Intraoperative Blood Product Transfusion Research Articles

Pre-operative Anemia as a Risk Factor of Morbidity and Mortality in Valvular Surgeries

Pre-operative anemia can be a hindrance to speedy recovery and will increase blood transfusion intraoperative and post operatively. Objective: To find a correlation between preoperative anemia and the subsequent morbidity and mortality rates in patients undergoing valvular surgeries. Methods: A retrospective observational study, involving 493 valvular surgeries’ patients. All patients had the same anesthetic and surgical techniques. According to the WHO, anemia is a hemoglobin level < 13 g/dl for men and <12 g/dl for women. Clinical variables were compared using chi-square and independent t-test. Results: The patients received cardiac surgery for valvular heart disorders and had an average age of 42.2±14.1 years, with 60.9% being male. Most patients exhibited NYHA III (48.9%) and CCS III (36.5%) functional class symptoms. Highest comorbidity was hypertension (35.1%), followed by diabetes (14.4%) and dyslipidemia (6.5%). 43.2% were anemic and older than non-anemic individuals (P=0.02). Anemic people had a significantly greater incidence of HTN (P 0.02) and DM (P < 0.001). Both groups exhibited identical perfusion and cross-clamp periods (P=0.4 vs. P=0.3). Though not statistically significant (P=0.08), non-anemic patients needed more intraoperative blood or blood product transfusions. Patients with anemia have worse outcomes, including increased rates of in-hospital mortality (P=0.03), extended artificial breathing (P=0.04), and postoperative blood/product transfusion (P<0.001). 44.8% of anemic individuals needed RCC, 41.9% FFP, and 41.4% platelets. Conclusions: anemia is associated with the poorest post-operative results. There is conflicting information about the impact of preoperative anemia, particularly iron deficiency anemia, on valvular surgery.

The Adherence to an Intraoperative Blood Product Transfusion Algorithm Is Associated With Reduced Blood Product Transfusions in Cardiac Surgical Patients Undergoing Coronary Artery Bypass Grafts and Aortic and/or Valve Replacement Surgery: A Single-Center, Observational Study

Objective(s)To demonstrate the value of a viscoelastic-based intraoperative transfusion algorithm to reduce blood product administration in adult cardiac surgical patients. DesignProspective observational. SettingQuaternary academic teaching hospital. ParticipantsCardiac surgical patients. InterventionsViscoelastic-based intraoperative transfusion algorithm. Measurements and Main ResultsWe compared intraoperative blood product transfusion rates in 184 cardiac surgical patients to 236 historical controls after implementing a viscoelastic-based algorithm. We found a 43.9% reduction in RBC units transfused (1.98 units ±2.24 vs 0.55 ±1.36; p=0.008). We found a reduction in transfusion of 23.8% for FFP (0.84 units ±1.4 vs 0.64 ±1.38; p=ns), 33.4% for platelets (0.90 units ±1.39 vs 0.60 ±131; p=ns), and 15.8% for cryoprecipitate (0.19 units ±0.54 vs 0.16 ±0.50; p=ns). There was no statistically significant difference in time to extubation (8.0 hours [4.0, 21.0] vs 8.0 [4.0, 22.3], reoperation for bleeding (15 (12.3%) vs 10 (10.6%), ICU LOS (51.0 hours [28.0, 100.5] vs. 53.5 [33.3, 99.0]) or hospital length of stay (9.0 days [6.0, 15.0] vs. 10.0 [7.0, 17.0]). Deviation from algorithm adherence was 32.7% (48/147). PRBC, FFP, platelets, cryoprecipitate and cell saver were significantly reduced in the Algorithm Compliant Cohort compared with Historical Controls while times to extubation, ICU and hospital lengths of stay did not reach significance. ConclusionsFollowing implementation of a viscoelastic-based algorithm, patients received fewer PRBC, FFP, platelets, cryoprecipitate and cell saver. Algorithm Compliant patients received fewer transfusions; however, reductions in times to extubation, ICU and hospital lengths of stay were not statistically significant compared with historical controls.

Temporary Portocaval Shunt Provides Superior Intraoperative Hemodynamics and Reduces Blood Loss and Duration of Surgery in Live Donor Liver Transplantation: A Randomized Control Trial.

To compare intraoperative hemodynamic parameters, blood loss, renal function, and duration of surgery with and without temporary portocaval shunt (TPCS) in live donor liver transplantation (LT) recipients. Secondary objectives were postoperative early graft dysfunction, morbidity, mortality, total intensive care unit, and hospital stay. Blood loss during recipient hepatectomy for LT remains a major concern. Routine use of TPCS during LT is not yet elucidated. This study is a single-center, open-label, randomized control trial. The sample size was calculated based on intraoperative blood loss. After exclusion, a total of 60 patients, 30 in each arm (TPCS vs no TPCS) were recruited in the trial. The baseline recipient and donor characteristics were comparable between the groups. The median intraoperative blood loss ( P = 0.004) and blood product transfusions ( P < 0.05) were significantly less in the TPCS group. The TPCS group had significantly improved intraoperative hemodynamics in the anhepatic phase as compared with the no TPCS group ( P < 0.0001), requiring significantly less vasopressor support. This led to significantly better renal function as evidenced by higher intraoperative urine output in the TPCS group ( P = 0.002). Because of technical simplicity, the TPCS group had significantly fewer inferior vena cava injuries (3.3 vs 26.7%, P = 0.026) and substantially shorter hepatectomy time and total duration of surgery (529.4 ± 35.54 vs 606.83 ± 48.13 min, P < 0.0001). The time taken for normalization of lactate in the immediate postoperative period was significantly shorter in the TPCS group (median, 6 vs 13 h; P = 0.04). Although postoperative endotoxemia, major morbidity, 90-day mortality, total intensive care unit, and hospital stay were comparable between both groups, tolerance to enteral feed was earlier in the TPCS group. In live donor LT, TPCS is a simple and effective technique that provides superior intraoperative hemodynamics and reduces blood loss and duration of surgery.

Preoperative Anemia as a Negative Risk Factor for Coronary Artery Bypass Grafting Surgery: A Retrospective Study

OBJECTIVES The objective of this study is to check the effects of Anemia on mortality and morbidity in patients having ischemic heart disease and undergoing coronary artery bypass graft surgery (CABG). METHODOLOGY The study involved all the patients who underwent isolated coronary artery bypass graft surgery from July 2019 to December 2022. The clinical data of patients was retrospectively collected from the departmental data pool and was then analyzed using the chi-square test and t-test. A p-value of less than 0.05 was considered significant. RESULTSThe study included 2570 patients who underwent isolated CABG; 78.2% of patients were males with a mean age of 57.87±9.20. Hypertension was the most common comorbidity (68.9%), followed by dyslipidemia (53.7%) &amp; Diabetes mellitus (49.9%). The preoperative mean hematocrit was 30.05±17.85. Of these 2570 patients, 52.37% were anaemic with a mean age of 58.69±9.05. Anemic patients had a significantly higher rate of IABP insertion (P 0.02) and intra-operative blood product transfusion (P &lt;0.001). Anemic patients had a significantly higher incidence of in-hospital mortality (P 0.04) and a higher rate of postoperative blood product transfusion (P &lt;0.001). There is no significant difference in terms of prolonged ventilation, reintubation, or readmission to ICU; however, nonanemic patients have a significantly higher rate of re-opening for bleeding/ tamponade (P 0.01). CONCLUSION Preoperative anaemia increases the mortality and morbidity in ischemic heart disease patients undergoing coronary artery bypass grafting. To improve the outcomes in CABG surgery, preoperative anaemia should be thoroughly investigated and treated to improve the outcomes of surgery.

Analysis of Perioperative Factor Replacement Therapy for Hemophilia

Background Hemophilia is a hereditary bleeding disorder, especially in severe hemophilia, that can lead to spontaneous bleeding. For hemophilia patients with inhibitors, even minor acute bleeding events or surgical procedures can have catastrophic consequences. Some hemophiliacs are forced to make surgical choices. There are many risks in perioperative period when hemophiliacs undergo major surgery. Seeking effective and safe perioperative clotting factor replacement therapy or bypass therapy is the basis of successful surgery. Aims To seek effective and safe perioperative coagulation factor replacement therapy or bypass therapy. Methods HA patients were treated with FVIII preparation during perioperative period. To calculate dosage, multiply the patient ' s weight in kilograms by the FVIII level in IU/dL desired, then multiply by 0.5. Example: 50 kg × 40 (IU/dL level desired) × 0.5 = 1000 IU of FVIII. HB patients were treated with PCC or FIX during perioperative period. To calculate dosage, multiply the patient ' s weight in kilograms by the FIX level in IU/dL desired. Example: 50 kg body weight × 40 (IU/dL level desired) = 2000 IU of plasma-derived FIX. For hemophilia patients with low titer inhibitors, estimate the amount of FVIII required as a neutralizing inhibitor loading dose as recommended by WFH. The following formula is used to estimate the amount of FVIII needed as a loading dose to neutralize the inhibitor: [body weight (kg) × 80 × [(1 − hematocrit) × antibody titer (BU)]. An additional 50 IU/kg above the calculated loading dose is added to achieve a measurable FVIII activity. Patients with hemophilia combined with high titer inhibitors were treated with rFVIIa combined with PCC SCBT regimen. Sequential use refers to alternating rFVIIa and aPCC every 3 hours. Results 69 patients with indications for surgery and/or desire for surgery who underwent different types of surgery with clotting factor replacement therapy or bypass therapy were evaluated (Table 1). There were 37 cases of severe hemophilia and 32 cases of non-severe hemophilia. There were 63 cases of HA, including 50 cases of negative inhibitor and 13 cases of positive inhibitor. After meeting the inclusion and exclusion criteria, 69 patients were evaluated for different types of surgery under clotting factor replacement therapy or bypass therapy during perioperative period. 59 cases underwent major operations, including: 49 cases underwent joint replacement, among which 34 cases underwent single joint replacement and 6 cases underwent double joint replacement and so on. 10 cases underwent minor operations. There were 14 cases of hemophilia with inhibitors, of which 13 were major operations with 175.38 (85.00-270.00) minutes of operation and 2 were minor operations with 45.00 minute of operation. In 12 patients with severe hemophilia and high titer inhibitors, the perioperative consumption of factor FVII was as follows: 447.62 (331.04-738.48)ug/kg on the day of surgery, and the total consumption was 2484.21 (1499.40-4500.00)ug/kg. The perioperative consumption of factor PCC was as follows: 126.10 (0-206.45)ug/kg on the day of surgery, and the total consumption was 1332.84 (529.20-1970.00)ug/kg. The mean preoperative FVIII:C level of the HA patients was 1.19 (0.00~6.00)%, the mean preoperative FIX:C level was 0.022 (0.01~0.07)% of the HB patients.The average intraoperative blood loss of the 69 patients was 537.98 (0-3000) ml. 20 patients received intraoperative transfusion of blood products (red blood cells or fresh frozen plasma) and 49 patients did not receive intraoperative transfusion of blood products. In 55 hemophiliacs without inhibitor, no inhibitor was found after surgery. Conclusion(s) It is safe and effective to adopt different schemes for perioperative alternative therapy for different hemophilia types.

Impact of intraoperative blood products, fluid administration, and persistent hypothermia on bleeding leading to reexploration after cardiac surgery

ObjectiveRisk factors for severe postoperative bleeding after cardiac surgery remain multiple and incompletely elucidated. We evaluated the impact of intraoperative blood product transfusions, intravenous fluid administration, and persistently low core body temperature (CBT) at intensive care unit arrival on risk of perioperative bleeding leading to reexploration. MethodsWe retrospectively queried our tertiary care center's Society of Thoracic Surgeons Institutional Database for all index, on-pump, adult cardiac surgery patients between July 2016 and September 2022. Intraoperative fluid (crystalloid and colloid) and blood product administrations, as well as perioperative CBT data, were harvested from electronic medical records. Linear and nonlinear mixed models, treating surgeon as a random effect to account for inter-surgeon practice differences, were used to assess the association between above factors and reexploration for bleeding. ResultsOf 4037 patients, 151 (3.7%) underwent reexploration for bleeding. Reexplored patients experienced remarkably greater postoperative morbidity (23% vs 6%, P < .001) and 30-day mortality (14% vs 2%, P < .001). In linear models, progressively increasing IV crystalloid administration (adjusted odds ratio, 1.11, 95% confidence interval, 1.03-1.19) and decreasing CBT on intensive care unit arrival (adjusted odds ratio, 1.20; 95% confidence interval, 1.05-1.37) were associated with greater risk of bleeding leading to reexploration. Nonlinear analysis revealed increasing risk after ∼6 L of crystalloid administration and a U-shaped relationship between CBT and reexploration risk. Intraoperative blood product transfusion of any kind was not associated with reexploration. ConclusionsWe found evidence of both dilution- and hypothermia-related effects associated with perioperative bleeding leading to reexploration in cardiac surgery. Interventions targeting modification of such risk factors may decrease the rate this complication.

Whole-body perfusion improves intraoperative transfusions in neonatal aortic arch surgery.

Whole body perfusion is the combination of lower body perfusion and antegrade cerebral perfusion. This perfusion technique is used in some centres when performing aortic arch reconstruction surgery in neonates and infants. Several studies have shown intra- and postoperative benefits of this technique. However, no studies have analysed the impact it may have on the transfusion of blood products and coagulation factors. We retrospectively analysed 65 consecutive neonates and infants who underwent aortic arch reconstruction surgery from January 2014 to July 2020. Patients operated from 2014-2017 underwent surgery with antegrade cerebral perfusion; in patients who underwent surgery from 2017-2020 a whole-body perfusion strategy was used. Demographic, intra- and postoperative parameters were compared as well as intraoperative blood-product and coagulation factor transfusions, chest-tube output in the first 24-hours and postoperative bleeding complications. Both groups required intraoperative transfusion of red blood cells, fresh frozen plasma, and platelets, as well as substitution of coagulation factors. The amount of transfused volumes of red blood cells, fresh frozen plasma, and platelets (p-values 0.01, <0.01, and <0.01) and intraoperative transfusions of fibrinogen and von Willebrand factor were significantly lower in the whole-body perfusion group (p-value 0.04 and <0.01). A whole-body perfusion strategy may lead to fewer intraoperative blood product and coagulation factor transfusions when compared to antegrade cerebral perfusion alone in neonates and infants undergoing complex aortic arch reconstruction surgery.

Intraoperative blood product transfusion in pediatric cardiac surgery patients: A retrospective review of adverse outcomes.

Resuscitation with blood products is often required for pediatric cardiac surgery patients following cardiopulmonary bypass. However, data suggest that blood product transfusion is an independent predictor of adverse outcomes. Most studies have specifically found detrimental effects of overall transfusion of red blood cells in particular, but few have analyzed outcomes by the other specific blood product components. The objective of this study is to analyze adverse outcomes associated with intraoperative transfusion of specific blood product components. A retrospective review was performed on 643 pediatric patients who underwent cardiac surgery requiring cardiopulmonary bypass to evaluate the risk of selected adverse outcomes associated with intraoperative blood product transfusion. Adverse outcomes included thrombotic complications, stroke, acute kidney injury, prolonged mechanical ventilation, and death. Univariate logistic and linear regression analyses were performed to explore the association between various blood products and the occurrence of postoperative complications. Multiple logistic and linear regression analyses were performed adjusting for age, cyanotic status, TheSocietyofThoracicSurgeons-EuropeanAssociationforCardio-ThoracicSurgeryScore(STAT score), and cardiopulmonary bypass time. Unadjusted analysis using univariate logistic and linear regressions showed statistically significant associations of almost all blood components (per 10mL/kg dose increments) with multiple postoperative complications, including mortality, thrombotic complications, stroke, and days of mechanical ventilation. After adjusting for patient age, cyanotic status, STAT score, and cardiopulmonary bypass time, multivariable logistic and linear regression analyses revealed no association between transfusion of blood products with acute kidney injury and stroke. Administration of red blood cells was the only category significantly correlated with increased days of mechanical ventilation (0.5 days increase in mechanical ventilation per 10mL/kg transfusion of redbloodcells). The only blood product to show complete lack of a statistically significant association with any of the studied outcomes was cryoprecipitate. Transfusion of blood products following cardiopulmonary bypass is associated with postoperative adverse outcomes. Future studies aimed at strategies to reduce intraoperative bleeding and decrease the amount of blood products administered are warranted.

Characteristics and Outcomes of Liver Transplantation Recipients after Tranexamic Acid Treatment and Platelet Transfusion: A Retrospective Single-Centre Experience.

Background and Objectives: Patients undergoing liver transplantation (LT) often require increased blood product transfusion due to pre-existing coagulopathy and intraoperative fibrinolysis. Strategies to minimise intraoperative bleeding and subsequent blood product requirements include platelet transfusion and tranexamic acid (TXA). Prophylactic TXA administration has been shown to reduce bleeding and blood product requirements intraoperatively. However, its clinical use is still debated. The aim of this study was to report on a single-centre practice and analyse clinical characteristics and outcomes of LT recipients according to intraoperative treatment of TXA or platelet transfusion. Materials and Methods: This was a retrospective observational cohort study in which we reviewed 162 patients' records. Characteristics, intraoperative requirement of blood products, postoperative development of thrombosis and outcomes were compared between patients without or with intraoperative TXA treatment and without or with platelet transfusion. Results: Intraoperative treatment of TXA and platelets was 53% and 57.40%, respectively. Patients who required intraoperative administration of TXA or platelet transfusion also required more transfusion of blood products. Neither TXA nor platelet transfusion were associated with increased postoperative development of hepatic artery and portal vein thrombosis, 90-day mortality or graft loss. There was a significant increase in the median length of intensive care unit (ICU) stay in those who received platelet transfusion only (2.00 vs. 3.00 days; p = 0.021). Time to extubate was significantly different in both those who required TXA and platelet transfusion intraoperatively. Conclusions: Our analysis indicates that LT recipients still required copious intraoperative transfusion of blood products, despite the use of intraoperative TXA and platelets. Our findings have important implications for current transfusion practice in LT recipients and may guide clinicians to act upon these findings, which will support global efforts to encourage a wider use of TXA to reduce transfusion requirements, including platelets.

Development of the PIP score: A metric for predicting Intensive Care Unit admission among patients undergoing emergency laparotomy

Emergency laparotomy cases account for a significant proportion of the surgical caseload requiring postoperative intensive care. However, access to Intensive Care Unit (ICU) services has been limited by the scarcity of resources, lack of guidelines, and paucity of triaging tools. This study aimed at developing a feasible Post-emergency laparotomy ICU admission Predictive (PIP) scoring tool. A case-control study utilizing the records of 108 patients who underwent emergency laparotomy was conducted. The primary outcome was the postoperative disposition status. Cases were defined as emergency laparotomy patients admitted to the ICU. The control group constituted patients admitted to the general ward. Logistic regression analysis was performed to identify the perioperative predictors of outcome. The PIP score was developed as a composite of each statistically significant variable remaining in the final logistic regression model. The significant positive predictors of ICU admission included a worsening American Society of Anesthesiologists - Physical Status, decreasing preoperative baseline axillary temperature, increasing preoperative baseline pulse rate, and intraoperative blood-product transfusion. The scoring system incorporating the identified predictors was presented as a numeric scale ranging from zero to four. Two levels of prediction were defined with reference to the optimum cut-off value; a score of <3 (low-intermediate prediction) and a score of ≥3 (high prediction [OR = 37.00, 95% CI = 11.22–122.02, p <0.001]). The score demonstrated an excellent predictive ability on the Receiver Operator Characteristic Curve (Area Under the Curve = 0.91, 95% CI = 0.851–0.973, p <0.001). The PIP score proves useful as a feasible postoperative triaging adjunct for emergency laparotomy cases. Nonetheless, further validation studies are required.

Comparison of trauma-dosed tranexamic acid versus aminocaproic acid in cardiac surgery in the setting of drug shortage.

Antifibrinolytic agents, tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), are often used during cardiac surgery to decrease the number of allogenic blood transfusions and to prevent perioperative bleeding. Weight-based TXA dosing regimens have been compared to fixed-dose regimens of EACA with variable outcomes in perioperative blood product transfusions and chest tube output. Serious adverse events, including seizures, have been reported with higher doses of TXA. Fixed-dose TXA regimens have been evaluated in trauma and orthopedic surgery but there is a paucity of evidence in the cardiac surgery population. To compare the safety and efficacy of fixed-dose TXA versus EACA in patients undergoing cardiac surgery. A single-center, retrospective chart review was conducted at a 793-bed tertiary care academic teaching hospital comparing cardiac surgery patients receiving either fixed-dose TXA 1000 mg followed by a 500-1000 mg infusion or EACA-7.5 gintravenousboluses followed by a 1-1.25 g/hinfusion for the duration of the surgery. The major endpoint included chest tube output at 12 h, 24 h, and 7 days postoperatively. Minor endpoints included quantity and incidence of blood product transfusions and reported safety events. There were 1544 patients included. Chest tube output was similar between groups and the TXA group required more intraoperative blood product transfusions (22.7% vs. 18.2%, p = .03). There were no differences in the median quantity of total blood products administered postoperatively at 24 h or at 7 days. Reported safety events were similar between groups. Both fixed-dose TXA and EACA may be considered safe and effective options for antifibrinolytic therapy in cardiac surgery patients.

Autologous blood transfusion in acute type A aortic dissection decreased blood product consumption and improved postoperative outcomes

ObjectiveTo evaluate the effect of autologous blood use on blood product consumption and outcomes after acute type A aortic dissection repair. MethodsFrom 2010 to October 2020, 497 patients underwent open acute type A aortic dissection repair, including those with autologous blood harvesting before cardiopulmonary bypass and transfusion after cardiopulmonary bypass (autologous blood transfusion [ABT], n = 397) and without autologous blood harvesting and transfusion (No-ABT, n = 100). The median ABT volume was 900 mL. Using propensity score matching, 89 matched pairs were identified based on age, sex, body mass index, preoperative hemoglobin, acute preoperative stroke, previous cardiac surgery, and cardiogenic shock. ResultsAfter propensity score matching, both groups were similar in demographic characteristics and aortic procedures. The ABT group required significantly less intraoperative transfusion of blood products (6 vs 11 units; P < .0001), including packed red blood cells (2 vs 4), fresh frozen plasma (2 vs 4), platelets (2 vs 2), and cryoprecipitate (0 vs 1); and combined intraoperative and postoperative transfusion (9 vs 13; P < .001). ABT was protective against intra- and postoperative blood product transfusion (odds ratio, 0.28; P = .01). The ABT group had significantly less sepsis, acute renal failure requiring dialysis, reintubation, and shorter intubation times and postoperative lengths of stay. Operative mortality was 6.7% in the ABT group versus 13% in the No-ABT group (P = .14). The midterm survival was similar between the 2 groups (5 year: 76% vs 74%). ABT had a hazard ratio of 0.81 for midterm mortality (P = .41). ConclusionsAutologous blood transfusion was associated with better short-term outcomes and could be used routinely for acute type A aortic dissection repair. External multicenter prospective validation would be warranted.

Outcomes of liver transplant recipients with high MELD scores: an experience from a Canadian centre.

Background:The frequency with which patients with high Model for End-Stage Liver Disease (MELD) scores undergo liver transplantation has been increasing. Canadian literature regarding the outcomes of liver transplantation in recipients with high MELD scores is limited. The primary objective of this study was to assess patient and graft survival among recipients with high (> 35) and low (≤ 35) MELD scores. Secondary objectives were to potentially identify independent predictors of graft failure and patient mortality.Methods:We conducted a retrospective chart review of patients undergoing liver transplantation at a single Canadian centre from 2012 to 2017.Results:A total of 332 patients were included in the study: 280 patients had a MELD score of 35 or lower, and 52 had a MELD score above 35. Patients with high MELD scores had higher rates of pretransplant acute kidney injury and dialysis (p < 0.001), admission to the intensive care unit (ICU) or intubation (p < 0.001), intraoperative blood product transfusions (p < 0.001) and post-transplantation acute kidney injury and dialysis (p < 0.001), as well as longer ICU (p < 0.001) and hospital stays (p = 0.002). One- and 3-year patient survival in recipients with MELD scores of 35 or lower was 93.1% and 84.9% versus 85.0% and 80.0% in recipients with MELD scores above 35 (p = 0.37). One- and 3-year graft survival in recipients with MELD scores of 35 or lower was 91.7% and 90.9% versus 77.2% and 72.8% in recipients with MELD scores above 35 (p < 0.001). Prior liver transplant was an independent predictor of patient mortality, and no independent predictors of graft failure were identified. When MELD was replaced with D-MELD (donor age × recipient MELD), it predicted graft failure but not patient survival.Conclusion:No difference in patient mortality was found between MELD groups. Graft survival was significantly lower in recipients with MELD scores above 35. D-MELD may potentially be used as an adjunct in determining risk of graft failure in recipients with high MELD scores.

Clinical Predictors of Lung Transplant Outcomes in Patients with Scleroderma Compared with Pulmonary Fibrosis

Purpose Primary Graft Disfunction (PGD) is the leading cause of early morbidity and mortality after lung transplant. We sought to identify risk factors for PGD and survival in patients with scleroderma undergoing lung transplant compared to patients with pulmonary fibrosis. Methods This was a single center retrospective cohort study, of patients that underwent lung transplantation for scleroderma or pulmonary fibrosis from 2007 to 2020. Propensity scores were used to match the scleroderma group with the pulmonary fibrosis group based on lung allocation score and age at lung transplant. Univariable analyses identified factors associated with the development of PGD 72 hours posttransplant, and six-month survival. Survival rates were compared using Kaplan-Meier analysis. Results We compared 104 patients with scleroderma to 389 patients with pulmonary fibrosis who underwent lung transplant. After propensity matching, compared with pulmonary fibrosis, scleroderma patients had reduced 90-day survival (99.0% vs 90.2%, p=0.007). However, there was no statistically significant difference in 1 year (84.4% vs 79.1%, p=0.23) or 5-year survival (64.9% vs 52.9%, p=0.98). Scleroderma patients were more likely to have PGD 72 hours posttransplant (29.4% vs 11.8%, p=0.01). Scleroderma patients who developed PGD had higher volumes of intraoperative transfusion of blood products (p=0.02), plasma (p=0.04), platelets (p=0.03), but not red blood cells (p=0.28). Preoperative history of chronic kidney disease (p<0.001) and postoperative Acute Kidney Injury [AKI] (p=0.028) were also associated with the development of PGD. Donor factors for developing PGD in scleroderma patients were traumatic brain injury as cause of donor death (p=0.015) and donor history of smoking (p=0.02). Risk factors for 6-month mortality were postoperative right ventricular dysfunction (p=0.02) or dilation (p=0.003), stroke (p=0.02), atrial fibrillation (p=0.01), PGD (p<0.001), AKI (p=0.005) and decreased glomerular filtration rate 3 months posttransplant (p=0.04). Conclusion Scleroderma had higher rates of post lung transplant PGD compared to pulmonary fibrosis. Kidney function plays a prominent role in the risk of developing PGD and mortality in this population. Despite reduced 90-day posttransplant survival in scleroderma patients, 1- and 5-year survival rates were similar. Primary Graft Disfunction (PGD) is the leading cause of early morbidity and mortality after lung transplant. We sought to identify risk factors for PGD and survival in patients with scleroderma undergoing lung transplant compared to patients with pulmonary fibrosis. This was a single center retrospective cohort study, of patients that underwent lung transplantation for scleroderma or pulmonary fibrosis from 2007 to 2020. Propensity scores were used to match the scleroderma group with the pulmonary fibrosis group based on lung allocation score and age at lung transplant. Univariable analyses identified factors associated with the development of PGD 72 hours posttransplant, and six-month survival. Survival rates were compared using Kaplan-Meier analysis. We compared 104 patients with scleroderma to 389 patients with pulmonary fibrosis who underwent lung transplant. After propensity matching, compared with pulmonary fibrosis, scleroderma patients had reduced 90-day survival (99.0% vs 90.2%, p=0.007). However, there was no statistically significant difference in 1 year (84.4% vs 79.1%, p=0.23) or 5-year survival (64.9% vs 52.9%, p=0.98). Scleroderma patients were more likely to have PGD 72 hours posttransplant (29.4% vs 11.8%, p=0.01). Scleroderma patients who developed PGD had higher volumes of intraoperative transfusion of blood products (p=0.02), plasma (p=0.04), platelets (p=0.03), but not red blood cells (p=0.28). Preoperative history of chronic kidney disease (p<0.001) and postoperative Acute Kidney Injury [AKI] (p=0.028) were also associated with the development of PGD. Donor factors for developing PGD in scleroderma patients were traumatic brain injury as cause of donor death (p=0.015) and donor history of smoking (p=0.02). Risk factors for 6-month mortality were postoperative right ventricular dysfunction (p=0.02) or dilation (p=0.003), stroke (p=0.02), atrial fibrillation (p=0.01), PGD (p<0.001), AKI (p=0.005) and decreased glomerular filtration rate 3 months posttransplant (p=0.04). Scleroderma had higher rates of post lung transplant PGD compared to pulmonary fibrosis. Kidney function plays a prominent role in the risk of developing PGD and mortality in this population. Despite reduced 90-day posttransplant survival in scleroderma patients, 1- and 5-year survival rates were similar.

Pain score and other factors affecting the postoperative discharge time of patients who underwent lung resection: a retrospective study

Aim: Many factors affect the hospitalization period of patients after surgery. One of the most important of them is postoperative pain. Our study aims to investigate the relationship between the postoperative discharge time and the postoperative 24-hour visual analog scale (VAS) pain scores of patients who underwent thoracotomy and lung resection. Additionally, we also want to identify the parameters that affect the day of discharge, VAS scores, and chest tube removal time of these patients.&#x0D; Material and Method: Data of patients who underwent elective thoracic surgery between February 2021 and August 2021 in a tertiary chest disease and thoracic surgery center were analyzed patients aged between 18 and 75 years, in the ASA I-II-III risk group, with a body mass index (BMI) in the range of 18.5-35 kg/m2, who underwent thoracotomy and resection due to lung malignancy. Following data were extracted co-morbidities, diagnoses, performed surgery, type of surgery, duration of surgery, intraoperative complications, intraoperative blood product transfusion history, postoperative advanced complications, postoperative 24-hour VAS, length of stay, and length of chest tube stay.&#x0D; Results: A total of 104 patients who underwent elective thoracotomy and lung resection under general anesthesia between February 2021 and August 2021 were included in the study. There was a positive and highly statistically significant correlation between discharge time and chest tube removal time (p &lt; 0.001). There was no statistically significant correlation between discharge times and VAS scores (p=0.553). Additionally, there was no statistically significant correlation between VAS scores and chest tube removal time. Discharge time had a low positive and statistically significant correlation with age (p=0.027), and with the duration of the operation (p &lt; 0.001). There was a low degree of negative statistically significant correlation between discharge day and BMI (p=0.017).&#x0D; Conclusion: While the prolonged chest tube withdrawal time was directly related to the longer discharge time, the VAS scores have no significant correlation with the discharge time and the chest tube removal time. Additionally, age and operation time were also found to be associated with prolonged discharge time. Prospective comprehensive studies on this subject will be useful in clarifying the factors affecting the discharge time after thoracic surgery.

1442 Are Blood Group and Antibody Screening Necessary Before Emergency Laparoscopic Appendicectomy?

Abstract Aim The incidence of bleeding complications in laparoscopic surgery are low. At present, there are no national guidelines on pre-operative blood group and antibody screening (G&amp;S) in patients undergoing emergency laparoscopic surgery. The aim of this study is to establish the incidence of intraoperative bleeding requiring transfusion during emergency laparoscopic appendicectomy. In turn, this will indicate the necessity of routine preoperative G&amp;S. Method Retrospective data collection of all emergency laparoscopic appendicectomy procedures at a large tertiary hospital from January 2015 to January 2020 (5 years). Patients having routine or open procedures were excluded. The transfusion department records were used to identify any patients receiving a transfusion intraoperatively. Results 1362 emergency laparoscopic appendicectomy procedures were performed during the 5-year period. 4/1362 (0.29%) patients received intraoperative transfusion of blood products. Of these, 3 patients had known haematological disorders. One patient was transfused for bleeding associated with intraoperative miscarriage. Conclusions No patients required transfusion for surgical haemorrhage. The small number of patients requiring transfusion were predictable because of pre-existing haematological disorders and clinical status. Our data is one of the largest series available and the results demonstrate that routine preoperative G&amp;S is not justified. Instead, a selective approach would ensure high risk patients are appropriately screened. In event of vessel injury and major haemorrhage, O negative blood can be used. Furthermore, we estimate that elimination of a routine second G&amp;S sample could have saved our institution approximately £2500 per year.

1422 Are Blood Group and Antibody Screening Necessary Before Elective or Day Case Laparoscopic Cholecystectomy?

Abstract Aim Laparoscopic cholecystectomy is generally safe with low rates of intraoperative bleeding. At present, there are no national guidelines on pre-operative blood group and antibody screening (G&amp;S) for this procedure. The aim of this study is to establish the incidence of intraoperative haemorrhage requiring transfusion during laparoscopic cholecystectomy. This will indicate the necessity of routine preoperative G&amp;S. Method Retrospective data collection of all patients having laparoscopic cholecystectomy at a large tertiary hospital from January 2015 to January 2020 (5 years). Patients having emergency procedures were excluded. The transfusion department records were used to identify any patients receiving a transfusion intraoperatively. Results 2894 laparoscopic cholecystectomy procedures were performed over the 5-year period. 150 patients having emergency surgery were excluded. The final group consisted of 2744 patients. 1392/2744 (50.7%) patients were managed as a day case. 1352/2744 (49.3%) patients underwent elective surgery. 5/2744 (0.002%) patients received an intraoperative transfusion of blood products for the management of pre-existing haematological disorders. Conclusions No patients required transfusion for surgical haemorrhage. The small number of patients requiring transfusion were predictable because of clinical status. Our data is one of the largest series available. The results demonstrate that routine preoperative G&amp;S is not justified. Instead, a selective approach would ensure high risk patients are appropriately screened. In event of vessel injury and major haemorrhage, O negative blood can be used. Furthermore, we estimate that elimination of a routine second G&amp;S sample could have saved our institution approximately £5200 per year.

Preoperative embolization of jugular paraganglioma tumors using particles is safe and effective.

Jugular paragangliomas represent a surgical challenge due to their vascularity and proximity to vital neurovascular structures. Preoperative embolization aids in reducing intraoperative blood loss, transfusion requirements, and improves surgical visualization. Several embolization agents have been used. The aim of this study is to evaluate the safety and efficacy of PVA in pre-operative embolization of jugular paragangliomas. A retrospective review of all patients who underwent jugular paraganglioma resection with pre-operative embolization between 2000 and 2020 was performed. Pre-operative data including baseline patient and tumor characteristics were documented. Outcomes of preoperative embolization including extent of devascularization and post-embolization complications were recorded. Early and long-term postoperative outcomes were reported. Twenty-nine patients met study criteria with a median age of 38 years. Average tumor size was 3.4±1.8 cm. The most commonly encountered arterial feeder was the ascending pharyngeal artery followed by the posterior auricular artery. More than 50% reduction in tumor blush was achieved in 25 patients (86.2%). None of the patients experienced new or worsening cranial neuropathy following embolization. Gross total or Near total resection was achieved in 13 patients (44.8%). A STR or NTR was chosen in these patients to preserve cranial nerve function or large vessel integrity. Average intraoperative estimated blood loss was 888 ml, 9 patients (31%) required intra-operative transfusion of blood products. Extent of resection and post-operative complications did not correlate with extent of devascularization. Pre-operative embolization of jugular paraganglioma tumors with PVA particles is an effective strategy with a high safety profile.

The Road to Transfusion-free Craniosynostosis Repair in Children Less Than 24 Months Old: A Quality Improvement Initiative.

Introduction:Pediatric craniofacial reconstruction has historically resulted in extensive blood loss necessitating transfusion. This single-center quality improvement initiative evaluates the impact of perioperative practice changes on the allogeneic transfusion rate for children 24 months and younger of age undergoing craniofacial reconstruction.Methods:At project initiation, an appointed core group of anesthesiologists provided all intraoperative anesthetic care for patients undergoing craniofacial reconstruction. Standardized anesthetic guidelines established consistency between providers. Using the Plan-do-check-act methodology, practice changes had been implemented and studied over a 5-year period. Improvement initiatives included developing a temperature-management protocol, using a postoperative transfusion protocol, administering intraoperative tranexamic acid, and a preincisional injection of 0.25% lidocaine with epinephrine. For each year of the project, we acquired data for intraoperative and postoperative allogeneic transfusion rates.Results:A cohort of 119 pediatric patients, ages 4–24 months, underwent anterior or posterior vault reconstruction for craniosynostosis at a tertiary children’s hospital between March 2013 and November 2018. Intraoperative and postoperative transfusion of allogeneic blood products in this cohort decreased from 100% preintervention to 22.7% postintervention.Conclusions:Interdepartmental collaboration and practice modifications using sequential Plan-do-check-act cycles resulted in a bundle of care that leads to a sustainable decrease in the rate of intraoperative and postoperative allogeneic blood transfusions in patients less than 24 months of age undergoing craniosynostosis repair. This bundle decreases the risk of transfusion-related morbidity for these patients. Other institutions looking to achieve similar outcomes can implement this project.

Intraoperative Continuous Renal Replacement Therapy During Liver Transplantation: A Meta-Analysis.

Continuous renal replacement therapy (CRRT) is frequently used to treat recipients with renal failure before or after liver transplantation (LT), though evidence supporting its use during surgery remains unclear. Therefore, we conducted a quantitative meta-analysis to evaluate the effect of intraoperative continuous renal replacement therapy (IORRT) in recipients with pretransplant severe renal dysfunction. We searched PubMed, Embase, and the Cochrane database for trials focusing on LT recipients supported with or without IORRT. Outcomes assessed were mortality, preoperative characteristics, intraoperative data, and predefined postoperative outcomes. Seven trials with 1051 recipients were eligible. Preoperatively, the IORRT group recipients had higher Model for End-Stage Liver Disease scores (weighted mean difference [WMD], 6.19; 95% confidence interval [CI], 2.51-9.87), Charlson scores (WMD, 0.45; 95% CI, 0.09-0.80), acute liver failure (odds ratio [OR], 1.82; 95% CI, 1.27-2.61), serum creatinine (WMD, 71.33 μmol/L; 95% CI, 1.98-140.69 μmol/L), total bilirubin level (WMD, 5.05 μmol/L; 95% CI, 1.75-8.35 μmol/L), intensive care unit admission (OR, 3.53; 95% CI, 1.23-10.13), vasoactive therapy (OR, 3.80; 95% CI, 2.64-5.46), ventilator care (OR, 2.52; 95% CI, 1.18-5.35), and renal replacement therapy (RRT) (OR, 29.37; 95% CI, 7.66-112.54) compared with control patients. IORRT patients also required more intraoperative blood product transfusion and had more post-LT RRT (OR, 25.67; 95% CI, 4.92-133.85). However, there were no significant differences in short-term mortality (OR, 2.12; 95% CI, 0.82-5.44) between the groups. In addition, worse longterm mortality was seen in the IORRT group. In conclusion, IORRT is feasible and safe and may help sicker recipients tolerate the LT procedure to achieve short-term clinical outcomes comparable with less ill patients without IORRT. More high-quality evidence is needed to verify our conclusion in the future.