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  1. The technique is being called "a vision of eye surgery in the future." The technique is being called "a vision of eye surgery in the future." air009/Shutterstock In a medical first, surgeons have used a robot to operate inside the human eye, greatly improving the accuracy of a delicate surgery to remove fine membrane growth on the retina. Such growth distorts vision and, if left unchecked, can lead to blindness in the affected eye. Currently, doctors perform this common eye surgery without robots. But given the delicate nature of the retina and the narrowness of the opening in which to operate, even highly skilled surgeons can cut too deeply and cause small amounts of hemorrhaging and scarring, potentially leading to other forms of visual impairment, according to the researchers who tested out the new robotic surgery in a small trial. The pulsing of blood through the surgeon's hands is enough to affect the accuracy of the cut, the researchers said. In the trial, at a hospital in the United Kingdom, surgeons performed the membrane-removal surgery on 12 patients; six of those patients underwent the traditional procedure, and six underwent the new robotic technique. Those patients in the robot group experienced significantly fewer hemorrhages and less damage to the retina, the findings showed. Continue reading
  2. Lola Garcia of Hemet, California, was the smallest infant in North America to undergo such a procedure. Physicians at Lucile Packard Children’s Hospital Stanford have performed open-heart surgery without a blood transfusion on the smallest infant ever to undergo such a procedure in North America. The surgery was done on a 10-day-old baby girl born in Hemet, California, with a serious congenital heart defect. Meticulous planning and execution of the surgery, an arterial switch procedure, allowed the medical team to surmount daunting technical challenges of treating a 7-pound open-heart patient without giving her a blood transfusion. It is the first “bloodless” open-heart surgery performed on an infant in the Western United States. “If you can do surgery safely and effectively without transfusion, there are several medical benefits,” said Frank Hanley, MD, chief of pediatric cardiac surgery at the hospital’s Betty Irene Moore Children’s Heart Center and one of two surgeons who performed the procedure. He said patients who do not receive blood products have fewer post-surgical complications, provided they do not lose too much blood. “You have to be able to do the surgery safely and not have the patient’s red blood cell count drop too low,” added Hanley, who is he Lawrence Crowley, MD, Professor in Child Health at the Stanford School of Medicine. A severe heart defect From the moment of her birth on Oct. 21, little Lola Garcia struggled to breathe. She and her parents, Felisa and Jared Garcia, were rushed to a children’s hospital near the family’s home. Lola was diagnosed with transposition of the great arteries, a rare condition in which the heart’s major arteries are not connected correctly. Normally, the blood follows a single, figure-eight-shaped circuit through the heart and lungs, then back to the heart and out to the body to supply oxygen to organs. In Lola’s heart, the blood made two separate circuits — from the heart to the lungs and back, and from the heart to the body and back. The normal figure-eight was separated into two poorly connected loops. Her brain and other organs were not getting enough oxygen. “They said she would definitely need heart surgery, and most likely a blood transfusion, to correct the problem,” said Felisa. “We were happy there was a solution, but when they said ‘transfusion,’ my heart dropped.” The Garcias are Jehovah’s Witnesses; they requested that Lola’s surgery be done without a blood transfusion because of their religious beliefs. Although many hospitals now offer bloodless surgery for adults, the challenges of avoiding transfusion are much greater in newborns who need open-heart procedures. Several hospitals around the country turned the family down. But the pediatric cardiothoracic surgery team at Packard Children’s offered to attempt baby Lola’s arterial switch procedure without transfusing blood. “Very few people have the technical expertise to do this,” said Vamsi Yarlagadda, MD, a clinical associate professor of pediatrics at the School of Medicine and the cardiologist at Packard Children’s who cared for Lola. Technical hurdles During surgery, Lola needed to be connected to a heart-lung machine, which would pump her blood through a circuit of tubing and membranes for re-oxygenation. The machine’s tubing is primed with saline that mixes with the patient’s blood. For an adult, the volume of saline in a standard heart-lung machine does not dilute the blood enough to be dangerous, but a 7-pound newborn has less blood to begin with. Connecting Lola to a standard heart-lung circuit would have dangerously lowered her red blood cell count. In the past, the problem has been solved by transfusing blood. For Lola, the Packard Children’s team took a different approach. Read more: http://med.stanford.edu/news/all-news/2018/02/newborn-first-in-western-us-to-have-bloodless-open-heart-surgery.html
  3. Bloodless medical care seeks to avoid the need for transfusions. The following is a review of the most important considerations for setting up a bloodless care center. “Bloodless” medical care was first recognized in the 1970s when Denton Cooley, MD, performed cardiac surgery on hundreds of patients who were Jehovah’s Witnesses (JW).1 These patients were often turned away by other physicians because they were prohibited from receiving allogeneic transfusions. Bloodless care became more common in the 1980s, when the risks for viral infections transmitted through transfusion reached an all-time high, especially for HIV and viral hepatitis. The practice of bloodless medicine was further developed and promoted by the Society for the Advancement of Blood Management (SABM), which was founded in 2001 and continues to specialize in this area today. Bloodless care shares many principles in common with “patient blood management” (PBM),2 which aims to prevent and manage anemia, optimize coagulation to reduce or prevent hemorrhage, and promote optimal blood conservation, and to achieve these goals in order to improve outcomes with an evidence-based, patient-centered focus.3 PBM was an outgrowth of multiple randomized clinical trials, all of which compared a restrictive with a liberal transfusion strategy based on hemoglobin (Hb) triggers of 7 to 8 versus 9 to 10 g/dL, respectively, in which every trial showed either no benefit from or increased adverse outcomes with the liberal strategy.4-11 Perhaps these trigger trials were a natural progression from the high prevalence of viral risk that emerged in the blood supply during the 1980s or were efforts to reduce other transfusion-related risks and complications. Nonetheless, it is now generally accepted that “less is more” when it comes to transfusion, with the exception of ischemic brain and ischemic heart syndromes, for which the ideal Hb trigger is yet to be determined.12 Bloodless care can be thought of as extreme PBM, in which the goal is to avoid rather than reduce the need for transfusions. In this article, we will review the top 10 issues to consider when setting up a bloodless program, which are summarized in Table 1. http://www.anesthesiologynews.com/Review-Articles/Article/10-16/Bloodless-Medicine-and-Surgery-Top-10-Things-To-Consider/38274
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