Intra-operative intravenous fluid restriction reduces perioperative red blood cell transfusion in elective cardiac surgery, especially in transfusion-prone patients: a prospective, randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Cardiac surgery is a major consumer of blood products, and hemodilution increases transfusion requirements during cardiac surgery under CPB. As intraoperative parenteral fluids contribute to hemodilution, we evaluated the hypothesis that intraoperative fluid restriction reduces packed red-cell (PRC) use, especially in transfusion-prone adults undergoing elective cardiac surgery.</p> <p>Methods</p> <p>192 patients were randomly assigned to restrictive (group A, 100 pts), or liberal (group B, 92 pts) intraoperative intravenous fluid administration. All operations were conducted by the same team (same surgeon and perfusionist). After anesthesia induction, intravenous fluids were turned off in Group A (fluid restriction) patients, who only received fluids if directed by protocol. In contrast, intravenous fluid administration was unrestricted in group B. Transfusion decisions were made by the attending anesthesiologist, based on identical transfusion guidelines for both groups.</p> <p>Results</p> <p>137 of 192 patients received 289 PRC units in total. Age, sex, weight, height, BMI, BSA, LVEF, CPB duration and surgery duration did not differ between groups. Fluid balance was less positive in Group A. Fewer group A patients (62/100) required transfusion compared to group B (75/92, p < 0.04). Group A patients received fewer PRC units (113) compared to group B (176; p < 0.0001). Intraoperatively, the number of transfused units and transfused patients was lower in group A (31 u in 19 pts vs. 111 u in 62 pts; p < 0.001). Transfusions in ICU did not differ significantly between groups. Transfused patients had higher age, lower weight, height, BSA and preoperative hematocrit, but no difference in BMI or discharge hematocrit. Group B (p < 0.005) and female gender (p < 0.001) were associated with higher transfusion probability. Logistic regression identified group and preoperative hematocrit as significant predictors of transfusion.</p> <p>Conclusions</p> <p>Our data suggest that fluid restriction reduces intraoperative PRC transfusions without significantly increasing postoperative transfusions in cardiac surgery; this effect is more pronounced in transfusion-prone patients.</p> <p>Trial registration</p> <p>NCT00600704, at the United States National Institutes of Health.</p

Opioid-induced respiratory depression in the acute care setting: a compendium of case reports

Opioid-induced respiratory depression (OIRD) is a potentially fatal complication of treatment with opioids. Little is known about patient- and case-related factors associated with OIRD. One-hundred-and-five available case reports on OIRD in 134 patients (12 years and older) in the perioperative, obstetric or emergency care setting, published since 1980, were retrieved from the literature. The most frequently reported case-related factors were: morphine use, perioperative setting and obstetrics, neuraxial or intravenous administration. The most frequently reported patient-related factors involved were: female gender, sleep-disordered breathing, obesity, renal impairment, pulmonary disease and CYP450 enzyme polymorphisms. While the analysis has limitations, it confirms that OIRD in the acute setting involves complex and interrelated factors and is a significant cause of preventable morbidity and mortality