Blood Loss In Elderly Patients Research Articles

Efficacy and safety of tranexamic acid use in elderly patients undergoing anterior cervical discectomy and fusion: a retrospective study.

To evaluate the safety and efficacy of intravenous tranexamic acid (TXA) administration in anterior cervical discectomy fusion (ACDF) for the treatment of cervical spondylosis in the elderly. Data from elderly patients who underwent ACDF between January 2020 and January 2023 were retrospectively reviewed. Patients who received 1 g intravenous TXA administration before skin incision (TXA group) were compared with patients who did not receive TXA (controls). Total and hidden blood loss were calculated, and the following outcomes were recorded: haemoglobin and haematocrit drop, operation time, drainage duration, drain volume, length of hospitalization, coagulation changes, and incidence of complications. A total of 114 patients were included (TXA group, n = 53 and controls, n = 61). Total blood loss, hidden blood loss, and postoperative drainage volume, haemoglobin and haematocrit drop were significantly lower in the TXA group than the control group. There were no significant differences in operation time, intraoperative blood loss, drainage duration, length of hospitalization, or coagulation function between the two groups. The incidence of complications did not differ significantly between the two groups during 3 months of follow-up. Intravenous TXA is effective in reducing perioperative blood loss in elderly patients undergoing ACDF without changing the coagulation function or increasing the risk of complications.

Antithrombotic therapy and spinal surgery: a retrospective cohort study of 289 consecutive elderly patients with degenerative lumbar stenosis.

Lumbar spinal stenosis (LSS) is a disabling degenerative process of the spine, mainly affecting older patients. LSS manifests with low-back and leg pain and neurogenic claudication. Disability and impairment in activities of daily living are consequences of the progressive narrowing of the lumbar spinal canal. Surgical decompression has been shown to be superior to conservative management. Nonetheless, intraoperative and postoperative blood loss in elderly patients taking antiplatelet or anticoagulant drugs owing to cardiovascular comorbidities may be a special issue. This study describes and compares early outcomes after surgical procedures in different groups of patients receiving antithrombotic drugs. The authors' study retrospectively recruited 289 consecutive patients aged ≥ 65 years who received lumbar decompression for spinal stenosis between January 2021 and May 2022. First, 183 patients taking antiplatelet therapy were divided into two groups according to the rationale for use: primary versus secondary prophylaxis of cardiovascular events (group 1 vs group 2). Primary prevention was stopped preoperatively, or secondary prevention was not discontinued during the perioperative period. Secondly, 106 patients who were not taking antiplatelet mediation were divided into two groups, depending on whether preoperative low-molecular-weight heparin had not been administered or had been (group A vs group B). Intraoperative blood loss, surgical time, and postoperative hospitalization were analyzed. No significant statistical differences were observed between groups 1 and 2 in terms of intraoperative blood loss and time of surgery, or between groups A and B in terms of all analyzed variables. No early or delayed complications were observed, perioperatively or during the postoperative 3-month follow-up period. The results of this study suggest that the use of anticoagulant and antiplatelet therapies in elective decompressive surgery could be devoid of early complications and could be safely continued perioperatively.

Early Posttraumatic Antifibrinolysis Reduces Perioperative Hidden Blood Loss in Elderly Patients with an Intertrochanteric Fracture: A Randomized Controlled Trial.

This study aimed to determine the efficacy and safety of posttraumatic antifibrinolysis with multidose tranexamic acid (TXA) in reducing perioperative hidden blood loss (HBL) in elderly intertrochanteric fracture patients. Ninety-six elderly intertrochanteric fracture patients admitted to our department from June 2021 to September 2022 were randomized into two groups. The control group (Group A) received 100 mL of normal saline, while the experimental group (Group B) received 1.5 g of TXA intravenously q12 h from postadmission Day 1 (PAD1) to the day before surgery, and both groups received 1.5 g of TXA q12 h from postoperative Day 1 (POD1) to POD3. Haemoglobin (Hb), haematocrit (Hct), coagulation parameters, fibrinogen degradation product (FDP), and D-dimer (D-D) were recorded from PAD1 to POD3. HBL was calculated using the gross formula and recorded as the primary outcome. In all-over analyses, the patients in Group B had lower perioperative HBL (on PAD3, POD1, and POD3), preoperative HBL (HBLpre), decline of haemoglobin (ΔHb-on PAD3), allogeneic blood transfusion (ABT) rate, FDP (on PAD3), and D-D (on PAD3) compared with Group A. No significant differences were exhibited in postoperative HBL (HBLpost) between the 2 groups. In subgroup analyses, for patients who received intervention within 24 h, the result is consistent with the whole. For patients who received intervention over 72 h of injury, there were no significant differences in perioperative HBL, ΔHb, ABT rate, FDP, and D-D between the 2 groups. There were no significant differences in APTT, PT, the rate of venous thromboembolism, wound complications, or 90-day mortality between the 2 groups. For elderly intertrochanteric fracture patients, early posttraumatic antifibrinolysis with multidose TXA is effective in reducing perioperative HBL, which mainly manifests as the reduction of preoperative HBL, especially for patients injured within 24 h. Application of TXA beyond 72 h of injury was ineffective.

Longer Operative Time and the Use of Anticoagulants Are Associated With Increased Blood Loss in Elderly Patients Undergoing Arthroscopic Rotator Cuff Repair

To study the effects of rotator cuff tear size, operation time, and the use of anticoagulant on blood loss in elderly patients undergoing arthroscopic rotator cuff surgery. Patients aged older than 65 years who underwent arthroscopic rotator cuff repair with subacromial decompression at our hospital from January 2015 to December 2021 were identified. We measured hemoglobin levels preoperatively, postoperatively, and 7 days after surgery. First, subjects were divided according to the operation time (group I, <90 minutes; group II, <120 minutes; group III <150 minutes; and group IV, >150 minutes). Second, we classified the subjects by the size of the rotator cuff tear (group A, <3 cm; group B, <5 cm; and group C, >5 cm). Lastly, we categorized the subjects into 2 groups according to the use of anticoagulant medication. A total of 566 patients were included. The mean hemoglobin (Hgb) levels were 13.8 ± 1.4 g/dL preoperatively, 13.2 ± 1.4 g/dL postoperatively, and 12.8 ± 1.3 g/dL 7 days after surgery, and the differences among them were statistically significant (P < .001). The Hgb level changes 7 days after surgery showed a significant decrease in the group with a longer operation time, and the Hgb loss increased from group 1 to group 4 (P < .001). They did not show any difference in the Hgb levels among the groups according to the size of a cuff tear preoperatively, postoperatively, and 7 days after surgery. The subjects with anticoagulant use showed more decrease in Hgb levels between immediately after the surgery and 7 days after the surgery (P= .031). Still, both groups did not show a statistical difference in the Hgb level 7days after surgery (P= .115). In this study, blood loss after arthroscopic rotator cuff repair in elderly patients was greater than expected. Bleeding increased in elderly patients who had longer surgical times or were taking anticoagulant medications after surgery. Tear size was not associated with a decrease in Hgb levels. Level III, retrospective comparative study.

Is Blood Loss Greater in Elderly Patients under Antiplatelet or Anticoagulant Medication for Cervical Spine Injury Surgery? A Japanese Multicenter Survey.

Introduction In elderly patients with cervical spinal cord injury, comorbidities such as cardiovascular and cerebrovascular diseases are common, with frequent administration of antiplatelet/anticoagulant (APAC) drugs. Such patients may bleed easily or unexpectedly during surgery despite prior withdrawal of APAC medication. Few reports have examined the precise relationship between intraoperative blood loss and history of APAC use regarding surgery for cervical spine injury in the elderly. The present multicenter database survey aimed to answer the question of whether the use of APAC drugs affected the amount of intraoperative blood loss in elderly patients with cervical spinal cord trauma. Methods The case histories of 1512 patients with cervical spine injury at 33 institutes were retrospectively reviewed. After excluding cases without spinal surgery or known blood loss volume, 797 patients were enrolled. Blood volume loss was the outcome of interest. We calculated propensity scores using the inverse probability of treatment weighting (IPTW) method. As an alternative sensitivity analysis, linear mixed model analyses were conducted as well. Results Of the 776 patients (mean age: 75.1±6.4 years) eligible for IPTW calculation, 157 (20.2%) were taking APAC medications before the injury. After weighting, mean estimated blood loss was 204 mL for non-APAC patients and 215 mL for APAC patients. APAC use in elderly patients was not significantly associated with surgical blood loss according to the IPTW method with propensity scoring or linear mixed model analyses. Thus, it appeared possible to perform surgery expecting comparable blood loss in APAC and non-APAC cases. Conclusions This multicenter study revealed no significant increase in surgical blood loss in elderly patients with cervical trauma taking APAC drugs. Surgeons may be able to prioritize patient background, complications, and preexisting conditions over APAC use before injury when examining the surgical indications for cervical spine trauma in the elderly.

Effect and safety of topical application of tranexamic acid to reduce perioperative blood loss in elderly patients with intertrochanteric fracture undergoing PFNA.

The specific method and dose of tranexamic acid (TXA) topically applied for intertrochanteric fractures have not been well established. The aim of this study is to investigate the efficacy and safety of TXA topically administered via our protocol for perioperative bleeding management in elderly patients with intertrochanteric fractures who underwent proximal femoral nail anti-rotation (PFNA).A retrospective comparative analysis was performed. The TXA group was composed of 82 patients with topical use of TXA, and the control group was composed of 82 patients without TXA use during the PFNA procedure. Intraoperative, total and hidden amounts of blood loss, drainage volumes, postoperative blood transfusion volumes and complications were compared between the 2 groups.The intraoperative, total and hidden amounts of blood loss and the drainage volumes were significantly lower in the TXA group than in the control group (P = .012, P < .01, P < .01, P = .014, respectively). The volume and rate of blood transfusion in the TXA group were significantly lower than those in the control group (P < .01). There were no significant differences in complications between the 2 groups (P > .05).Topical application of TXA offers an effective and safe option for reducing perioperative blood loss and transfusion in elderly patients with intertrochanteric fractures undergoing PFNA.

Intramedullary Fixation Does Not Cause a Large Amount of Hidden Blood Loss in Elderly Patients with Intertrochanteric Fractures.

PurposeControversy remains around intramedullary fixation of intertrochanteric fractures in elderly patients when considering hidden blood loss (HBL). However, whether treating the fractures with intramedullary fixation causes a large amount of HBL is not known.Patients and MethodsIn this retrospective cohort study, 1,017 consecutive patients aged ≥65 years with acute intertrochanteric fractures were included and assigned to three groups (non-operative group, delayed surgery group, and acute surgery group) between July 2013 and January 2018. The data of patients’ demographics, injury-related data, operation-related data, comorbidities, perioperative hemoglobin values, transfusion data and serial of HBL calculated during hospitalization were collected and compared among three groups. All independent variables were further analyzed by multiple linear regression to evaluate the influential factors of HBL. A long-term follow-up was conducted and survival analysis was performed for all individuals.ResultsOur results showed that fixation by proximal femoral nail anti-rotation for intertrochanteric fracture has been estimated to contribute 11–34% of the increase of HBL during hospitalization and it does not increase the allogeneic transfusion rate. For HBL, male patients, unstable fracture, and blood transfusion may have strong influences. Surgical delay was associated with longer time from injury to hospital admission, higher ASA-grade, and comorbidities such as diabetes and coronary heart disease. Survival analysis revealed that mortality increased in patients with conservative treatment, where a rapid decline was found in the first year, especially in the 90 days after injury. A higher mortality rate was also obtained in patients with surgery delay than acute surgery patients.ConclusionIn conclusion, HBL is the main component of total blood loss and it is more likely to result from the initial trauma rather than the surgery. Intertrochanteric fracture treated by intramedullary fixation does not cause a large amount of HBL.

Early intravenous tranexamic acid intervention reduces post-traumatic hidden blood loss in elderly patients with intertrochanteric fracture: a randomized controlled trial

PurposeElderly patients with intertrochanteric fractures exhibit post-traumatic hidden blood loss (HBL). This study aimed to evaluate the efficacy and safety of reducing post-traumatic HBL via early intravenous (IV) tranexamic acid (TXA) intervention in elderly patients with intertrochanteric fracture.MethodsA prospective randomized controlled study was conducted with 125 patients (age ≥ 65 years, injury time ≤ 6 h) who presented with intertrochanteric fracture from September 2018 and September 2019. Patients in the TXA group (n = 63) received 1 g of IV TXA at admission, whereas those in the normal saline (NS) group (n = 62) received an equal volume of saline. Hemoglobin (Hgb) and hematocrit (Hct) were recorded at post-traumatic admission (PTA) and on post-traumatic days (PTDs) 1–3. HBL was calculated using the Gross formula. Lower extremity venous ultrasound was performed to detect venous thrombosis.ResultsHgb on PTDs 2 and 3 was statistically higher in the TXA group than in the NS group. Hct and HBL on PTDs 1–3 were significantly less in the TXA group compared to the NS group. Preoperative transfusion rate was significantly lower in the TXA group compared with the NS group. There was no difference between the two groups with regard to the rates of complications.ConclusionEarly IV TXA intervention could reduce post-traumatic HBL and pre-operative transfusion rate in elderly patients with intertrochanteric fractures without increasing the risk of venous thrombosis.

Efficacy and safety of tranexamic acid sequential rivaroxaban on blood loss in elderly patients during lumbar interbody fusion

To investigate the effect and safety of tranexamic acid sequential rivaroxaban on perioperative blood loss and preventing thrombosis for elderly patients during lumbar interbody fusion (LIF) with a prospective randomized controlled study. Between April and October 2019, the elderly patients with lumbar degenerative diseases requiring LIF were included in the study, among which were 80 patients met the selection criteria. According to the antifibrinolysis and anticoagulation protocols, they were randomly divided into a tranexamic acid sequential rivaroxaban group (trial group) and a simple rivaroxaban group (control group) on average. Finally, 69 patients (35 in the trial group and 34 in the control group) were included for comparison. There was no significant difference in general data ( P>0.05) such as gender, age, body mass index, disease duration, diseased segment, type of disease, and preoperative hemoglobin between the two groups. The operation time, intraoperative blood loss, drainage within 3 days after operation, perioperative total blood loss, and proportion of blood transfusion patients were compared between the two groups, as well as postoperative venous thrombosis of lower extremities, pulmonary embolism, and bleeding-related complications. The operations of the two groups completed successfully, and there was no significant difference in the operation time ( P>0.05); the intraoperative blood loss, drainage within 3 days after operation, and perioperative total blood loss in the trial group were significantly lower than those in the control group ( P<0.05). The proportion of blood transfusion patients in the trial group was 25.71% (9/35), which was significantly lower than that in the control group [52.94% (18/34)] ( χ 2=5.368, P=0.021). Postoperative incision bleeding occurred in 4 cases of the trial group and 3 cases of the control group, and there was no significant difference in bleeding-related complications between the two groups ( P=1.000). There was 1 case of venous thrombosis of the lower extremities in each group after operation, and there was no significant difference in the incidence between the two groups ( P=1.000). Besides, no pulmonary embolism occurred in the two groups. Perioperative use of tranexamic acid sequential rivaroxaban in elderly LIF patients can effectively reduce the amount of blood loss and the proportion of blood transfusion patients without increasing the risk of postoperative thrombosis.

Efficacy and safety of tranexamic acid for reducing blood loss in elderly patients with intertrochanteric fracture treated with intramedullary fixation surgery: A meta-analysis of randomized controlled trials.

The aim of this study was to evaluate the efficacy and safety of tranexamic acid (TXA) in elderly patients with intertrochanteric fracture undergoing intramedullary fixation surgery. We searched MEDLINE, the Cochrane Library and EMBASE for published randomized clinical trials relevant to use of TXA in elderly patients with intertrochanteric fracture treated with intramedullary fixation surgery. Meta-analysis was performed according to the guidelines of the Cochrane Reviewer's Hand book. Five trials assessing 540 patients were included for meta-analysis. The pooled results showed that the mean total blood loss in TXA group was significant lower than that in the control group (mean difference - 172.83, 95% CI -241.43 to -104.23; p<0.00001, fixed-effect model). The intra- and postoperative transfusion rate for the TXA group was 34.4% (91/264) and for the control group was 49.27% (136/276), and the relative risk was 0.71 (95% CI 0.52 to 0.97; p<0.03, random-effect model) with substantial heterogeneity (I2=63%, p=0.03). The overall incidence of thrombotic events was 6.43% (17/264) in the intravenous TXA group, 7.63% (21/275) in the control group, with no significant difference (relative risk 0.84, 95% CI 0.46 to 1.54; p=0.57, fixed-effect model). The present evidence shows that TXA can significantly reduce total and hidden blood loss, transfusion rate, and do not increase the risk of thrombotic events in elderly patients with intertrochanteric fracture undergoing intramedullary fixation surgery. However, the impact of TXA on thrombotic events needs to be researched in more high-quality, large-sample randomized clinical trials. Level I Therapeutic Study.

Effects of aminocaproic acid on perioperative hidden blood loss in elderly patients with femoral intertrochanteric fracture treated with proximal femoral nail anti-rotation.

ObjectiveTo determine the efficacy of aminocaproic acid on perioperative hidden blood loss (HBL) in elderly patients with femoral intertrochanteric fracture treated with proximal femoral nail anti-rotation (PFNA).MethodsSeventy consecutively admitted elderly patients with femoral intertrochanteric fracture treated with PFNA between 1 May 2017 and 1 May 2018 were recruited. The patients were randomised into the experimental and control groups receiving 1 g aminocaproic acid in 200 mL saline and only 200 mL normal saline intravenously, respectively. The following factors were recorded: demographic characteristics, haemoglobin and haematocrit levels on preoperative day 1 and postoperative days 1 and 3, surgical blood loss, postoperative drainage, the rate and volume of transfusion, and complications.ResultsNo significant differences were seen in surgical blood loss and postoperative drainage between the experimental and control groups, though total blood loss was greater in the control group. Visible blood loss and HBL were significantly lower in the experimental group than in the control group, and a lower rate and volume of transfusion were also recorded in the experimental group.ConclusionAminocaproic acid significantly reduced perioperative HBL and volume and rate of transfusion in elderly patients with femoral intertrochanteric fracture receiving PFNA.

Influence of postoperative intravenous infusion of tranexamic acid on perioperative blood loss in elderly patients with femoral intertrochanteric fractures treated with proximal femoral nail antirotation

Objective To evaluate the effect and safety of postoperative intravenous infusion of tranexamic acid on the perioperative blood loss in elderly patients with femoral intertrochanteric fractures treated with proximal femoral nail antirotation. Methods A retrospective case-control study was conducted on 60 aged patients with unilateral intertrochanteric fracture who were treated with proximate femoral nail annotation from January 2015 to March 2017. Patients were divided into two groups according to method of administration, with 30 cases in each group. Patients in the single administration group were given 15 mg per kilogram of tranexamic acid 20 minutes before surgery by intravenous drip (Group A), whereas patients in the twice administration group were given 15 mg per kilogram 20 minutes before surgery and 1 g 7 hours later by intravenous drip (Group B). There were 11 males and 19 females in Group A, with the age of (78.57±7.60)years. Group B included 12 males and 18 females, and the age was (76.80±7.90)years. Perioperative data including operation time, intraoperative blood loss, total blood loss, recessive blood loss, postoperative drainage volume, mean blood transfusion volume, blood transfusion rate, maximum hemoglobin drop after surgery, and postoperative hospitalization time as well as complications including deep vein thrombosis, pulmonary embolism, wound infection, intermuscular venous thrombosis, exudate, hematoma, fat liquefaction were compared between the two groups. Results The operation time was (85.00±19.17)minutes in Group A and (81.10±19.23)minutes in Group B (P>0.05). The intraoperative blood loss was (113.33±56.77)ml in Group A and (129.33±93.70)ml in Group B (P>0.05). The total blood loss was (748.47±246.71)ml in Group A and (477.83±213.78)ml in Group B(P 0.05). Conclusion Compared with the single administration of tranexamic acid, the twice administration is more effective in controlling perioperative blood loss, which is worthy of clinical application. Key words: Aged; Femoral fractures; Tranexamic acid; Blood loss, surgical

Clinical analysis of peri-operative hidden blood loss of elderly patients with intertrochanteric fractures treated by unreamed proximal femoral nail anti-rotation

The purpose of this study was to quantify the peri-operative blood loss of elderly patients with intertrochanteric fractures treated by unreamed proximal femoral nail anti-rotation (PFNA) and analyze whether the substantial hidden blood loss was induced by initial trauma or the operation. The clinical data of 123 patients with intertrochanteric fracture treated with unreamed PFNA from Jan 2013 to Apr 2017 were analyzed retrospectively. Blood routine on admission day (ADM), pre-operative day one (PRE), post-operative days one and three (POD1 and POD3) and the visible blood loss (VBL) were obtained. The total blood loss (TBL) from ADM to POD1 and POD3 were 693.5 ± 359.6 ml and 863.8 ± 429.9 ml, of which the corresponding hidden blood loss (HBL) was 86.8% and 89.4% respectively. The mean TBL and HBL from ADM to PRE (375.5 ± 242.0 ml, 375.5 ± 242.0 ml) were higher than that from PRE to POD1 (318.0 ± 183.4 ml, 226.5 ± 163.2 ml), p < 0.001 respectively. There was no significant difference between HBL from ADM to PRE and HBL from PRE to POD3 (375.5 ± 242.0 ml, 396.7 ± 254.0 ml, p = 0.361). The majority of peri-operative HBL occurred before surgery, it was mainly associated with the initial trauma rather than the operation.

Impact of nutritional status on perioperative hidden blood loss in elderly patients with intertrochanteric fracture treated with proximal femoral nail antirotation

Objective To observe the effect of nutritional status variation on hidden blood loss in elderly patients with intertrochanteric fracture treated with proximal femoral nail antirotation (PFNA). Methods Ninety-six elderly patients with femoral intertrochanteric fracture aged 72-94 years [mean, (78.7±9.5)years] were submitted to closed reduction and PFNA internal fixation. According to the mini nutritional assessment (MNA) score, the patients were randomized into normal-nourishment group (n=26), potentially malnourishment group (n=32) and malnourishment group (n=38). Correlation between MNA score and serological examination was analyzed. Total blood loss and hidden blood loss were calculated depending on height, weight, intra-operative blood loss, post-operative blood loss, pre-and post-operative Hct, and blood transfused. According to the mean hidden blood loss, patients were divided into low (n=51) and high (n= 45) hidden blood loss groups. Relationship among high hidden blood loss, MNA score, and serological examination was evaluated. Results Preoperative MNA score showed strong correlation with nutritional evaluation results assessed by serological examination, and the detection effectiveness of malnutrition by albumin (ALB), prealbumin (PA), transferrin (TRA), and T lymphocyte percentage (TLP) was better than that by total protein (TP), total lymphocyte count (TLC) and hemoglobin (Hb). Nutritional status was further deteriorated after PFNA in patients with malnutrition. Forty-five patients were found to have high hidden blood loss. Incidence of high hidden blood loss revealed significant difference among groups (P<0. 05). Preoperative incidence of hidden blood loss assessed by ALB, PA, TRA, TLP and Hb in high hidden blood loss group was obviously higher than that in low hidden blood loss group. Postoperative incidence of hidden blood loss assessed by the serological examination in high hidden blood loss group was evidently higher than that in low hidden blood loss group as well as higher than the preoperative results. Preoperative MNA score, ALB, PA, TRA, TLP and Hb showed strong correlations with high hidden blood loss (r =0.495, 0.480, 0.471, 0.502, 0.367 and 0.309, respectively, P<0.05). Conclusions Total blood loss, hidden blood loss and incidence of high hidden blood loss are gradually increased with the deterioration of nutritional status. MNA score and serological examination (ALB, PA, TRA, TLP and Hb) have significant values in predicting the risk of high hidden blood loss. Key words: Hip fractures; Nutritional status; Blood loss, surgical; Perioperative

Effect of pre-injury anticoagulant and antiplatelet agents on blood loss in elderly patients with severe trauma.

It has been widely reported that pre-injury use of anticoagulant and antiplatelet agents can affect traumatic brain injury and the associated risk of mortality, however, the effect of these agents on non-head injury site-related blood loss remains unclear. Therefore, we investigated the effects of pre-injury anticoagulant and antiplatelet agents on the transfusion amount and the need for massive transfusion in elderly patients with severe trauma. We retrospectively reviewed a cohort of elderly patients with severe trauma (age, ≥65 years; Injury Severity Score, ≥16) between September 2006 and March 2014. The selected patients were subsequently divided into patients who were: only taking warfarin, aspirin, or clopidogrel; taking various combinations of these agents; and a control group who were not taking any of these agents. During the study period, 67 patients (20%) were taking anticoagulant and antiplatelet agents and 272 patients were included in the control group. Among these patients, 10 were receiving only warfarin, 28 were receiving only aspirin, 14 were receiving only clopidogrel, and 13 were receiving various combinations of these medications. The amount of red cell concentrate and need for massive transfusions were only significantly increased in the warfarin group (P < 0.05). Furthermore, the warfarin group had a significantly higher risk of needing a massive transfusion with multivariate logistic regression analysis (odds ratio, 5.03; 95% confidence interval, 1.25-20.20; P < 0.05). Patients who were receiving only warfarin before their injury had an increased risk of bleeding due to non-head injuries.

Liver Resection in the Elderly: Significance of Comorbidities and Blood Loss

ObjectiveLiver resection is increasingly performed in elderly patients who are suspected of increased postoperative morbidity (PM) and reduced overall survival (OS). Patient selection based on the identification of age-adjusted risk factors may help to decrease PM and OS. Design and ParticipantsProspectively collected data of 879 patients undergoing elective hepatic resection were analyzed. This population was stratified into three age cohorts: >70 years (n = 228; 26 %), 60–69 years (n = 309; 35 %), and <60 years (n = 342; 39 %). Multivariate survival analysis was performed. ResultsThe incidence of severe (p < 0.01) and non-surgical (p < 0.001) postoperative complications was higher in older compared to younger patients. Major estimated blood loss (EBL; p = 0.039) and comorbidities (p = 0.002) independently increased PM. EBL was comparable between all age cohorts. However, preexisting comorbidities, major EBL, and postoperative complications markedly decreased OS in contrast to younger patients. Adjusted for age, independent predictors of OS were comorbidities (HR = 1.51; p = 0.001), major hepatectomy (HR = 1.33; p = 0.025), increased EBL (HR = 1.32; p = 0.031), and postoperative complications (HR = 1.64; p < 0.001). ConclusionAlthough increased age should not be a contraindication for liver resection, this study accents the avoidance of major blood loss in elderly patients and a stringent patient selection based on preexisting comorbidities.

Gastrointestinal Blood Loss Due to Cholesterol Crystal Embolization

Gastrointestinal blood loss in elderly atherosclerotic patients may be due to cholesterol crystal embolization (CCE) leading to ischemic lesions in the gastrointestinal tract. The diagnosis of CCE is favored by accompanying clinical or biochemical signs, such as blue toes, renal insufficiency, and eosinophilia. Our report describes the clinical data of four patients with gastrointestinal blood loss due to CCE. In two the bleeding source was in the duodenum, and in the other two the source was in the distal colon. The diagnosis was made by histological examination of endoscopic biopsies in three and of a sigmoid resection specimen in one. Provoking factors were anticoagulant therapy in one, anticoagulant therapy and aortography in another, and aortography followed by aorta bifurcation prosthesis implantation in the third, whereas no provoking factor could be identified in the remaining patient. Accompanying signs included eosinophilia in one, a blue toe with renal insufficiency in one, and retinal cholesterol crystals in another patient. Our findings, in line with previous reports, highlight the importance of CCE in the differential diagnosis of gastrointestinal blood loss in elderly patients.