Lower Transfusion Requirements Research Articles

Grade V renal trauma management: results from the multi-institutional genito-urinary trauma study.

To investigate management trends for American Association for the Surgery of Trauma (AAST) grade V renal trauma with focus on non-operative management. We used prospectively collected data as part of the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We included patients with grade V renal trauma according to the AAST Injury Scoring Scale 2018 update. All cases submitted by participating centers with radiology images available were independently reviewed to confirm renal trauma grade. Management was classified as expectant, conservative (minimally invasive, endoscopic or percutaneous procedures), or operative (renal-related surgery). Eighty patients were included, 25 of whom had complete imaging and had independent confirmation of AAST grade V renal trauma. Median age was 35years (Interquartile range (IQR) 25-50) and 23 (92%) had blunt trauma. Ten patients (40%) were managed operatively with nephrectomy. Conservative management was used in nine patients (36%) of which six received angioembolization and three had a stent or drainage tube placed. Expectant management was followed in six (24%) patients. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size and laceration size. Vascular contrast extravasation was more likely in operatively managed patients though a statistically significant association was not found. Successful use of nonoperative management for grade V injuries is used for a substantial subset of patients. Lower transfusion requirement and less severe injury radiologic phenotype appear to be important characteristics delineating this group.

The Use of Tranexamic Acid in Hip Fracture Surgery-A Systematic Review and Meta-analysis.

To analyze the effect of intravenous tranexamic acid (TXA) on blood transfusion requirements in adult patients undergoing hip fracture surgery. Secondary aim was to evaluate the safety by assessing thromboembolic events. Cochrane Central Register of Controlled Trials, Medline, PubMed, and Embase were searched for randomized controlled trials published in English from 2010. Studies eligible for inclusion were randomized controlled trials that analyzed the use of intravenous TXA on blood transfusion requirement in hip fracture surgery. Titles and abstracts were screened and assessed for eligibility by 2 independent reviewers. Quality and risk of bias was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach and the Cochrane risk-of-bias tool (RoB2). Meta-analysis with random and fixed effect models was performed. Risk ratio (RR) was calculated for dichotomous outcomes and estimated with a 95% confidence interval (CI). For continuous data, the risk difference (RD) was estimated with a 95% CI. A total of 13 trials involving 1194 patients were included. Pooled results showed that patients in the TXA group had significantly lower transfusion requirements (RR 0.50, 95%CI 0.30-0.84, P = 0.009). Similar findings were observed in the subcohort of patients with transfusion threshold of Hb < 8g/dL, (RR 0.42, 95%CI 0.31-0.56, P < 0.0001). This risk reduction was not observed in the subcohort of patients with transfusion threshold of Hb 8.1-10g/dL who received TXA (RR 0.77, 95%CI 0.51-1.18, P = 0.23) and no statistically significant differences were found for total thromboembolic events (RR 0.01, 95%CI -0.02-0.04, P = 0.47). This meta-analysis demonstrated that intravenous TXA reduced blood transfusion rates and did not increase the risk of thromboembolic events. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of iliofemoral conduits during fenestrated-branched endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms

ObjectiveTo describe the technical pitfalls and outcomes of iliofemoral conduits during fenestrated-branched endovascular repair (FB-EVAR) of complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs). MethodsWe retrospectively reviewed the clinical data of 466 consecutive patients enrolled in a previous prospective nonrandomized study to investigate FB-EVAR for CAAAs/TAAAs (2013-2021). Iliofemoral conduits were performed through open surgical technique (temporary or permanent) in patients with patent internal iliac arteries or endovascular technique among those with occluded internal iliac arteries. End points were assessed in patients who had any iliac conduit or no conduits, and in patients who had conduits performed prior or during the index FB-EVAR, including procedural metrics, technical success, and major adverse events (MAE). ResultsThere were 138 CAAAs, 141 extent IV, and 187 extent I-III TAAAs treated by FB-EVAR with an average of 3.89 ± 0.52 vessels incorporated per patient. Any iliac conduit was required in 35 patients (7.5%), including 24 patients (10.4%) treated between 2013 and 2017 and 11 (4.7%) who had procedures between 2018 and 2021 (P = .019). Nineteen patients had permanent conduits using iliofemoral bypass, 11 had temporary iliac conduits, and 5 had endoconduits. Iliofemoral conduits were necessary in 12% of patients with extent I to III TAAA, in 6% with extent IV TAAA, and in 3% with CAAA (P = .009). The use of iliofemoral conduit was more frequent among women (74% vs 27%; P < .001) and in patients with chronic obstructive pulmonary disease (49% vs 28%; P = .013), peripheral artery disease (31% vs 15%; P = .009), and American Society of Anesthesiologists classification of III or higher (74% vs 51%; P = .009). There were no inadvertent iliac artery disruptions in the entire study. The 30-day mortality and MAE were 1% and 19%, respectively, for all patients. An iliofemoral conduit using retroperitoneal exposure during the index FB-EVAR was associated with longer operative time (322 ± 97 minutes vs 323 ± 110 minutes vs 215 ± 90 minutes; P < .001), higher estimated blood loss (425 ± 620 mL vs 580 ± 1050 mL vs 250 ± 400 mL; P < .001), and rate of red blood transfusion (92% vs 78% vs 32%; P < .001) and lower technical success (83% vs 87% vs 98%; P < .001), but no difference in intraoperative access complications and MAEs, compared with iliofemoral conduits without retroperitoneal exposure during the index FB-EVAR and control patients who had FB-EVAR without iliofemoral conduits, respectively. There were no differences in mortality or in other specific MAE among the three groups. ConclusionsFB-EVAR with selective use of iliofemoral conduits was safe with low mortality and no occurrence of inadvertent iliac artery disruption or conversion. A staged approach is associated with shorter operating time, less blood loss, and lower transfusion requirements in the index procedure.

Comparison of the Results of Suture and Resorbable Plate-Screw Fixation in Craniosynostosis

Although many fixation methods are used alone or in combination for craniosynostosis, only few studies have compared the effectiveness and long-term results of these methods. In this study, patients in whom suture or resorbable plate-screw system was used for fixation were evaluated in terms of postoperative results and complications. The data of patients who underwent surgery for craniosynostosis between 2002 and 2019 were retrospectively reviewed and evaluated. A total of 70 patients, 41 in the suture group and 29 in the resorbable plate-screw group, were included in the study. Whitaker classification was used for head shape evaluation, and anthropometric head circumference measurements were performed in all patients in the preoperative and postoperative periods. In the postoperative period, all patients were compared in terms of the operation time, transfusion requirement, discharge, follow-up period, and complications according to the chosen fixation method.The mean age, postoperative complication rates, anthropometric head circumference measurements, and Whitaker scores of both groups were found to be statistically similar. Although the resorbable plate-screw group had a longer follow-up period, the operation time was longer in the suture group. Furthermore, the suture group had lower transfusion requirement and earlier discharge from the hospital than the resorbable plate-screw group. If fixation with suture is chosen in suitable patients, in addition to the low patient cost, this method can be safely applied in centers with limited logistical possibilities, because of the results and complication rates being similar to fixation with resorbable plate-screws.

Kualitas Hasil Uji Limbah Pool-Plasma Komponen Packed Red-Blood Cell (PRC) Sebagai Antisera Golongan Darah ABO

PRC is the most needed component for current blood transfusion. Plasma is one of the separation product of PRC from whole blood. These components are often discarded due to low plasma transfusion requirements. The residual plasma contains natural ABO agglutinins that can be utilized as polyclonal antisera in blood grouping tests. This study aims to determine the quality of pool residual plasma of PRC component as the ABO blood grouping antisera. This research uses descriptive analytic design in the form of comparative study. Samples of the test materials and the testers were obtained by purposive sampling, which consisting of each 20 units of A, B and O (positive control) plasma, and also 2 units of AB plasma (negative control) as the test materials, and each 25 of A and B fresh blood specimens as the tester materials. All of those materials should meet the inclusion and exclusion criteria of this study. According to their blood type, each of the plasma were mixed proportionaly according to its weight. Then, each pool-plasma and the commercial antisera were tested together against the same fresh blood specimens by the slide method. The degree of each agglutination was observed by 2 panelists, and then analyzed statistically by Wilcoxon Signed Rank Test with error rate (α) = 5%. The degree of agglutination by using the B pool-plasma against the A fresh blood was obtained in proportions of 8.0% (2+), 38.0% (3+) and 54.0% (4+) with the difference in proportion of 34.0% (3+) higher and 42.0% (4+) lower than anti-A commercial antisera. Meanwhile, by using the A pool-plasma against the B fresh blood was obtained in proportion of 18,0% (3+) and 82,0% (4+) with difference in proportion of 18,0% (3+) higher and 18,0% (4+) lower than anti-B commercial antisera. There are significant differences between the commercial antisera and the pool residual plasma as blood grouping test materials based on observation of all panelists (p value = 0.000).

Right minithoracotomy and resternotomy approach in patients undergoing a redo mitral valve procedure.

OBJECTIVESA minimally invasive approach via a thoracotomy is an alternative in challenging redo cardiac procedures. Our goal was to present our early postoperative experience with minimally invasive cardiac surgery via a right minithoracotomy (minimally invasive) and resternotomy in patients undergoing a mitral valve procedure as a reoperation.METHODSFrom 2017 until 2020, reoperation of the mitral valve was performed through a right-sided minithoracotomy in 27 patients and via a resternotomy in 26 patients. Patients with femoral vessels suitable for cannulation underwent a minimally invasive technique. Patients requiring concomitant procedures regarding the aortic valve were operated on via a resternotomy.RESULTSThe mean age was 66 ± 12 years in the minimally invasive group and 65 ± 12 years in the whole cohort. The average Society of Thoracic Surgeons score was 11 ± 10% in the minimally invasive group and 13 ± 9% in all patients. The majority of the patients underwent reoperation because of severe mitral valve insufficiency (48% and 55%, respectively). The mean time to reoperation was 7 ± 9 years (minimally invasive group). The 30-day mortality was 4% in the minimally invasive group and 11% in the whole cohort. The blood loss was 566 ± 359 ml in the minimally invasive group and 793 ± 410 ml totally. There were no postoperative neurological complications in the minimally invasive group and 1 (2%) in the whole cohort. Postoperative echocardiography revealed competent mitral valve/prosthesis function in all patients.CONCLUSIONSA minimally invasive approach for a mitral valve reoperation in selected patients is a safe alternative to resternotomy with a low transfusion requirement. Both surgical techniques are associated with good postoperative outcomes.

Dyserythropoiesis Evaluated By Red Score and Hepcidin/Ferritin Levels Predicts Response to Epoetin Zeta in Lower Risk MDS

▪INTRODUCTION: Erythropoiesis stimulating agents (ESA) are generally the first line of treatment of anemia in lower risk myelodysplastic syndrome (MDS) patients (pts) with a recent approval of epoetin alfa in this indication in EU. Predictive factors of response to ESA (E Hellström, BJH 2003, S Park et al, Blood 2008, V Santini et al, Blood 2013; O Kosmider et al., Haematologica 2016) include low RBC transfusion requirement, low serum EPO level, serum ferritin (SF) level<300ng/ml, low IPSS-R, and ≤2 somatic mutations. In a clinical trial using a biosimilar (epoetin zeta) in lower risk MDS pts, we investigated new biomarkers using flow cytometry (Ogata and Red Scores) (Mathis et al, Leukemia 2013), somatic mutations, GDF-15 and hepcidin levels.METHODS: Main inclusion criteria for this multicenter prospective trial involving 16 French centers from 2013 to 2017 were: (1) IPSS low or int-1 MDS (2) ESA naive, (3) with Hb level< 10g/dL, transfusion dependent (TD) or not (4) without unstable cardiovascular disease, renal failure, folates, vitamin B12 or iron deficiency or active inflammatory status. Pts received epoetin zeta 40000 IU/week for at least 12 weeks and erythroid response (HI-E, IWG 2006 criteria) was assessed at W12. sEPO level, iron homeostasis markers, Ogata and Red Score (RS), GDF15, hepcidin, and molecular analysis by NGS on a 39-gene panel were determined at baseline (T0), and Ogata and RS were reassessed at W12.RESULTS: 70 pts were included. Median age was 78 years (range 57-93), M/F: 31/39. At inclusion, WHO classification was 22 RCMD, 19 RCUD, 14 RARS, 4 RAEB, 6 CMML, 2 del 5q-, 3 unclassifiable, IPSS was 43 low (61.4%), 27 int-1 (38.5%), and R-IPSS was 13 very low (18.5%), 47 low (67%), 9 int (13%) and high (0.7%). Twenty (28.5%) pts were TD (median of 2 RBC/ 8weeks). ECOG was ≥1 in 30 pts.Median Hb level was 9.5g/dL (IQR 8.9-10), Transferrin Saturation (TS) 39% (IQR 28-56), SF 411 ng/ml (IQR 258-831), sEPO level 49 U/L (IQR 25-122). Median Ogata score was 1 (IQR 1-2) at T0 and 2 (IQR 1-2) at W12. Median Red score (RS) was 7 (IQR 5-7) at T0 (with 90% of pts having RS ≥3), and 5 (IQR 4.75-7) at W12.Median GDF15 level was 1971 pg/ml (IQR 1236-2860). GDF15 was lower in IPSS low vs int-1 pts, and correlated with TS (p<0.003). Hepcidin level was 27 ng/ml (IQR 14-42; normal 1.3-26.4). Median hepcidin/ferritin ratio (HFR) was 5.5 (IQR 1.9-11.85). HFR was inversely correlated with MCV, serum iron, TS, GDF15, and RS at T0 and at W12, and with the number of mutations.Before treatment, NGS was performed in 68 pts. Most frequent mutations involved SF3B1 (n=26), TET2 (n=18), ASXL1 (n=14), SRSF2 (n=9), DNMT3A (n=9), U2AF1 (n=7), IDH2 (n=6), and EZH2 (n=6). No, 1, 2, 3, 4 or 5 mutations were detected in 12, 12, 26, 10, 7 and 1 pts respectively, and 26% of pts had >2 mutations.The erythroid response (HI-E) rate was 47.6%. Median duration of response was 13 months. Three pts progressed to AML. Twelve pts had died. Median OS was 41 mo.Responders had significantly lower baseline RS (median 5 in responders vs 7 in non-responders, p=0.01), higher HFR (median 9 vs 4.8, p=0.04), lower IPSS (p=0.01). GDF15 tended to be lower in responders (1822 pg/mL) vs non-responders (2180 pg/mL; p=0.47). Age, sex, ECOG, blood cell count (ANC, platelets, Hemoglobin), number and type of mutations, IPSS-R, SF, sEPO level, T0 and W12 Ogata score, previous RBC transfusions, decrease of RS and of Ogata score between T0 and W12 were not significantly associated with response. In multivariate analysis, only RS≥5 at T0 was significantly associated with worse HI-E (p= 0.007, OR 19, 95% IC: 2.1-476). HI-E was 39% in pts with RS≥5 vs 75% in pts with RS<5.CONCLUSION: Erythroid response (HI-E) to epoetin zeta was 48% in lower risk MDS and was correlated with higher baseline hepcidin/ferritin ratio and lower Red score at T0. In multivariate analysis, only Red Score≥5 was associated with worse HI-E, in this population with very low median sEPO level. DisclosuresMaloisel:Pfizer/Hospira: Research Funding. Drenou:Alexion: Consultancy, Honoraria. Fenaux:Celgene: Honoraria, Research Funding; Amgen: Honoraria, Research Funding; Amgen: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Astex: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Astex: Honoraria, Research Funding. Laribi:MUNDIPHARMA: Research Funding; NOVARTIS: Honoraria, Research Funding; ROCHE: Research Funding; TEVA: Research Funding; HOSPIRA: Research Funding; AMGEN: Honoraria; TAKEDA: Honoraria, Research Funding. Pegourie:Takeda, Novartis, Janssen, BMS: Consultancy. Wagner Ballon:Alexion: Consultancy, Honoraria. Park:Celgene: Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; Hospira/Pfizer: Research Funding.

O42: THE ROLE OF TOURNIQUETS IN TRANSTIBIAL AMPUTATION FOR PERIPHERAL VASCULAR DISEASE: A SYSTEMATIC REVIEW &amp; META-ANALYSIS

Abstract Introduction The use of lower limb tourniquets is traditionally discouraged in severe atherosclerotic disease. However, blood loss and increased transfusion requirements are associated with post-operative morbidity in patients undergoing major lower limb amputation. The aim of this systematic review is to summarise and pool the available data to determine the impact of tourniquet application when performing trans-tibial amputation for peripheral vascular disease. Method This systematic review was conducted according to PRISMA guidelines. A systematic search of Medline, Embase and Cochrane Library was undertaken for articles which compared the use of a tourniquet versus no tourniquet in patients undergoing trans-tibial amputation for peripheral vascular disease. The main outcomes included intra-operative blood loss, post-operative transfusion requirement, need for revision surgery and 30-day mortality. Result Four studies met the inclusion criteria for quantitative analysis with a total of 267 patients. A tourniquet was used in 130 patients. Both groups were matched for age, gender, co-morbidities and pre-operative haemoglobin. In patients undergoing trans-tibial amputation, tourniquets were associated with significantly lower intra-operative blood loss (Mean difference= -147.6mls; P=0.03) and lower transfusion requirements (pooled odds ratio (OR), 0.12, p=0.03). The need for stump revision (OR, 0.7; p=0.48), proceeding to transfemoral amputation within 30 days (OR, 0.67; p=0.25) and 30-day mortality (OR, 0.65; p=0.41) all favoured tourniquet use but the differences were not found to be significant. Conclusion Tourniquets can reduce intra-operative blood loss and transfusion requirements in patients undergoing trans-tibial amputation without increasing ischaemic complications and need for revision surgery. Take-home message Tourniquets are safe to use in trans-tibial amputation for severe peripheral vascular disease and can reduce intra-operative blood loss without increasing ischaemic complications.

SUCCESSFUL ROBOTIC MITRAL VALVE REPAIR OF ENDOCARDITIS WITH LEAFLET PERFORATION IN A HIGH RISK PATIENT

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Indications and timing of surgery for infective endocarditis are theoretically well framed but in practice, may be difficult to employ based on the patient's clinical status, co-morbidities and overall operative risk. We present a patient with methicillin susceptible staphylococcus aureus (MSSA) endocarditis in whom complex decision making was done for appropriate treatment. CASE PRESENTATION: A 39-year-old year old female with sickle cell disease and end stage renal disease on hemodialysis presented with septic arthritis and resulting MSSA bacteremia. Initial transesophageal echocardiogram (TEE) revealed a 1.4 x 0.6 cm mobile density on the A3 leaflet with associated P2 leaflet prolapse and perforation, as well as severe mitral regurgitation (MR). Multiple masses was also seen on the tip of the dialysis catheter and in the superior vena cava. The decision was made initially to defer cardiac surgery until multiple other sources of infection could be controlled, including dialysis catheter removal, abscess drainage of an old arteriovenous graft and septic arthritis debridement. Bacteremia cleared within a week of oxacillin treatment. Repeat TEE at the end of 6 week of antibiotics revealed resolution of A3 leaflet vegetation, but a new 0.8 cm mass was seen on the P2 leaflet with prolapse again with severe MR. Despite her multiple co-morbidities and severe de-conditioning from her prolonged hospital stay, the decision was made to proceed with surgery and to pursue robotic mitral valve repair with an annuloplasty ring and leaflet perforation closure over a traditional sternotomy approach. Her postoperative course was uneventful. DISCUSSION: Surgery was indicated in our patient due to the severe valve dysfunction with leaflet perforation and a staphylococcus aureus vegetation > 1cm. There is no consensus on the exact timing of surgery, especially in a severely debilitated high risk patient with multiple extra cardiac foci of infection. In our patient surgery was initially delayed to allow for optimal infection control along with an attempt to improve her global preoperative status. But failure of antibiotic treatment made surgery inevitable. The mortality or morbidity of open mitral valve repair is 32% per the Society of Thoracic Surgeons risk calculator, while studies report as low as 2% mortality with robotic repair. Minimally invasive surgery offers lower transfusion requirements, sternal wound complications along with a shorter hospital stay. Ring annuloplasty and leaflet repair was chosen over traditional valve replacement as ESRD predisposes to accelerated valve calcification and to avoid long term anticoagulation in this young patient with hemoglobinopathy. CONCLUSIONS: Robotic valve repair with experienced operator is the preferred option for high risk surgical patients. A multidisciplinary team approach with advanced surgical management is vital in complex endocarditis. Reference #1: Kang D Timing of surgery in infective endocarditis Heart 2015;101:1786-1791. Reference #2: Gillinov AM, Suri R, Mick S, Mihaljevic T. Robotic mitral valve surgery: current limitations and future directions. Ann Cardiothorac Surg. 2016;5(6):573–576. doi:10.21037/acs.2016.03.13 DISCLOSURES: No relevant relationships by Arnar Geirsson, source=Web Response No relevant relationships by Daniel Gomez, source=Web Response No relevant relationships by Gini Priyadharshini Jeyashanmugaraja, source=Web Response No relevant relationships by Kristin Stawiarski, source=Web Response No relevant relationships by stuart zarich, source=Web Response

Reversing Bleeding Associated With Antiplatelet Use: The Role of Tranexamic Acid.

Dual antiplatelet therapy (DAPT) is the mainstay of therapy in patients that have been diagnosed with coronary artery disease. DAPT has known risk factors such as an increased risk of bleeding, and, currently, no specific medication is indicated to reverse bleeding associated with antiplatelet use. One medication that may help reduce blood loss is tranexamic acid (TXA). A retrospective review of the literature regarding TXA in the setting of antiplatelet associated bleeding through a systematic search strategy was conducted. This review of the literature followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines and included seven studies. Multiple studies demonstrated the impact on platelet function resulting from administering TXA through lower volumes of blood loss, lower transfusion requirements, and lower incidence of reoperations. TXA is not widely recommended to reverse antiplatelet medications; however, it is widely available, has a positive track record for use in various types of bleeding, and is relatively inexpensive and safe. Large-scale randomized trials are warranted to make a strong recommendation for TXA in reversing bleeding associated with antiplatelet therapy.

Tu1485 ENDOSCOPIC BAND LIGATION COMPARED TO THERMAL THERAPY FOR GASTRIC ANTRAL VASCULAR ECTASIA: A SYSTEMATIC REVIEW AND META-ANALYSIS

Gastric antral vascular ectasia (GAVE) is an infrequent cause of gastrointestinal-related blood loss and is associated with portal hypertension and cirrhosis. Bleeding from GAVE is associated with increased healthcare burdens as it entails multiple endoscopies, hospitalizations, and blood transfusions. Endoscopic therapy remains the mainstay of treatment and most commonly involves endoscopic thermal therapy (ETT) with argon plasma coagulation (APC) or heat probe. Endoscopic band ligation (EBL) has been studied as an alternative therapy with promising results. The primary aim was to compare the efficacy of EBL and ETT in terms of the average number of post-procedural mean transfusion requirements and mean hemoglobin change. The secondary aim was to compare the number of sessions needed for cessation of bleeding from GAVE. PubMed, Medline, SCOPUS, and Cochrane Controlled Trials Register were reviewed. Randomized controlled trials and retrospective studies comparing EBL and ETT in bleeding GAVE with a follow up period of at least 6 months were included. OpenMetaAnalyst was used for the statistical analysis, which was performed using the random-effects model, and mean difference (MD) with 95% confidence intervals (CI) were evaluated for the quantitative analyses of all outcomes. Our database search yielded a total of 516 papers. After removing duplicates, excluding papers published in languages other than English, and removing pediatric studies and those not looking at our outcomes of interest, 5 studies were selected for analysis (1–5). Of the selected studies, 3 were retrospective and 2 were randomized control trials. The pooled number of included patients was 207. EBL was performed in 93 patients and ETT was performed in 114 patients. Our meta-analysis showed that over a follow-up period of at least 6 months, patients treated with EBL had significantly lower post-procedural transfusion requirements compared to the those in ETT group with a mean difference of 2 transfusions [MD -2.092; 95% CI (-2.419 – -1.766)]. There was no difference in the mean hemoglobin change after either EBL or ETT [MD 0.920; 95% CI (0.392 – 1.449)]. There was a trend towards a lower average of required sessions with EBL compared to APC, but that was not statically significant [MD -1.135; 95% CI (-2.271 - 0.001)]. While the number of procedures required and the post-procedural hemoglobin changes are not different between bleeding GAVE patients treated with EBL and those treated with ETT, the lower transfusion requirements may lead to decreased healthcare burden and costs.

Penetrating Renal Trauma: Nonoperative Management is Safe in Selected Patients

Present literature seems to support the nonoperative management of penetrating renal trauma although data remain limited. We conducted a nine-year retrospective review of nonoperative versus operative management and mechanism of injury [stab wound (SW) versus gunshot wound (GSW)] among patients admitted with penetrating renal trauma. Of 203 patients, the median age was 24 years, with the majority being male and having GSW injuries. More than half (52.2%) were treated nonoperatively (69.9% of SW and 40% of GSW injured patients). When compared with all operative patients combined, nonoperative patients had a lower median Injury Severity Score (17 vs 26, P < 0.001), lower transfusion requirement (27.4% vs 77.3%, P < 0.001), shorter median hospital stay (4.7 vs 12.6 days, P < 0.001), and lower mortality (1.9% vs 13.4%, P = 0.002). Gunshot wound patients had a higher median Injury Severity Score (26 vs 14, P < 0.001), higher median American Association for the Surgery of Trauma-Organ Injury Score (3 vs 2, P = 0.001), greater need for transfusion (69.2% vs 29.3%, P < 0.001), longer median hospital length of stay (12.1 vs 3.9 days, P < 0.001), and greater mortality (12.5% vs 0%, P < 0.001) than SW patients. Nonoperative management of penetrating renal injury is safe in selected patients. In addition, renal GSW injuries are associated with a greater morbidity and mortality.

Impact of intraoperative hypovolemic phlebotomy on blood loss and perioperative transfusion in patients undergoing hepatectomy for cancer

Background: Intraoperative blood loss (IOBL) and allogeneic blood transfusion are important determinants of outcome in patients undergoing elective hepatectomy for cancer. We assessed whether intraoperative hypovolemic phlebotomy (HP) used to perform hepatectomy under low central venous pressure (CVP) was associated with lower IOBL and perioperative transfusion rates, and whether these factors were linked to patient oncological outcomes. Methods: Restrospective analysis of a prospectively maintained database of consenting patients who underwent hepatectomy for primary and secondary liver malignancies between 01/2011 and 06/2017 in one academic center. Perioperative blood transfusion was defined as red blood cell unit transfused during hepatectomy until hospital discharge, and data were extracted from the hospital transfusion medicine database. We used the Fisher’s exact test to compare proportions, the Mann-Whitney or the Kruskal-Wallis tests to compare means, the Spearman r test for correlations, and Log Rank test and Cox regression for associations of variables with survival outcomes. Results: Intraoperative HP was used in 520 (76.0%) of the 684 patients included in this study. The median phlebotomy volume was 400 ml (range 50 to 900 ml), and median volume per patient weight was 5.3 ml/kg (range 0.5 to 30.1 ml/kg). Patients with large HP (>5.3 ml/kg) had lower IOBL than those with smaller HP (507 ml vs. 640.2 ml, p = 0.008). HP volume/weight was negatively correlated with IOBL (Spearman r = -0.11, p = 0.019). The perioperative transfusion rate was 14.6% in patients when HP was used, compared to 22.2% (p = 0.022) when HP was not used. The transfusion rate was lower in HP patients compared to non-HP patients even though more major hepatectomies (≥4 segments) (36.0% vs. 27.1%, p = 0.02) and less laparoscopic surgery (4.9% vs. 11.1%) were done in the HP group. Intraoperative HP reduced the perioperative transfusion risk by 8.9% (relative risk 0.91, 95% CI 0.82 to 0.99), and the number needed to treat to avoid one transfusion was 13 patients. The preoperative three-point transfusion risk score (hemoglobin 12.5 g/dl or less, primary liver malignancy, and resection of ≥ 4 liver segments) stratified patients by low vs. high transfusion requirements (13.3% if score 0 or 1 vs. 31% if score 2 or 3, p < 0.0001), irrespective of the use of HP. We did not find a significant association between IOBL or perioperative transfusions and recurrence-free or disease-specific survival. Conclusion: Intraoperative HP in patients undergoing hepatectomy was associated with lower IOBL and a perioperative transfusion rate of 14.6%, which was lower than non-HP patients and the 22% to 32% rate reported in contemporaneous series. Prospective studies with optimized preoperative hemoglobin level, standardized intraoperative hemostatic and fluid management methods, and defined perioperative transfusion criteria are needed to determine whether HP is superior to other anesthesiological techniques of low CVP for reducing IOBL and transfusion requirements.

Comparison of 7 and 11–12 French Access for REBOA: Results from the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) Registry

Background: The introduction of low-profile devices designed for resuscitative endovascular balloon occlusion of the aorta (REBOA) after trauma has the potential to change practice, outcomes, and complication profiles.Methods: The AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry was used to identify REBOA patients from 16 centers. Presentation, intervention, and outcome variables were compared via traditional 11–12 French access platforms and trauma-specific devices requiring only 7 French access.Results: From November 2013 to December 2017, 242 patients with complete data were identified, constituting 124 7 French and 118 11–12 French uses. Demographics of presentation were not diff erent between the two groups, except that patients using the 7 French had a higher mean Injury Severity Score (39.2 vs. 34.1, p = 0.028). The 7 French was associated with a lower cut-down requirement for access (22.6% vs. 37.3%, p = 0.049) and increased ultrasound guidance utilization (29.0% vs. 23.7%, p = 0.049). The 7 French afforded earlier aortic occlusion in the course of resuscitation (median 25.0 mins vs. 30 mins, p = 0.010) and a lower median requirement of packed red blood cells (10.0 vs. 15.5 units, p = 0.006) and fresh frozen plasma (7.5 vs. 14.0 units, p = 0.005). The 7 French patients were more likely to survive 24 h (58.1% vs. 42.4%, p = 0.015) and less likely to suff er in-hospital mortality (57.3% vs. 75.4%, p = 0.003). Finally, the 7 French device was associated with a four times lower rate of distal extremity embolism (20.0% vs. 5.6%, p = 0.014; OR 95% CI 4.25 [1.25–14.45]) compared to the 11–12 French. Conclusions: The introduction of trauma-specific 7 French REBOA devices appears to have infl uenced REBOA practices, with earlier use in severely injured hypotensive patients via less invasive means that are associated with lower transfusion requirements, fewer thrombotic complications, and improved survival. Additional study is required to determine optimal REBOA use.

Relationships Between Vein Repairs, Postoperative Transfusions, and Survival in Single Digit Replantation.

Background: The general teaching is that increased number of vein repairs in digit replantation leads to improved venous outflow, resulting in lower need for iatrogenic bleeding, lower postoperative transfusion requirements, and better survival rates. The purpose of this study was to determine whether the traditional teaching that emphasizes the repair of multiple veins per arterial anastomosis results in superior survival rates. Methods: A retrospective review of a single urban replant center's single-digit replants distal to the mid-metacarpal level in adult patients from 2007 to 2017 was performed. Data on patient demographics, mechanism and level of injury, veins repaired, iatrogenic bleeding, postoperative transfusions, and replant survival were obtained. Results: There were a total of 54 single-digit replants. The most common mechanism was lacerations (N = 38), and the most common injury level was at the proximal phalanx (N = 21). All digits were replanted with a single arterial anastomosis-44% via grafting. In all, 0 to 3 veins were repaired per digit (mean = 1.5 veins). The mean transfusion requirement was 1.7 units. The survival rate was 50%. Digits with 1 or 2 veins repaired had lower transfusion requirements (1.1-1.3 units) and higher survival rates (56%-61%) compared with those replanted with 0 or 3 veins repaired (2.9-3.5 transfused units, 25%-29% survival). There were no differences between those digits replanted with either 1 or 2 veins repaired for transfusion requirements or survival. Conclusions: More veins repaired do not necessarily improve survival or possibly venous outflow, calling into question the traditional teaching that 2 veins should be repaired for every arterial anastomosis.

Variability in blood transfusions after pancreaticoduodenectomy: A national analysis of the University HealthSystem Consortium

Variability in blood use after pancreaticoduodenectomy and the associated impact on readmission, mortality, and cost is not well understood at the national level. The University HealthSystem Consortium database was queried for all pancreaticoduodenectomies performed between the years 2011-2013 (n = 9,582). Patients were grouped according to transfusion requirements into none (0 units, 64%), low (1-2 units, 15%), medium (3-5 units, 13%), and high (>5 units, 8%). Multivariable analyses were used to determine predictors of increased transfusions, readmission, in-hospital mortality, and cost. Of the patients undergoing pancreaticoduodenectomy, 36% received blood perioperatively. Patients with high transfusion requirements were less often white, more often male, and had a higher severity of illness (all P < .01). High transfusion requirements correlated with higher readmission rates (OR 1.23, P = .03), cost (RR 1.84, P < .01), length of stay (18 vs. 13 vs. 10 vs. 8 days, P < .01), and in-hospital mortality (12.5% vs. 3.1% vs. 0.5% vs. 0.4%, P < .01). Higher-volume surgeons demonstrated lower transfusion requirements (OR 0.61, P < .01). Significant variability exists nationally in transfusion practices for patients undergoing pancreaticoduodenectomy, which may be driven most by severity of illness and surgeon volume. Efforts to reduce such variability could lead to improved outcomes and healthcare cost savings.

Modification of the Melbourne Method for Total Calvarial Vault Remodeling.

Background:Sagittal synostosis is the most common form of single suture synostosis. It often results in characteristic calvarial deformities, including a long, narrow head, frontal bossing, a bullet-shaped occiput, and an anteriorly placed vertex. Several methods for correcting the phenotypic deformities have been described, each with their own advantages and challenges. In this study, we describe a modification of the Melbourne method of total calvarial remodeling for correcting scaphocephaly.Methods:We conducted a retrospective review of all consecutive patients who underwent total calvarial remodeling using a modified version of the Melbourne technique from 2011 to 2015. We evaluated clinical photographs, computed tomographic imaging, and cephalic indices both pre- and postoperatively to determine morphologic changes after operation.Results:A total of 9 patients underwent the modified Melbourne technique for calvarial vault remodeling during the study period. Intraoperative blood loss was 260 mL (range, 80–400 mL), and mean intraoperative transfusion was 232 mL (range, 0–360 mL). The average length of stay in the hospital was 3.9 days. The mean cephalic indices increased from 0.66 to 0.74 postoperatively (P < 0.01).Conclusions:A modified Melbourne method for calvarial vault reconstruction addresses the phenotypic aspects of severe scaphocephaly associated with isolated sagittal synostosis and maintains a homeotopic relationship across the calvaria. It is associated with shorter operative times, lower blood loss, and lower transfusion requirements.

Short- and intermediate-term outcomes of hybrid coronary revascularization for double-vessel disease

ObjectiveWe sought to evaluate midterm survival data and resource use for patients who received hybrid coronary revascularization for 2-vessel coronary disease (robotic-assisted left internal thoracic artery graft to left anterior descending coronary artery (minimally invasive direct coronary artery bypass), coupled with a stent to the circumflex or right coronary artery), compared with a concurrent cohort who had traditional coronary artery bypass grafting. MethodsA comprehensive retrospective review was undertaken of our prospectively collected database from January 2009 to December 2016. We propensity matched 207 patients who underwent hybrid coronary revascularization for double-vessel disease with patients who underwent coronary artery bypass grafting. Eight-year survival data were obtained from the National Death Index. ResultsThirty-day mortality was 1 patient (0.5%) in each of the hybrid coronary revascularization and coronary artery bypass grafting groups. Eight-year survival for the hybrid coronary revascularization group was 187 of 207 patients (90.3%) compared with 182 of 207 patients (87.9%) for the coronary artery bypass grafting cohort. End-stage renal disease independently predicted late mortality in all patients (overall hazard ratio, 5.60, P < .001; hybrid coronary revascularization hazard ratio, 5.58, P = .002; coronary artery bypass grafting hazard ratio, 4.59, P = .006). Female patients who underwent hybrid coronary revascularization had a higher incidence of late death (hazard ratio, 2.47, P = .05). Length of stay and perioperative transfusion requirements were lower in the hybrid coronary revascularization group (P < .0001). ConclusionsHybrid coronary revascularization for double-vessel coronary disease is associated with similar short-term outcomes and intermediate-term survival as traditional coronary artery bypass grafting. Hybrid coronary revascularization is associated with lower transfusion requirements and a shorter length of stay than coronary artery bypass grafting.

Utility of intraoperative rotational thromboelastometry in thoracolumbar deformity surgery.

OBJECTIVE Blood loss during surgery for thoracolumbar scoliosis often requires blood product transfusion. Rotational thromboelastometry (ROTEM) has enabled the more targeted treatment of coagulopathy, but its use in deformity surgery has received limited study. The authors investigated whether the use of ROTEM reduces transfusion requirements in this case-control study of thoracolumbar deformity surgery. METHODS Data were prospectively collected on all patients who received ROTEM-guided blood product management during long-segment (≥ 7 levels) posterior thoracolumbar fusion procedures at a single institution from April 2015 to February 2016. Patients were matched with a group of historical controls who did not receive ROTEM-guided therapy according to age, fusion segments, number of osteotomies, and number of interbody fusion levels. Demographic, intraoperative, and postoperative transfusion requirements were collected on all patients. Univariate analysis of ROTEM status and multiple linear regression analysis of the factors associated with total in-hospital transfusion volume were performed, with p < 0.05 considered to indicate statistical significance. RESULTS Fifteen patients who received ROTEM-guided therapy were identified and matched with 15 non-ROTEM controls. The mean number of fusion levels was 11 among all patients, with no significant differences between groups in terms of fusion levels, osteotomy levels, interbody fusion levels, or other demographic factors. Patients in the non-ROTEM group required significantly more total blood products during their hospitalization than patients in the ROTEM group (8.5 ± 4.2 units vs 3.71 ± 2.8 units; p = 0.001). Multiple linear regression analysis showed that the use of ROTEM (p = 0.016) and a lower number of fused levels (p = 0.022) were associated with lower in-hospital transfusion volumes. CONCLUSIONS ROTEM use during thoracolumbar deformity correction is associated with lower transfusion requirements. Further investigation will better define the role of ROTEM in transfusion during deformity surgery.

Dose optimisation of intravenous tranexamic acid for elective hip and knee arthroplasty: The effectiveness of a single pre-operative dose.

ObjectivesWe have increased the dose of tranexamic acid (TXA) in our enhanced total joint recovery protocol at our institution from 15 mg/kg to 30 mg/kg (maximum 2.5 g) as a single, intravenous (IV) dose. We report the clinical effect of this dosage change.MethodsWe retrospectively compared two cohorts of consecutive patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) surgery in our unit between 2008 and 2013. One group received IV TXA 15 mg/kg, maximum 1.2 g, and the other 30 mg/kg, maximum 2.5 g as a single pre-operative dose. The primary outcome for this study was the requirement for blood transfusion within 30 days of surgery. Secondary measures included length of hospital stay, critical care requirements, re-admission rate, medical complications and mortality rates.ResultsA total of 1914 THA and 2537 TKA procedures were evaluated. In THA, the higher dose of TXA was associated with a significant reduction in transfusion (p = 0.02, risk ratio (RR) 0.74, 95% confidence interval (CI) 0.58 to 0.96) and rate of re-admission (p < 0.001, RR 0.50, 95% CI 0.35 to 0.71). There were reductions in the requirement for critical care (p = 0.06, RR 0.55, 95% CI 0.31 to 1.00), and in the length of stay from 4.7 to 4.3 days (p = 0.02). In TKA, transfusion requirements (p = 0.049, RR 0.64, 95% CI 0.41 to 0.99), re-admission rate (p = 0.001, RR 0.56, 95% CI 0.39 to 0.80) and critical care requirements (p < 0.003, RR 0.34, 95% CI 0.16 to 0.72) were reduced with the higher dose. Mean length of stay reduced from 4.6 days to 3.6 days (p < 0.01). There was no difference in the incidence of deep vein thrombosis, pulmonary embolism, gastrointestinal bleed, myocardial infarction, stroke or death in THA and TKA between cohorts.ConclusionWe suggest that a single pre-operative dose of TXA, 30 mg/kg, maximum 2.5g, results in a lower transfusion requirement compared with a lower dose in patients undergoing elective primary hip and knee arthroplasty. However, these findings should be interpreted in the context of the retrospective non-randomised study design.Cite this article: R. J. M. Morrison, B. Tsang, W. Fishley, I. Harper, J. C. Joseph, M. R. Reed. Dose optimisation of intravenous tranexamic acid for elective hip and knee arthroplasty: The effectiveness of a single pre-operative dose. Bone Joint Res 2017;6:499–505. DOI: 10.1302/2046-3758.68.BJR-2017-0005.R1.