Perioperative Transfusion Requirements Research Articles

Hematopoietic Stimulation During Impella 5.5 Support to Avoid Transfusions in a Jehovah's Witness.

The population presenting with cardiogenic shock is heterogenous. Anemia is common in advanced heart failure and associated with poor outcomes. Microaxial flow pumps may cause ongoing blood trauma and worsen anemia. Treatment with recombinant erythropoietin, iron, vitamin B, and folate is recommended before cardiac surgery to reduce perioperative transfusion requirements but no data exist on the feasibility and safety during support with microaxial flow pumps. This novel strategy was born out of necessity to support a Jehovah's Witness who opposes blood transfusion but required mechanical circulatory support. We present its efficacy over the duration of 19 days of Impella 5.5 support where hemoglobin level remained stable, and platelet count significantly improved despite a brief episode of gastrointestinal bleeding. No thromboembolic complications occurred. We anticipate this strategy could help not only Jehovah's Witnesses, but also patients awaiting cardiac transplantation since transfusions stimulate development of antibodies which may preclude or postpone finding a suitable donor organ. Furthermore, it may minimize or prevent perioperative needs for transfusions for patients being bridged to durable left ventricular assist devices.

(1059) Peri-Operative Transfusion Requirements and ICU Length of Stay after Heart Transplantation for Patients with LVADs Anticoagulated with Apixaban - Initial Experience

(1059) Peri-Operative Transfusion Requirements and ICU Length of Stay after Heart Transplantation for Patients with LVADs Anticoagulated with Apixaban - Initial Experience

Efficacy of Intravenous Tranexamic Acid on Perioperative Blood Loss and Transfusion Requirement in Spine Fusion Surgery

Introduction: Blood loss associated with spine fusion surgery is a common potential cause of morbidity and often requires a blood transfusion, which subjects patients to risks of blood transfusion. Tranexamic acid is used intra-operatively to reduce bleeding in major surgeries. This study aims to evaluate its efficacy on perioperative blood loss and transfusion requirement in patients undergoing spine fusion surgery
 Methods: This prospective randomised controlled study was conducted at Department of Orthopedics of Tribhuvan University Teaching Hospital between August 2015 and July 2016. Patients undergoing spine fusion surgery were randomly assigned to group A (TXA) and group B (control) equally, thirty patients in each group. TXA was given to group A in a loading dose of 10 mg/kg, followed by continuous infusion of 1 mg/kg/hr during surgery. Outcome measures included perioperative blood loss, amount of blood transfusion, and safety and adverse effects. The data were analyzed by means of SPSS version 21.0. The results were presented as mean ± SD. Differences were considered significant if the P-value was <0.05.
 Results: Sixty patients (31 males, 29 females) with mean age of 39.95 years were enrolled in study, thirty patients in each group. Statistical analysis showed no significant differences between the 2 study groups with regard to age, sex, weight, preoperative hemoglobin, level of fusion as well as operative time. The amount of perioperative blood loss was significantly less in the group A versus group B, 241.274±162.819 ml vs 661.053±189.469 ml, p=0.000. There was no difference in the incidence of allogenic blood transfusion. There were no complications related to use of TXA in this study.
 Conclusion: TXA provided an effective and safe method for reduction of blood loss during and after spine fusion surgery. However, there was no difference in the incidence of perioperative allogeneic blood transfusion.

A novel predictive model of perioperative blood transfusion requirement in tuberculous spondylitis patientsundergoing posterior decompression and instrumentation.

Retrospective study. The aim of this study was to develop apredictive model for determining perioperative blood transfusion in tuberculous spondylitis patients undergoingposterior decompression and instrumentation. Tuberculous spondylitis is a common infection found in the spine. This condition may result in the need of surgical treatment, especially when there is a delay in diagnosis with inadequate antituberculosis drug treatment. The procedure results in high amount of bleeding on many occasions, leading to the higher rate of intraoperative transfusion.We develop a predictive model that can be used to determine blood transfusion requirement in spinal tuberculosis surgery. We reviewed the medical records of 83 tuberculous spondylitis patients who underwent posterior decompression and instrumentation. The clinical characteristics of the patients were analyzed using bivariate and multivariate regression test. The impact and strength of these variables was assessed to predict the probability of intraoperative red blood cell transfusion presence based on unstandardized beta, standard error, receiver operating characteristic, and confluence of sensitivity and specificity curve analyses. Furthermore, validation of this newly proposed predictive scoring system was performed using a set of 45 patients. The factors that significantly affect the need of blood transfusion during posterior spondylitis tuberculosis surgery were BMI (p = 0.005), pre-operative Hb (p < 0.001), number of affected segments (p = 0.042), and duration of surgery (p = 0.003). Our predictive model showed good sensitivity and specificity values based on a large area under the curve (0.913) and strong Pearson's r testing (correlation coefficient of 0.752). Validation set also resulted a large area under the curve (0.905) and strong correlation coefficient of 0.713. BMI, pre-operative Hb, number of affected segments, and duration of surgery became the significant factors which correlated to the presence of red blood cell transfusion in patients undergoing posterior spondylitis tuberculosis surgery. This predictive scoring system can be used to further adjust blood matching and inventory, determine intraoperative blood management, and ensure the safety of surgery in a comprehensive manner.

The Effect of Tranexamic Acid and Controlled Hypotension on Perioperative Blood Loss in Craniosynostosis Surgery.

Open cranial vault reconstruction is the standard technique of craniosynostosis correction that may cause significant blood loss. The current study aimed at comparing the effect of tranexamic acid (TXA), controlled hypotension, and their combination on perioperative blood loss and transfusion requirement in craniosynostosis surgery. The present randomized, double-blind clinical trial was conducted on 75 infants referred for craniosynostosis surgery during 2017 - 2018. Ten minutes before the start of surgery, 10 mg/kg of TXA was administered intravenously to patients in the first group (TXA group). In the second group, patients were subjected to the controlled hypotension anesthesia (CHA) using intravenous remifentanil 0.1 μ/kg (CHA group). In the third group, the patients underwent CHA similar to that of the second group, along with intravenous injection of 10 mg/kg of TXA (CHA-TXA group). Then, patients' mean arterial pressure (MAP), heart rate (HR), total blood loss, and transfusion volume were evaluated and recorded. The results of the present study revealed that although the changes in MAP and HR parameters over time (three hours after surgery) were significant in all three groups, the lowest decrease was observed in the CHA-TXA group (P-value < 0.05). In addition, the total perioperative blood loss in the CHA-TXA group with the mean of 181.20 ± 82.71 cc was significantly less than the total perioperative blood loss in the CHA and TXA groups with the means of 262.00 ± 104.04 cc and 212.80 ± 80.75 cc, respectively (P-value < 0.05). Moreover, the transfusion volume in the CHA-TXA group with the mean of 112.40 ± 53.50 cc was significantly lower than the transfusion volume in the CHA and TXA groups with the means of 174.00 ± 73.93 cc and 160.63 ± 59.35 cc, respectively (P-value < 0.05). In contrast, the total blood loss and transfusion volume were not significantly different between the CHA and TXA groups (P-value > 0.05). According to the results of the present study, although the administration of TXA alone could effectively prevent blood loss and was associated with fewer transfusion requirements, the combination of this approach with hypotensive anesthesia resulted in more reduction in perioperative blood loss and transfusion volume as well as better hemodynamic stability.

Intraoperative Cell Savage, Infection and Organ Failure in Infective Endocarditis Patients-A Retrospective Single Center Evaluation.

Surgery is indicated in about 50% of infective endocarditis patients, and bleeding or the transfusion of blood a common finding. The intraoperative use of cell salvage may reduce the perioperative transfusion requirement, but its use is limited in the underlying disease. In this retrospective study, we therefore evaluated n = 335 patients fulfilling the modified Duke criteria for infective endocarditis characterized by the use of intraoperative cell salvage with autologous blood retransfusion. Inflammation markers and organ dysfunction, including catecholamine dependency, were evaluated by using linear regression analysis. Between 2015 and 2020, 335 patients underwent surgery for left-sided heart valve endocarditis. Intraoperative cell salvage was used in 40.3% of the cases, especially in complex scenarios and reoperation. Intraoperative cell salvage significantly altered the white blood cell count after surgery. On average, leucocytes were 3.0 Gpt/L higher in patients with intraoperative cell salvage compared to patients without after adjustment for confounders (95% CI: 0.39-5.54). Although the difference in WBC was statistically significant, i.e., higher in the ICS group compared to the no-ICS group, this difference may be clinically unimportant. Organ dysfunction, including hemodynamic instability and lactate values, were comparable between groups. In conclusion, intraoperative cell salvage enhanced the re-transfusion of autologous blood, with minor effects on the postoperative course of inflammatory markers, but was not associated with increased hemodynamic instability or organ dysfunction in general. The restriction of intraoperative cell salvage in surgery for infective endocarditis should be re-evaluated, and more prospective data in this topic are needed.

2107. Epidemiology and Outcomes Associated with Enterococcal Blood Stream Infection among Abdominal Solid Organ Transplant Recipients

Abstract Background Bloodstream infections (BSIs) account for 18% of bacterial infections in the first year after solid organ transplantation (SOT). Enterococcus is an important cause of nosocomial BSI, accounting for up to 20% of BSIs in this population, with Vancomycin-resistant enterococcus (VRE) posing a particular risk. This study aims to characterize the epidemiology and outcomes of enterococcal BSIs in abdominal SOTs. Methods A retrospective, single-center, case-control study of adult abdominal organ transplant (kidney transplant (KT), liver transplant (LT), simultaneous liver-kidney transplant (SLK), pancreas transplant, or simultaneous pancreas-kidney transplant) recipients between 01/01/2016 - 07/30/2021 was conducted at Beth Israel Deaconess Medical Center. Subjects were identified and reviewed using the Organ Transplant Tracking Record, their online medical record, and Vigilanz. Subjects with an enterococcal BSI within the first 6 months post-transplant were compared to those with non-enterococcal BSIs in the same period. Results We identified 26 subjects with enterococcal BSIs and 28 controls with non-enterococcal BSIs (n = 54; 10.2%). Cases were mostly LT recipients (n = 20; 77%) with a median MELD at transplant of 33 (range 14 - 43). Controls included 8 LT recipients (29%), 14 KT recipients (50%), and 6 SLK recipients (21.4%). Groups differed significantly (all p&amp;lt; 0.05) by factors including perioperative transfusion requirements, need for reoperation, and number of interventions post-transplant. Most cases (n = 16; 62%) and 11 controls (39%) had received antibiotics within the month prior to transplant. Cases had a median time of 25.5 days to infection and controls 100.5 days (p &amp;lt; 0.0001) (Figure 1). There were no differences in 1-year mortality (Figure 2) between the groups. E. faecium was the predominant species of Enterococcus (n = 23; 88.5%), with a majority (91.3%) of the isolates being VRE. The VRE rate was 80.8% among cases, 38.9% among all BSIs, and 4.0% among all transplants. Table 1:Demographic, Surgical, Hospitalization, and Antimicrobial Data. Baseline demographic and clinical characteristics of enterococcal BSI cases and non-enterococcal BSI controls are compared, along with transplant characteristics, transfusion requirements, surgical risk factors, hospitalization data, outcomes, and antibiotic exposures. Microbiological and resistance data are also presented. Enterococcal BSIs had lower odds of being a kidney transplant and having CKD or CKD on RRT; they had higher odds of being a liver transplant and having prior immunosuppression, steroid induction alone, reoperations, and macrolide exposure. Enterococcal BSIs had lower KDPIs, higher transfusion requirements, lower cold ischemia times, more procedures, and a shorter time to BSI (Chi-square and Fischer exact tests for categorical variables; Mann-Whitney tests for continuous variables). **Liver and simultaneous liver-kidney transplants; ***Kidney and simultaneous liver-kidney transplants; ****Reoperation within two weeks of primary closure; *****Biopsy proven acute antibody or cellular rejection within 6 months of transplant; ******ERCP stenting compared to IR stenting, among those with biliary complication. BSI – bloodstream infection; CKD – chronic kidney disease; HIV – human immunodeficiency virus; MELD – model of end stage liver disease; KDPI – kidney donor profile index; CMV – cytomegalovirus; pRBC – packed red blood cells; ERCP – endoscopic retrograde cholangiopancreatography; RRT – renal replacement therapy. Figure 1:Time to Bloodstream InfectionProbability of BSI-free survival illustrated, with enterococcal BSIs occurring significantly earlier than non-enterococcal BSIs post-transplantation (Kaplan-Meier survival analysis). BSI – bloodstream infection.Figure 2:MortalityProbability of survival, without significant difference between enterococcal and non-enterococcal BSIs. Data censored at one year of follow-up. BSI – bloodstream infection. Conclusion In our abdominal organ SOTs, enterococcal BSIs occurred early among LT recipients. The high incidence of VRE among E. faecium isolates in this population warrants further investigation into the optimal approach to empiric antimicrobials for bacteremia in the early post-transplant period. Disclosures Carolyn D. Alonso, MD, Cidara Therapeutics: Advisor/Consultant|Merck: Advisor/Consultant.

Timing and safety of hip fracture surgery in patients on direct-acting oral anticoagulants

BackgroundMany geriatric patients presenting for emergency hip fracture surgery are on direct oral anticoagulants (DOACs) most of which are not easily reversible. A safe policy was required to reduce delays to surgery. Prior to institution of our hospital's protocol in January 2021, most of these patients had surgery after 48 h following the last dose of DOAC due to concerns about increased perioperative blood loss. MethodsThis was a prospective closed loop audit of the protocol-surgery within 24 h from last dose of DOAC (if creatinine clearance >50 ml/min) with administration of 1-g of tranexamic acid at anesthesia induction. 131 eligible patients (DOAC, n = 22; no anticoagulation, n = 109) between January–June 2021 who had emergency hip fracture surgery were identified. Primary outcome measures were peri-operative blood loss, transfusion requirements and policy compliance. Secondary outcome measures were 30-day mortality, thrombotic complications and wound bleeding. ResultsCompliance with surgical timing and tranexamic acid administration were 55% and 81% respectively after the second audit cycle. The mean estimated blood loss (EBL) in the DOAC group versus the non-anticoagulated control group was 500 ml and 330 ml respectively. The difference between these groups was statistically significant at an alpha level of 5% (P = 0.0115, 95% CI 38.48–299.16). The difference for intra-operative (RR 3.43; 95% CI 1.68–7.01) and post-operative blood transfusion (RR 2.10; 95% CI 1.23–3.58) for the 2 groups was also statistically significant. However, there was no case of massive blood transfusion in both groups. The DOAC group had a lower risk for 30-day mortality (RR 0.71; 95% CI 0.09-5.46). There was no major thrombotic complication in the DOAC group. ConclusionThis audit has shown that this protocol is safe although clinicians should anticipate some degree of increased intra-operative blood loss. We will recommend continuation of this policy with sustained safety monitoring in order to reduce delays to surgery.

Single shot of intravenous iron in cardiac surgery: The ICARUS study

BackgroundIron deficiency (ID), with or without anemia, is commonly observed among patients scheduled for cardiac surgery. We investigated if screening ID in the immediate preoperative period and treating ID patients regardless of anemia could reduce perioperative transfusion requirements. MethodsThis is an observational single-center propensity score-matched study including candidates to elective cardiac surgery prospectively and retrospectively enrolled. Prospectively enrolled patients were screened for ID at hospital admission: if ferritin was ≤100 μg/L or ≤ 300 μg/L with transferrin saturation index ≤20% they received intravenous ferric carboxymaltose, B12-vitamin, and folic acid. A retrospective series of patients not screened for ID and matched for gender, type of surgery, BMI, Goudie transfusion risk score, hemoglobin level, and red blood cell (RBC) indices, served as controls. The primary outcome was the proportion of patients requiring ≤1 packed RBC (pRBC) unit within day 7 or discharge The main secondary outcomes were intraoperative and postoperative pRBC transfusions, duration of hospitalization, and cost-effectiveness of ID screening and treatment. ResultsWe included 479 prospective and 833 retrospective cases: 442 patients screened for ID and 442 matched controls with unknown iron status were analyzed. ID was observed in 196 patients (44.3%) and iron was administered 1 day (IQR 1–2) before surgery. Overall, 76.9% of patients in the prospective group and 69.7% of controls received ≤1 pRBC transfusion (p = 0.014). The risk for multiple transfusions was lower in patients screened for ID (OR 0.689, 95% CI 0.510–0.930). Despite similar Hb levels at day 7, patients in the prospective group received fewer postoperative pRBC transfusions (p < 0.001) and had a shorter hospital length of stay (p < 0.001). Globally, hospitalization costs were lower in patients screened and treated for ID. ConclusionsShort-term pre-operative iron therapy is associated with a reduction in postoperative transfusions in anemic and non-anemic ID cardiac surgery patients and has a favorable impact on hospitalization costs. Clinical trial registrationNCT04744181

Tranexamic acid in pertrochanteric fractures: a retrospective analysis of perioperative outcomes after fixation with a proximal femoral nail

BackgroundTreatment of pertrochanteric femoral fractures is often associated with significant blood loss. It has already been demonstrated that the administration of tranexamic acid (TXA) for endoprosthetic procedures reduces blood losses and leads to a decreased frequency of postoperative complications. The aim of this study is to demonstrate whether the administration of TXA as part of osteosynthesis treatment for pertrochanteric fractures using a proximal femoral nail reduces perioperative blood losses and haemorrhage-related complications.MethodsIn a two-centre retrospective cohort study, 1 g TXA i.v. was administered preoperatively to 294 patients who had suffered from pertrochanteric femoral fractures. The subjects were compared clinically to a historical control group who did not receive TXA (nonTXA). Outcomes were evaluated on the basis of perioperative blood loss, transfusion requirement, and occurrence of complications.ResultsThe TXA group showed evidence of a reduction in blood loss (TXA = 0.97 ± 0.47 l; nonTXA = 1.06 ± 0.47 l; p = 0.004) and a lower frequency of transfusion (TXA = 20%; nonTXA = 31%; p = 0.032) as compared to the nonTXA group. However, evidence of this therapeutic effect could only be demonstrated at one of the centres on subgroup comparison between the two centres. At the second centre, the data did not show a significant difference. A trend could be seen towards a reduction in postoperative renal failure. No complications occurred resulting from the administration of tranexamic acid.ConclusionPreoperative administration of TXA does not lead to an increased rate of thromboembolic complications when applied for treatment of pertrochanteric femoral fractures. Evidence of a positive effect could be seen in principle in relation to the reduction in perioperative blood loss and the frequency of transfusion. The difference in effect between the two centres remains to be clarified: for this reason, it is possible to assume that further factors influencing the efficacy of TXA administration are at play which were not taken into account in this study.

Safety and efficacy of perioperative tranexamic acid infusion in acetabular fracture fixation: A randomized placebo-controlled double-blind prospective study

IntroductionOpen reduction and internal fixation of acetabular fracture is associated with significant blood loss. Although Tranexamic acid (TXA) infusion effectively reduces perioperative blood loss and transfusion requirements in elective orthopedic surgery, its efficacy in major orthopedic trauma surgery is controversial. Material and methodsSixty-three patients undergoing open reduction and internal fixation of acetabular fracture were randomized into either TXA (n = 36) or placebo (n = 27) group. TXA group received a bolus dose of TXA (10 mg/kg) 15 min prior to incision, followed by another similar dose after 3 h of surgery. The placebo group received the same volume of normal saline similarly. All patients were operated on by a single pelviacetabular surgeon with a uniform perioperative protocol. The intraoperative blood loss, drain output, the number of blood transfusions, postoperative hemoglobin (Hb) drop, and hematocrit (Hct) drop were calculated. ResultsBoth groups were similar in relation to age, sex, BMI, preoperative Hb, the timing of surgery, fracture pattern, operative time, and surgical approaches. The mean postoperative Hb was 10.35 ± 1.36 gm% in TXA group and 9.74 ± 1.98 gm% in placebo group (p-value 0.158). There were no differences in intraoperative blood loss (438.11 ml vs. 442.81, p=.947), drain output (131.94 ml vs. 129.63, p=.870), and blood transfusion (8 patients vs. five patients, p=.719) between the groups. The drop in Hb and Hct in the postoperative period was also statistically not significant between the groups. ConclusionThere is no significant reduction in blood loss and blood transfusion with the use of intravenous Tranexamic acid in open reduction and internal fixation of acetabular fractures.

Anesthesia management in patients with abnormally invasive placenta: A single-center experience

Aim: Postpartum hemorrhage is a life-threatening obstetric emergent clinical situation accompanied by blood loss of more than 500 ml after vaginal delivery and more than 1000 ml after cesarean section. This situation, frequently encountered in placental adhesion anomalies, is essential in terms of follow-up, treatment, and multidisciplinary management. We aimed to retrospectively evaluate the perioperative anesthesia management, transfusion requirement, and postoperative intensive care unit requirement of patients diagnosed with placental invasion anomaly who had an intraoperative hemorrhage&#x0D; Methods: In our single-center study, a total of 58 female patients diagnosed with of placental invasion anomaly with a cesarean section between 2017-2020 were examined. Patients under 18 years of age and missing data were excluded from the study. Demographic data of patients (age, American Society of Anesthesiologists score (ASA)), diagnosis, duration of operation, perioperative laboratory findings, anesthesia type, perioperative hemodynamics (highest heart rate, lowest mean arterial pressure, shock index), amount of bleeding, blood products, and fluids used, surgical interventions (B-Lynch, Bacri balloon application, uterine artery ligation, hysterectomy), intraoperative vasopressor/inotrope use, ICU stay, laboratory results in the first 24 hours postoperatively, and total hospital stay were recorded.&#x0D; Results: In the preoperative evaluation, 27 (46.5%) patients were diagnosed with placenta accreta, and placenta previa was diagnosed in 19 (32.7%) patients. Perioperatively mean of 3.08 ± 1.7 units of Red blood cell was used. In patients with postoperative intensive care unit hospitalization, the highest intraoperative lactate value was 3.5±1.8 mmol/L, shock index was 1.3±0.3 (0.6-1.8). In patients given intraoperative fibrinogen concentrate, the intraoperative shock index was 1.5±0.2 (0.9-1.8), the amount of intraoperative bleeding was 2575±302.2 ml, and the fibrinogen levels measured in the first 24 hours after surgery were 294.7±79.7 mg/dl.&#x0D; Conclusions: Anesthesia management of patients diagnosed with abnormal placental invasion is important because of significant hemorrhage. Due to unstable hemodynamics, preoperative blood product preparation with a multidisciplinary approach and a postoperative intensive care unit plan should be made for these patients.

Role of DOAC plasma concentration on perioperative blood loss and transfusion requirements in patients with hip fractures.

There is an ever-increasing number of hip fracture (HF) patients on direct oral anticoagulants (DOAC). The impact of DOAC plasma level prior to HF surgery on perioperative blood loss and transfusion requirements has not been investigated so far. In this retrospective study of HF patients on DOACs admitted to the AUVA Trauma Center Salzburg between February 2015 and December 2021. DOAC plasma levels were analysed prior to surgery. Patients were categorized into four DOAC groups: Group A < 30ng/mL, Group B 30-49ng/mL, Group C 50-79ng/mL, and Group D ≥ 80ng/mL. Haemoglobin concentration was measured upon admission, prior to surgery, after ICU/IMC admission, and on day 1 and 2 post-surgery. Difference in the blood loss via drains, transfusion requirements and time to surgery were compared. A total of 155 subjects fulfilled the predefined inclusion criteria. The median age of the predominantly female patients was 86 (80-90) years. Haemoglobin concentration in Group D was lower upon admissions but did not reach statistical significance. The decrease in haemoglobin concentration over the entire observation time was comparable between groups. Blood transfusion requirements were significantly higher in Group D compared to Group A and B (p = 0.0043). Time to surgery, intra- and postoperative blood loss via drains were not different among groups. No strong association between the DOAC plasma levels and perioperative blood loss was detected. Higher transfusion rates in patients with DOAC levels ≥ 80ng/mL were primarily related to lower admission haemoglobin levels. DOAC concentration measurement is feasible and expedites time to surgery.

Comparison of 30-day complications between reverse shoulder arthroplasty and open reduction internal fixation for the treatment of proximal humerus fractures.

While the use of open reduction internal fixation (ORIF) has remained stable over the last decade, there has been a significant increase in the use of reverse total shoulder arthroplasty (RTSA) for proximal humerus fractures (PHFs). This study sought to compare the complication profiles of RTSA to ORIF in a large, validated, retrospective cohort. Patients who underwent surgical treatment for PHFs with RTSA or ORIF were identified in a national database (NSQIP) using CPT and ICD codes. Demographics and comorbidities were identified for each cohort of patients. Thirty-day complications were analyzed with univariate and multivariate analyses using Chi-square, Fischer's exact and analysis of variance testing. The total number of patients included in this study was 2157.522 (24.2%) underwent RTSA and 1635 (75.8%) underwent ORIF. Patients undergoing RTSA were older with an average age of 73.52years compared with 63.84years in those undergoing ORIF (p < 0.001). Patients with RTSA were more likely to experience any complications (p < 0.001), pulmonary complications (p = 0.029), extended length of stay > 3days (p < 0.001), and perioperative transfusion requirement (p < 0.001) after univariate analysis. After controlling for demographic differences, the only statistically significant complication was perioperative transfusion requirement (OR 1.383). After controlling for demographic variables and comorbidities, RTSA placed patients at increased risk for perioperative blood transfusion. Patients undergoing RTSA should be counseled prior to surgery regarding the risk for transfusion and potentially optimized medically through multidisciplinary care if the surgeon elects to proceed with RTSA versus ORIF for the treatment of PHFs.

Intravenous iron supplementation treats anemia and reduces blood transfusion requirements in patients undergoing coronary artery bypass grafting-A prospective randomized trial.

Study Objective:Preoperative anemia results in two- to sixfold increased incidence of perioperative blood transfusion requirements and reduced postoperative hemoglobin (Hb) level. This prospective study was designed to investigate the effect of preoperative intravenous infusion of iron on Hb levels, blood transfusion requirements, and incidence of postoperative adverse events in patients undergoing coronary artery bypass grafting.Design:Prospective randomized trial.Setting:Academic university hospital.Patients:Eighty patients (52–67 years old) underwent coronary artery bypass grafting and received either iron therapy or saline infusion preoperatively.Interventions:Patients were randomly allocated to iron or placebo groups. In the iron group, patients received a single intravenous dose of ferric carboxymaltose (1000 mg in 100 mL saline) infused slowly over 15 min 7 days before surgery. In placebo group, patients received a single intravenous dose of saline (100 mL saline) infused slowly over 15 min 7 days before surgery.Measurements:Patients were followed up with regards to incidence of anemia, Hb level on admission, preoperatively, postoperatively, 1 week and 4 weeks after discharge, aortic cross-clamp time, the number of packed red blood cells (pRBCs) units, the percentage of reticulocytes pre–postoperatively and 1 week later, hospital stay and intensive care unit (ICU) stay length, and the incidence of postoperative complications.Main Results:Iron therapy was associated with lower incidence of anemia 4 weeks after discharge (P < 0.001). Hb level was significantly higher in the iron group compared to the placebo group preoperatively and postoperatively, and 4 weeks after discharge (P < 0.001). Iron therapy resulted in shorter hospital and ICU stay (P < 0.001) and shorter aortic cross-clamp time, reduced pRBCs requirements postoperatively. Percentage of reticulocytes was significantly higher in placebo group than in iron group postoperatively and 1 week after discharge and the incidence of postoperative complications was similar to the placebo group.Conclusions:Preoperative IV iron infusion is a safe and feasible way to manage preoperative anemia. Preoperative administration of IV iron is associated with a higher postoperative Hb level, shorter hospital and ICU stay, and reduced perioperative red blood cell transfusion requirements with insignificant difference in incidence of postoperative complications.

Performance Of The MELDXI Score In A Modern Left Ventricular Assist Device Cohort

<h3>Introduction</h3> The Model for End-Stage Liver Disease (MELD) risk score has been linked with poor outcomes for patients undergoing left ventricular assist device (LVAD) placement. However, many patients are on anticoagulation before LVAD and thus the MELD-XI (eXcluding International Normalized Ratio) has been proposed as an alternate score. Prior studies have reviewed MELD-XI performance in patients with mainly HeartMate II (HM2) and HeartWare HVAD devices. We systematically evaluated the impact of MELD-XI on outcomes following LVAD in a modern cohort including HeartMate3 (HM3) devices. <h3>Hypothesis</h3> An elevated MELD -XI will have a higher risk of adverse perioperative events and lower 24-month survival. <h3>Methods</h3> At a single center, 177 patients received LVAD therapy between June 2011 and October 2018. Patients were classified into either low MELD-XI (<17, n=83) or high MELD-XI (≥ 17, n=33) based on preoperative levels. A cut off of 17 was chosen based on previously established values. 61 patients were excluded due to missing data. Baseline characteristics and post-operative adverse events were compared using Fishers exact and Wilcoxon rank sum tests. Pearson correlation coefficient was used to assess for linear correlation between pre-operative MELD-XI and perioperative transfusion requirements. Kaplan-Meir plot and log-rank statistics were used for survival analysis. Unadjusted and adjusted Cox models were used to examine the association of high MELD-XI and 24-month all-cause mortality. <h3>Results</h3> Both cohorts consisted of predominately Caucasian males with an average age of 62 who had LVAD implanted as a destination therapy (68%). Of the LVAD types, HM2 was the most commonly implanted (61%), followed by HM3 (28%) and HVAD (11%). Red blood cell transfusion in the first 24 hours and 30 days post LVAD implantation did not reveal a strong relationship (r=0.23, p=0.01) and (r=0.11, p=0.23). Post-operative bleeding was no different between groups (20.5 vs 37.5%, p=0.06). However, a higher MELD-XI was associated with other post-operative adverse events including renal failure (7.2 vs 37.5%, p<0.001), stroke (6.1 vs 18.7%, p=0.04), need for tracheostomy (10.8 vs 31.2%, p=0.008) and hepatic dysfunction (4.8 vs 34.4%, p=0.02). 24-month survival was equal across groups (p=0.08). Risk adjusted Cox proportional hazard ratios for 24-month mortality for a MELD-XI ≥ 17 was 1.53 (0.92 - 2.53, p=0.10). <h3>Conclusions</h3> A preoperative MELD-XI score of >17 identifies LVAD candidates, including those planned to receiving HM3, with a higher risk of mortality and other postoperative adverse events but not necessarily bleeding.

Effect of Obesity and Hypertension on Blood Loss and Blood Transfusion Requirements in Primary Elective Total Knee Arthroplasty: A Prospective Clinical Study

Introduction: Identifying risk factors of operative blood loss is imperative toward establishing an effective blood management implementation strategy and further minimize the requirement for perioperative blood loss and transfusion. Aim: To investigate whether the factors like obesity and hypertension affect blood loss and transfusion requirements in primary elective Total Knee Arthroplasty (TKA). Materials and Methods: A prospective clinical study was conducted at Shalby Hospitals in Ahmedabad, Gujarat, India, from November 2017 to November 2019, on 91 patients recruited for primary elective TKA. The subjects were divided into two groups, i.e, group A (normotensive and non obese; n=46) and group B (Hypertensive and obese; n=45). Charlson-Deyo comorbidity score were given to each patient as a measure of surgical risk. Data on intraoperative and postoperative blood loss, blood parameters (drop in haemoglobin, haematocrit value), and incidence of transfusion rates were recorded and assessed. All patients had standardized protocols of anesthesia, postsurgical and rehabilitation care protocols following surgery. Fisher’sexact test, Chi-square test, and student’s t-test were used for statistical analysis. Pearson’s correlation was performed to identify factors associated to blood loss. The p-value &lt;0.05 was considered significant. Statistical Package for Social Sciences (SPSS) version 22.0 was used. Results: The intraoperative, postoperative and total blood loss (drop of haemoglobin and haematocrit) were significantly greater in the hypertensive and obese patients (p-value &lt;0.001). The immediate postoperative day 1 haemoglobin and day 1 and 2 haematocrit were significantly better in the normotensive and non obese patients (p-value &lt;0.001). Significantly greater number of hypertensive and obese patients required blood transfusion (p-value=0.045). There was a positive correlation between intraoperative blood loss and operative time in both groups (RA=0.04, p-value=0.74; RB=0.09, p-value=0.52) although statistically insignificant. Hypertensive and obese patients required longer hospitalization (p-value &lt;0.0001). Three patients from group B were diagnosed to develop pulmonary embolism while admitted in hospital which was managed successfully by intensivists without any fatality. Conclusion: Hypertension and obesity were associated with greater blood loss and transfusion requirement compared to non obese and normotensive patients undergoing primary elective TKA.

Temporary 12-Hour Drain Clamping versus 3-Hour Drain Clamping in Simultaneous Bilateral Total Knee Arthroplasty.

Total knee arthroplasty (TKA) is a procedure that has a risk of perioperative blood loss and allogeneic blood transfusion. The purpose of the present study was to compare the perioperative blood loss and transfusion rate between the 3-hour interval clamping and 12-hour interval clamping of closed suction drainage after simultaneous bilateral total knee arthroplasty (SBTKA). A total of 122 SBTKAs were enrolled in this retrospective study. A 3-hour clamping protocol was applied in 53 SBTKAs and a 12-hour clamping protocol was applied in 69 SBTKAs. The amount of perioperative blood loss, transfusion requirements, postoperative hemoglobin and hematocrit levels, the lowest hemoglobin and hematocrit levels during hospitalization, readmission within 90 days, and clinical outcomes were compared between the 3-hour clamping group and the 12-hour clamping group. The 12-hour clamping group had fewer patients requiring transfusion (26.1%, 18/69) than did the 3-hour clamping protocol group (49.1%, 26/53) (p = 0.008). The 12-hour clamping group had a lower amount of estimated blood loss (1,426.9 ± 421.5 mL) than did the 3-hour clamping protocol group (1,882.1 ± 445.6 mL) (p < 0.001). The 12-hour clamping group showed higher hemoglobin and hematocrit levels (both p < 0.001) on postoperative day 5 than did the 3-hour clamping group. The lowest hemoglobin and hematocrit levels were higher in the 12-hour clamping group than in the 3-hour clamping group (p = 0.039 and p = 0.016, respectively). Within 1 postoperative month, there were 2 cases of wound dehiscence in each group (p = 0.585). But, at 1 year after the operation, no serious complications occurred in the two groups. Compared to the 3-hour clamping protocol, the 12-hour clamping protocol significantly reduced transfusion requirements, estimated blood loss volume, and hemoglobin and hematocrit levels after SBTKA. We suggest that 12-hour temporary clamping should be considered for reducing transfusion rates.

The Prognostic Role of In-Hospital Transfusion of Fresh Frozen Plasma in Patients with Cholangiocarcinoma Undergoing Curative-Intent Liver Surgery

Introduction: Major hepatectomy for perihilar and intrahepatic cholangiocarcinoma (CCA) is often associated with a significant intraoperative blood loss and the requirement for perioperative transfusion of blood products. The aim of this study was to investigate the oncological impact of fresh frozen plasma (FFP) transfusion during hospitalization in patients undergoing hepatectomy for CCA as adverse effects have been described in other malignancies.

Effect of Two Different Tranexamic Acid Doses on Blood Loss in Head and Neck Cancer Surgery: A Randomized, Double-Blind, Controlled Study.

Background and aimHead and neck cancer is frequent, and surgeries pose more significant morbidity and mortality due to multitudinal causes; heavy blood loss and transfusion are among them. Tranexamic acid (TXA) is known to stabilize the micro clots hence controlling excessive blood loss. The present study aimed to compare perioperative blood loss with two different doses of TXA and placebo to find the effectiveness and optimal dose.MethodsWith ethical approvals and informed consent, the present prospective, randomized, double-blind, controlled study was conducted in a teaching institute from May 31, 2018, to Dec 28, 2019. Patients undergoing elective head and neck cancer (HNC) surgeries were included. Preoperative Hb < 7 gm% or > 16 gm%, known coagulopathy, anticoagulant therapy, contraindications to TXA, intraoperative torrential or blood loss due to arterial injury were excluded. Group T-1 received TXA 10mg/kg, T-II received 15 mg/kg, while the control group (Gr-C) received equal volume normal saline. Data about demography, surgical time, intraoperative and postoperative blood loss, and transfusion were collected and compared. SPSS software was used for analysis; p-value <0.05 was considered significant.ResultsNinety patients were screened, 84 completed the study. All three groups were similar in demographics. The median blood loss with 25th -75th percentile in group C, T-I, and T-II groups were 762.5 (513.5-1193), 541.5 (296.5-787), and 536.0 (180.5 - 879) mL, respectively; p: 0.025. There was a significant difference between the control group and T-I (p-value: 0.0153), and control and T-II (p-value: 0.0248), but an insignificant difference between T-I and T-II (p-value: 0.706). 5 (17.85%) in each of T-I and T-II required transfusion, whereas 14 (50%) in the control group required it; p < 0.011). No major clinically significant related to study drugs were noted.ConclusionCompared to placebo (normal saline), preoperative administration of TXA in bolus significantly reduced perioperative blood losses and transfusion requirement in patients undergoing HNC surgery as estimated using the Hb-based method. A bolus dose of doses of 10mg/kg and 15 mg/kg is equally effective.