Perioperative Transfusion Requirements Research Articles

Comparação entre duas doses de ácido tranexâmico intra‐articular no sangramento pós‐operatório de artroplastia total do joelho: estudo clínico randomizado

IntroductionTranexamic Acid (TXA), an antifibrinolytic that inhibits the fibrinolytic activity of plasmin is used to decrease perioperative blood loss and transfusion requirements in orthopedic surgery. The aim of our study was to compare postoperative bleeding in two intra‐articular doses (1g and 2g) of tranexamic acid in adult patients undergoing unilateral total knee replacement. MethodWe conducted a single‐operator, randomized, and controlled, double‐blind study in two groups. The G1 group received 1g of intra‐articular TXA and the G2 group 2g of intra‐articular TXA. Both groups received 15mg.kg‐1 IV before the surgical incision (TXA induction dose) and then 10mg.kg‐1, orally, 6 and 12hours after the induction dose of TXA. The primary endpoint was bleeding measured by blood loss in postoperative drainage. Secondary outcomes were change in hemoglobin and hematocrit levels on the first and third postoperative days, and the need for transfusion during hospitalization. ResultsIn total, 100 patients were randomized, and 100 were included in the analysis. Blood loss in postoperative drainage was similar in both groups (200±50 vs. 250±50mL, G1 and G2 groups respectively). Change in hematocrit and hemoglobin values (% of change) between preoperative and day 3 were not statically significant between groups G1 and G2 (18±5 vs. 21±4; 21±7 vs. 22±5 respectively). No patients received blood transfusion. ConclusionsOur study did not show superiority of 2g of intra‐articular tranexamic acid compared to 1g.ClinicalTrials.gov Identifier NCT04085575

Comparison of two doses of intra-articular tranexamic acid on postoperative bleeding in total knee arthroplasty: a randomized clinical trial

IntroductionTranexamic Acid (TXA), an antifibrinolytic that inhibits the fibrinolytic activity of plasmin is used to decrease perioperative blood loss and transfusion requirements in orthopedic surgery. The aim of our study was to compare postoperative bleeding in two intra-articular doses (1g and 2g) of tranexamic acid in adult patients undergoing unilateral total knee replacement. MethodWe conducted a single-operator, randomized, and controlled, double-blind study in two groups. The G1 group received 1g of intra-articular TXA and the G2 group 2g of intra-articular TXA. Both groups received 15mgkg−1 IV before the surgical incision (TXA induction dose) and then 10mgkg−1, orally, 6 and 12hours after the induction dose of TXA.The primary endpoint was bleeding measured by blood loss in postoperative drainage. Secondary outcomes were change in hemoglobin and hematocrit levels on the first and third postoperative days, and the need for transfusion during hospitalization. ResultsIn total, 100 patients were randomized, and 100 were included in the analysis. Blood loss in postoperative drainage was similar in both groups (200±50 vs. 250±50mL, G1 and G2 groups respectively). Change in hematocrit and hemoglobin values (% of change) between preoperative and day 3 were not statically significant between groups G1 and G2 (18±5 vs. 21±4; 21±7 vs. 22±5 respectively). No patients received blood transfusion. ConclusionsOur study did not show superiority of 2g of intra-articular tranexamic acid compared to 1g.ClinicalTrials.gov Identifier NCT04085575

Can goal-directed fluid therapy decrease the use of blood and hemoderivates in surgical patients?

The purpose of goal-directed therapy (GDT) is to improve patient outcome by the optimization of hemodynamic status, as it is considered that many perioperative complications are related to microcirculatory disturbance due to an imbalance between oxygen delivery and consumption. The application of GDT protocols incorporating the assessment and optimization of patients' intravascular status should theoretically lead to a reduction in perioperative bleeding and transfusion requirements, as both hypervolemia and hypovolemia and their consequences such as dilutional coagulopathy, anemia and inadequate oxygen delivery to the tissues are avoided. However, the research reporting decreased usage of blood products in patients which received targeted fluid management is sparse; decreased blood loss and transfusion requirements were reported in spine surgery using GDT, while studies in abdominal or cardiac surgery did not consistently report significant decreases in blood products transfusion when GDT were applied. These heterogenous results reported can be explained by the differences between the GDT protocols used, as the differences in therapeutic goals can impact on blood transfusion requirements. In the future, the GDT protocols should include not only the prediction of fluid responsiveness and optimization of hemodynamic status, but also the assessment of microcirculation and measures to improve tissue oxygenation, parameters which can also guide the decision for blood product transfusion. A better standardization of GDT algorithms is also required in order to perform a more accurate assessment of the effects of applying GDT on the consumption of blood products.

Intraoperative tranexamic acid to decrease blood loss during myomectomy: a randomized, double-blind, placebo-controlled trial

Myomectomy is associated with a significant risk of hemorrhage. Tranexamic acid is a synthetic lysine derivative with antifibrinolytic activity used in other surgical disciplines to reduce blood loss during surgery. However, its utility in gynecologic surgery is not well understood. This study aimed to determine the effect of early administration of intravenous tranexamic acid on perioperative bleeding and blood transfusion requirements in women undergoing myomectomy. This study was a double-blinded, randomized, placebo-controlled trial conducted in an academic teaching hospital. Women with symptomatic fibroids thought to be at risk for large intraoperative blood loss who met the following criteria were included in the study: (1) at least 1 fibroid ≥10 cm, (2) any intramural or broad ligament fibroid ≥6 cm, and/or (3) at least 5 total fibroids based on preoperative imaging. Patients were randomized to receive a single intravenous bolus injection of tranexamic acid 15 mg/kg (intervention group) versus an intravenous bolus injection of saline of equivalent volume (placebo group) 20 minutes before the initial surgical incision. Perioperative bleeding was defined by measuring intraoperative estimated blood loss, change between pre- and postoperative hemoglobin, and frequency of blood transfusions. Estimated blood loss was calculated by combining the blood volume collected within the suction canister and the weight of used sponges. The 2 groups were compared for age; body mass index; perioperative hemoglobin and hematocrit; perioperative blood loss; duration of surgery; blood transfusion requirements; and the number, total weight, and volume of myomas removed. A total of 60 patients (30 per arm) were enrolled into the study between March 1, 2015, and January 29, 2018. Age, body mass index, baseline hemoglobin and/or hematocrit, number and total weight of myomas removed, and size of myomas did not differ between arms. Of 60 patients, 32 (53%) had laparoscopic myomectomy, 24 (40%) had robotic myomectomy, and 4 (7%) had laparotomy. Median estimated blood loss was 200 mL for the tranexamic acid group and 240 mL for the placebo group (P=.88). There was no difference in median duration of surgery (165 vs 164 minutes; P=.64) or change in perioperative hemoglobin (1.00 vs 1.1 g/dL; P=.64). Patients in the tranexamic acid group did not require blood transfusions; however, 4 patients (13.3%) in the placebo group (P=.11) required blood transfusions. Intravenous administration of tranexamic acid in patients undergoing laparoscopic or robotic myomectomies was not associated with decreased blood loss.

A Single Preoperative Dose of Tranexamic Acid Reduces Perioperative Blood Loss: A Meta-analysis.

To review the efficacy and safety of a single dose of intravenous tranexamic acid (TXA) given preoperatively. TXA is a synthetic antifibrinolytic that has been used in various surgical disciplines to reduce blood loss, blood transfusions, ecchymosis, and hematoma formation. However, there is no universal standard on the most effective dose and route of TXA administration, limiting its routine use in many centers. This study evaluates the current evidence for the efficacy and safety of a single preoperative dose of TXA on surgical blood loss in all surgical disciplines. With the guidance of a research librarian, in accordance with the Cochrane Handbook Medline, Cochrane Central and Embase were searched in November 2018. Search terms included "Tranexamic Acid" AND "Intravenous," with studies limited to randomized controlled trails in adult humans. Two independent reviewers and an arbitrator assessed articles for inclusion. Criteria included a single preoperative bolus dose of intravenous TXA, surgical patients, and intraoperative blood loss measurement or perioperative blood loss up to 24 hours postsurgery. Quality assessment was done using the Cochrane Collaboration risk-of-bias tool by 2 reviewers. Statistical analysis was carried out using Cochrane Review Manager 5.3. The primary outcome was surgical blood loss. Secondary outcomes included venous thromboembolic complications, transfusion requirements, and dosing. A total of 1906 articles were screened, 57 met inclusion criteria. The majority of included studies were orthopedic (27), followed by obstetric and gynecological (16), oral maxillofacial and otolaryngology (10), cardiac (3), and 1 plastic surgery study focusing on acute burn reconstruction. Across all surgical specialties (n = 5698), the perioperative estimated blood loss was lower in patients receiving TXA, with a standard mean difference of -153.33 mL (95% CI = -187.79 to -118.87). Overall, surgical patients with TXA had a 72% reduced odds of transfusion (odds ratio = 0.28 [95% CI = 0.22-0.36]). The most frequently used dose of TXA was 15 mg/kg. There was no difference in the incidence of venous thromboembolic events between TXA and control groups. While there is a growing body of evidence to support benefits of perioperative TXA use, this is the first meta-analysis to identify the efficacy and safety of a single preoperative dose of IV TXA. The potential implications for expanding the use of preoperative TXA for elective day surgery procedures is substantial. Preoperative intravenous TXA reduced perioperative blood loss and transfusion requirements in a variety of surgical disciplines without increasing the risk of thromboembolic events. Therefore, it should be considered for prophylactic use in surgery to reduce operative bleeding.

Effect of oxytocin infusion versus tranexamic acid on reducing blood loss during hysteroscopic myomectomy: A Randomized control trial

Abstract Background Women undergoing hysteroscopic myomectomy are prone to significant blood loss and hematological disturbances. Oxytocin is a uterotonic drug. Tranexamic acid has been used to reduce blood loss in many surgeries. The aim of our study was to compare between oxytocin and tranexamic acid as regard their safety and effectiveness on reducing perioperative blood loss and perioperative transfusion requirement during hysteroscopic myomectomy. Methods This study included 60 patients scheduled for hysteroscopic myomectomy allocated into 2 groups: group A: Patient received 10 mg/kg of tranexamic acid slowly intravenous after induction of anesthesia, group B: Patients received infusion of 10 IU of oxytocin at a rate of 400 mIU/min till the end of the procedure. Preoperative and postoperative hemoglobin and hematocrit, need for blood transfusion, duration of operation, complications and medications’ side effects were recorded. Results The 2 groups were comparable in terms of mean difference between preoperative and postoperative hemoglobin an hematocrit, operative time, operative complication and medications’ adverse effects. No patient needed any blood component transfusion in both groups. Conclusions We concluded that tranexamic acid and oxytocin are equally effective in reducing blood loss and transfusion requirements in hysteroscopic myomectomy with good safety profile. Both of them can be used according to the availability.

3:36 PM Abstract No. 340 Perioperative blood loss after preoperative prostatic artery embolization in patients undergoing simple prostatectomy: a propensity score matched study

To compare peri-operative blood loss in patients undergoing simple prostatectomy with and without preoperative prostatic artery embolization using propensity score matching. From September 2014 to July 2019, 56 patients (mean age, 67.4 ± 8.1 years) with prostatic hypertrophy resulting in severe lower urinary tract symptoms (LUTS). Twelve patients (66.8 ± 8.5 years) underwent preoperative embolization prior to prostatectomy. A retrospective chart review provided demographic data, medical history, pertinent labs (i.e., hemoglobin levels), procedural/operative information, surgical details (estimated blood loss (EBL), intraoperative transfusion), hospital course (length of stay, continuous bladder irrigation), and pathology. Ten patients (83%) underwent bilateral treatment. Two patients were treated unilaterally due to severe prostate artery stenosis. The mean EBL for patients without preoperative embolization was 548.9 ± 343.8 mL. The mean EBL for patients who underwent bilateral PAE was 250.0 ± 135.4 mL and unilateral PAE was 950 ± 70.7 mL. There was a significant difference in EBL between the no embolization and bilateral PAE group (P < 0.01). Twenty patients that underwent prostatectomy without preoperative embolization were selected for 2:1 Propensity Score Match Analysis based on age, race, surgery type, prostate gland size, and comorbidities. The mean EBL for these patients was 487.5, still statistically higher than the PAE group (P < 0.01). Propensity score match analysis also demonstrated a significant decrease in procedure time in patients who underwent preoperative PAE (P < 0.05). There were no differences in length of stay or perioperative transfusion requirements. For patients undergoing PAE, there were no complications related to the procedure. Preoperative PAE appears to be safe and may be effective in minimizing perioperative bleeding and procedure time. Unilateral treatment may not be sufficient in these cases.Tabled 12:1 MatchControlPAEPAge63.964.80.754RaceBlack10%20%0.516RaceHisp65%50%0.462RaceUnk25%30%0.787SurgType_Robot50%50%1.000PG.Size128.3112.30.137BPH15%10%0.703DM15%20%0.753HTN45%50%0.807HLD20%20%1.000CAD0%10%0.343Malignancy10%30%0.254 Open table in a new tab

Selective Use of Anticoagulation or Dual Antiplatelet Therapy for Patients with Extra-anatomic Bypasses

The benefit of long-term anticoagulation or dual antiplatelet therapy (DAPT) for patients with extra-anatomic bypasses to the lower extremity remains poorly defined. Our study analyzed the real-world use of antithrombotic therapy in patients with extra-anatomic bypass grafts to the lower extremity and compared graft and patient outcomes by antithrombotic regimen. We studied patients who underwent axillofemoral or femoral-femoral bypass within the Vascular Quality Initiative with one-year follow-up data. Primary exposures were anticoagulation and DAPT, at the time of index procedure and one-year follow-up. Primary outcomes were major adverse limb events (MALE) defined as reintervention or above-ankle amputation, and primary patency. Secondary outcomes included perioperative blood transfusion requirements and the need for reoperation specifically for bleeding. We analyzed outcomes using the Kaplan-Meier estimation and examined factors associated with choice of antithrombotic therapy via logistic regression. Our cohort included 2,760 patients (axillofemoral bypass, n=857; femoral-femoral bypass, n=1,903) across 168 centers from 2009 to 2018. Mean age was 66.5±10.5years and 59% were male. Patients were infrequently prescribed long-term anticoagulation (19%) or DAPT (22%). One-year primary patency was 86% and was similar by anticoagulation (log-rank P=0.12) and DAPT status (log-rank P=0.26). Freedom from MALE was 87% at 1year and was slightly inferior for patients on anticoagulation (88 vs. 83%, log-rank P=0.001) but was similar by DAPT (log-rank P=0.19). Transfusion was more common in patients who were anticoagulated than those who were not (30 vs. 25%, P<0.01), but there was no increase in reoperation because of bleeding (anticoagulation 0.8 vs. 0.8, P=0.98). Anticoagulation was more commonly prescribed according to disease severity, such as rest pain (adjusted odds ratio (OR): 1.6 (95% confidence interval (CI): 1.20-2.20), tissue loss (OR: 1.9, CI: 1.28-2.73), or acute limb ischemia (OR: 1.9, CI: 1.35-2.71) or prior bypass graft (OR: 2.6, CI: 2.07-3.35). Patients were more commonly prescribed DAPT according to comorbidities, including hypertension (OR: 1.4, CI: 1.04-1.94) and coronary artery disease (OR: 1.6, CI 1.26-1.95). Antithrombotics are selectively used in patients with extra-anatomic bypass to the lower extremity, the selection of which appears associated with disease severity for anticoagulants and patient comorbidities for DAPT. Primary patency and MALE rates are similar with focused utilization of anticoagulants or DAPT. Blood transfusions are more common among patients on antithrombotics without a difference in the need for reoperation for bleeding.

Preoperative embolization in surgical treatment of long bone metastasis: a systematic literature review.

Surgery of long bone metastases is associated with a significant risk of perioperative blood loss, which may necessitate blood transfusion.Successful embolization (> 70% obliteration of vascularity) can be achieved in 36–75% of cases.The reported rate of embolization-related complications is 0–9%.Three out of six level III evidence studies showed a reduction in perioperative blood loss and/or blood transfusion requirement after preoperative embolization of renal cell carcinoma metastasis in long bones; three out of six studies did not.One level III evidence study did not show a reduction in perioperative blood loss and/or transfusion requirement after preoperative embolization of hepatocellular carcinoma metastases in long bones.There were no studies found that support preoperative embolization of thyroid metastases or other frequent long bone metastases (e.g. mamma carcinoma, lung carcinoma, or prostate carcinoma).The clinical level of evidence of the studies found is low and randomized studies taking into account primary tumour, location of metastases and type of surgery are therefore desired.Cite this article: EFORT Open Rev 2020;5:17-25. DOI: 10.1302/2058-5241.5.190013

Retraction: Does the preoperative administration of tranexamic acid reduce perioperative blood loss and transfusion requirements after head neck cancer surgery? A randomized, controlled trial.

[This retracts the article on p. 384 in vol. 9, PMID: 26712979.].

Comparison of Blood-Conserving and Allogenic Transfusion-Sparing Effects of Antifibrinolytics in Scoliosis Correction Surgery.

Background:Intraoperative antifibrinolytic drug administration is a safe and effective method of reducing blood loss and allogenic transfusions in patients undergoing spine deformity correction.Aim:This study aimed to compare the effectiveness of two antifibrinolytic drugs tranexamic acid (TXA) and epsilon amino caproic acid (EACA) in reducing peri-operative blood loss and transfusion requirements against a placebo control in patients with idiopathic scoliosis undergoing correction surgery.Setting and Design:This is a prospective, randomized, double-blinded, controlled comparative study.Methodology:Patients in TXA group received 50 mg.kg−1 bolus and 10 mg.kg−1.h−1 infusion as against 100 mg.kg−1 and 10 mg.kg−1.h−1 infusion in EACA group. The placebo group had saline bolus and infusion. Parameters observed included baseline demographic and deformity data, duration of surgery, total peri-operative blood loss, and allogenic packed red cell transfusion requirements.Statistical Analysis:Mean and standard deviation were used to represent the quantitative continuous data, and percentage was used to represent categorical data. The Student's t-test and ANOVA were used to compare means between groups. Bonferroni's multiple comparison test was used to find out the association between categorical variables.Results:A total of 36 patients were enrolled with 12 patients in each group. Peri-operative blood loss was 50.1% lower in patients receiving TXA and 17.7% lower in patients receiving EACA compared with the placebo group. The volume of total packed red cell transfusion was 66.7% lower in patients receiving TXA and 45.6% lower in patients receiving EACA compared with placebo.Conclusion:TXA was more effective in reducing total peri-operative blood loss and allogenic transfusion requirement in idiopathic scoliosis correction surgery compared to EACA.

One stage bilateral total hip arthroplasty in Indian patients

There are few studies which investigate peri-operative safety and surgical outcome of one stage bilateral total hip arthroplasty. Avascular necrosis of hip is the most common indication for total hip arthroplasty which is frequently bilateral. In present study, we studied 30 patients who were operated with one stage bilateral total hip arthroplasty. Most of them (93%) were suffering from avascular necrosis of hip. We analysed intra-operative blood loss, peri-operative blood transfusion requirement, length of hospital stay and peri-operative complications for the aforesaid patients. All patients were followed up for a period of 6 months post-operatively to determine functional outcome using harris hip score. We concluded that one stage bilateral total hip arthroplasty is safe and efficacious treatment modality for our patients. This study also demonstrates brisk rehabilitation in patients operated with single stage bilateral total hip arthroplasty.

ABO Blood Group and Transfusions In the Intraoperative and Postoperative Period After LVAD Implantation

To assess whether blood group O patients undergoing left ventricular assist device (LVAD) insertion have higher perioperative transfusion requirements, postoperative chest tube output, and postoperative changes in hematocrit. Retrospective review of 116 LVAD patients from August 2015 to May 2018. Single-institution, urban academic medical center. One hundred sixteen LVAD patients analyzed by blood group: group O (n = 49) versus non-O (n = 67). Transfusions in the combined intraoperative and postoperative period at 7 days and 90 days after LVAD implantation, chest tube output in the first 24 hours, and hematocrit change in the first 48 hours postoperatively. There was no difference between group O and non-O within the univariable analysis for both 7-day and 90-day transfusion rates. Adjusting for covariables, blood type O was not associated with packed red blood cells transfusion after accounting for multiple comparisons (odds ratio 1.33 [1.07-1.66], p = 0.01, where p < 0.005 was considered statistically significant as a Bonferroni correction was performed to control the familywise error rate). Additionally, there was no difference in chest tube output over the first 24 hours (1,129 v 1,057 mL, p = 0.47) or hematocrit change in the first 48 hours postoperatively (3.49 v 4.53%, p = 0.15). O blood group is not a significant predictor of transfusion requirements in the combined intraoperative and postoperative period up to 90 days after LVAD implantation.

Relationship Between Preoperative Plasma Fibrinogen Concentration, Perioperative Bleeding, and Transfusions in Elective Adult Spinal Deformity Correction

Study DesignRetrospective analysis. ObjectiveThis study sought to investigate the relationship between preoperative (preop) fibrinogen, bleeding, and transfusion requirements in adult spinal deformity corrections. Summary of Background DataBlood loss after major spinal reconstruction increases the risks and costs of surgery. Preoperative fibrinogen levels may predict intra- and postoperative blood loss. MethodsData were collected from clinic charts and hospital medical records of all 142 of a single surgeon's consecutive adult spine patients undergoing 7 or more levels deformity correction surgeries from January 2011 to December 2014. t tests were used to compare perioperative variables between patients with total blood loss in the upper quartile (≥1,000 mL) and the remaining patients. Similarly, patients receiving >2 units of packed red cells (PRCs) were compared with others. Analysis of variance was used to compare the blood loss between the patients' groups (quartiles) based on their preoperative fibrinogen concentration. ResultsMean total blood loss was 847.9 (±543.6) mL. Overall, mean preoperative fibrinogen concentration was 254.8 (±82.9) mg/dL. Patients with lower fibrinogen concentration (<193 mg/dL) experienced significantly higher blood loss than those with higher concentrations (p < .05). Patients with transfusion >2 units PRC had significantly greater number of spinal levels treated, higher mean operative time, total blood loss and lower mean preoperative fibrinogen than those transfused 2 or fewer units PRC (p < .05). Total blood loss correlated significantly with preoperative fibrinogen concentration (r = −0.51, p < .05). All the thromboelastography (TEG) variables (G, K, and Angle) correlated significantly with preoperative fibrinogen (p < .05). ConclusionsIn our cohort undergoing correction of adult spinal deformity, patients with preoperative fibrinogen level lower than 193 mg/dL had significantly higher bleeding than their counterparts. Perioperative transfusion requirements correlated moderately both with the blood loss and preoperative fibrinogen concentration. Incorporation of preoperative fibrinogen allows better prediction of total perioperative blood loss and may therefore guide the treatment team in use of ameliorating therapies. Level of EvidenceLevel IV.

Preoperative Vitamin K Reduces Blood Transfusions at Time of Left Ventricular Assist Device Implant

Congestive heart failure patients have hepatic congestion and abnormal coagulation profiles, increasing perioperative bleeding at time of ventricular assist device implantation. This study examined the impact of the preoperative administration of vitamin K on perioperative blood transfusion requirements. Retrospectively, 190 patients met inclusion criteria. Patients received no vitamin K (n= 62) or two 10-mg doses of intravenous vitamin K (n= 128) in the 24 hours before assist device implantation. Primary end points included transfusion requirements and reexploration rates for bleeding. Secondary outcomes were pump thrombosis and in-hospital mortality. Baseline characteristics were similar between the 2 groups, with slight differences (not statistically significant) noted in the Interagency Registry for Mechanically Assisted Circulatory Support profile and total bilirubin levels. The only significant difference noted was the year of implantation (P < .001). Blood product usage was significantly lower in the vitamin K group compared to the no vitamin K group (P < .001). Higher rates of reexploration for bleeding (29.7% vs 13.6%, P= .023) and death at hospital discharge (16.2% vs 2.8%, P= .004) were noted for the no vitamin K group compared with the vitamin K group. After adjusting for age, sex, race, body mass index, Interagency Registry for Mechanically Assisted Circulatory Support profile, total bilirubin, surgeon, and year of operation, reexploration rates and death did not achieve statistical significance. No statistically significant difference was observed in stroke and pump thrombosis rates between the 2 groups. Preoperative vitamin K administration may help reduce blood product use without any increased risk for strokes or pump thrombosis.

Reoperative mitral valve surgery via sternotomy or right thoracotomy: A propensity-matched analysis.

There is, as yet, no broad consensus regarding the optimal surgical approach for patients requiring reoperative mitral valve surgery. Consequently, we sought to evaluate the perioperative outcomes for patients undergoing redo mitral surgery via right mini thoracotomy as compared with traditional resternotomy. A comprehensive retrospective review of our prospectively collected database was undertaken from January 2011 to December 2017. We propensity matched 90 patients who underwent reoperative mitral valve surgery via right mini thoracotomy with a concurrent cohort of patients who had redo median sternotomy. Intraoperative data and short-term clinical outcomes were analyzed. The 30-day mortality was 3.3% (six deaths) in the entire cohort, not significantly different between redo sternotomy and mini thoracotomy groups. Patients who had their procedure via right mini thoracotomy had reduced intensive care unit (P = .029) and overall hospital (P < .0001) lengths of stay, a diminished requirement for perioperative transfusion (P = .023), and a trend towards faster postoperative extubation. Right thoracotomy patients experienced shorter cardiopulmonary bypass (P = .012) and cardiac arrest (P < .0001) times than did the sternotomy cases. Peripheral cannulation was utilized more frequently in the mini thoracotomy group, as were fibrillatory arrest techniques. Reoperative mitral valve surgery via right mini thoracotomy is safe, and is associated with shorter extracorporeal circulation times, reduced transfusion, and faster postoperative recovery.

Prophylactic use of tranexamic acid reduces blood loss and transfusion requirements in patients undergoing cesarean section: A meta-analysis.

Tranexamic acid (TXA) has been used to treat peripartum hemorrhage, while preoperative use of TXA in cesarean section (CS) remains controversial. To assess the effectiveness and safety of prophylactic application of TXA, a meta-analysis was performed. Electronic databases (MEDLINE [PubMed], Cochrane central register of controlled trials and Embase) were searched up to November 2018. The relevant data and quality of included trail were analyzed by RevMan 5.3. The study was registered at PROSPERO (CRD42018111165). Twenty-one randomized controlled trials with a total of 3852 patients were included. Only one research reported thromboembolic events. Compared with control groups, the intra-operative blood loss (mean difference [MD] -155.23 mL, 95% confidence interval [CI] -195.64 - 114.81; P<0.01), postoperative blood loss (MD -26.67 mL, 95% CI -32.98 to -20.36; P<0.01), total blood loss (MD -184.88 mL, 95% CI -218.83 to -150.94; P<0.01), transfusion requirements (relative risk [RR] 0.29, 95% CI 0.18-0.49, P<0.01), massive hemorrhage (RR 0.39, 95% CI 0.30 to 0.51; P<0.01) and additional uterotonic agents use (RR 0.40, 95% CI 0.30-0.55, P<0.01) were markedly reduced in TXA-treated patients. Besides, TXA yielded a significant reduction in hemoglobin drop (MD -0.80 g/dL, 95% CI -1.07 to -0.53; P<0.01) and hematocrit drop (MD -2.05, 95% CI -3.09 to -1.01; P<0.01) compared with control groups. Prophylactic application of TXA can decrease perioperative blood loss and transfusion requirements in patients undergoing CS. More high-quality researches are needed to determine optimal dose of the drug.

Propensity and impact of autologous platelet rich plasma use in acute type A dissection

BackgroundCoagulopathy in patients undergoing open repair of acute type A aortic dissection using cardiopulmonary bypass and hypothermic circulatory arrest is a common complication. Autologous platelet rich plasma is an intraoperative blood conservation technique, which has been shown in previous studies to promote hemostasis, leading to a reduction of blood product transfusions during elective aortic surgery. The purpose of this study is to evaluate the effectiveness of autologous platelet rich plasma as a blood conservation technique during open surgical repair of acute type A aortic dissection. MethodsWe reviewed all acute type A aortic dissection cases using hypothermic circulatory arrest, excluding patients presenting in extremis. Perioperative transfusion requirements and clinical outcomes were analyzed. The end points analyzed included early mortality, postoperative stroke, renal dysfunction, prolonged ventilation, coagulopathy, and length of postoperative intensive care unit stay. Parsimonious and saturated propensity scores were calculated for platelet rich plasma use, and all outcomes were propensity adjusted. ResultsBetween 2003 and 2014, 85 of 391 acute type A aortic dissection repairs used autologous platelet rich plasma. Mean age of patients was 58 ± 15 years, and 70% were male. Obstructive sleep apnea (22% vs 13%, P = .04) and baseline ejection fraction (57% ± 6.7% vs 55% ± 10%; P = .014) were higher in the autologous platelet rich plasma group. Intraoperative propensity-adjusted blood products, 2 units fewer packed red blood cells (P = .001), 4 units fewer fresh-frozen plasma (P = .001), 6 units fewer platelets (P = .001), 1.3 units fewer cell-savers (P = .002), and 5 units fewer cryoprecipitate (P = .001) were significantly reduced by autologous platelet rich plasma use. Significant unadjusted reduction in postoperative reoperation for bleeding (8% vs 17%, P = .046) after autologous platelet rich plasma was reported, although propensity adjustment eliminated significance (P = .079). No difference in stroke, cardiac, or renal complications was observed. Postoperative transfusion needed during the first 3 days was significantly reduced in the autologous platelet rich plasma group: 2 units fewer packed red blood cells (P = .13), 2 units fewer fresh-frozen plasma (P = .018), and 5 units fewer platelets (P = .001), when compared with those without autologous platelet rich plasma. Ventilation time was reduced by 3 days (P = .002), and intensive care length of stay was reduced by 3 days (P = .063) after intraoperative autologous platelet rich plasma use. ConclusionsThe use of autologous platelet rich plasma in patients undergoing open repair of acute type A aortic dissection was associated with a reduction in intraoperative and postoperative blood transfusions, as well as decreased early postoperative morbidity.

The use of tranexamic acid in adult spinal deformity: is there an optimal dosing strategy?

BACKGROUND CONTEXTASD (Adult spinal deformity) surgery often entails complex osteotomies and realignment procedures, particularly in the setting of rigid deformities. Although previous studies have established the efficacy of tranexamic acid (TXA), data evaluating the widely variable dosing regimens remains sparse. PURPOSETo improve understanding of blood loss and transfusion requirements for low-dose and high-dose TXA regimens for adult spinal deformity (ASD) surgery. STUDY DESIGN/SETTINGThis is a retrospective cohort study of 318 ASD patients who received TXA. Outcome measures include estimated blood loss (EBL), perioperative transfusion requirement, and complications. METHODSA retrospective review was conducted on 318 ASD patients: 258 patients received a low-dose regimen of TXA (10 or 20 mg/kg loading dose with a 1 or 2 mg/kg/h maintenance dose) and 60 patients received a high-dose regimen of TXA (40 mg/kg loading dose with a 1 mg/kg/h maintenance dose, 30 mg/kg loading dose with a 10 mg/kg/h maintenance dose, or 50 mg/kg loading dose with a 5 mg/kg/h maintenance dose). RESULTSCompared with the low-dose TXA group, the high-dose TXA group had significantly decreased EBL (1402 vs. 1793 mL, p=.009), blood volume lost (30.3 vs. 39.4%, p=.01), intraoperative packed red blood cell (pRBC) transfusion (0.9 vs. 1.6 U, p<.0001), and intraoperative platelet transfusion (0 vs. 0.1 U, p<.0001). High-dose TXA was predictive of 515 cc less EBL (p=.002), 11.4% less blood volume lost (p=.004), and 1 U pRBC less transfused intraoperatively (p<.0001) than the low-dose TXA group. The high-dose TXA group had a higher incidence of postop atrial fibrillation (5 vs. 0%, p<.0001) and myocardial infarction (1.7 vs. 0%, p=.04). CONCLUSIONSVarying dosing regimens of TXA are utilized for ASD surgery, with a prevailing theme of dosing ambiguity. These data demonstrate that high-dose TXA is more effective than low-dose TXA in reducing blood loss and blood product transfusion requirement in ASD surgery. Importantly, rates of MI and postop AF were higher in the high-dose TXA group.

Improved perioperative outcomes with direct anterior approach total hip arthroplasty in a Veteran's Affairs patient population

BackgroundA trend toward improved perioperative outcomes with direct anterior approach total hip arthroplasty (DAA THA) in comparison to posterior approach THA has been described. The benefits of the DAA THA have not been examined in the Veteran's Affairs (VA), a health system unique in its highly comorbid patient demographic and federally subsidized budget. Optimizing outcomes in this population could help reduce costs, readmissions, and complications. This study sought to compare the perioperative and radiographic outcomes of veterans who underwent a DAA THA versus a posterior approach THA. MethodsWe retrospectively reviewed the records of 110 primary posterior approach THAs and 93 primary DAA THAs performed for primary osteoarthritis by a single surgeon at a VA hospital between 2012 and 2018. We compared mean surgical duration, intraoperative blood loss, perioperative blood transfusion requirements, discharge disposition, hospital length of stay, as well as acetabular component inclination, femoral offset discrepancy, and leg length discrepancy using postoperative anteroposterior pelvis radiographs. ResultsThe DAA group demonstrated significantly lower perioperative blood transfusion rates (5% vs. 20%), increased likelihood of discharge prior to postoperative day three (OR 2.12; 95% CI 1.02–4.44), and higher rate of discharge to home (65% vs. 40%). Acceptable acetabular inclination rate was higher in the DAA group (83% vs. 37%). ConclusionAmong veterans undergoing primary THA at a VA hospital, patients undergoing DAA THA had better perioperative outcomes than patients treated with the posterior approach despite similar demographics, American Society of Anesthesiologists score, and the DAA learning curve.