Perioperative Transfusion Requirements Research Articles

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.

Predictors of Perioperative Platelet Transfusion Requirement for Caesarean Section: A Retrospective Cohort Study Based on Nationwide Real-World Data

Background: Pregnant women undergoing caesarean section (CS) are at higher risk of postpartum hemorrhage. Platelet component is particularly scarce, and is not routinely cross-matched prior to CS. This might hinder its timely availability in unanticipated bleeding. Therefore, the aim of this study was to investigate the antepartum predictors for platelet transfusion in parturients receiving CS. Methods: We performed a retrospective cohort study based on real-world data from a nationwide system collecting inpatient medical records from 2012 to 2018. Effects of potential predictors for platelet transfusion were analyzed using multiple logistic regression model. Findings: Among the 262,705 women included, 773 (0.29%) received platelet transfusion. General anesthesia (OR 1.72, 95% CI 1.44-2.04), emergent operation (1.38, 1.08-1.76), ASA≥III (1.41, 1.21-1.65), anemia (61.55, 39.62-95.62), coagulation dysfunction (82.04, 69.80-96.44), thrombocytopenia (1.57, 1.33-1.84), heart failure (2.47, 1.42-4.29), renal dysfunction (3.36, 1.80-6.29,), respiratory dysfunction (1.77, CI 1.17-2.66), fibroid (2.47, 1.42-4.297), hypertensive disorder (1.87, 95% 1.49-2.36), previous CS (1.43, 1.16-1.75), placenta previa/accreta (1.49, 1.12-1.97), and placental abruption (3.94, 2.58-6.01) were associated with the platelet transfusion. On the contrary, macrosomia (0.44, 0.27-0.71), fetal malposition (0.65, 0.46-0.91), pelvic deformity (0.50, 0.31-0.81), and premature rupture of membrane (0.75, 0.58-0.98) may reduce the risk of platelet transfusion. Interpretation: A series of predictors were found to be related with platelet transfusion in parturients receiving CS. These findings allow us to identify high-risk parturients who may benefit from preoperatively ordering platelet units. Funding: Chinese Academy of Medical Sciences (CAMS) Innovation Fund for Medical Sciences (CIFMS) (2016-I2M-3-024). Declaration of Interest: All authors disclose that they have no financial or personal relationships with other people or organizations. Ethical Approval: The research protocol was approved by the institutional review board of Peking Union Medical College Hospital (reference number: S-K741), and the requirement of informed consent was waived since all the data was recorded anonymously without any information that may help to identify certain participant.

Exclusion criteria and adverse events in perioperative trials of tranexamic acid in cardiac surgery: a systematic review and meta-analysis.

Tranexamic acid (TXA) reduces perioperative blood loss and transfusion requirement following cardiac surgery. Nevertheless, TXA remains underutilized because of concerns regarding development of adverse events. We conducted a systematic review to determine which patients are commonly excluded from TXA cardiac surgery clinical trials to determine if there are patient groups lacking safety data on TXA. The databases Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were searched until September 2017. Eligible studies were randomized-controlled trials (RCTs) administering systemic TXA perioperatively to patients undergoing any cardiac surgery. Our primary outcome was the exclusion criteria for each RCT, and the secondary endpoint was TXA safety. A descriptive synthesis was performed to analyze the exclusion criteria. TXA safety was assessed with meta-analysis. Seventy eligible RCTs were included. The most common reasons for excluding patients from TXA cardiac surgery trials were major hepatic, renal, or cardiac comorbidities (76% of studies). Meta-analysis showed that TXA did not increase the risk of adverse events compared with placebo or no intervention (risk ratio, 0.97; 95% confidence interval, 0.88 to 1.07), including thrombosis and seizure. We found that systemic TXA is safe to use in cardiac surgery. Certain patient groups are frequently excluded from TXA cardiac surgery trials, and may consequently have limited efficacy and safety data on TXA. Further research in these patient groups may be needed; nevertheless, for many patient populations there are sufficient data to inform evidence-based guidelines for TXA use in cardiac surgery. PROSPERO (CRD42017060971); registered 4 April, 2017.

Rotational thromboelastometry-guided transfusion during lumbar pedicle subtraction osteotomy for adult spinal deformity: preliminary findings from a matched cohort study.

OBJECTIVESignificant blood loss and coagulopathy are often encountered during adult spinal deformity (ASD) surgery, and the optimal intraoperative transfusion algorithm is debatable. Rotational thromboelastometry (ROTEM), a functional viscoelastometric method for real-time hemostasis testing, may allow early identification of coagulopathy and improve transfusion practices. The objective of this study was to investigate the effect of ROTEM-guided blood product management on perioperative blood loss and transfusion requirements in ASD patients undergoing correction with pedicle subtraction osteotomy (PSO).METHODSThe authors retrospectively reviewed patients with ASD who underwent single-level lumbar PSO at the University of Virginia Health System. All patients who received ROTEM-guided blood product transfusion between 2015 and 2017 were matched in a 1:1 ratio to a historical cohort treated using conventional laboratory testing (control group). Co-primary outcomes were intraoperative estimated blood loss (EBL) and total blood product transfusion volume. Secondary outcomes were perioperative transfusion requirements and postoperative subfascial drain output.RESULTSThe matched groups (ROTEM and control) comprised 17 patients each. Comparison of matched group baseline characteristics demonstrated differences in female sex and total intraoperative dose of intravenous tranexamic acid (TXA). Although EBL was comparable between ROTEM versus control (3200.00 ± 2106.24 ml vs 3874.12 ± 2224.22 ml, p = 0.36), there was a small to medium effect size (Cohen's d = 0.31) on EBL reduction with ROTEM. The ROTEM group had less total blood product transfusion volume (1624.18 ± 1774.79 ml vs 2810.88 ± 1847.46 ml, p = 0.02), and the effect size was medium to large (Cohen's d = 0.66). This difference was no longer significant after adjusting for TXA (β = -0.18, 95% confidence interval [CI] -1995.78 to 671.64, p = 0.32). More cryoprecipitate and less fresh frozen plasma (FFP) were transfused in the ROTEM group patients (cryoprecipitate units: 1.24 ± 1.20 vs 0.53 ± 1.01, p = 0.03; FFP volume: 119.76 ± 230.82 ml vs 673.06 ± 627.08 ml, p < 0.01), and this remained significant after adjusting for TXA (cryoprecipitate units: β = 0.39, 95% CI 0.05 to 1.73, p = 0.04; FFP volume: β = -0.41, 95% CI -772.55 to -76.30, p = 0.02). Drain output was lower in the ROTEM group and remained significant after adjusting for TXA.CONCLUSIONSFor ASD patients treated using lumbar PSO, more cryoprecipitate and less FFP were transfused in the ROTEM group compared to the control group. These preliminary findings suggest ROTEM-guided therapy may allow early identification of hypofibrinogenemia, and aggressive management of this may reduce blood loss and total blood product transfusion volume. Additional prospective studies of larger cohorts are warranted to identify the appropriate subset of ASD patients who may benefit from intraoperative ROTEM analysis.

Efficacy and safety of antifibrinolytic agents in spinal surgery: a network meta-analysis.

Background:Significant blood loss is still one of the most frequent complications in spinal surgery, which often necessitates blood transfusion. Massive perioperative blood loss and blood transfusion can create additional risks. Aprotinin, tranexamic acid (TXA), and epsilon-aminocaproic acid (EACA) are antifibrinolytics currently offered as prophylactic agents to reduce surgery-associated blood loss. The aim of this study was to evaluate the efficacy and safety of aprotinin, EACA, and low/high doses of TXA in spinal surgery, and assess the use of which agent is the most optimal intervention using the network meta-analysis (NMA) method.Methods:Five electronic databases were searched, including PubMed, Cochrane Library, ScienceDirect, Embase, and Web of Science, from the inception to March 1, 2018. Trials that were randomized and compared results between TXA, EACA, and placebo were identified. The NMA was conducted with software R 3.3.2 and STATA 14.0.Results:Thirty randomized controlled trial (RCT) studies were analyzed. Aprotinin (standardized mean difference [SMD]=−0.65, 95% credibility intervals [CrI;−1.25, −0.06]), low-dose TXA (SMD = −0.58, 95% CrI [−0.92, −0.25]), and high-dose TXA (SMD = −0.70, 95% CrI [−1.04, −0.36]) were more effective than the respective placebos in reducing intraoperative blood loss. Low-dose TXA (SMD = −1.90, 95% CrI [−3.32, −0.48]) and high-dose TXA (SMD = −2.31, 95% CrI [−3.75, −0.87]) had less postoperative blood loss. Low-dose TXA (SMD = −1.07, 95% CrI [−1.82, −0.31]) and high-dose TXA (SMD = −1.07, 95% CrI [−1.82, −0.31]) significantly reduced total blood loss. However, only high-dose TXA (SMD = −2.07, 95% CrI [−3.26, −0.87]) was more effective in reducing the amount of transfusion, and was significantly superior to low-dose TXA in this regard (SMD = −1.67, 95% CrI [−3.20, −0.13]). Furthermore, aprotinin (odds ratio [OR] = 0.16, 95% CrI [0.05, 0.54]), EACA (OR = 0.46, 95% CrI [0.22, 0.97]) and high dose of TXA (OR = 0.34, 95% CrI [0.19, 0.58]) had a significant reduction in transfusion rates. Antifibrinolytics did not show a significantly increased risk of postoperative thrombosis. Results of ranking probabilities indicated that high-dose TXA had the greatest efficacy and a relatively high safety level.Conclusions:The antifibrinolytic agents are able to reduce perioperative blood loss and transfusion requirement during spine surgery. And the high-dose TXA administration might be used as the optimal treatment to reduce blood loss and transfusion.

Povezanost upalnog statusa, patohistoloških karakteristika i perioperativne potrebe za transfuzijskim liječenjem u bolesnika s kolorektalnim karcinomom

Povezanost upalnog statusa, patohistoloških karakteristika i perioperativne potrebe za transfuzijskim liječenjem u bolesnika s kolorektalnim karcinomom

Preoperative Immune Response is Associated with Perioperative Transfusion Requirements in Glioma Surgery.

Immunosuppression induced by transfusion causes postoperative adverse events including poor prognosis in cancer, but data on influence of the immune response on blood transfusion requirements during perioperative period are limited. The aim of this study was to investigate whether the preoperative immune response is associated with perioperative blood cell transfusion in a glioma surgical patient population. The authors identified 321 cases of surgery for treatment of glioma. Patient variables, preoperative laboratory variables (hemoglobin, platelet count, activated partial thromboplastin time, prothrombin time, hematocrit, red and white blood cell count), and transfusions were registered. Plasma concentration of Th-associated cytokines was measured by flow cytometry. Multivariable regression analysis and receiver operating characteristic curve were undertaken to identify predictors of transfusion. Of 321 patients, 157 (48.90%) received red blood cells transfusion. The mean age is significantly higher in transfusion group compared to no transfusion group, while postoperative hospital stay, preoperative hemoglobin, prothrombin time, activated partial thromboplastin time, platelet count, red and white blood cell count and hematocrit of patients did not differ significantly between the two groups. No significant differences of IL-2, -4, -6, -10 and INF-γ concentration were observed between transfusion and no transfusion group. The concentration of TNF and IL-17A was significantly lower in transfusion patients than in the no transfusion subjects. Low plasma TNF and IL-17A levels predicted high perioperative transfusion rate, the combination of them enlarged the prognostic accuracy of testing. Our study demonstrates that the preoperative immune response influences transfusion requirements, and TNF and IL-17 are important predictive risk factors for perioperative use of blood components in glioma patients.

Robot-Assisted Total Gastrectomy: Preliminary Evaluation

Background: Laparoscopic total gastrectomy with extended lymphadenectomy is a technically demanding surgical procedure with steep learning curve that has limited its widespread use. The aim of this study was to evaluate the feasibility of the robotic approach in total gastrectomy for cancer. We present our experience of 17 consecutive patients who underwent robotic total gastrectomy with intracorporal sutured Roux-en-Y esophagojejunostomy and jejuno jejunostomy between 2014 and 2017. Methods: Data were collected, and patients' demographics and outcomes were examined retrospectively. Results: Seventeen patients with a median age of 68 years (range 32-81) were identified (10 males, 7 females). Mean operative time was 198 minutes (range 108-277) including mean anastomosis time of 25 minutes (range 18-35). There was no conversion to open surgery or requirement for perioperative blood transfusion. Median length of hospital stay was 9 days (range 2-30). Two patients developed postoperative complications including one anastomotic leakage treated conservatively and one internal hernia requiring surgical revision. There was no 90-day mortality or readmission. Conclusion: Robot-assisted total gastrectomy is feasible and reproducible. It overcomes several laparoscopic technical difficulties especially regarding anastomosis. It has the potential to become an alternative to open gastrectomy for gastric cancer. Nevertheless, further follow-up and randomized clinical trials are needed to evaluate mid-term and long-term outcomes of this approach.

Does Transfusion of Blood and Blood Products Increase the Length of Stay in Hospital?

We aimed to analyze the use of blood products in cardiac surgery and to investigate its effect on clinical outcomes. Perioperative transfusion requirement, survival and complication rates and the duration of hospitalization were noted. Patients were divided into two groups considering the duration of hospital and intensive care unit (ICU) stay. The cardiopulmonary bypass time and the cross clamp time, and the amount of used cryoprecipitate, fresh frozen plasma, platelet, red blood cell and the bleeding amount were significantly higher in groups that stayed at the hospital for > 7days and at the ICU for > 2days (p > 0.05). In the univariate model, to predict the patients who might stay at the hospital for more than 1week and who might stay at the ICU for more than 3days, we considered the significant efficacy of postoperative blood transfusion, bleeding amount, and the cardiopulmonary bypass time (p < 0.05). In the reduced multivariate model, however, we analyzed the significant-independent efficacy of the postoperative fresh frozen plasma use to determine the patients who would stay at the hospital for more than 1week and who would stay at the ICU for more than 3days (p < 0.05). We have concluded that increased use of blood products was associated with the cross clamp and cardiopulmonary bypass time and prolonged duration of hospital and ICU stays. In open cardiac surgeries, the use of blood products due to bleeding was identified as a predictor for staying longer than 3days at the ICU and longer than 7days at the hospital.

A prospective comparative study between intravenous and intraarticular tranexamic acid administration in decreasing the perioperative blood loss in total knee arthroplasty

PurposeTotal knee arthroplasty (TKA) is a common and safe surgical procedure, but the high perioperative blood loss is a cause of concern. Use of tranexamic acid to address this issue has gained popularity recently but no clear consensus is available regarding its ideal mode of administration. We conducted this study to evaluate and compare the efficacy of intravenous as well as intraarticular routes of administration of tranexamic acid. Methods300 patients planned for B/L Total Knee Arthroplasty were randomized into 3 groups; group IV (Intravenous, n = 100), group IA (Intraarticular, n = 100) and a control group (n = 100). In group IV, patients received 1 g tranexamic acid intravenously; in group IA 2.5 g tranexamic acid was given intraarticular in both knees and a control group which did not receive tranexamic acid. The primary outcomes measures were total blood loss (intraoperative blood loss + drain amount), pre and post surgery haemoglobin levels and the transfusion rate and quantity. The secondary outcome measures were complications. ResultsAdministration of tranexamic acid through either of the two routes resulted in statistically significant decrease in the total perioperative blood loss and transfusion requirement. There was no statistically significant difference in the results between the two test groups. ConclusionsBoth intravenous as well as intraarticular administration of tranexamic acid provided excellent results no known adverse effects. However neither of the two modalities should be considered superior to the other.

Effectiveness and Sustainability of a Standardized Care Pathway Developed with Use of Lean Process Mapping for the Treatment of Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

Recent changes in health care have begun to shift the industry from a volume-based to a value-based focus. This shift has led to standardized care pathways that decrease care variability, improve outcomes, and decrease cost. Although numerous studies have described standardized pathways for adolescent idiopathic scoliosis (AIS), few have demonstrated sustainability. We report the effectiveness and sustainability of a standardized care pathway for patients undergoing posterior spinal fusion for AIS. A standardized care pathway was developed and implemented (in March 2015) at our pediatric hospital for all patients undergoing posterior spinal fusion for AIS. This pathway was developed with use of the Lean process mapping technique to create an evidence-based protocol for preoperative, operative, postoperative, and post-discharge care. The 44 patients managed prior to implementation of the pathway (pre-pathway group) were compared with the 169 patients managed after implementation (post-pathway group). The post-pathway group was divided into 5 cohorts, each representing a 6-month time period. Clinical outcomes (pain scores, medication requirements, transfusions) and efficiency metrics (length of stay) were used to determine pathway sustainability. The pre-pathway group included patients managed in the 8 months prior to implementation (July 2014 to February 2015) and the post-pathway group included patients who underwent surgery from March 2015 to July 2017, divided into 5 cohorts representing 6 months each. Patients in the post-pathway group had lower postoperative pain scores, and used significantly less opioids at each time interval, compared with the pre-pathway group. Perioperative transfusion requirements and postoperative length of stay were significantly lower across all post-pathway cohorts compared with the pre-pathway group. There were no significant differences in clinical results among the 5 post-pathway cohorts. Implementation of a standardized care pathway developed with use of Lean process mapping demonstrated effective and sustained improvements to the care of patients with AIS, as well as decreased postoperative length of stay. These outcomes have been maintained over 2.5 years, indicating that high-quality care for patients with AIS undergoing spinal fusion can be achieved and sustained with use of a standardized care pathway. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Early Outcomes for Normothermic and Hypothermic Cardiopulmonary Bypass in Children Undergoing Congenital Heart Surgery

Objective: Comparison of early outcomes of normothermic cardiopulmonary bypass (N-CPB, ≥35°C) with hypothermic cardiopulmonary bypass (H-CPB, 28–34°C) for congenital heart defects.Methods: Data from 99 patients <2 years operated with N-CPB (n = 48) or H-CPB (n = 51) were retrospectively reviewed: aortic X-clamping and CPB duration, vasoactive inotropic score (VIS), arterial lactate, pH and base excess, urine output, extubation, PICU stay, transfusion requirements, chest drain losses, costs of transfusions, and costs of PICU stay.Results: The two groups were homogeneous for diagnosis, risk factors, surgery and demographic variables: N-CPB age 7.7 ± 6.1 months, weight 6.2 ± 2.4 kg, and H-CPB age 6.6 ± 6.5 months, weight 6.1 ± 2.4 kg.There were no hospital deaths in either group. VIS in N-CPB was lower than H-CPB on PICU arrival (9.7 ± 5.9 vs. 13.4 ± 7.9, P < 0.005), after 4 h (7.0 ± 5.2 vs. 11.1 ± 7.3, P < 0.001) and 24 h (2.8 ± 3.6 vs. 5.6 ± 5.6, P < 0.003); arterial pH was better at PICU arrival (7.33 ± 0.09 vs. 7.30 ± 0.09, P = 0.046) after 4 h (7.35 ± 0.07 vs. 7.32 ± 0.07, P = 0.022) and after 24 h (7.37 ± 0.05 vs. 7.35 ± 0.05, P = 0.01). Extubation was earlier in N-CPB than in H-CPB (22 ± 27 vs. 48 ± 57 h, P = 0.003) as PICU discharge (61 ± 46 h vs. 87 ± 69 h, P = 0.021). Transfusion requirements in operating room were lower in N-CPB vs. H-CPB for RBC, FFP, cryoprecipitate, and platelets, while during the first 24 h in PICU were lower only for cryoprecipitate and platelets.Chest drain losses (mL/kg) on PICU arrival, after 4 and 24 h were lower with N-CPB vs. H-CPB (respectively 1.5 ± 1.4 vs. 2.5 ± 2.7, P = 0.013, 7.8 ± 6.0 vs. 10.9 ± 8.7, P = 0.025, and 23.0 ± 12.0 vs. 27.9 ± 15.2, P = 0.043). Tranexamic acid infusion was required in 7/48 (14.6%) patients with N-CPB vs. 18/51(= 35.3%) in H-CPB (P = 0.009). The average total costs/patient of blood and blood products (RBC, FFP, cryoprecipitate, platelets) were lower in N-CPB vs. H-CPB for both the first 24 h after surgery (£204 ± 169 vs. £306 ± 254, P = 0.011) as well as during the total duration of PICU stay (£239 ± 193 vs. £427 ± 337, P = 0.001). The average cost/patient/day of stay in PICU was lower in N-CPB than in H-CPB (£4,067 ± 3,067 vs. £5,800 ± 4,600, P = 0.021).Conclusions: N-CPB may reduce inotropic and respiratory support, shorten PICU stay, and decrease peri-operative transfusion requirements, with subsequent costs reduction, compared to H-CPB. Future studies are needed to validate and support wider use of N-CPB.

Effects of terlipressin infusion on blood loss and transfusion needs during liver resection: A randomised trial.

Blood loss and perioperative blood transfusion requirements affect the long-term survival after liver resection for malignant tumours. Terlipressin is a synthetic vasopressin analogue with relative specificity for the splanchnic circulation where it causes vasoconstriction with subsequent reduction of blood loss during abdominal surgeries. We tried to examine the impact of terlipressin on blood loss and blood transfusion needs during liver resection. In this randomised, double-blind placebo-controlled trial 84 patients scheduled for major liver resections were randomly assigned to receive either terlipressin at the onset of surgery as an initial bolus dose of (1 mg over 30 minutes) followed by a continuous infusion of 2 μg/kg/h throughout the procedure (Terlipressin group) or the same volume and rate of 0.9% saline (Placebo group).The primary outcome was the amount of intra-operative blood loss. The mean (SD) of the amount of intra-operative blood loss was 1351 (887) in the terlipressin group versus 1892 (889) mL in the placebo group (P = 0.006). Thirteen (30%) patients received blood transfusion in the terlipressin group compared with t27 (64.2%) in the placebo group (P = 0.002) with a statistically significant difference in the median (range) number of the transfused units of packed RBCs [0 (0-5) units and 1 (0-6) units in the two groups respectively; P = 0.001]. Terlipressin infusion during major liver resection was associated with less bleeding compared to placebo. More studies are required to confirm our results especially in patients with normal portal pressure.

Adjusted calculation model of heparin management during cardiopulmonary bypass in obese patients: A randomised controlled trial.

Anticoagulation during cardiopulmonary bypass (CPB) is usually adapted to total body weight (TBW). This may be inaccurate in obese patients and lead to heparin overdose with a risk of bleeding. To validate the efficacy and safety of an adjusted calculation model of heparin dosing based on ideal body weight (IBW) rather than TBW in obese CPB patients, with an expected target mean plasma heparin concentration of 4.5 IU ml after onset of CPB in the experimental group. Randomised controlled study. University hospital. Sixty obese patients (BMI ≥ 30 kg m) scheduled for CPB were included from January to June 2016. Patients received a bolus dose of unfractionated heparin of either 300 IU kg of TBW or 340 IU kg of IBW before onset of CPB. Additional adjusted boluses were injected to maintain an activated clotting time (ACT) of at least 400 s. Plasma heparin concentration and ACT were measured at different time points. Total heparin doses and transfusion requirements were recorded. The target heparin concentration of 4.5 IU ml was reached in the IBW group at the onset of CPB and maintained at all time points during CPB. Heparin concentrations were significantly higher in the TBW group after the bolus (6.52 ± 0.97 vs. 4.54 ± 1.13 IU ml, P < 0.001) and after cardioplegia (5.10 ± 1.03 vs. 4.31 ± 1.00 IU ml, P = 0.02). Total heparin doses were significantly higher in the TBW group. Mean ACT was significantly lower in the IBW group but remained over 400 s during CPB. The correlation between heparin and ACT was poor. Peri-operative bleeding and transfusion requirements were comparable. No thrombotic event occurred in the CPB circuit. The current IBW-adjusted regimen of heparin administration may be used efficiently in obese CPB patients, thereby avoiding overdose which cannot be accurately assessed by ACT monitoring alone. ClinicalTrials.gov identifier: NCT02675647.

Radical nephrectomy and intracaval thrombectomy for advanced renal cancer with extensive inferior vena cava involvement utilising cardiopulmonary bypass and hypothermic circulatory arrest: Is it worthwhile?

ObjectiveTo report our long-term outcomes of surgical treatment of renal tumours with inferior vena cava (IVC) tumour thrombus above the hepatic veins, utilising cardiopulmonary bypass (CBP) and hypothermic circulatory arrest (HCA), as surgical resection remains the only effective treatment for renal cancers with extensive IVC tumour thrombus. Patients and methodsWe retrospectively reviewed 48 consecutive patients (median age 58 years) who underwent surgical treatment for non-metastatic renal cancer with IVC tumour thrombus extending above the hepatic veins. Perioperative, histological, disease-free (DFS) and overall survival (OS) data were recorded. ResultsTumour thrombus was level III in 23 patients and level IV in 25 patients. The median (range) CBP and HCA times were 162 (120–300) min and 35 (9–64) min, respectively. Three patients underwent synchronous cardiac surgical procedures. There were three (6.3%) perioperative deaths. American Society of Anesthesiologists grade and perioperative blood transfusion requirement were significant factors associated with perioperative death (P < 0.05). Despite extensive preoperative screening for metastases the median (range) DFS was only 10.2 (1.2–224.4) months. The median (range) OS was 23 (0–224.4) months. Cox regression analysis revealed that perinephric fat invasion conferred a significantly poorer DFS (P = 0.005). ConclusionsRadical surgery for patients with extensive IVC tumour thrombus has acceptable operative morbidity and mortality. It provides symptom palliation and the possibility of long-term survival. Improvements in preoperative detection of occult metastasis may improve case selection and newer adjuvant therapies may improve survival in this high-risk group.

Antifibrinolytic Agents in Plastic Surgery: Current Practices and Future Directions.

Prevention of blood loss is a chief consideration in plastic and reconstructive surgery. The antifibrinolytic drugs tranexamic acid and ε-aminocaproic acid have emerged as promising agents to reduce both perioperative blood loss and transfusion requirements. However, published reports in the plastic surgery literature are lacking. The authors sought to summarize the current knowledge of the use of antifibrinolytics in plastic surgery by reviewing the existing literature for clinical outcomes and recommendations. A systematic review of the PubMed, Cochrane, and Google Scholar databases was conducted for publications examining the use of antifibrinolytics in plastic surgery. Studies were abstracted for procedure type, antifibrinolytic dose, time and mode of administration, blood loss, transfusion requirements, and complications. Thirty-three studies were deemed eligible for inclusion, comprising a total of 1823 patients undergoing plastic surgical procedures with tranexamic acid (n = 1328) and/or ε-aminocaproic acid (n = 495). Tranexamic acid and ε-aminocaproic acid are widely used to reduce blood loss and transfusion requirements in craniofacial and orthognathic surgery, without an increased risk of adverse events. Intravenous administration is most commonly used, although topical formulations show similar efficacy with a reduced systemic distribution. Tranexamic acid has also emerged as a promising agent in aesthetic surgery and burn care, due to its favorable safety profile and role in reducing blood loss, achieving an improved surgical field, and reducing edema and ecchymosis. Further investigation of these agents in the fields of burn care, aesthetic surgery, and microsurgery is warranted to standardize protocols for clinical use.

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

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

Pancreatoduodenectomy in the cirrhotic patient: predictors of outcome

Background: Hepatic cirrhosis is a formidable risk for mortality in gastrointestinal surgery. Though cirrhosis has been considered to be a contraindication to pancreatoduodenectomy (PD), few data are available in this patient population. We analyzed a large population of cirrhotic patients undergoing PD, seeking to identify preoperative predictors of morbidity and mortality. Methods: Patients undergoing PD with biopsy-proved cirrhosis were evaluated. Primary endpoints were mortality and morbidity. Child score, MELD score, and radiographic evidence of portal hypertension were assessed for accuracy in preoperative risk stratification. Results: Between 2005 and 2013, 36 cirrhotic patients underwent PD; follow-up was complete. Median survival was 37.3 months (range 0.2–116). Overall perioperative (90-day) mortality was 13.9%. Median Child score was 6 (range 5–10); median MELD score was 9 (range 7–18). Age at time of surgery, smoking, operative duration, perioperative transfusion requirement did not predict mortality. MELD ≥ 10 was associated with increased postoperative mortality (23% vs 8.7%, p = 0.004). Radiographic evidence of portal hypertension (pHTN) was observed in 16/29 (55%). Irrespective of Child or MELD score, those with pHTN had poor outcomes including significantly greater intraoperative blood loss, increased transfusion requirement, increased incidence of major complication, and length of stay. Postoperative mortality was significantly higher with pHTN (19% vs 7.7%, p = 0.01). Conclusion: Pancreatoduodenectomy may be considered in carefully selected cirrhotic patients. MELD ≥ 10 predicts postoperative mortality. Specific attention should be afforded to patients with preoperative radiographic evidence of portal hypertension as this group experiences poor outcomes irrespective of MELD or Child score.

Prophylactic use of tranexamic acid in noncardiac surgery : Update 2017

Minimising perioperative bleeding is akey goal of "patient blood management" programs. One component of respective strategies includes preventive inhibition of fibrinolysis using protease inhibitors, such as tranexamic acid (TXA). TXA inhibits plasminogen activation and plasmin-induced fibrin degradation. The present article provides an overview of the existing literature and TXA applications in the prophylaxis of perioperative bleeding. Literature search in PubMed/MEDLINE (U.S. National Library of Medicine®, Bethesda, MD, USA). TXA reduces perioperative blood loss and transfusion requirements in several randomized controlled trials (RCTs) and meta-analyses in the field of hip and knee arthroplasty for both intravenous and topical use. Moreover, evidence favours use of TXA in complex spine surgery and reconstructive surgery (e. g. craniosynostosis in children). Single RCTs showed benefits of TXA in abdominal hysterectomy, open prostatectomy, liver surgery and actively bleeding trauma patients. For prophylaxis of peripartum haemorrhage (PPH) following vaginal delivery or Caesarean section, TXA cannot be routinely recommended, although evidence points to benefits in actively bleeding patients. A recommendation exists for the treatment of (active) PPH. For prophylactic perioperative administration, different dosage regimens exist for adults. Most often an initial i. v. bolus of 1 g or 10-15 mg/kg body weight with/without repetition after 6 h or continuous infusions over 8 h is administered. Increased rates of thromboembolic events were not noted. Protease inhibitors such as TXA reduce perioperative blood loss and transfusion requirements in selected surgical fields.