Reduce Perioperative Allogenic RBC Transfusion Cell salvage for
Reduce Perioperative Allogenic RBC Transfusion. Cell salvage for minimising perioperative allogeneic blood transfusion (Review). Carless PA. . , to June 2009 (1) 출혈 억제제 사용 : aprotinin, tranexamic acid, epsilon aminocaproic acid, fibrin sealant (2) 적혈구 형성 촉진제의 사용(promote red blood cell production) : erythropoietin (3) 자가수혈법 (techniques for re-infusing a patient’s own blood) : pre-operative autologous donation, acute normovolaemic haemodilution, cell salvage
Basic science of leiomyomas
수술 전 수혈을 줄이는 방법 [약제 사용] • 여성호르몬 – 종양의 크기 감소, 절개시 출혈 감소, 수술 전 생리 조절 • 대표적인 호르몬 피임제재(OC), 프로게스틴(progestin) 프로게스테론 수용체대항제 (progesterone receptor antagonist, mifepristone), 선택적 프로게스테론 수용체조정자 (progesterone receptor antagonist modulator, SPRM, asoprisnil) 생식샘자극호르몬분비호르몬 작용 제(Gn. RH agonist), 생식샘자극호르몬분비호르몬 대항 + Gene Tx. : 제(Gn. RH antagonist) § Dominant-negative estrogen Rc gene § Apoptosis in leiomyoma cells § Arrest of tumor growth without fuction ERs
Blood Supply Uterine artery
자궁동맥색전시술 • 적응증 – – Postpartum hemorrhage Bleeding after gynecologic surgery or pelvic trauma Treatment of a pelvic arteriovenous malformation Treatment of uterine fibroids • TAE of uterine fibroids – Ravina and colleagues, 1995 – UAE as an alternative -> Ischemic change to myoma without damage to uterus – Deliver particulate material into both uterine arteries (polyvinyl alcohol particles, PVA microspheres, gelatin-coated tris-acryl polymer microspheres)
Uterine Artery Embolization(UAE) A 5 -French flush catheter is placed from a right common femoral approach external iliac artery(ext iliac art) aortic bifurcation internal iliac artery(int iliac art) uterine artery(ut art) Fertil Steril 2000; 74: 858
Uterine Artery Embolization(UAE) Pelvic arteriogram after UAE Fertil Steril 2000; 74: 862
Trocar Insertion for Laparoscopic Surgery
Laparoscopic Myomectomy Laparoscopic myomectomy • • (744 pts, 1991~1998) More rapid recovery Fewer transfusion Less postop fever Procedure duration: only slightly longer Seracchioli R, Rossi S, Govoni F, et al. Human Reprod 2000
Laparoscopic Myomectomy Laparoscopic resection, using bipolar coagulation of subserosal myoma Wallach. Uterine Myomas. Obstet Gynecol 2004.
Laparoscopic Myomectomy with grasping forceps and electrical morcellator Wallach. Uterine Myomas. Obstet Gynecol 2004.
Hysteroscopic Myomectomy Loop resectoscope of submucosal myoma Wallach. Uterine Myomas. Obstet Gynecol 2004.
Cell Saver Developed by Allen Latham, 1974 • Procedure – aspirates blood from the bleeding site through heparinised tubing via a 25 um ultrafilter into a collecting reservoir – The cells are separated by centrifugation in 0. 9% saline – finally washed in 1 -2 L of 0. 9% saline • Products – removes circulating fibrin, debris, plasma, leucocytes, microaggregates, complement, platelets, free haemoglobin, circulating pro-coagulants, heparin. – Salvaged red cells are superior or at least equal to banked homologous blood in terms of red cell survival, morphological changes, p. H, 2. 3 DPG, potassium • Returned Cell – Packed red cells – 250 ml in 3 min, using an in-line 40 um filter
CONTROVERSIES IN CELL SALVAGE -IN CANCER Ernil Hansen, German / Linz, Austria • To remove tumor cells from intraoperative cell salvage blood 106 cancer cells Use of a leucocyte filter 2 -4 log reduction 100 cancer cells 50 Gy blood irradiation 12 log reduction & high quality with normal 2, 3 DPG/ATP 24 hr survival rate nearly 0 cancer cells [단점] -하지만 급속도로 증가할 수 있는 암세포의 성질상 위험하기는 마찬가지 -수술 중 수혈의 급한 상황에서 방사선요법의 여유가 부족 (소요 시간 20~30분)
Suctioning of Accumulated Blood in Laparoscopic OP • through a 5 -mm trocar • inserted into the peritoneum JSLS (2003)7: 97 -100
CONTROVERSIES IN CELL SALVAGE –IN INFECTION Jonathan H, USA / Linz, Austria • Removing Rate of Contaminated Blood with cell washing 5 - 23% with washing + leukocyte-depletion filtration 99% [단점] -세균에서 배출되는 염증성 물질에 대한 처리 능력의 의구심 -cell washing + leukocyte-depletion filtration + 항생제 복합요법 권 장
a-Fetoprotein Contamination of Cell Saved Blood (ku/L) International Journal of Obstetric Anesthesia (1999) 8. 79. 84
Contamination of cell saved blood International Journal of Obstetric Anesthesia (1999) 8. 79. 84
[Controversy] Etiology of Amniotic Fluid Embolus Am J. Obstet Gynecol 1995; 172: 1158 -1169. • amniotic fluid embolus is an anaphylactoid response involving endogenous mediator release, following exposure to small amounts of amniotic fluid • Fetal squames can be detected routinely in pulmonary circulation of normal obstetric patient Fetal squames are probably irrelevant to clinical picture of amniotic fluid embolus
Special Procedure in Obstetrics OP • Blood salvaged only after delivery of baby, placenta • remove amniotic fluid by separate suction apparatus This reduces amniotic fluid contamination.
What is NATA? • NATA is the Network for Advancement of Transfusion Alternatives. • It is an international network of medical practitioners, researchers, and opinion leaders from a wide variety of medical and scientific disciplines who are dedicated to helping their peers learn more about recent advances in blood conservation and transfusion alternatives. • NATA was founded in Graz, Austria, in April 1998. Today, NATA consists of world-renowned experts in the field of blood conservation in surgery and medicine, as well as lawyers specializing in medical law and medical ethicists.
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