Perioperative Continuous Infusion Research Articles

Perioperative continuous infusions of factor VIII versus factor IX for patients with hemophilia A or B undergoing major surgery.

Continuous factor VIII (FVIII) or factor IX (FIX) infusions are commonly used for patients with hemophilia A (HA) or B (HB) undergoing surgery to secure perioperative hemostasis. To describe differences between the initial recovery and subsequent FIX and FVIII levels, and describe clinical outcomes among HB and HA patients receiving perioperative continuous infusion (CI) of recombinant FVIII and FIX concentrates. Retrospective chart review was conducted on 8 consecutive patients with HB and 7 consecutive patients with HA who underwent major surgery between 2014 and 2018 and received continuous infusions of standard half-life factor concentrate. Median initial bolus dose per kilogram was higher for HB compared to HA patients [90.8 (IQR 78.0-98.7) vs. 52.1 (IQR 48.6-55.6) IU/kg], while initial CI dose-rates were similar [4.3 (IQR 3.8-4.6) vs. 4.2 (IQR 3.8-4.4) IU/kg/h]. Median post-bolus recovery was higher for FVIII compared to FIX [1.70 (IQR 1.23-1.75) vs. 0.88 (IQR 0.75-1.00) IU/mL]. Median factor levels also were higher for FVIII on post-operative days 1 to 3. HB patients had greater mean intraoperative estimated blood loss [285.7 (range 0-1000) vs. 142.8 (range 0-400) mL] and longer median length of hospital stay [9 (IQR 8-12) vs. 5 (IQR 4-6.5) days]. Our initial evidence suggests greater in vivo yield of rFVIII compared to rFIX in the perioperative setting. We identified poorer clinical outcomes in this small cohort of perioperative HB patients indicating that they may benefit from a higher CI rate for adequate surgical hemostatic coverage.

Intravenous amino acid therapy for kidney protection in cardiac surgery a protocol for a multi-centre randomized blinded placebo controlled clinical trial. The PROTECTION trial

BackgroundPostoperative acute kidney injury (AKI) is frequent in cardiac surgery patients. Its pathophysiology is complex and involves decreased renal perfusion. Preliminary clinical evidence in critically ill patients shows that amino acids infusion increases renal blood flow and may decrease the incidence and severity of AKI. We designed a study to evaluate the effectiveness of perioperative continuous infusion of amino acids in decreasing AKI. MethodsThis is a phase III, multi-center, randomized, double-blind, placebo-controlled trial. Adults undergoing cardiac surgery with cardiopulmonary bypass (CPB) are included. Patients are randomly assigned to receive either continuous infusion of a balanced mixture of amino acids in a dose of 2 g/kg ideal body weight/day or placebo (balanced crystalloid solution) from the operating room up to start of renal replacement therapy (RRT), or ICU discharge, or 72 h after the first dose. The primary outcome is the incidence of AKI during hospital stay defined by KDIGO (Kidney Disease: Improving Global Outcomes). Secondary outcomes include the need for, and duration of, RRT, mechanical ventilation; ICU and hospital length of stay; all-cause mortality at ICU, hospital discharge, 30, 90, and 180 days after randomization; quality of life at 180 days. Data will be analyzed in 3500 patients on an intention-to-treat basis. DiscussionThe trial is ongoing and currently recruiting. It will be one of the first randomized controlled studies to assess the relationship between amino acids use and kidney injury in cardiac surgery. If our hypothesis is confirmed, this practice could reduce morbidity in the studied population. Study registrationThis trial was registered on ClinicalTrials.gov with the trial identification NCT03709264 in October 2018.

Prasad R, Patki A, Padhy S, Ramchandran G. Single intravenous bolus versus perioperative continuous infusion of tranexamic acid to reduce blood loss in abdominal oncosurgical procedures: a prospective randomized double-blind clinical study. J Anaesthesiol Clin Pharmacol. 2018;34(4):529-534.

Prasad R, Patki A, Padhy S, Ramchandran G. Single intravenous bolus versus perioperative continuous infusion of tranexamic acid to reduce blood loss in abdominal oncosurgical procedures: a prospective randomized double-blind clinical study. J Anaesthesiol Clin Pharmacol. 2018;34(4):529-534.

Combined Popliteal Catheter with Single Injection Versus Continuous Infusion Saphenous Nerve Block

Category: Ankle, Bunion, Hindfoot, Lesser Toes, Midfoot/Forefoot, Sports, Trauma Introduction/Purpose: Surgical and analgesic advancements have increasingly allowed more foot and ankle procedures to be performed on an outpatient basis. Dual nerve blockade of saphenous and popliteal nerves minimizes post-operative pain, and continuous infusion via catheter can provide extended pain relief. In our experience, the combination of popliteal nerve catheters and single-shot saphenous nerve block effectively eliminates post-operative pain after most foot and ankle surgery. However, the early return of pain in the saphenous nerve distribution can cause early discomfort and even readmission for pain control. We hypothesized that patients receiving continuous popliteal nerve infusion with single-injection saphenous nerve block (single) will have greater post-operative pain than those patients receiving continuous popliteal and saphenous nerve infusion (dual). Methods: A cohort of 62 patients undergoing outpatient foot and ankle surgery by a single fellowship trained orthopaedic surgeon were prospectively, sequentially enrolled. The surgeon rated each procedure for degree of saphenous involvement as limited, moderate, or extensive. Demographics, American Society of Anesthesiologists physical status classification system (ASA), anesthesia time and post-anesthesia care unit (PACU) time were documented. Total analgesia requirement and reported numeric pain score (NPS) at rest and with activity were recorded. Student’s t-test and chi-square test were utilized for single and dual block comparisons, and one-way ANOVA tested for differences in saphenous involvement. Results: The dual catheter group took significantly less opioid medication on post-operative day (POD) 1 compared to the single catheter group (Table 1; p=0.02). The dual catheter group reported significantly greater satisfaction with pain at POD 1 and POD 3 (p=0.03) and a significantly lower NPS at POD 1 and POD 2 (p=0.005). This trend is observed in all 3 subgroups of medial involvement. Patients in the single catheter group report about twice as much pain as patients in the dual catheter group when medial involvement was limited (7.4 v 3.8; p=0.033) or moderate (5.9 v 3.4; p=0.025). For patients with extensive medial involvement, pain was reduced when dual blocks were employed (5.4 v 6.7), but this difference was not significant (p=0.288). Conclusion: Patients in the single catheter group reported more pain and less satisfaction with pain control on POD 1, suggesting dual catheter use is superior to managing early post-operative pain in outpatient foot and ankle surgery. Interestingly, degree of medial involvement did not seem to correlate with better pain control within the dual group; in contrast, patients with less medial involvement reported better pain relief with dual than with a single catheter. From a pain management perspective, discharging patients on the day of routine outpatient foot and ankle surgery is appropriate with the judicious use of perioperative continuous infusion nerve catheters.

Single intravenous bolus versus perioperative continuous infusion of tranexamic acid to reduce blood loss in abdominal oncosurgical procedures: A prospective randomized double-blind clinical study.

Background and Aims:Intraoperative use of a single bolus dose of tranexamic acid may not be sufficient to prevent bleeding in the early postoperative period. The present study was carried out to compare the effect of two dose regimens of tranexamic acid in reducing perioperative blood loss and the amount of allogenic blood transfusion in abdominal tumor surgery.Material and Methods:In this prospective, controlled, and double-blind investigation, 60 patients electively posted for abdominal oncosurgical procedures were randomly assigned to receive a single bolus dose of tranexamic acid (10 mg/kg) (Group A), a bolus dose of tranexamic acid (10 mg/kg) followed by infusion (1 mg/kg/h) till 4 h postoperatively (Group B), and a bolus followed by infusion of normal saline (group C). Total intraoperative blood loss, amount of allogenic blood transfusion, postoperative drain collections, and hemoglobin and hematocrit levels were recorded at different time intervals. Data obtained after comparing three groups were analyzed by analysis of variance test for variables following normal distribution, Kruskal–Wallis test for nonparametric data, and post-hoc Tukey–Kramer test for intergroup analysis. A probability value of less than 5% was considered significant.Results:There was no significant difference in intraoperative blood loss in all the three groups. Both the tranexamic acid groups showed reduction in postoperative blood collection in drain at 6 h and 24 h in comparison to the control group (P < 0.001). There was also a significant difference in the amount of blood in postoperative drain at 24 h within the tranexamic acid groups, where lesser collection was seen in the infusion group (P = 0.007). Hemoglobin and hematocrit levels measured at different postoperative time intervals showed a significant reduction from the baseline in the control group compared to the tranexamic acid groups together.Conclusion:Tranexamic acid causes more effective reduction in post-operative blood loss when used as a bolus followed by an infusion continued in the postoperative period in comparison to its use as a single intravenous bolus in abdominal tumor surgery.

Comparison of continuous infusion versus bolus injection of factor concentrates for blood management after total knee arthroplasty in patients with hemophilia

BackgroundTotal knee arthroplasty (TKA) has become the treatment of choice for end-stage hemophilic arthropathy of the knee. Theoretically in hemophilia A, perioperative continuous infusion (CI) of factor VIII (FVIII) would provide a more consistent FVIII level than general bolus injections (BI) in TKA. Current study was designed to evaluate the effectiveness of CI of coagulation factor concentrates during the perioperative period compared to BI.MethodsA total of 42 TKAs were performed in 31 patients with severe hemophilia A. Under the supervision of a multidisciplinary hemophilia team, CI and BI were monitored during application of a standardized regimen. Perioperative clinical parameters including postoperative hemoglobin drop, drained blood volume, transfusion rate, total consumption of FVIII, and perioperative complications were assessed.ResultsThe difference in the postoperative hemoglobin drop was significant between two groups with a lower decrease in the CI group (p = 0.002). The drained blood volume for postoperative 24 h was significantly lower in the CI than the BI groups (p = 0.037). Total consumption of factor concentrates for postoperative 5 days was greater in the CI group than in the BI group (p = 0.000). One postoperative hematoma and wound dehiscence occurred in BI group and no other complication developed.ConclusionsAlthough good control of hemostasis could be achieved using either method during the perioperative period of TKA, CI seems more tolerable and effective than BI to provide perioperative blood management undergoing TKA in patients with hemophilia.Trial registrationThe study was retrospectively registered in WHO ICTRP under identifier KCT0002404 (date of registration: August 04, 2017).

The Effects of Perioperative Ketorolac Infusion on Platelet Function and Blood Loss: Comparison of Anesthesia Methods

Background: The purposes of this study were to investigate the effects of perioperative continuous infusion of ketorolac on platelet function and blood loss under either general or spinal anesthesia. Methods: The patients under general anesthesia received saline 1 ml (C group) or ketorolac 30 mg (GK group) intravenously 10 min before skin incision, followed, respectively, by a continuous infusion of saline (4 ml/h) or ketorolac (2.5 mg/h) for 24 h. The patients under spinal anesthesia (SK group) received the same amount of ketorolac as that of the GK group. Blood loss was collected and measured at 3 h, 6 h, 12 h and 24 h postincision. Platelet count, hemoglobin, platelet aggregometry (PA) with adenosine diphosphate (ADP) and collagen, and bleeding time (BT) were measured at 30 min before skin incision and at 3 h and 24 h postincision. Blood coagulation status was analysed using thromboelastography (TEG) at 30 min before skin incision and at 3 h postincision. Results: BT in the SK group at postincision increased significantly compared to preoperative value and were significantly higher than those of the GK and C group. PA with collagen at 3 h after skin incision was lower in the SK group than in the C group. There were no significant differences in any of the TEG variables among the three groups. No significant differences were observed in blood loss among the three groups. Conclusions: Blood loss was not increased by ketorolac under either general or spinal anesthesia, although platelet function was impaired under spinal anesthesia.