Moderate Blood Loss Research Articles

Reduced Blood Loss with Intraoperative Artery Ligation During Angiofibroma Excision

Background: Juvenile Nasopharyngeal Angiofibroma (JNA) is a rare, highly vascularized tumor primarily affecting males during early puberty. Recurrent epistaxis and anemia are common presentations. Intraoperative artery ligation has been proposed as a strategy to minimize blood loss during JNA excision surgeries. This study aims to explore the correlation between intraoperative artery ligation and blood loss in JNA excision surgeries. Objective: To investigate the association between intraoperative artery ligation and blood loss during surgical excision of Juvenile Nasopharyngeal Angiofibroma. Methodology: This retrospective comparative study analyzed medical records of 12 patients who underwent JNA excision surgeries in ENT Unit I of Jinnah Hospital, Lahore. Two groups were compared: patients with intraoperative artery ligation and a control group without this intervention. Stratified Random Sampling was employed, and data, including demographics, clinical presentation, diagnostic information, surgical details, intraoperative blood loss, operative time, blood transfusions, and postoperative complications, were collected. Statistical analysis was performed using SPSS version 23, and a p-value below 0.05 was considered significant. Results: Patients with intraoperative artery ligation showed a focused blood loss distribution. 50% experienced 251-750ml, and none exceeding 750ml. In contrast, the non-ligation group showed a broader range, with 50% experiencing blood loss beyond 750ml. The mean blood loss in the ligation group was 375ml (SD=250ml), while the non-ligation group had a mean of 916.67ml (SD=401.83ml). Statistical analysis confirmed a significant association (p < 0.05) between intraoperative artery ligation andreduced blood loss. The study suggests that intraoperative artery ligation contributes to a more controlled and moderate blood loss in JNA excision surgeries.Conclusion: This retrospective comparative study reveals a significant correlation between intraoperative artery ligation and reduced blood loss in Juvenile Nasopharyngeal Angiofibroma excision surgeries. Patients with intraoperative artery ligation demonstrated a more controlled and focused distribution of blood loss, emphasizing its potential efficacy in managing hemorrhage during surgery. The study contributes valuable insights into the application of intraoperative artery ligation in JNA surgeries, providing clinicians with a potential strategy to minimize blood loss and improve surgical outcomes.

Evaluation of blood type as a potential risk factor for hemorrhage during vaginal hysterectomy

ObjectiveTo examine the association between the O blood type and bleeding tendency in patient undergoing vaginal hysterectomy. MethodsThis was a retrospective cohort study including all women who had undergone vaginal hysterectomy at our institution between January 2015 and September 2020. All women underwent blood type and complete blood count testing pre- and post-operatively. The estimated intraoperative blood loss, the need for blood transfusion, pre- and postoperative hemoglobin and hematocrit measurements and surgical data were recorded for all patients. Patients with known coagulopathies or those taking antithrombotic medications were excluded from the study. Statistical analysis was performed using student t, χ2, Fischer exact, and ANOVA tests as well as a stepwise logistic regression model. ResultsThe study included 106 patients (35.2 %) with O and 195 patients (64.8 %) with non-O (i.e., A, B or AB) blood types. The O blood type was significantly associated with a higher risk for moderate blood loss (defined as a pre- to postoperative Hb or HCT drop >2gr or >6 %, respectively) (p = 0.012), but not with severe (defined as a Hb or HCT drop of >3gr or >9 %, respectively) perioperative bleeding, nor with the need for blood transfusion. ConclusionThe O blood type was found to be significantly associated with moderate but not with severe intraoperative bleeding during and following vaginal hysterectomy.

Влияние гипотермии легкой степени на сосудистый тонус микроциркуляторного русла головного мозга

Acute blood loss is associated with deterioration of blood circulation, including microcirculation. Clinical and experimental studies are focused on the search for the possibility of neutralizing the consequences of such impairment. The use of hypothermia is considered not only as a method to improve survival, but also as a method to improve cerebral microcirculation in hemorrhage. The study was aimed to assess the state of the rats’ cerebral arteries in cases of mild hypothermic exposure after acute moderate blood loss. The study involving anesthetized Wistar rats was performed by vital microscopy. We assessed the responses of pial arteries (initial diameter 10–40 µm) in animals cooled to the rectal temperature of 34 °С under conditions of hemodynamic stability and when simulating blood loss (20% of total blood loss) in normothermic animals and animals with mild hypothermia. The findings showed that 3.5 h of exposure were associated with vasoconstriction in animals of all studied groups. Hypothermic state of the body was associated with initial decrease in the diameter by 9% of the baseline (24.9 ± 0.9 µm to 22.7 ± 0.7 µm; p < 0.05) followed by restoration of the diameter after 2 h (to 25.7 ± 1.7; p > 0.05). Blood loss was associated with the decrease in the diameter of cerebral blood vessels by 20–25% within the first hour (23.4 ± 0.7 µm to 17.6 ± 1.1 µm; p < 0.001) and no subsequent restoration (the diameter was 16.7 ± 0.8 µm after 3.5 h of monitoring). When using hypothermia, vasoconstriction following blood loss was 8–10% in the first 45 min of monitoring (22.6 ± 1.3 µm to 20.3 ± 1.2 µm; p < 0.05), then the constriction decrease was observed (the diameter was 21.4 ± 1.4 µm after 3.5 h of monitoring). It was concluded that the use of mild hypothermia resulted in the reduced vasoconstrictor effect of moderate blood loss on the pial microvessels.

Drugs to reduce bleeding and transfusion in major open vascular or endovascular surgery: a systematic review and network meta-analysis.

Drugs to reduce bleeding and transfusion in major open vascular or endovascular surgery: a systematic review and network meta-analysis.

Mean Blood Loss in Third Stage of Labour Treated with and without Prophylactic Tranexamic Acid

Background: Massive obstetrical hemorrhage, a leading contributor towards maternal fatality in economically developing countries, is occasionally related with the passive and apathetic management of the third stage of labor. The increasing frequency of anaemia among pregnant women in developing countries, mild to moderate blood loss during labour necessitates massive transfusions with associated complications. Aim: Recent studies claimed that prophylactic tranexamic acid can significantly reduce the mean blood loss during 3rd stage of labour and advocated it in future practice. Methods: The research was conducted as randomized controlled trial carried out from February 2021 to October 2021 in the Department of Diagnostic Radiology and Obstetrics & Gynaecology Department, Ganga Ram Hospital, Lahore. A total of 116 pregnant women aged between 18-35 years presenting in labor at term (37-42 weeks of gestation as per dating scan) which were randomly allocated into two groups. Patients in Group-A were given additional tranexamic acid at the end of 2nd stage of labor while those in Group-B received conventional treatment alone. Results: Patients were 28.33±4.77 years with the mean age while the mean gestational age at delivery was 39.39±1.69 weeks. 30(25.9%) women were primiparas and 86 (74.1%) were multiaparas. The mean BMI of these patients was 27.50±3.90 Kg/m2 while the average duration of 3rd stage of labor was 4.69±1.83 minutes. Patients taking prophylactic tranexamic acid lost significantly less blood in the third stage of labors than controls (244.83±21.47 vs. 354.09±22.36 ml; p-value<0.001). Conclusion: In the present study, prophylactic tranexamic acid was found to significantly reduce the mean blood loss during 3rd stage of labor which along with low cost, widespread availability and oral administration advocates the routine use of tranexamic acid (during 3rd stage of labor) in future obstetric practice to minimize blood loss with subsequent decreased need for blood transfusion and better patient’s recovery. Keywords: Third Stage of Labor, Blood Loss, Tranexamic Acid

Ultrasonographic Inferior Vena Cava Measurement is More Sensitive Than Vital Sign Abnormalities for Identifying Moderate and Severe Hemorrhage.

Ultrasound inferior vena cava (IVC) diameter has been shown to decrease in response to hemorrhage. IVC diameter cut points to identify moderate and severe blood loss have not been established. This study sought to find ultrasound IVC diameter cut points to identify moderate and severe hemorrhage and assess the performance of these cut points vs. vital sign abnormalities. This is a secondary analysis of data from a study that described changes in vital signs and sonographic measurements of the IVC during a lower body negative pressure model of hemorrhage. Using receiver operator curve analyses, optimal cut points for identifying moderate and severe hemorrhage were identified. The ability of these cut points to identify hemorrhage in patients with no vital sign abnormalities was then assessed. In both long- and short-axis views, maximum and minimum IVC diameters (IVCmax and IVCmin) were significantly lower than baseline in severe blood loss. The optimal cut point for IVCmax in both axes was found to be ≤ 0.8 cm. This cut point is able to distinguish between no blood loss vs. moderate blood loss, and no blood loss vs. severe blood loss. The optimal cut point for IVCmin was variable between axes and blood loss severity. IVC diameter cut points obtained were able to identify hemorrhage in patients with no vital sign abnormalities. An ultrasound IVCmax of ≤ 0.8 cm may be useful in identifying moderate and severe hemorrhage before vital sign abnormalities are evident.

Safety and efficacy of iron supplementation after myocardial infarction in mice with moderate blood loss anaemia.

AimsIron deficiency is frequently observed in patients with acute coronary syndrome and associates with poor prognosis after acute myocardial infarction (AMI). Anaemia is linked to dysregulation of iron metabolism, red blood cell dysfunction, and increased reactive oxygen species generation. Iron supplementation in chronic heart failure is safe and improves cardiac exercise capacity. Increases in iron during ischaemia or immediately after reperfusion are associated with detrimental effects on left ventricular (LV) function. The safety and applicability of iron during or immediately after reperfusion of AMI in anaemia are not known. We aimed to study the safety and efficacy of iron supplementation within 1 h or deferred to 24 h after reperfusion of AMI by analysing LV function and infarct size.Methods and resultsIn a mouse model of moderate blood loss anaemia (n = 6–8 mice/group), the effects of iron supplementation (20 mg iron as ferric carboxymaltose per kg body weight) within 1 h and deferred to 24 h after ischaemia/reperfusion were assessed. Cardiac function was analysed in vivo by echocardiography at baseline (Day 3) with and without anaemia, after AMI (24 h), and after administration of intravenous iron. Anaemia was characterized by iron deficiency and a trend towards increased haemolysis, which was supported by increased plasma free‐haemoglobin [sham vs. anaemia (n = 8/group): P < 0.05]. Anaemia increased heart rate, LV end‐diastolic volume, stroke volume, and cardiac output, while LV end‐systolic volume remained unchanged at baseline. Superimposition of AMI deteriorated global LV function, whereas infarct sizes remained unaffected [sham vs. anaemia (n = 6/group): P = 0.9]. Deferred iron supplementation 24 h after ischaemia/reperfusion resulted in reversal of end‐systolic volume increase and reduced infarct size [% of area at risk: sham vs. anaemia + iron after 24 h; (n = 6/group); 48 ± 7 vs. 38 ± 7; P < 0.05], whereas administration within 1 h after reperfusion was neutral [sham vs. anaemia + iron; (n = 6/group); 48 ± 7 vs. 42 ± 8; P = 0.56]. Moreover, iron application after reperfused AMI showed unaltered mortality compared with sham.ConclusionsIron supplementation 24 h after reperfusion of AMI is safe and reversed enlargement of end‐systolic volume after AMI resulting in increased stroke volume and cardiac output. This highlights its potential as adjunctive treatment in anaemia with ID after reperfused AMI. Time point of iron application after reperfusion appears critical.

Modulation of Peripheral CD4+CD25+Foxp3+ Regulatory T Cells Ameliorates Surgical Stress-Induced Atherosclerotic Plaque Progression in ApoE-Deficient Mice.

Systemic inflammation associated with major surgery rapidly accelerates atherosclerotic plaque progression in mice. Regulatory T cells (Tregs) have emerged as important modulators of atherogenesis. In coronary artery disease patients, low frequency of Tregs constitutes an independent risk factor for cardiovascular complications after non-cardiac surgery. In this exploratory analysis, we investigate whether preoperative Treg levels affect surgery-induced atherosclerotic lesion destabilization in a murine model of perioperative stress. After 9 weeks of high-cholesterol diet, atherosclerotic apolipoprotein E-deficient mice with modulated Treg levels were subjected to a 30-minute surgical procedure consisting of general isoflurane anesthesia, laparotomy and moderate blood loss. Controls underwent general anesthesia only. Brachiocephalic arteries were harvested 3 days after the intervention for histomorphological analyses of atherosclerotic plaques. Tregs were depleted by a single dose of anti-CD25 monoclonal antibody (mAb) administered 6 days prior to the intervention. Expansion of Tregs was induced by daily injections of IL-2/anti-IL-2 complex (IL-2C) on three consecutive days starting 3 days before surgery. Isotype-matched antibodies and PBS served as controls. Antibody-mediated modulation was Treg-specific. IL-2C treatment resulted in an eight-fold elevation of peripheral CD4+CD25+Foxp3+ Tregs compared to mice administered with anti-CD25 mAb. In mice treated with PBS and anti-CD25 mAb, surgical stress response caused a significant increase of atherosclerotic plaque necrosis (PBS: p < 0.001; anti-CD25 mAb: p = 0.037). Preoperative Treg expansion abrogated perioperative necrotic core formation (p = 0.556) and significantly enhanced postoperative atherosclerotic plaque stability compared to PBS-treated mice (p = 0.036). Postoperative plaque volume (p = 0.960), stenosis (p = 0.693), lesional collagen (p = 0.258), as well as the relative macrophage (p = 0.625) and smooth muscle cell content (p = 0.178) remained largely unaffected by preoperative Treg levels. In atherosclerotic mice, therapeutic expansion of Tregs prior to major surgery mitigates rapid effects on perioperative stress-driven atherosclerotic plaque destabilization. Future studies will show, whether short-term interventions modulating perioperative inflammation qualify for prevention of cardiovascular events associated with major non-cardiac surgery.

P.26 Routine use of tranexamic acid during elective caesarean section: A district general’s experience

Introduction: The use of tranexamic acid (TXA) to help reduce bleeding or blood transfusions is widely acknowledged, with NICE [1] NICE guideline Blood Transfusion 2015, https://www.nice.org.uk/guidance/ng24 Google Scholar recommending that TXA is offered to all adult patients undergoing surgery, where moderate blood loss is expected. In addition the WOMAN [2] Woman trial collaborators. Effect of early tranexamic acid administration on mortality,hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international randomised, double-blind, placebo-controlled trial. Lancet 2017;389:2105-16 Google Scholar trial also supports its use within the obstetric population, for patients with postpartum haemorrhage. As part of development of our enhanced recovery protocol for elective caesarean patients, we decided to introduce routine administration of TXA, 1g intravenous dose at cord clamping, for all eligible patients, from 1 January 2018.

Safety and efficiency of performing transvaginal ultrasound-guided tru-cut biopsy for pelvic masses

ObjectiveTo assess the safety, adequacy and accuracy of transvaginal ultrasound-guided tru-cut biopsy of pelvic masses. MethodsWe performed a retrospective analysis of consecutive women who underwent transvaginal ultrasound-guided tru-cut biopsies between June 2014 and October 2018 at the Department of Obstetrics and Gynecology of the University Hospitals Leuven. Main indications for tru-cut biopsy were tissue collection for diagnosis of pelvic tumors in cases of suspected disseminated disease or recurrence, or tissue banking for research purposes. Data about adverse events occurring within 2 weeks of the procedure (including bleeding, blood transfusion, hospital admission, urgent surgery, pelvic infection or death) were extracted from electronic medical records. Tissue samples were recorded as adequate if tumor identification and immunohistochemistry were possible. Accuracy was defined in patients who underwent surgery as the agreement between histology after tru-cut biopsy and final histology. Results176 tru-cut biopsies were performed in 155 patients. Procedure related events were limited to moderate blood loss (<50 ml) without the need for treatment in 4.5%. There were no major complications. Biopsies were deemed adequate for histological evaluation in 84.3% of biopsies performed for diagnostic purposes and in 71.4% of research cases in whom a single tissue cylinder was available for diagnosis. When at least two cylinders were available, diagnostic adequacy increased to >95%. Comparing final histology, the diagnostic accuracy of the tru-cut biopsies was 97.2%. ConclusionTransvaginal tru-cut biopsy for diagnosis of pelvic masses is a safe procedure. To allow an adequate and accurate diagnosis, we advise taking at least 2 core biopsies.

Effects of 150- and 450-mL Acute Blood Losses on Maximal Oxygen Uptake and Exercise Capacity.

This study investigated whether maximal oxygen uptake (V˙O2max) and exercise capacity are affected by small acute blood loss (150 mL) and elucidated compensatory mechanisms. Thirteen male subjects (V˙O2max, 63 ± 9 mL·kg-1·min-1; mean ± SD) performed incremental exercise to exhaustion on a cycle ergometer in three experimental conditions: in euvolemia (control; blood volume [BV], 6.0 ± 0.7 L) and immediately after acute BV reductions of 150 mL (BVR150mL) and 450 mL (BVR450mL). Changes in plasma volume (PV) and BV during exercise were calculated from hematocrit, hemoglobin concentration, and hemoglobin mass (carbon monoxide rebreathing). The reduction in V˙O2max per milliliter of BVR was 2.5-fold larger after BVR450mL compared with BVR150mL (-0.7 ± 0.3 vs -0.3 ± 0.6 mL·min-1·mL-1, P = 0.029). V˙O2max was not significantly changed after BVR150mL (-1% ± 2%, P = 0.124) but reduced by 7% ± 3% after BVR450mL (P < 0.001) compared with control. Peak power output only decreased after BVR450mL (P < 0.001). At maximal exercise, BV was restored after BVR150mL compared with control (-50 ± 185 mL, P = 0.375) attributed to PV restoration, which was, however, insufficient in restoring BV after BVR450mL (-281 ± 184 mL, P < 0.001). The peak heart rate tended to increase (3 ± 5 bpm, P = 0.062), whereas the O2 pulse (-2 ± 1 mL per beat, P < 0.001) and vastus lateralis tissue oxygenation index (-4% ± 8% points, P = 0.080) were reduced after BVR450mL, suggesting decreased stroke volume and increased leg O2 extraction. The deteriorations of V˙O2max and of maximal exercise capacity accelerate with the magnitude of acute blood loss, likely because of a rapid PV restoration sufficient to establish euvolemia after a small but not after a moderate blood loss.

The effect of moderate intraoperative blood loss and norepinephrine therapy on sublingual microcirculatory perfusion in patients having open radical prostatectomy: An observational study.

It is not clear whether moderate intraoperative blood loss and norepinephrine used to restore the macrocirculation impair the microcirculation and affect microcirculation/macrocirculation coherence. We sought to investigate the effect of moderate intraoperative blood loss and norepinephrine therapy administered to treat intraoperative hypotension on the sublingual microcirculation. Prospective observational study. University Medical Center Hamburg-Eppendorf, Hamburg, Germany, from November 2018 to March 2019. Thirty patients scheduled for open radical prostatectomy and 29 healthy volunteer blood donors. Simultaneous assessment of the macrocirculation using a noninvasive finger-cuff method and the sublingual microcirculation using vital microscopy. The main outcome measures were changes in the sublingual microcirculation caused by moderate intraoperative blood loss and norepinephrine therapy. General anaesthesia decreased median [IQR] mean arterial pressure from 100 [90 to 104] to 79 [69 to 87] mmHg (P < 0.001), median heart rate from 69 [63 to 79] to 53 [44 to 62] beats per minute (P < 0.001), median cardiac index from 2.67 [2.42 to 3.17] to 2.09 [1.74 to 2.49] l min-1 m-2 (P < 0.001), and median microvascular flow index from 2.75 [2.66 to 2.85] to 2.50 [2.35 to 2.63] (P = 0.001). A median blood loss of 600 [438 to 913] ml until the time of prostate removal and norepinephrine therapy to treat intraoperative hypotension had no detrimental effect on the sublingual microcirculation: There were no clinically important changes in the microvascular flow index, the proportion of perfused vessels, the total vessel density, and the perfused vessel density. Blood donation resulted in no clinically important changes in any of the macrocirculatory or microcirculatory variables. Moderate intraoperative blood loss and norepinephrine therapy administered to treat intraoperative hypotension have no detrimental effect on the sublingual microcirculation and the coherence between the macrocirculation and microcirculation in patients having open radical prostatectomy.

Patient blood management

Background. Blood transfusions (BT) remain one of the most common medical procedures: about 110,000 doses of whole blood are collected annually and almost as many are transfused. Approximately every 10th patient who undergoes invasive procedures in the hospital needs BT. However, 40-60 % of BT in patients without bleeding are inappropriate.&#x0D; Objective. To describe modern views on the BT.&#x0D; Materials and methods. Analysis of the literature on this issue.&#x0D; Results and discussion. The triad of major risk factors for perioperative complications includes three interrelated factors: blood loss, anemia, and BT. The use of blood products is accompanied by an increase in the number of complications (not directly related to BT) and 30-day mortality. Fatal consequences of blood transfusion are also possible. They include acute lung damage associated with BT, hemolytic and bacterial complications, circulatory overload, anaphylaxis. Patient blood management (PBM) includes early detection and treatment of preoperative anemia, especially in patients at high risk of bleeding; minimization of blood loss and maximally blood-saving tactics; rational and guideline-adequate administration of allogenic blood products. About 39 % of patients scheduled for surgery have preoperative anemia. Absolute iron deficiency (ID) is present in 62 % of patients with preoperative anemia. Ferritin level &lt;30 μg/L is an indicator of such anemia. Preoperative anemia is an independent risk factor for mortality and complications, so in presence of anemia, major emergency surgery should be postponed until hemoglobin returns to normal. The target level of the latter in the treatment of preoperative anemia should be 130 g/L for both sexes. If surgery is scheduled 6-8 weeks after the revealing of ID with or without anemia, oral replacement therapy should be performed. Parenteral forms of iron are used if there are &lt;6 weeks left before the planned operation or the hemoglobin level is &lt;100 g/L. If necessary, BT can be performed according to a liberal (BT is prescribed at a hemoglobin level &lt;90-100 g/L) or restrictive (&lt;70-80 g/L) strategy. According to a large-scale meta-analysis, the latter almost halves the risk of erythromass transfusion compared to the former. As recommended by the National Institute for Health and Care Excellence, it is advisable to apply a single-dose strategy with reassessment of BT requirements after each blood transfusion. Decisions in patients with chronic BT-dependent anemia and cancer should be made individually. The use of intravenous iron supplements before surgery can reduce the number of BT in the postoperative period. Sufer (“Yuria-Pharm”) is a trivalent iron for intravenous use, which effectively, quickly and safely increases hemoglobin levels. As it was mentioned, another element of the PBM is the minimization of blood loss. Tranexamic acid preparations (Sangera, “Yuria-Pharm”) can be prescribed for this purpose. Tranexamic acid is a lysine-like inhibitor of fibrinolysis; it is recommended for the prevention of bleeding with expected moderate and severe blood loss (&gt;500 ml). In patients with trauma with massive blood loss or with a high risk of intracranial hemorrhage, it is also advisable to use tranexamic acid. Its activity is 26 times higher than the activity of aminocaproic acid. Tranexamic acid is highly effective; it reduces the need for BT without increasing the risk of thrombosis.&#x0D; Conclusions. 1. The triad of major risk factors for perioperative complications includes three interrelated factors: blood loss, anemia, and BT. 2. PBM includes early detection and treatment of preoperative anemia, minimization of blood loss and adequate administration of allogenic blood products. 3. In conditions of preoperative anemia, it is advisable to correct diabetes with oral or parenteral forms of iron. 4. Tranexamic acid drugs are prescribed to minimize blood loss.

Anaemia is associated with severe RBC dysfunction and a reduced circulating NO pool: vascular and cardiac eNOS are crucial for the adaptation to anaemia

Anaemia is frequently present in patients with acute myocardial infarction (AMI) and contributes to an adverse prognosis. We hypothesised that, besides reduced oxygen carrying capacity, anaemia is associated with (1) red blood cell (RBC) dysfunction and a reduced circulating nitric oxide (NO) pool, (2) compensatory enhancement of vascular and cardiac endothelial nitric oxide synthase (eNOS) activity, and (3) contribution of both, RBC dysfunction and reduced circulatory NO pool to left ventricular (LV) dysfunction and fatal outcome in AMI. In mouse models of subacute and chronic anaemia from repeated mild blood loss the circulating NO pool, RBC, cardiac and vascular function were analysed at baseline and in reperfused AMI. In anaemia, RBC function resulted in profound changes in membrane properties, enhanced turnover, haemolysis, dysregulation of intra-erythrocytotic redox state, and RBC-eNOS. RBC from anaemic mice and from anaemic patients with acute coronary syndrome impaired the recovery of contractile function of isolated mouse hearts following ischaemia/reperfusion. In anaemia, the circulating NO pool was reduced. The cardiac and vascular adaptation to anaemia was characterised by increased arterial eNOS expression and activity and an eNOS-dependent increase of end-diastolic left ventricular volume. Endothelial dysfunction induced through genetic or pharmacologic reduction of eNOS-activity abrogated the anaemia-induced cardio-circulatory compensation. Superimposed AMI was associated with decreased survival. In summary, moderate blood loss anaemia is associated with severe RBC dysfunction and reduced circulating NO pool. Vascular and cardiac eNOS are crucial for the cardio-circulatory adaptation to anaemia. RBC dysfunction together with eNOS dysfunction may contribute to adverse outcomes in AMI.

Comparison of Hemorrhoidectomy by Ligasure with Conventional Milligan Morgan’s Hemorrhoidectomy

Hemorrhoidal disease is one of most common anorectal disease and surgical hemorrhoidectomy remains one of most common operation in general surgery. The aim of the present study is to compare between conventional Milligan-Morgan hemorrhoidectomy and ligasure hemorrhoidectomy in treating patients with 3rd and 4th degree hemorrhoids. This randomized control trial was conducted at Alfayhaa teaching hospital during 2016 to 2018. The 3rd and 4th degree hemorrhoid patients (n=60, age 16-70 years) were randomly divided into two groups based on the surgical procedure, i.e. ligasure hemorrhoidectomy (n=30) and conventional hemorrhoidectomy (n=30). In ligasure hemorrhoidectomy, operative time, pain score on the 1st operative day and 1st week, duration of wound healing were 12.2 ± 03, 4.1 ± 05, 5.3 ± 02min and 3.1 ± 02, respectively. While in the conventional hemorrhoidectomy, it was 23.3 ± 02, 6.2 ± 03, 2.1 ± 09min and 4.4 ± 07, respectively. In ligasure hemorrhoidectomy 15 patients didn’t have blood loss, 10 patients had a mild blood loss and 5 patients had a moderate blood loss. While, in conventional hemorrhoidectomy all patients suffered from blood loss, i.e. 14 patients have mild blood loss and 11 patients have blood loss. In conventional hemorrhoidectomy postoperative bleeding, necrosis, residual disease and anal ____stenosis ___ were 19.2 ± 03 (p<0.001); 02.5 ± 01 (p<0.01); 08.9 ± 08 and 01.5 ± 01, respectively. While, in ligasure hemorrhoidectomy postoperative bleeding, necrosis and residual disease were reduced to 07.3 ± 07; 00.0 ± 00 and 04.9 ± 09, respectively. Anal ________stenosis ____ was found to be increased to 06.4 ± 06 as compared to the conventional hemorrhoidectomy. Ligasure hemorrhoidectomy is better than conventional hemorrhoidectomy in terms of less operative time,less intraoperative pain and less postoperative complication and earlier wound healing and return to daily work hence higher patient satisfaction.

Clinical and financial evaluation of carbetocin as postpartum haemorrhage prophylaxis at caesarean section: A retrospective cohort study.

The long-acting oxytocic agent; carbetocin, has been consistently shown to reduce the need for additional uterotonics at caesarean section, but not postpartum haemorrhage (PPH). While promising, current evidence is limited by heterogenicity in study design and findings. To examine whether carbetocin confers clinical or economic benefit compared to oxytocin at caesarean section in an all-risk Australian population. A retrospective cohort study was undertaken of all singleton caesarean sections at a public tertiary hospital from 2008 to 2010 (n=2499). From 1 January 2008 to 24 March 2009 all women received prophylactic oxytocin 5-10 units slow push intravenously at delivery, after which all patients received 100μg intravenous carbetocin. Outcomes were PPH (≥1000mL) and the requirement of secondary uterotonics. A post hoc cost analysis was also performed. A total of 1467 and 1024 patients received carbetocin and oxytocin, respectively. Incidence of PPH ≥1000mL was 7.8% for carbetocin compared to and 9.7% for oxytocin (odds ratio (OR) 0.79, 95% CI 0.59-1.05). Moderate blood loss >500mL was significantly reduced with carbetocin; occurring in 27.3% versus 39.4% (OR 0.57, 95% CI 0.49-0.68). There was a 20.0% reduction in secondary uterotonic treatment with carbetocin (OR 0.42, 95% CI 0.35-0.49). Average drug costs were lower with oxytocin at $4.74 versus $36.42/patient. However, the 1.9% reduction in PPH with carbetocin resulted in a $63.46 reduction in cost per patient, with a cost-effectiveness ratio of $1667 to prevent one case of PPH ≥1000mL. Carbetocin reduced moderate blood loss >500mL, but not PPH ≥1000mL. Carbetocin conferred a 20% reduction in secondary uterotonic treatment, as well as lowering direct medical costs.

Comparison of Five Treatment Strategies for Cesarean Scar Pregnancy

Objective: To explore appropriate treatment strategy for cesarean scar pregnancy (CSP) in the first and second trimester. Methods: Clinical characteristics and treatment strategies in 182 patients with CSP were retrospectively analyzed. Treatment strategies were as follows: Group A (n = 102), uterine artery chemoembolization (UACE) followed by dilation and curettage (DC Group B (n = 63), DC Group C (n = 6), hysteroscopy; Group D (n = 6), laparotomy; and Group E (n = 5), laparoscopy. The basic clinical findings were collected and analyzed, along with the curative effects. Results: The preoperative serum beta-human chorionic gonadotropin (β-HCG) level was in the order of Group D, A>B, C>E (P = 0.001); the size of gestational sac (GS) was in the order of Group D, E>A, C>B (P = 0.000); and the thickness of the anterior myometrium was in the order of Group B>A, C>D, E (P = 0.000). Three cases in the second trimester were all in Group D; two cases were treated with UACE before laparotomy with moderate blood loss (100 and 200 mL, respectively) and the third case was initially treated with D&C and had severe hemorrhage. Conclusions: The diameter of GS, thickness of the anterior myometrium, and preoperative β-HCG level are important factors for the choice of treatment. UACE combined with D&C is a useful measure for most Type 2 CSP cases in the first trimester. For Type 2 CSP cases in the second trimester, UACE before laparotomy could be a reasonable choice.

An evaluation of the mixed pediatric unit for blood loss replacement in pediatric craniofacial surgery.

Surgical correction for craniosynostosis is often associated with significant perioperative hemorrhage. We implemented a transfusion strategy with a strict protocol including transfusion triggers, frequent assessment of coagulation tests, and the use of a novel transfusion unit, the mixed pediatric unit. The aim of the study was to evaluate if the applied transfusion strategy could reduce total blood loss and number of blood donors. Children <1 year old admitted for craniosynostosis surgery were included for the study. On the day before surgery, an adult red blood cell unit was mixed with plasma and split into two mixed pediatric units-one intended for intraoperative use and the other saved for the postoperative period. A series of blood samples were obtained for standard coagulation parameters as well as thromboelastography to evaluate potential coagulopathy. Estimated blood loss, the number of additional standard packed red cell units opened in the first 24 h after surgery, the volume of fluid administered, and the total transfusion volumes were compared to a historical control group with similar age and characteristics. Nineteen infants were included in the study group, and were compared to 21 historical controls. There was a significant reduction of intraoperative transfusion volume. Twelve patients were transfused postoperatively, but in 8 of these additional exposure to packed red cell donor blood was avoided by using the saved mixed pediatric unit. In the historical controls, a total of 10 packed red cell units were used in nine patients postoperatively. No additional transfusions of plasma, platelets, fibrinogen, or tranexamic acid were needed in either group, and the coagulation parameters including thromboelastography remained within their respective normal ranges in the study group. For craniofacial surgery in infants, moderate perioperative blood loss and avoidance of coagulopathy is possible when a multifactorial approach is implemented. In this setting, intraoperative, but not total perioperative blood loss was reduced with the studied protocol. The study indicates that there may be a role for mixed pediatric units to reduce exposure to multiple donors although the reduction in total donor exposure was not significant.

Face Cooling Increases Blood Pressure during Simulated Blood Loss

IntroductionBlood loss causes central hypovolemia and in severe instances, it can decrease blood pressure and lead to cardiovascular decompensation. Simple and quick interventions that can be used to prevent cardiovascular decompensation in pre‐hospital settings could be a valuable tool for first responsders. Cooling the forehead and cheeks using an ice/water slurry mixture has been shown to increase blood pressure for over 15 minutes. Therefore, face cooling could be used to mitigate decreases in blood pressure during blood loss.PurposeWe tested the hypothesis that face cooling during simulated blood loss will increase blood pressure.MethodsTen healthy participants (22 ± 2 years, 3 women) completed two randomized trials on separate days. Both trials began with 30 mmHg of lower body negative pressure (LBNP) to simulate blood loss for 6 minutes. Then, either a 2.5 L plastic bag of an ice/water slurry mixture (0 ± 0°C) (LBNP+FC) or a 2.5 L plastic bag of thermoneutral water (34 ± 1°C) (LBNP+SHAM) was placed on the forehead and eyes and 30 mmHg of LBNP was maintained for an additional 15 minutes. We continuously measured blood pressure (Penaz method), heart rate (ECG), stroke volume (Model flow), cardiac output, total peripheral resistance, and forehead temperature throughout the protocol.ResultsForehead temperature did not change from LBNP (34.2 ± 0.6°C) to LBNP+SHAM (33.9 ± 1.4°C, P &gt; 0.999) and decreased from LBNP (34.4 ± 0.5°C) to LBNP+FC (11.0 ± 1.6°C, P &lt; 0.001). Mean arterial pressure did not change from LBNP (82 ± 10 mmHg) to LBNP+SHAM (80 ± 8 mmHg, P = 0.978), but markedly increased during LBNP+FC. The peak increase from LBNP (77 ± 9 mmHg) was observed after 3 minutes of LBNP+FC (98 ± 15 mmHg, P &lt; 0.001). Heart rate during LBNP (76 ± 14 bpm, P = 0.978) was not different from LBNP+SHAM (75 ± 13 bpm). Heart rate was lower throughout LBNP+FC beginning at 2 minutes of FC (60 ± 16 bpm) versus LBNP (80 ± 19 bpm, P &lt; 0.001). Stroke volume did not change from LBNP (72 ± 15 mL) to LBNP+SHAM (67 ± 18 mL, P = 0.857). However, stroke volume increased from LBNP (78 ± 16 mL) to LBNP+FC, and peaked after 5 minutes of FC (97 ± 32 mL, P &lt; 0.001). Cardiac output did not change from LBNP (5.4 ± 1.0 L/min) to LBNP+SHAM (4.9 ± 1.0 L/min, P &gt; 0.415). Cardiac output slightly decreased from LBNP (6.2 ± 1.5 L/min) to 2 minutes of LBNP+FC (5.3 ± 1.6 L/min, P = 0.038). Total peripheral resistance did not change from LBNP (15.6 ± 3.7 mmHg/L/min) to LBNP+SHAM (17.3 ± 3.2 mmHg/L/min, P = 0.613). Total peripheral resistance throughout LBNP+FC was greater than LBNP. The peak increase in total peripheral resistance was observed after 2 minutes of LBNP+FC (20.0 ± 6.2 mmHg/L/min) versus LBNP (13.2 ± 3.9 mmHg/L/min, P &lt; 0.001).ConclusionsFace cooling during simulated moderate blood loss increases blood pressure through an increase in total peripheral resistance. Although more research is warranted, face cooling during blood loss is a potential simple and quick intervention that could delay cardiovascular decompensation.Support or Funding InformationUniversity at Buffalo IMPACT Award

Elective cesarean section or not? Maternal age and risk of adverse outcomes at term: a population-based registry study of low-risk primiparous women.

BackgroundMaternal age at delivery and cesarean section rates are increasing. In older women, the decision on delivery mode may be influenced by a reported increased risk of surgical interventions during labor and complications with increasing maternal age. We examined the association between maternal age and adverse outcomes in low-risk primiparous women, and the risk of adverse outcomes by delivery modes, both planned and performed (elective and emergency cesarean section, operative vaginal delivery, and unassisted vaginal delivery) in women aged ≥ 35 years.MethodsA population-based registry study was conducted using data from the Medical Birth Registry of Norway and Statistics Norway including 169,583 low-risk primiparas with singleton, cephalic labors at ≥ 37 weeks during 1999 − 2009. Outcomes studied were obstetric blood loss, maternal transfer to intensive care units, 5-min Apgar score, and neonatal complications. We adjusted for potential confounders using relative risk models and multinomial logistic regression.ResultsMost adverse outcomes increased with increasing maternal age. However, the increase in absolute risks was low, except for moderate obstetric blood loss and transfer to the neonatal intensive care unit (NICU). Operative deliveries increased with increasing maternal age and in women aged ≥ 35 years, the risk of maternal complications in operative delivery increased. Neonatal adverse outcomes increased mainly in emergency operative deliveries. Moderate blood loss was three times more likely in elective and emergency cesarean section than in unassisted vaginal delivery, and twice as likely in operative vaginal delivery. Low Apgar score and neonatal complications occurred two to three times more often in emergency operative deliveries than in unassisted vaginal delivery. However, comparing outcomes after elective cesarean section and planned vaginal delivery, only moderate blood loss (higher in elective cesarean section), neonatal transfer to NICU and neonatal infections (both higher in planned vaginal delivery) differed significantly.ConclusionsMost studied adverse outcomes increased with increasing maternal age, as did operative delivery. Although emergency operative procedures were associated with an increased risk of adverse outcomes, the absolute risk difference in complications between the modes of delivery was low for the majority of outcomes studied.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-016-1028-3) contains supplementary material, which is available to authorized users.