or a very marginal one.

• In patients with no known hemostatic defect prior to the bleeding episode for which trial drug was administered, the only truly positive results are those of the acute intracerebral hemorrhage (ICH) study by Mayer et al. Intracranial bleeding, mortality and severe incapacity were reduced significantly by rFVIIa. However, the incidence of arterial thrombotic adverse events was increased significantly in patients treated with the drug (an incidence of 5% vs. 0% in the placebo group). The recent publication of the American Heart Association/ American Stroke Association updated guidelines on the management of spontaneous intracerebral hemorrhage in adults recommends that before its use in patients with intracranial bleeding, the efficacy and safety of rFVIIa must be confirmed by phase III trials. Results of the retropubic prostatectomy trial were not convincing due to the very important blood losses in the control group. All other trials reported negative results by intent-to-treat analysis of the data. Two studies reported a significant benefit in selected patients (post-hoc, subgroup analyses). While the latter results suggest a beneficial effect of the drug in some patients, they cannot be considered positive and await confirmation by subsequent RCTs in those specific patient populations.

• In summary, at present, published RCTs do not support the efficacy of rFVIIa to control bleeding and reduce transfusions in various patient populations. In addition, the safety of rFVIIa remains a concern.Consequently, in light of the available evidence, the use of rFVIIa to prevent or to control bleeding in non-hemophiliac patients cannot be recommended.


Perioperative Management of Antiplatelet Agents


• Charles Marc Samama, Charles Marc Samama, MD, PhD, FCCPMD, PhD, FCCP

• Professor and Chairman, Professor and Chairman, Department of AnesthesiolDepartment of Anesthesiology andogy and

• Intensive Care, Hotel-Dieu Intensive Care, Hotel-Dieu University Hospital, Paris, University Hospital, Paris, FranceFrance

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Perioperative Management of Antiplatelet Agents

• Preoperative treatments with antiplatelet agents still represent a major problem for anesthesiologists. Different issues have to be considered. First, antiplatelet agents do not interact with the same magnitude with hemostasis, as far as the bleeding risk is concerned. Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) moderately increase intra- and postoperative bleeding while they are generally not responsible for an increase in transfusion requirements. Few data are available concerning clopidogrel, except in cardiac surgery. Second, the common preoperative withdrawal of antiplatelet agents is now challenged because an increased number of myocardial infarctions has been reported in patients in whom these treatments had been interrupted. Third, most vascular surgery procedures have to be performed in patients treated with aspirin. In many additional settings, aspirin should not be withdrawn. Fourth, in patients with bare-metal stents (BMS) and drug-eluting stents (DES) the dual antiplatelet therapy (aspirin + clopidogrel) should be continued for at least 6 weeks (BMS) and 12 months (DES), respectively, following the stent placement procedure, due to the very high risk of MI and death if the treatment is withdrawn. When a definite increase in intraoperative bleeding is feared, or when surgical hemostasis is difficult, aspirin and clopidogrel can be withdrawn for 5 days (no more). However, one should always consider the continuation of aspirin, especially in BMS and DES patients. Platelet transfusion should only be given when an overt bleeding is observed. Postoperatively, antiplatelet treatments will restart immediately after surgery (first 6 hours).


Thrombosis and Hemostasis• Questions and AnswersQuestions and Answers

• Charles-Marc SamamaCharles-Marc Samama

• Sylvain BélisleSylvain Bélisle

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Restrictive Fluid Therapy ImprovesPostoperative Outcomes: Pro

• Idit Matot, MDIdit Matot, MD

• Associate Professor,Associate Professor, Department of Ane Department of Anesthesiology and Critsthesiology and Critical Care Medicine, ical Care Medicine, Hadassah Hebrew Hadassah Hebrew University Medical University Medical Center, Jerusalem, ICenter, Jerusalem, Israelsrael

Pro and Con Discussion:Perioperative Fluid Managemen

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Restrictive Fluid Therapy ImprovesPostoperative Outcomes: Con


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• Donat R. Spahn, MD, Donat R. Spahn, MD, FRCAFRCA

• Professor and ChairmaProfessor and Chairman, Department of Anestn, Department of Anesthesiology, University Hhesiology, University Hospital Zurich, Zurich, ospital Zurich, Zurich, SwitzerlandSwitzerland

Restrictive Fluid Therapy ImprovesPostoperative Outcomes: Con

• Restricting fluid therapy is believed by some to improve outcome. However, such a general statement cannot be true for all patients, and fluid restriction should be replaced by goaldirected intravascular fluid administration.

• There are indeed several studies, mainly in the field of abdominal surgery, comparing “liberal” or “standard” with “restrictive” fluid regimens and finding less postoperative complications and shorter hospital stay in patients treated with a restrictive fluid regimen. Interestingly, in both studies there was an algorithm how to treat intraoperative hypovolemia, hypotension and oliguria, and the so-called “liberal” or “standard” control group received really high quantities of crystalloids whereas the “restrictive” group was on a very “dry” regimen. As a consequence, a high percentage of patients in the restrictive group became hypovolemic, hypotensive or oliguric intraoperatively and thus were treated according to the algorithm of the study protocol whereas most patients in the “liberal” or “standard” group never entered this algorithm. In other words, patients in the “restrictive” group were basically treated by the principle of goal-directed intravascular fluid administration whereas the majority of patients in the “liberal” or “standard” group tended to be overhydrated. The better outcome in the “restrictive” group is therefore not primarily due to running patients “dry” but to the avoidance of overhydration and the use of an algorithm allowing an individualized goaldirected regimen.


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• Interestingly, there are studies with fundamentally different results, also in patients undergoing abdominal surgery. Holte et al. found less pain, less postoperative nausea and vomiting, earlier discharge, better pulmonary function and a higher exercise capacity in patients in the liberal fluidregimen (40 mL/kg Ringer’s lactate) as compared with a more restrictive fluid regimen (15 mL/kg). The main difference compared to the above two studies showing a benefit for the restrictive (and goal-directed) groups is that Holte and colleagues investigated patients undergoing laparoscopic cholecystectomy and not major abdominal surgery. The benefit of a restrictive fluid regimen with a goal-directed treatment of hypovolemia, hypotension and oliguria may thus be limited to, or at least be particularly high, in major abdominal surgery with gastrointestinal anastomoses.

• Goal-directed fluid administration uses algorithms to optimize stroke volume. According to these algorithms successive boli of colloid are being administered and the effect assessed by the response of central venous pressure and more often by the response of the directly measured stroke volume. As long as stroke volume continues to increase due to the administration of successive colloid boli, more colloid is being administered. Once stroke volume does not increase any more, the administration of colloid boli is stopped. Stroke volume is typically measured in the descending aorta with a Doppler probe placed in the esophagus. This technology is neither generally available nor validated.2 The question thus is whether other, more generally available and possibly cheaper techniques might give us the same information. Most likely, a visual analysis of a simple arterial pressure curve and its variation with the respiratory cycle in mechanically ventilated patients may provides the same information.


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• As long as the heart is functionally hypovolemic, the inspiration with its high intrathoracic pressure impedes venous return. As a consequence, the subsequent heart beats are associated with a reduced stroke volume. During expiration, the intrathoracic pressure decreases and the venous return is less impeded and the stroke volume is higher. Irrespective of whether the heart is perfectly healthy or whether there is a systolic or a diastolic contractile dysfunction, as long as the heart is functionally hypovolemic there is a significant respiratory variation of the arterial pressure curve. Once the heart is correctly filled, no respiratory variation will be observed.2 There are at least 7 studies in which patients were filled in the above fashion, and in these studies patients treat by individual goal-directed volume loading had less postoperative complications and a shorter duration of hospital stay.6-13 Interestingly, when patients are being loaded in this individual goal-directed manner, less vasoconstrictors are being used intraoperatively.10 This may also be an important explanation why typically fewer postoperative complications are being observed.

• In conclusion, fluids should be given in an individual goaldirected manner to optimize stroke volume and not simply on a per-kilogram-of-body-weight basis. Hospital length of stay and postoperative complications decrease with such colloid based goal-directed fluid regimens and thus are of high clinical relevance.


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Pro and Con Discussion:Pro and Con Discussion:Perioperative Fluid ManagementPerioperative Fluid Management


• Idit MatotIdit Matot

• Donat R. SpahnDonat R. Spahn

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Prehospital Care: To Fill or Not to Fill?

• Ernest E. Moore, MDErnest E. Moore, MD

• Chief, Department of Chief, Department of Surgery, Denver Surgery, Denver Health Medical Health Medical Center, and University Center, and University of Colorado Health of Colorado Health Sciences Center, Sciences Center, Denver, Colorado, Denver, Colorado, USAUSA

Transfusion Strategies in Trauma

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• Walter B. Cannon, based on observations of combat casualties during World War I, admonished that fluid resuscitation should be restricted until the bleeding site can be controlled, but also suggested that the critical level of blood pressure to sustain tissue viability is 80 mmHg. Ninety years later, these principles are emerging as the guidelines for prehospital care in the US. The enthusiasm for prehospital fluid resuscitation of the severely injured patient was generated from experimental work employing controlled hemorrhage models. In the 1950s, Wiggers et al. demonstrated the concept of decompensatory shock with delayed resuscitation, and the work of Shires et al. in the 1960s showed that crystalloid administration could restore oxygen delivery following acute blood loss. Consequently, until a decade ago prehospital crystalloid loading to normalize blood pressure and heart rate was the standard. The Houston randomized clinical trial in 1994 showing no advantage to aggressive preoperative crystalloid resuscitation for penetrating torso wounds, and reduced survival for cardiac wounds, prompted an intense reassessment of prehospital resuscitation. The global hypothesis was that unbridled prehospital crystalloid resuscitation would disrupt the formation of thrombus at the site of vascular injury and dilute circulating coagulation factors. The US Army experimental work demonstrated that re-bleeding from an aortotomy occurred at 90 mmHg. Innumerable animal studies of uncontrolled hemorrhage have shown consistently that restrained crystalloid resuscitation is optimal until intracavitary bleeding can be controlled. An ongoing debate, however, is the blunt multisystem injured patient with a significant head injury. The current US guidelines for prehospital resuscitation of the severely injured patient with uncontrolled intracavitary blood loss is crystalloid resuscitation to a target of 90 mmHg; with associated head injury, the target is 100 mmHg.


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Management of Severe Coagulopathy


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• Donat R. Spahn, MD, FRCA

• Professor and Chairman, Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland

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The Potential Role of Blood Substitutes in TraumaThe USA Multicenter Prehospital HBOC Trial:

Scientific Basis and Preliminary Results


• Ernest E. Moore, MDErnest E. Moore, MD

• Chief, Department of Chief, Department of Surgery, Denver Health Surgery, Denver Health Medical Center, and Medical Center, and University of Colorado University of Colorado Health Sciences Center, Health Sciences Center, Denver, Colorado, USADenver, Colorado, USA

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The Potential Role of Blood Substitutes in Trauma• Background• In the USA, the standard approach to re

storing oxygen delivery following hemorrhagic shock has been crystalloid administration to expand intravascular volume, followed by stored red blood cells (RBCs) for critical anemia. Allogeneic RBCs, however, may have adverse immunoinflammatory effects that increase the risk of post-injury multiple organ failure (MOF). Blood substitutes employed in advanced clinical trials today are RBC substitutes derived from hemoglobin. The hemoglobin-based oxygen carriers (HBOCs) tested currently are polymerized hemoglobin solutions. Thus, we hypothesized that early postinjury resuscitation with an HBOC—instead of stored RBCs—would be safe and effective in restoring oxygen delivery and reduce MOF.

• Methods• We pursued our hypothesis with in vitro stud

ies testing human polymerized hemoglobin solution (PolyHeme®, Northfield Laboratories, Evanston, IL, USA) with isolated human neutrophils and endothelium, and then an in vivo two-event rodent model of post-injury MOF. Concurrent with these experiments, we conducted inhospital phase II trials in which injured patients were resuscitated with progressively larger quantities of PolyHeme (up to 20 units). Encouraged by these results, we then designed a multicenter prehospital trial in which severely injured patients with major blood loss (systolic blood pressure ≤ 90 mmHg) were randomized to initial field resuscitation with crystalloid versus HBOC. During the hospital phase, patients in the control group were further resuscitated with stored RBCs, whereas the study group received HBOC (up to 6 units) in the first 12 hours.

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• Results• This challenging phase III trial (with waiver of consent) involved > 35

00 emergency medical technicians and > 300 ambulance services in 18 states, and was conducted at 30 level 1 trauma centers. Of the 720 patients enrolled, 714 were randomized and received some study treatment. The independent drug monitoring committee did not identify safety issues throughout the trial. Due to the complexity of the protocol, however, 18% of the patients were found to have major protocol violations. There was no statistically significant difference in mortality in either the total or protocol compliant populations.

• Conclusion• Experimental results, Phase II in-hospital studies, and preliminary data

from the Phase III prehospital trial suggest that PolyHeme is useful as an RBC substitute when stored blood is not available.

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Transfusion Strategiesin TraumaTransfusion Strategiesin Trauma• Questions and AnswersQuestions and Answers

• Ernest E. MooreErnest E. Moore• Donat R.SpahnDonat R.Spahn

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Acute Normovolemic Hemodilution

Transfusion Alternatives inCardiothoracic Surgery

• Konrad Messmer, MD, and OKonrad Messmer, MD, and Oliver Habler, MD, PhDliver Habler, MD, PhD

• Emeritus Professor, University Emeritus Professor, University of Munich, Munich, Germanyof Munich, Munich, Germany

• Professor of Anesthesiology anProfessor of Anesthesiology and Intensive Care Medicine, Clind Intensive Care Medicine, Clinic of Anesthesiology, Intensive ic of Anesthesiology, Intensive Care and Pain Control, Johann Care and Pain Control, Johann Wolfgang Goethe University, FrWolfgang Goethe University, Frankfurt am Main, Germanyankfurt am Main, Germany

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• Acute normovolemic hemodilution (ANH) was initially conceived as a means of avoiding transfusion of allogeneic blood in patients undergoing elective surgery with anticipated major blood losses. Prerequisite to accepting intentional anemia was the systematic investigation of the mechanisms allowing the adaptation of the organism to the acute dilutionassociated reduction of the oxygen content of arterial blood. Numerous studies from various laboratories around the world have addressed the cardiovascular responses to acute anemia induced by exchange of whole blood for red blood cell (RBC)-free crystalloid and/or colloidal solutions. There is general agreement that the maintenance of normovolemia is the basis for eliciting and preserving adequate cardiovascular compensation for intentional dilutional anemia. While the macrocirculation responds with an increase in cardiac output and organ blood flow (provided that normovolemia is maintained), the microcirculation responds with an increase of red cell flow velocity, a more homogeneous distribution of microvascular flow and a well-maintained functional capillary density (number of RBC-perfused capillaries per tissue unit). These adaptational changes allow the preservation of sufficient organ tissue oxygenation until the so-called critical hematocrit is reached. It appears that in the absence of disease, in particular of coronary artery disease, hematocrit values around 20% can be tolerated; this value defines the socalled transfusion trigger. Above this hematocrit value, the dilutional reduction of whole blood viscosity is considered as a beneficial effect (moderate hemodilution); below 20% hematocrit (extreme hemodilution), very low blood viscosity may be harmful because the local shearing forces may be too low to allow release nitric oxide from the microvascular endothelium, thereby affecting functional capillary density. For this reason, at extreme hemodilution the elevation of plasma viscosity by means of a colloid with relatively high solution viscosity seems preferable. If very low hematocrit values are encountered, hyperoxic ventilation presents as an additional safety mechanism because vasoconstriction due to hyperoxia does not take place in dilutional anemia.


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• For clinical ANH, the target hematocrit can be calculated by different mathematical formulae and will be achieved by exchanging blood for the chosen diluent (preferably a synthetic colloid). The occurrence of tachycardia, hypotension, lactacidemia and in particular ECG changes) in a diluted patient calls for instantaneous control of hematocrit/hemoglobin concentration, volume status and assessment of ST-segment changes in the ECG.

• The efficacy of ANH in avoiding allogeneic blood transfusions depends upon the patient’s initial hematocrit, the target hematocrit chosen and the amount of intraoperative blood loss. While age per se is no contraindication to ANH, patients with coronary and pulmonary disease, as well as those presenting with coagulation disorders, should not undergo routine hemodilution. The efficacy of ANH is a matter of debate; nevertheless, normovolemic hemodilution with deliberate tolerance of low hemoglobin and hematocrit concentrations presents the basic element of all strategies to avoid transfusions of allogeneic blood.

• It should be noted that ANH requires no special equipment and no special monitoring devices. ANH can therefore be performed in all hospitals performing surgical procedures.

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Pharmacological Alternatives in Cardiothoracic Surgery

• Sylvain Bélisle, MSylvain Bélisle, MD, FRCPCD, FRCPC

• Department of AneDepartment of Anesthesiology, Univesthesiology, University of Montreal,rsity of Montreal,

• Montreal, Quebec, Montreal, Quebec, CanadaCanada


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Blood Conservation Strategies in Cardiac Surgery

• Philippe Van der Linden, MD, PhD

• Department of Anesthesiolgy, CHU Brugmann – HUDERF, Free University of Brussels, Brussels, Belgium


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Blood Conservation Strategies in Cardiac Surgery

• Most of the techniques developed to reduce patients’ exposure to allogeneic blood have been evaluated in cardiac surgery. Preoperative autologous blood donation (PABD), pre-bypass acute normovolemic hemodilution (ANH), minimizing the priming of the CPB circuit, intra- and postoperative cell salvage and the use of pharmacological agents in addition to careful surgical hemostasis have all been associated with a significant reduction in allogeneic blood use. Many of these blood conservation techniques are available for children, although their use will depend on patient age and type of surgery.1 However, the true impacts of the different techniques on allogeneic blood requirements and their clinical benefits remain to be determined. Reviewing the efficacy of autologous transfusion techniques, Carless et al.2 showed that non-randomized studies always reported a larger effect than randomized trials. Intervention effects were also substantially reduced when these techniques were performed under well-defined transfusion protocols. In addition, most of the studies presented serious methodological weaknesses that hampered clear interpretation of the results. Reviewed studies reported few clinical outcomes and adverse event data. Therefore, previous statements regarding reduced rate of mortality and infection with autologous transfusion could therefore not be confirmed.


• The effects of combining different techniques are not as predictable as it may seem at first glance. Techniques do not necessarily interact in a strict additive way. If PABD is associated with a decrease in preoperative hematocrit, it will decrease the potential yield on intraoperative hemodilution and/ or cell salvage. Conversely, increasing preoperative red blood cell mass may increase the usefulness of these techniques. The addition of low-volume ANH to other techniques also aimed at reducing perioperative blood loss (pharmacological agents and cell salvage) can obviously not be effective. Postoperative blood salvage will be of little help if the patient reaches this stage profoundly anemic. Finally, any actor who cannot accept measuring a low hematocrit in an asymptomatic patient without transfusing him will ruin the efforts of a whole team. This point again emphasizes the necessity of adopting a standardized multidisciplinary transfusion policy before developing any blood conservation technique.

• The real efficacy of combining different techniques should also take into account the costs of these alternatives, some of them being potentially expensive (PABD, cell salvage, use of aprotinin). In high-risk bleeding cardiac surgery patients, Nutall et al. showed that the combination of tranexamic acid and intraoperative blood collection provided similar reduction in blood loss and transfusion requirements than aprotinin alone, but that bleeding-related costs were significantly lower in the combined therapy group than in the aprotinin group. The cost-effectiveness of the different alternatives will depend not only on the surgical procedure and technique, but also on the patient’s limitations, the health care environment and the immediate and long-term costs.

• Developing a comprehensive multimodality blood conservation program adapted to the specific surgical team represents the best approach to reduce the use of allogeneic blood products in patients undergoing cardiac surgery. More than 10 years ago, Ovrum et al. developed a blood conservation program based on simple and inexpensive measures. With the use of such a program, the authors reported that 96% of the patients undergoing primary elective myocardial revascularization did not receive any allogeneic blood products.


• Helm et al. developed a more sophisticated blood conservation program in patients undergoing non emergent primary CABG surgery. They reported that the use of a such comprehensive riskfactor based multimodality blood conservation approach in an optimized integrated, and algorithmic manner significantly decrease bleeding and need for allogeneic transfusion Despite the use of expensive alternatives such as cell salvage and aprotinin in this program, total costs for the study group in each of the three major diagnostic-related groups were equivalent to, or significantly less than those in the consecutive series of diagnostic-related group-matched control patients.We also evaluated the impact of a standardized multidisciplinary blood conservation strategy approach on allogeneic blood exposure in patients undergoing all kinds of non-emergent cardiac surgery.8 The strategy involved, firstly, a standardized blood transfusion policy shared by anesthesiologists, ICU physicians and cardiac surgeons, and, secondly, a rigorous algorithmically-based blood conservation program aiming at decreasing perioperative blood loss. The blood transfusion policy was based mainly on clinical judgment and not only on a specific hemoglobin concentration. Data obtained in a first group of consecutive patients when the transfusion strategy was progressively developed were compared to those obtained in a second group including consecutive patients when the transfusion strategy was applied uniformly. Patients in the study group underwent ANH more frequently, had a higher core temperature at arrival in the ICU and presented lower postoperative blood losses. Use of expensive blood transfusion alternatives such as aprotinin, cell salvage and hemofiltration was not different among groups. Application of such a standardized multidisciplinary approach resulted in a 53% decrease in the use of RBC units and a 46% reduction in the number of patients receiving any blood product. These results were obtained without any significant different in postoperative hemoglobin concentrations between the two groups. They demonstrated that the adoption of a standardized multidisciplinary blood conservation strategy decreases perioperative bleeding and transfusion requirements in a safe and cost-effective manner. More recently, in patients undergoing off pump cardiac surgery, Casati et al.9 demonstrated that the addition of intraoperative ANH to a comprehensive blood-sparing protocol can be associated with a reduction in allogeneic transfusion requirements.


Transfusion Alternatives in Transfusion Alternatives in Cardiothoracic SurgeryCardiothoracic Surgery


• Konrad MessmerKonrad Messmer

• Sylvain Bélisle,MontrealSylvain Bélisle,Montreal

• Philippe Van der LindenPhilippe Van der Linden

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B.Braun Satellite SymposiumB.Braun Satellite Symposium

• Ailun Luo, MDAilun Luo, MD• Department of AnesthesiDepartment of Anesthesi

ology, Peking Union Meology, Peking Union Medical College Hospital, Cdical College Hospital, Chinese Academy of Medichinese Academy of Medical Sciences and Peking Ual Sciences and Peking Union Medical College, Benion Medical College, Beijing, Chinaijing, China

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B.Braun Satellite SymposiumB.Braun Satellite Symposium• Gelatin SolutionsGelatin Solutions

• 明胶溶液明胶溶液• Yuguang Huang, MDYuguang Huang, MD

• Department of AnestheDepartment of Anesthesiology, Peking Union siology, Peking Union Medical CollegeMedical College

• Hospital, Chinese AcaHospital, Chinese Academy of Medical Sciendemy of Medical Sciences and Pekingces and Peking

• Union Medical College,Union Medical College, Beijing, China Beijing, China

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B.Braun Satellite Symposium B.Braun Satellite Symposium

于布为教授上海交通大学医学院

附属瑞金医院

• 液体治疗与心肺功能液体治疗与心肺功能

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THANKSTHANKS

编后编后• 本次会议的成功举办，得益于中法双方的通力合作。本次会议的成功举办，得益于中法双方的通力合作。• 特别是岳云教授在会议全程的辛勤操劳；特别是岳云教授在会议全程的辛勤操劳；• 朝阳医院张汝金医生为大会翻译了专家讲稿，非常精彩。朝阳医院张汝金医生为大会翻译了专家讲稿，非常精彩。• 本次会议的内容丰富，参会专家积极热情。为促进世界的本次会议的内容丰富，参会专家积极热情。为促进世界的

血浆代用品行业以及麻醉手术专业学术交流写下了光辉的血浆代用品行业以及麻醉手术专业学术交流写下了光辉的一笔。一笔。

• 本光盘内容翔实、素材丰富；大部分课程有实况录音；实为学习、收本光盘内容翔实、素材丰富；大部分课程有实况录音；实为学习、收藏之珍品藏之珍品 !!

• 关于光盘使用如有任何问题，请联系：关于光盘使用如有任何问题，请联系：• 白雪白雪 MP:13466727736 e-mail: [email protected]:13466727736 e-mail: [email protected]

4 th nata asian symposium jointly organized by nata and the chinese society of anesthesiology july...

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