Biomedical subjects

Francesco Torella

Publications and source records attributed to Francesco Torella.

13 recordsLinked to original sources

PubMed2006

Acute normovolemic hemodilution in moderate blood loss surgery: a randomized controlled trial.

BACKGROUND: The risks associated with allogeneic blood transfusion are increasingly recognized. More blood is cross-matched for moderate blood loss surgery than any other indication. The role of acute normovolemic hemodilution (ANH) as a blood transfusion strategy was evaluated in a prospective randomized controlled trial. STUDY DESIGN AND METHODS: A total of 155 patients undergoing elective hip surgery were randomly assigned to either "ANH" (n = 78) or "standard transfusion" (n = 77). ANH on induction of anesthesia was to a target hemoglobin (Hb) level of 110 g per L with return of autologous blood on wound closure. Allogeneic blood was prescribed by an objective transfusion trigger based on an Hb level of less than 80 g per L. Transfusion requirements and postoperative complications were recorded. RESULTS: Allogeneic transfusion was necessary in 22 (29%) standard transfusion patients and 15 (19%) ANH (odds ratio [OR], 0.6; 95% CI, 0.28-1.3; p = 0.23) with 63 and 33 units transfused, respectively (p = 0.1). Significant postoperative complications occurred in 30 (38%) standard transfusion patients compared with 14 (18%) of those randomly assigned to ANH (OR, 0.3; 95% CI, 0.14-0.65; p = 0.009). The major difference between the groups was the frequency of infective complications. CONCLUSION: Despite modest allogeneic transfusion requirements in hip surgery, ANH reduced postoperative complications.

Adolescent↗

PubMed2004

Effect of improved endograft design on outcome of endovascular aneurysm repair.

OBJECTIVE: This study was undertaken to identify factors that lead to improvements in the results of endovascular aneurysm repair, with particular focus on new endograft design. METHODS: We analyzed data for patients enrolled in the European Collaborators on Stent Graft Techniques for Abdominal Aortic Aneurysm Repair (EUROSTAR) registry, and compared those for endografts now withdrawn from the market with those for endografts currently in use. Patients in whom a variety of endograft types were used in small numbers were excluded. Postoperative and long-term outcomes were initially compared with univariate analyses, and subsequently multivariate tests were used to adjust for baseline differences between the 2 groups. The main outcome measures were freedom from a variety of secondary interventions, aneurysm rupture, and death. RESULTS: Some 1224 patients received "withdrawn" endografts, and 2768 patients received "current" endografts. The 2 groups were generally similar, but patients with current devices were more often men, significantly older, more frequently unfit for open surgery, and had larger aneurysms with wider necks. Of no surprise, current endografts were also more often used by experienced (>60 previous cases) surgical teams (44% vs 20%; P <.0001). Thirty-day clinical outcomes were comparable in the 2 groups, although patients with withdrawn devices were less likely to have type II endoleak (9.2% vs 5.5%; P <.0001), and those with current devices had a shorter mean hospital stay (5.4 vs 6.8 days; P <.0001). At 3 years more patients with current devices were free from secondary transfemoral intervention (88.4% vs 76%; P <.0001) and conversion to open repair (95.4% vs 93.4%; P =.007). Aneurysm-related mortality at 3 years, defined as death due to aneurysm rupture or within 30 days of a secondary intervention, was also less frequent with current endografts (2.7% vs 4.4%; P =.02). Aneurysm rupture at 3 years was infrequent (0.8% vs 1.8%; P =.07). At multivariate analysis the use of current devices was a protective factor against late conversion to open repair (hazard ratio, 0.49; 95% confidence interval, 0.28-0.86; P =.014) and aneurysm-related death (hazard ratio, 0.51, 95% confidence interval, 0.34-0.75; P =.0008). Larger aneurysm or neck diameter and shorter neck length were also associated with late conversion to open repair; larger aneurysm diameter, older age, and unfitness for open surgery were predictive of aneurysm-related death. CONCLUSION: Modern endograft design has improved the results of endovascular aneurysm repair.

Aged↗

PubMed2004

The role of hospital transfusion committees in blood product conservation.

Transfusion committees have been created in different countries to oversee all aspects of blood product transfusion within individual institutions. A fundamental role of hospital transfusion committees is to ensure appropriate blood product use by developing local policies, educating clinicians, and auditing blood use. Unfortunately, this task is hampered by the lack of universally accepted criteria for blood product transfusion. Several examples of specific interventions directed toward improving blood use have been described in the literature. Despite some limitations of these reports, largely because of shortfalls in study design, such interventions appear to be generally effective, but there is not enough evidence to recommend a specific course of action to ensure appropriate blood use. Notwithstanding such problems, a functional hospital transfusion committee can have a major impact on local rates of inappropriate transfusion.

Blood Banks↗

PubMed2004

The surgical high dependency unit: an educational resource for surgical trainees.

BACKGROUND: Learning to recognise the seriously ill patient and developing the ability to manage them is a very important part of the education and training of surgeons. A general surgical senior house officer (SHO) spends 4 months on our surgically-led high dependency unit (HDU), as part of their basic surgical training programme. AIM: To assess a surgical high dependency unit as an educational resource. METHODS: We interrogated our specifically designed database for a 5-year period (April 1997 to March 2002) to look at what a 4-month attachment offered SHOs in respect of: the number of patients treated; their modes of presentation; the specialty; the physiological and operative scores as determined by the POSSUM scoring system; and the interventions that occurred. DISCUSSION: We have demonstrated that a 4-month attachment to a surgical HDU provides a consistent and valuable clinical resource for teaching and learning in surgical education and training.

Critical Illness↗

PubMed2003

Cerebral and peripheral oxygen saturation during red cell transfusion.

BACKGROUND: Changes in regional hemoglobin oxygen saturation occur in response to blood transfusion and can be measured by near infrared spectroscopy. PATIENTS AND METHODS: Cerebral (CsO2) and peripheral (PsO2) oxygen saturation were monitored with an INVOS 4100 near infrared spectroscopy oximeter in 29 patients undergoing 84 intraoperative blood transfusions during aortic or spinal surgery. Hemoglobin concentration was measured before and after transfusion. Mean arterial pressure, end tidal carbon dioxide tension, and arterial oxygen saturation were also monitored. RESULTS: Mean arterial pressure, arterial oxygen saturation and end tidal carbon dioxide tension remained stable during transfusion, while CsO2 rose by a mean (95% CI) of 4.2 (3.2-5.2%; P = 0.001) and PsO2 rose by a mean (95% CI) of 1.6 (0.3-2.8%; P = 0.016). The rise in CsO2 correlated well with the rise in hemoglobin (r = 0.59, P < 0.001) and with the volume transfused (r = 0.58, P < 0.001). PsO2 correlated with the volume transfused (r = 0.35, P = 0.019) but not with hemoglobin concentration (r = 0.08, P = 0.47). CONCLUSIONS: Near infrared spectroscopy detected significant rises in tissue oxygenation in response to blood transfusion, particularly in the cerebral cortex. CsO2 may be developed into a blood loss monitor if further research confirms our findings.

Adult↗

PubMed2003

Routine beta-blockade in vascular surgery.

We have evaluated the safety and efficacy of routine beta-blockade for the prevention of cardiac complications in a comprehensive series of patients undergoing major vascular surgery and amputation for atherosclerotic arterial disease. From 1 December 2001 to 31 May 2002, patients received perioperative beta-blockade by atenolol. Outcomes in this period were compared to the immediately antecedent 6 months. The main outcome measure was the occurrence of cardiac complications. Fifty-three patients underwent surgery in the first period and 54 in the second. After introduction of routine beta-blockade, only one patient suffered cardiac complications compared to 10 in the first period (P=0.01). There were eight deaths in the first and two in the second period (P=0.052). On multivariate analysis, treatment with beta-blockers was the only variable significantly associated with a decrease in cardiac morbidity (OR=0.12; 95% CI=0.002-0.66; P=0.014). Two patients suffered bronchospasm leading to discontinuation of atenolol. Routine perioperative beta-blockade was safe and reduced the occurrence of cardiac complications after vascular surgery.

Adrenergic beta-Antagonists↗

PubMed2002

Monitoring blood loss with near infrared spectroscopy.

Experimental research has shown correlation between near infrared spectroscopy (NIRS) and blood loss, but these findings have not been validated in man. Ten blood donors were monitored before, during and for 10 min after blood collection (470 ml) with NIRS. A Somanetics INVOS 4100 oximeter monitored regional haemoglobin saturation in the cerebral cortex (cSO(2)-left frontal area) and from the left calf (pSO(2)). A Critikon 2001 Cerebral Redox Model monitored total (tHb), oxygenated (O(2)Hb) and deoxygenated (HHb) haemoglobin from the right calf. The oxygenation index [HbD]=[O(2)Hb]-[HHb] was derived from the data. cSO(2) (P<0.001), pSO(2) (P<0.001) and HbD (P=0.001) decreased during blood collection. Maximum changes occurred 10 minutes after collection for cSO(2), with a mean fall (95% C.I.) of 2.5 (-0.06-4.86)%, at the end of blood collection for pSO(2), with a mean fall (95% C.I.) of 3 (0.74-5.26)% and after 8% of blood volume loss for HbD, with a mean fall (95% C.I.) of 7.2 (2.25-12.16). Cerebral and peripheral oxygenation did not recover after blood collection. There was good correlation between NIRS parameters and blood loss. NIRS is a potentially useful technique for monitoring blood loss in humans. Further research is needed to define its role in clinical practice.

Adult↗

PubMed2002

The severity of muscle ischemia during intermittent claudication.

PURPOSE: The degree of ischemia during intermittent claudication is difficult to quantify. We evaluated calf muscle ischemia during exercise in patients with claudication with near infrared spectroscopy. METHODS: A Critikon Cerebral Redox Model 2001 (Johnson & Johnson Medical, Newport, Gwent, United Kingdom) was used to measure calf muscle deoxygenated hemoglobin (HHb), oxygenated hemoglobin (O(2)Hb), and total hemoglobin levels and oxygenation index (HbD; HbD = O(2)Hb - HHb) in 16 patients with claudication and in 14 control subjects before, during, and after walking on a treadmill for 1 minute (submaximal exercise). These measures were repeated after a second maximal exercise in patients with claudication and after 7 minutes walking in control subjects. Near-infrared spectroscopy readings during maximal exercise were then compared with a model of total ischemia induced with tourniquet in 16 young control subjects. RESULTS: Total hemoglobin level changed little during exercise in both patients with claudication and control subjects. HHb levels rose, and O(2)Hb level and HbD falls were more pronounced in patients with claudication than in control subjects after submaximal and maximal exercise. During maximal exercise, HbD fell markedly by a median (interquartile range) of 210.5 micromol/cm (108.2 to 337.0 micromol/cm) in patients with claudication compared with 66.0 micromol/cm (44.0 to 101.0 micromol/cm) in elderly control subjects and 41.0 micromol/cm (36.0 to 65.0 micromol/cm) in young control subjects (P <.001). This fall also was greater than the HbD fall induced with tourniquet ischemia at 90.8 micromol/cm (57.6 to 126.2 micromol/cm; P =.006). CONCLUSION: Hemoglobin desaturation in exercising calf muscle is profound in patients with claudication, considerably greater even than that induced with three minutes of tourniquet occlusion. Further studies are necessary to investigate the relationship between the inflammatory response and near-infrared spectroscopy during exercise in patients with claudication.

Adult↗

PubMed2002

Acute normovolemic hemodilution and intraoperative cell salvage in aortic surgery.

OBJECTIVE: The objective of this study was to report current transfusion requirements and outcomes in patients undergoing elective aortic surgery with autologous transfusion. METHODS: This was a retrospective review of transfusion practice in infrarenal aortic surgery in a tertiary vascular unit with a longstanding interest in autologous transfusion. One hundred and ten consecutive patients underwent infrarenal aortic surgery with a combination of acute normovolemic hemodilution (ANH) and intraoperative cell salvage (ICS). All patients underwent hemodilution to a target hemoglobin concentration of 11 g/dL and underwent ICS with a centrifugal device. RESULTS: Median blood loss was 1140 mL (interquartile range [IQR], 683 to 1609 mL) in 78 aneurysm repairs and 775 mL (IQR, 400 to 1225 mL) in 32 aortobifemoral bypasses for occlusive disease (P =.02), resulting in a median salvaged red cell volume of 403 mL (IQR, 256 to 563 mL) for aneurysm repairs and 250 mL (IQR, 200 to 290 mL) in bypass surgery (P =.001). Thirty-six patients (33%) needed transfusion of stored blood, for a total of 115 units, with just four patients needing more than five units. The mortality rate was 8% (9/110). With multivariate analysis, low hemoglobin level (P =.006) and low platelet count (P =.023) were associated with stored blood transfusion. CONCLUSION: Blood loss is too small to justify ICS in surgery for occlusive disease; ANH alone may be a suitable strategy. With appropriate experience, the combination of ANH and ICS may render crossmatching unnecessary, even in aortic aneurysm surgery.

Aged↗

PubMed2002

Autologous versus allogeneic transfusion in aortic surgery: a multicenter randomized clinical trial.

OBJECTIVE: To evaluate the efficacy of acute normovolemic hemodilution (ANH) and intraoperative cell salvage (ICS) in blood-conservation strategies for infrarenal aortic surgery. SUMMARY BACKGROUND DATA: Recent concerns over the risks of transfusion-related infection have resulted in sharp rises in the cost of blood preparations. Autologous transfusion may be a safe alternative to allogeneic transfusion, which has been associated with immune modulation and postoperative infection. METHODS: This multicenter prospective randomized trial compared standard transfusion practice with autologous transfusion combining ANH with ICS in 145 patients undergoing elective aortic surgery. The primary outcome measures were the proportion of patients requiring allogeneic blood and the volume of allogeneic transfusion. The secondary outcome measures were the frequency of complications, including postoperative infection, and postoperative hospital stay. RESULTS: The combination of ANH and ICS reduced the volume of allogeneic blood transfused from a median of two units to zero units. The proportion of patients transfused was 56% in allogeneic and 43% in autologous. There were no significant differences in complications or length of hospital stay. CONCLUSIONS: Both ANH and ICS were safe and reduced the allogeneic blood requirement in patients undergoing elective infrarenal aortic surgery.

Adult↗

PubMed2002

Regional tissue oxygenation during hemorrhage: can near infrared spectroscopy be used to monitor blood loss?

We investigated whether near infrared spectroscopy could be used to monitor regional tissue oxygenation during uncompensated hemorrhage in man. A Somanetics INVOS 4100 oximeter was used to measure regional hemoglobin oxygen saturation in the cerebral cortex (CsO2, left frontal area) and from the left calf muscle (PsO2) in 40 volunteers donating 470 mL of the whole blood. A Critikon 2001 Cerebral Redox Instrument was used to monitor total (tHb), oxygenated (O2Hb), and deoxygenated (HHb) hemoglobin in the right calf muscle. The oxygenation index, [HbD] = [O2Hb] - [HHb] was derived. CsO2 decreased by a mean (95% CI) of 2 (1-3.3%) (P < 0.001), PsO2 decreased by a mean (95% CI) of 3.2 (1.7-4.6%) (P < 0.001), and HbD decreased by a median (95% CI) of 6.4 (2.65-10.16) delta microM/cm (P < 0.001) during blood collection. There was an inverse correlation between blood loss and CsO2 (R = -0.59, P < 0.001), PsO2 (R = -0.61, P < 0.001), and HbD (R = -0.5, P < 0.001). Regional tissue oxygenation decreases in proportion to uncompensated blood loss. Near infrared spectroscopy may potentially be developed into a transfusion trigger.

Adult↗

PubMed2002

Can hospital transfusion committees change transfusion practice?

Blood and blood products are commonly over-used in hospital practice. We investigated whether the introduction of a red-cell transfusion trigger (haemoglobin <8 g dL(-1)) influenced transfusion practice in surgery. Coronary artery bypass grafts (CABGs, n=400), total hip replacements (n=107), colectomies (n=85) and transurethral prostatectomies (TURPs, n=158) were reviewed over two periods of six months, before and after the introduction of the policy by the local hospital transfusion committee. After introduction of the policy, the proportion of patients transfused fell from 57% to 45% with CABGs (P=0.02) and from 52% to 26% with hip replacements (P=0.006); for colectomies and TURPs there was no change. Hospital stay did not increase in any of the groups. In the second period, haemoglobin concentration on discharge was lower after total hip replacement, by a mean (95% CI) of 0.7 (0.3-1.2) g dL(-1) (P=0.002) and after colectomy, by a mean of 0.6 (0.1-1.1) g dL(-1) (P=0.03). Although other factors cannot be excluded, we suggest that the reductions in red-cell transfusion were in large part attributable to the new transfusion policy.

Arthroplasty, Replacement, Hip↗

PubMedDate not supplied

Screening, diagnosis and advances in aortic aneurysm surgery.

BACKGROUND: Aortic aneurysms are common in the elderly and a frequent cause of sudden death. As elective aneurysm repair has a mortality drastically lower than that associated with rupture, the emphasis must be on early detection and repair free from complications. Recent advances include ultrasound screening for asymptomatic abdominal aortic aneurysm (AAA) and clinical trials on the size of AAA that require repair. Pre-operative assessment, management of cardiac risk, autologous blood transfusion strategies, and endovascular stent graft technology to avoid major open surgery are all issues to be addressed. METHODS: Following a computerized Medline search for publications on the detection and treatment of abdominal and thoracic aortic aneurysm, the publications identified were then read and the references within those publications examined for further publications on this topic. We have reviewed these publications without attempting a meta-analysis. RESULTS: Randomized population studies have addressed ultrasound screening for AAA. Attendance for screening was good and AAA detection inexpensive. Screening men from 65 years reduces the mortality from rupture and is cost-effective. Open thoracic and abdominal aneurysm repair has a mortality of around 8%, with myocardial infarction being a frequent cause of death. Pre-operative reduction of cardiac risk by cardiac investigations and beta-blockade may reduce this mortality. Autologous transfusion techniques such as acute normovolaemic haemodilution and interoperative cell salvage reduce the need for allogeneic blood and the complications associated with open surgery. Minimally invasive endovascular repair is now possible for 40% of the AAA and an increasing proportion of thoracic aneurysms. CONCLUSIONS: The combination of screening, reduced pre-operative risk, and new minimally invasive techniques extends aortic aneurysm treatment into an increasingly elderly population. The combination of these techniques will reduce mortality from ruptured aortic aneurysm in the elderly and also reduce the stress associated with aneurysm surgery.

Aged↗