Intraoperative Use Of Tranexamic Acid Research Articles

An Algorithm for Control of Excessive Perioperative Bleeding and Ecchymosis in Rhinoplasty Patients Based on 4 Decades of Experience.

Persistent intraoperative bleeding, excessive post-operative ecchymosis, epistaxis, or blood collection in the supratip area increases the complexity of rhinoplasty, causing suboptimal outcomes. We present an intraoperative bleeding management algorithm developed by the senior author (B.G.) based on 43 years of experience and assess its efficacy in achieving hemostatic control through 103 consecutive cases. A retrospective chart review was conducted on 103 consecutive patients who had undergone septorhinoplasty by a single surgeon. Patient demographics, coagulopathies, medications, diet, intraoperative use of tranexamic acid (TXA), desmopressin (DDAVP), Vitamin K, and post-operative complications were reviewed. Twenty-six (25.2%) patients did not receive intraoperative hemostatic agents. Twenty-six (25.2%) patients required TXA only, three (2.91%) patients were given DDAVP only, one (0.97%) patient received Vitamin K only, and forty-six (44.7%) patients required both TXA and DDAVP. One (0.97%) patient needed TXA, DDAVP, and vitamin K. Intraoperative bleeding was controlled in all patients. One patient with known factor 11 deficiency received both TXA and DDAVP intraoperatively but did not require fresh frozen plasma. Intraoperative bleeding was controlled by first administering 10 mg/kg of TXA intravenously, followed by DDAVP with a maximum dose of 0.3 mcg if needed, and 10 mg of Vitamin K if bleeding persisted. Patients with known type I or IIa Von Willebrand disease received DDAVP preoperatively. No patient experienced post-operative epistaxis, thromboembolism, or other associated complications. The algorithm of TXA, DDAVP, and Vitamin K is effective in controlling excessive intraoperative bleeding, post-operative ecchymosis, and epistaxis. IV.

Same-Day Discharge vs. Inpatient Total Shoulder Arthroplasty: An Age Stratified Comparison of Postoperative Outcomes and Hospital Charges

As the number of total shoulder arthroplasty (TSA) procedures increases, there is a growing interest in improving patient outcomes, limiting costs, and optimizing efficiency. One approach has been to transition these surgeries to an outpatient setting. Therefore, the purpose of this study was to conduct an age-stratified analysis comparing the 90-day postoperative outcomes of primary TSA in the same-day discharge (SDD) and inpatient (IP) settings with a specific focus on the super-elderly. This retrospective study included all patients who underwent primary anatomic or reverse TSA between January 2018 and December 2021 in ambulatory and inpatient settings. The outcome measures included LOS, complications, hospital charges, ED utilization, readmissions, and reoperations within 90-days following TSA. Patients with LOS ≤8 hours were considered as SDD, and those with LOS >8 hours were considered as IP. P <0.05 was considered statistically significant. There were 121 and 174 procedures performed in SDD and IP settings, respectively. There were no differences in comorbidity indices between the SDD and IP groups (ASA score P=0.12, ECI P=0.067). The SDD cohort was younger than the IP group (SDD 67.0 years vs. 73.0 IP years, P<0.001), and the SDD group higher rate of intraoperative tranexamic acid use (P=0.015) and lower estimated blood loss (P=0.009). There were no differences in 90-day overall minor (P=0.20) and major complications (P=1.00), ED utilization (P=0.63), readmission (P=0.25) or reoperation (P =0.51) between the SDD and IP groups. When stratified by age, there were no differences in overall major (P=0.80) and minor (P=0.36) complications among the groups. However, the LOS was directly correlated with increasing age (LOS=8.4 hours in ≥65 to < 75-year cohort vs. LOS=25.9 hours in ≥80-year cohort; P<0.001). There were no differences in hospital charges between SDD and IP primary TSA in all 3 age groups (P=0.82). SDD TSA has a shorter LOS without increasing postoperative major and minor complications, ED encounters, readmissions, or reoperations. Older age was not associated with an increase in the complication profile or hospital charges even in the SDD setting, although it was associated with increased LOS in the IP group. These results suggest that TSA can be safely performed expeditiously in an outpatient setting. Level III; Retrospective Comparative Study.

The cost-utility of intraoperative tranexamic acid in adult spinal deformity patients undergoing long posterior spinal fusion.

This study aims to evaluate the cost-utility of intraoperative tranexamic acid (TXA) in adult spinal deformity (ASD) patients undergoing long posterior (≥ 5 vertebral levels) spinal fusion. A decision-analysis model was built for a hypothetical 60-year-old adult patient with spinal deformity undergoing long posterior spinal fusion. A comprehensive review of the literature was performed to obtain event probabilities, costs and health utilities at each node. Health utilities were utilized to calculate Quality-Adjusted Life Years (QALYs). A base-case analysis was carried out to obtain the incremental cost and effectiveness of intraoperative TXA. Probabilistic sensitivity analysis was performed to evaluate uncertainty in our model and obtain mean incremental costs, effectiveness, and net monetary benefits. One-way sensitivity analyses were also performed to identify the variables with the most impact on our model. Use of intraoperative TXA was the favored strategy in 88% of the iterations. The mean incremental utility ratio for using intraoperative TXA demonstrated higher benefit and lower cost while being lower than the willingness-to-pay threshold set at $50,000 per quality adjusted life years. Use of intraoperative TXA was associated with a mean incremental net monetary benefit (INMB) of $3743 (95% CI 3492-3995). One-way sensitivity analysis reported cost of blood transfusions due to post-operative anemia to be a major driver of cost-utility analysis. Use of intraoperative TXAs is a cost-effective strategy to reduce overall perioperative costs related to post-operative blood transfusions. Administration of intraoperative TXA should be considered for long fusions in ASD population when not explicitly contra-indicated due to patient factors.

Impact of intraoperative tranexamic acid use on overall survival and cancer specific survival in patients undergoing radical cystectomy.

642 Background: Perioperative blood transfusion has been reported in up to 60% of patients undergoing RC. Unfortunately, perioperative blood transfusion in patient undergoing RC has been associated with poor oncological outcomes. Tranexamic acid (TXA) use has been proposed to decrease the need for perioperative blood transfusion. Here we seek to investigate the impact of intraoperative TXA on survival outcomes in patients undergoing radical cystectomy (RC) for bladder cancer. Methods: We queried the prospectively maintained Mayo Clinic Radical Cystectomy registry and identified all RC performed for bladder cancer between 1990-2021. Primary outcomes were patient’s overall survival and cancer specific survival among patients who received TXA versus patients who did not receive TXA. Results: Among 2929 patients who underwent RC in our institution between 1990-2021, 468 received TXA (IV) intraoperatively (Group A) and were propensity score matched 1:1 for age, neoadjuvant chemotherapy, adjuvant chemotherapy, pT stage, pN stage, and preoperative hemoglobin with a group who did not receive TXA (Group B, n= 468). At 8 years followup, 61% of patients who received TXA were alive versus 46% of patients who did not receive TXA. In univariable and multivariable analyses of factors associated with CSS (Table1), node positive disease, pT2-T4, peri-operative blood transfusion were associated with poor survival outcomes. While use of TXA was associated with improved CSS outcomes. Conclusions: In our study, TXA use in patients undergoing radical cystectomy was associated with decreased risk or peri-operative transfusion, improved patient’s overall survival, and cancer specific survival. We can’t explain the biological rational for improved survival however these findings warrant further prospective investigation. [Table: see text]

Safety of intraoperative tranexamic acid use on the risk of venous thromboembolism (VTE) in patients undergoing robotic assisted radical cystectomy (RARC).

641 Background: Perioperative blood transfusion is associated with an increased risk of adverse events and tranexamic acid (TXA) use has been proposed to decrease the need for perioperative blood transfusion. Herein, we seek to investigate the impact of intraoperative TXA on perioperative risk of VTE in a subset of patients who underwent robotic-assisted radical cystectomy (RARC) for bladder cancer. Methods: We queried the prospectively maintained Mayo Clinic Radical Cystectomy registry and identified patients who underwent RARC between 2004-2021 and received TXA intraoperatively. In univariable and multivariable analyses, we investigated factors associated with bleeding and VTE within 30 days post-operatively. Results: Of 2862 patients, we identified 94 patients who received TXA (IV) intraoperatively (Group A) and were propensity score matched 1:1 for age, neoadjuvant chemotherapy, pT stage, pN stage, and preoperative hemoglobin with a group who did not receive TXA; 38 patients (Group B). In univariable and multivariable models, use of TXA has no statistically significant impact on patient’s risk of bleeding or VTE. In a univariable model, number of positive lymph nodes and extent of lymph node dissection were associated with increased risk of VTE (Table 1). Conclusions: In our study, use of TXA in patient’s undergoing RARC was safe and was not associated with increased risk of VTE. [Table: see text]

Postoperative clinical outcomes with and without short-term intravenous tranexamic acid after posterior lumbar interbody fusion: A prospective cohort study.

The use of tranexamic acid (TXA) in posterior lumbar interbody fusion (PLIF) surgery is believed to be beneficial for reducing intraoperative blood loss, postoperative drainage volume (PDV), and length of hospital stay (LOS). However, whether continued administration of intravenous TXA within 24 hours after surgery is more beneficial to patients has not yet been studied. This study prospectively analyzed the perioperative outcomes of patients who received and did not receive intravenous TXA within 24 hours after PLIF (≥2 segments) surgery from January 2018 to December 2021. A total of 78 and 69 patients were included in the TXA (receive intravenous TXA intraoperatively and within 24 hours postoperatively) and non-TXA (only receive intravenous TXA intraoperatively) groups, respectively. No significant differences were observed in the intraoperative blood loss and operative time between the 2 groups. The postoperative drainage volume, postoperative drainage time, and length of hospital stay in the TXA group were significantly lower than those in the non-TXA group. The rates and volumes of postoperative blood and albumin transfusions were significantly lower in the TXA group than those in the non-TXA group. No significant differences were observed in the perioperative complication rates between the 2 groups. No increase in thrombosis-related complications was observed with postoperative TXA administration. Short-term TXA use after PLIF (≥2 segments) surgery is safe. In addition to intraoperative use of TXA, additionally administration of intravenous TXA within 24 hours postoperatively can improve the perioperative clinical outcomes of patients without increasing the risk of thrombotic events.

Tranexamic Acid in Reducing Intraoperative Bleeding in Dogs Undergoing Thoracolumbar and Lumbar Hemilaminectomy and Intervertebral Disc Fenestration

Hemilaminectomy associated with intervertebral disc fenestration (HF) is the most used spinal decompression surgical technique for the treatment of intervertebral disc extrusion (IVDE). The surgical procedure can be hampered by excessive bleeding from the venous sinuses; however, tranexamic acid intravenously (IV) is a possible adjunct to hemostasis in these patients. This study aimed to verify the effectiveness of tranexamic acid in reducing intraoperative bleeding in dogs with thoracolumbar and lumbar IVDE submitted to HF. Sixteen dogs with IVDE undergoing HF were included. These were distributed into a TXA group (tranexamic acid 20 mg/kg IV bolus, followed by 2 mg/kg/h IV continuous infusion) (n = 8) and a control group, with saline solution (n = 8). Blood loss was measured using the gravimetric method. The difficulty of operative visualization due to bleeding was classified by the surgeon. Median blood loss (%) in patients in the TXA group was lower than those in the control group (2.75 ± 1.23 and 4.99 ± 4.44, respectively) (P = .028). Intraoperative visualization difficulty due to bleeding occurred in 10 patients in the control group, and in no patients in the TXA group. A severe arterial thromboembolic complication was recorded, potentially due to tranexamic acid. The use of intraoperative tranexamic acid was effective in reducing bleeding and facilitating operative visualization in dogs with IVDE undergoing hemilaminectomy and intervertebral disc fenestration.

Predisposing factors for allogeneic blood transfusion in patients with rheumatoid arthritis undergoing primary unilateral total knee arthroplasty.

To determine the incidence and identify the predisposing factors for allogeneic blood transfusion (ABT) in patients with rheumatoid arthritis (RA) undergoing primary unilateral total knee arthroplasty (TKA). A total of 702 patients with RA who underwent primary unilateral TKA between 2003 and 2022 at a single center, were retrospectively enrolled. Patients were stratified into the ABT and non-ABT groups. Data on patient demographics, laboratory parameters, and disease- and surgery-related parameters were collected from chart reviews and compared between the ABT and non-ABT groups. Multivariate logistic regression analysis was conducted to identify the possible factors associated with postoperative ABT. A total of 173 (24.6%) patients underwent ABT after surgery. Significant risk factors for ABT included the degree of flexion contracture [odds ratio (OR) = 1.018, P = 0.005] and thickness of insertion (OR = 1.170, P = 0.014). Conversely, body mass index (OR = 0.937, P = 0.018), preoperative hemoglobin level (OR = 0.973, P < 0.001), and intraoperative use of tranexamic acid (TXA) (OR = 0.119, P < 0.001) were associated with a lower risk of ABT in TKA. We identified the significant risk and protective factors for ABT during TKA in patients with RA. This information could be helpful in optimizing perioperative blood management strategies during these surgeries.

Intravenous tranexamic acid is associated with an increased risk of pulmonary embolism following sarcoma resection.

Tranexamic acid (TXA) is an antifibrinolytic drug that has been shown to reduce blood loss following surgery. The use of TXA during orthopedic procedures has gained widespread acceptance, with multiple clinical studies demonstrating no increase in thrombotic complications. While TXA has been shown to be safe and effective for several orthopedic procedures, its use in orthopedic sarcoma surgery is not well established. Cancer-associated thrombosis remains a significant cause of morbidity and mortality in patients with sarcoma. It is unknown if intraoperative TXA use will increase the risk of developing a postoperative thrombotic complication in this population. This study aimed to compare the risk of postoperative thrombotic complications in patients who received TXA during sarcoma resection to patients who did not receive TXA. A retrospective review was performed of 1099 patients who underwent resection of a soft tissue or bone sarcoma at our institution between 2010 and 2021. Baseline demographics and postoperative outcomes were compared between patients who did and did not receive intraoperative TXA. We evaluated 90-day complication rates, including: deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), cerebrovascular accident (CVA), and mortality. TXA was used more commonly for bone tumors (p < 0.001), tumors located in the pelvis (p = 0.004), and larger tumors (p < 0.001). Patients who received intraoperative TXA were associated with a significant increase in developing a postoperative DVT (odds ratio [OR]: 2.22, p = 0.036) and PE (OR: 4.62, p < 0.001), but had no increase in CVA, MI, or mortality (all p > 0.05) within 90 days of surgery, following univariate analysis. Multivariable analysis confirmed that TXA was independently associated with developing a postoperative PE (OR: 10.64, 95% confidence interval: 2.23-50.86, p = 0.003). We found no association with DVT, MI, CVA, or mortality within 90 days postoperatively, following intraoperative TXA use. Our results demonstrate a higher associated risk of PE following TXA use in sarcoma surgery and caution is warranted with TXA use in this patient population.

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.

Effectiveness of intraoperative use of tranexamic acid in total knee arthroplasty

Effectiveness of intraoperative use of tranexamic acid in total knee arthroplasty

Intraoperative use of tranexamic acid eliminates bleeding complications in thyroid and parathyroid surgery

Abstract Introduction Postoperative neck bleeding is a rare but life-threatening complication in thyroid and parathyroid surgery. It requires an emergency treatment algorithm to prevent asphyxia and severe brain injury. Tranexamic acid is an antifibrinolytic medication which treats or prevents excessive blood loss in a variety of clinical situations such as, major trauma, postpartum bleeding, and heavy menstruation. We studied the use of tranexamic acid to eliminate the incidence of postoperative neck hematoma. Methods All thyroid and parathyroid patients operated from the same surgical team were evaluated. The patients were divided in two groups: Group A before and Group B after the use of tranexamic acid. The medication was used intravenously to all Group B patients during the hemostasis control and prior the neck wound closure. Results A total of 1457 consecutive patients were studied from 01-01-2001 to 06-06-2021. Group A included 669 patients (620 thyroid and 49 parathyroid patients) from 01-01-2001 until 27-06-2018. Group B included 788 patients (705 thyroid and 83 parathyroid patients) from 27-06-2018 until 06-06-2021. Group A had 15 (2,24% incidence) postoperative neck hematomas and 6 of them (0,89%) required emergency surgical drainage. Group B had no postoperative bleeding episodes with the intraoperative use of tranexamic acid. Conclusion The use of tranexamic acid eliminates postoperative bleeding episodes in thyroid and parathyroid surgery.

Intraoperative use of tranexamic acid in the control of bleeding in long bong fracture surgeries: a meta-analysis

&lt;p class="abstract"&gt;Tranexamic acid (TXA) has been used successfully in the practice of orthopedics to reduce perioperative blood loss, particularly in total hip and knee arthroplasty and spine surgery. The use of TXA has shown potential to reduce blood loss, transfusion rates and volumes, perioperative hemoglobin change and hospital-related costs at various degrees. This review aimed to evaluate the clinical results of the intraoperative use of TXA in long bone fracture surgeries. Relevant electronic articles were reviewed through a systematic search and selection process, resulting in the selection of five randomized control trials with a total of 295 participants. These studies compared the primary outcome of this meta-analysis, which was blood loss. Four of the studies included post-operative hemoglobin levels as their outcomes. Furthermore, two studies compared drop in hemoglobin levels, while three studies included blood transfusion events. Results showed a significant difference in terms of total blood loss when intraoperative administration of TXA was compared to placebo in long bone surgeries with a mean difference of -76.94 [-106.62, -47.26] (95% CI) (p≤0.00001). There was no significant difference in terms of post-operative hemoglobin levels (p=0.27) with a mean difference of 0.31 [-0.24, 0.86] (95% CI). No significant difference was also shown between the two groups as to drop in hemoglobin levels (p=0.29) with a mean difference of -0.34 [-0.97, 0.29] (95% CI). This meta-analysis showed that intraoperative use of TXA given during long bone fracture surgeries can effectively reduce total blood loss and reduce risk of transfusion events or avoid transfusion events.&lt;/p&gt;

Tranexamic acid use decreases transfusion rate in children with cerebral palsy undergoing proximal femoral varus derotational osteotomy.

Previous studies demonstrated the safety of tranexamic acid (TXA) use in cerebral palsy (CP) patients undergoing proximal femoral varus derotational osteotomy (VDRO), but were underpowered to determine if TXA alters transfusion rates or estimated blood loss (EBL). The purpose of this study was to investigate if intraoperative TXA administration alters transfusion rates or EBL in patients with CP undergoing VDRO surgery.We conducted a retrospective review of 390 patients with CP who underwent VDRO surgery between January 2004 and August 2019 at a single institution. Patients without sufficient clinical data and patients with preexisting bleeding or coagulation disorders were excluded. Patients were divided into 2 groups: those who received intraoperative TXA and those who did not.Out of 390 patients (mean age 9.4 ± 3.8 years), 80 received intravenous TXA (TXA group) and 310 did not (No-TXA group). There was no difference in mean weight at surgery (P = .25), Gross Motor Function Classification System level (P = .99), American Society of Anesthesiologist classification (P = .50), preoperative feeding status (P = .16), operative time (P = .91), or number of procedures performed (P = .12) between the groups. The overall transfusion rate was lower in the TXA group (13.8%; 11/80) than the No-TXA group (25.2%; 78/310) (P = .04), as was the postoperative transfusion rate (7.5%; 6/80 in the TXA group vs 18.4%; 57/310 in the No-TXA group) (P = .02). The intraoperative transfusion rate was similar for the 2 groups (TXA: 7.5%; 6/80 vs No-TXA: 10.3%; 32/310; P = .53). The EBL was slightly lower in the TXA group, although this was not significant (TXA: 142.9 ± 113.1 mL vs No-TXA: 177.4 ± 169.1 mL; P = .09). The standard deviation for EBL was greater in the No-TXA group due to more high EBL outliers. The percentage of blood loss based on weight was similar between the groups (TXA: 9.2% vs No-TXA: 10.1%; P = .40). The number needed to treat (NNT) with TXA to avoid one peri-operative blood transfusion in this series was 9.The use of intraoperative TXA in patients with CP undergoing VDRO surgery lowers overall and postoperative transfusion rates.Level of evidence: III, Retrospective Comparative Study.

Use of Tranexamic Acid for Elective Resection of Intracranial Neoplasms: A Systematic Review

As an established antifibrinolytic agent, tranexamic acid (TXA) has garnered widespread use during surgery to limit intraoperative blood loss. In the field of neurosurgery, TXA is often introduced in cases of traumatic brain injury or elective spine surgeries; however, its role during elective cranial surgeries is not well established. We report a systematic review of the use of TXA in elective surgical resection of intracranial neoplasms. We performed this systematic review following PRISMA guidelines to identify studies investigating the use of TXA in elective neurosurgical resection of intracranial neoplasms. Variables extracted included patient demographics, surgical indications, type of surgery performed, TXA dose and route of administration, operative duration, blood loss, transfusion rate, postoperative hemoglobin level, and complications. After careful screening, 4 articles (consisting of 682 patients) met our inclusion/exclusion criteria. The studies included 2 prospective cohort studies, 1 retrospective cohort study, and 1 case series. A χ2 test of pooled data demonstrated that patients administered TXA had a significantly decreased need for blood transfusions during surgery (odds ratio, 0.6273; 95% confidence interval, 0.4254-0.9251; P= 0.018). Mean total blood loss was 821.9 mL in the TXA group and 1099.0 mL in the control group across the studies. There was no significant difference in postoperative hemoglobin levels, with a mean of 11.4 g/dL in both the TXA and control groups. These results support the use of intraoperative TXA in tumor resection. However, its role in tumor resection has been less well investigated compared with its use in other areas of neurosurgery.

Perioperative management of acetabular and pelvic fractures: evidence-based recommendations.

The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF. A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis. A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic. The literature supports the use of radiation therapy for HO prophylaxis, early (< 5days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Influence of tranexamic acid use on venous thromboembolism risk in patients undergoing surgery for spine tumors.

Patients with spine tumors are at increased risk for both hemorrhage and venous thromboembolism (VTE). Tranexamic acid (TXA) has been advanced as a potential intervention to reduce intraoperative blood loss in this surgical population, but many fear it is associated with increased VTE risk due to the hypercoagulability noted in malignancy. In this study, the authors aimed to 1) develop a clinical calculator for postoperative VTE risk in the population with spine tumors, and 2) investigate the association of intraoperative TXA use and postoperative VTE. A retrospective data set from a comprehensive cancer center was reviewed for adult patients treated for vertebral column tumors. Data were collected on surgery performed, patient demographics and medical comorbidities, VTE prophylaxis measures, and TXA use. TXA use was classified as high-dose (≥ 20 mg/kg) or low-dose (< 20 mg/kg). The primary study outcome was VTE occurrence prior to discharge. Secondary outcomes were deep venous thrombosis (DVT) or pulmonary embolism (PE). Multivariable logistic regression was used to identify independent risk factors for VTE and the resultant model was deployed as a web-based calculator. Three hundred fifty patients were included. The mean patient age was 57 years, 53% of patients were male, and 67% of surgeries were performed for spinal metastases. TXA use was not associated with increased VTE (14.3% vs 10.1%, p = 0.37). After multivariable analysis, VTE was independently predicted by lower serum albumin (odds ratio [OR] 0.42 per g/dl, 95% confidence interval [CI] 0.23-0.79, p = 0.007), larger mean corpuscular volume (OR 0.91 per fl, 95% CI 0.84-0.99, p = 0.035), and history of prior VTE (OR 2.60, 95% CI 1.53-4.40, p < 0.001). Longer surgery duration approached significance and was included in the final model. Although TXA was not independently associated with the primary outcome of VTE, high-dose TXA use was associated with increased odds of both DVT and PE. The VTE model showed a fair fit of the data with an area under the curve of 0.77. In the present cohort of patients treated for vertebral column tumors, TXA was not associated with increased VTE risk, although high-dose TXA (≥ 20 mg/kg) was associated with increased odds of DVT or PE. Additionally, the web-based clinical calculator of VTE risk presented here may prove useful in counseling patients preoperatively about their individualized VTE risk.

Tips and Tricks When Performing an Adenomyomectomy

<h3>Study Objective</h3> To present principles and techniques for safe and efficient laparoscopic surgery during excision of an adenomyoma. <h3>Design</h3> Stepwise educational demonstration of techniques with narrated video footage. <h3>Setting</h3> Adenomyomas are not always easily excised and often a surgical plane cannot be easily identified. Similar to myomectomies, an adenomyomectomy may be associated with increased blood loss. In this video, we review key principles and techniques to safely perform a laparoscopic adenomyomectomy. <h3>Patients or Participants</h3> 33-year-old female with a 9cm uterine mass experiencing menorrhagia and dysmenorrhea. <h3>Interventions</h3> The key principles for safe and effective laparoscopic adenomyomectomy include: - Preoperative administration of Misoprostol - Instillation of Vasopressin in planned incision line - Intraoperative use of tranexamic acid - Performing a uterine artery ligation - Knowledge of anatomical landmarks - Performing a careful dissection - Uterine instillation of methylene blue - Appropriate instrument use <h3>Measurements and Main Results</h3> The patient recovered well without any postoperative complications. <h3>Conclusion</h3> Adenomyoma excision can be safely performed if one understands appropriate surgical techniques and solutions to improve surgical outcomes.

Institutionally Adopted Perioperative Blood Management Program Significantly Decreased the Transfusion Rate of Patients Having Primary Total Hip Replacement Surgery

Perioperative transfusion in patients undergoing orthopedic surgery increases the number of postoperative complications. Thus, we have introduced an institution-tailored perioperative blood management program (PBM) to decrease the amount of blood transfused in patients going through primary total hip replacement (THR) surgery. We have conducted a before-after observational cohort study in two predetermined observational periods. Demographic and clinical data, ASA scores, laboratory parameters, features of surgical procedure, and anesthesia were registered. Parameters of perioperative fluid administration, transfusion rate, and postoperative complications were also assessed. One hundred patients in the first and 108 patients in the second observational period were enrolled. Eventhough the ratio of posttraumatic THR procedures increased (9% vs. 17%), the PBM protocol has been utilized effectively and a significant decrease in perioperative blood transfusion rate has been observed (61% vs. 21%). The abolishment of routine preoperative LMWH prophylaxis (90% vs. 16%), intraoperative use of tranexamic acid (10% vs. 84%), and the encouraged exploitation of our postoperative observational facility (5% vs. 39%) were abided by our colleagues. Patients still requiring transfusion had lower preoperative hemoglobin levels (129 vs. 147 g/l), scored higher in ASA (ASA III: 46% vs. 19%), and more often presented postoperative hypotension (40% vs. 7%), oliguria (23% vs. 5%), and infections (9% vs. 2%). We conclude that the individualized perioperative blood management protocol was successfully implemented and yielded a lower transfusion rate and better outcomes. Our study suggests that a partial, institution-tailored PBM program may be suitable and beneficial in countries where the modalities of perioperative blood management are limited.

A break-even analysis of tranexamic acid for prevention of periprosthetic joint infection following total hip and knee arthroplasty

PurposeDespite the commonplace use of tranexamic acid in total joint arthroplasty, much of the current data regarding its cost-effectiveness examines savings directly related to its hemostatic properties, without considering its protective effect against periprosthetic joint infections. Using break-even economic modeling, we calculated the cost-effectiveness of routine tranexamic acid administration for infection prevention in total joint arthroplasty. Materials and methodsThe cost of intraoperative intravenous tranexamic acid, the cost of revision arthroplasty for periprosthetic joint infections, and the baseline rates of periprosthetic joint infections in patients who did not receive intraoperative tranexamic acid were obtained from the literature and institutional purchasing records. Break-even economic modeling incorporating these variables was performed to determine the absolute risk reduction in infection rate to make routine intraoperative tranexamic acid use economically justified. The number needed to treat was calculated from the absolute risk reduction. ResultsRoutine use of intraoperative tranexamic acid is economically justified if it prevents at least 1 infection out of 3125 total joint arthroplasties (absolute risk reduction = 0.032%). Cost-effectiveness was maintained with varying costs of tranexamic acid, infection rates, and periprosthetic joint infection costs. ConclusionThe routine use of intraoperative tranexamic acid is a highly cost-effective practice for infection prevention in primary and revision total joint arthroplasty. The use of tranexamic acid is warranted across a wide range of costs of tranexamic acid, initial infection rates, and costs of periprosthetic joint infection treatment.