Postoperative Blood Transfusion Research Articles

Current Practices and Guidelines for Perioperative Blood Management in Post-Bariatric Body Contouring Surgery: A Comprehensive Review of Literature.

With the increase in obesity prevalence, a noticeable increase in bariatric surgeries has been reported in national and international statistics. Therefore, body contouring surgeries have increased to help individuals achieve their desired body shape. Plastic surgeons need to consider potential hematologic complications that may occur in this specific group of patients before performing body contouring surgery. This review illustrates the perioperative medical, laboratory, and management strategies needed to minimize blood loss and blood transfusion requirements during body contouring. Using Google Scholar and PubMed, a comprehensive literature review was conducted to identify articles discussing post-bariatric body contouring perioperative blood management strategies, including the effects of bariatric surgery on hemostasis as well as basic hematology and coagulation. In preoperative blood management, blood investigations aid in the early detection of electrolytes, protein, and vitamin deficiencies and anemia, resulting in the early correction of nutritional deficiencies. In order to reduce postoperative complications, surgical and anesthesia techniques, as well as intraoperative pharmacological therapy, play an essential role. Postoperative blood transfusion and restrictive transfusion thresholds are tailored to the patient's needs and depend on various physiological indicators, such as heart rate, blood pressure, urine output, and laboratory findings, such as acidosis and hematocrit level. Generally, post-bariatric body contouring blood management measures are still lacking, and more research is required to develop standardized guidelines for optimizing patient safety and satisfaction.Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.

Consequences of anastomotic leaks after minimally invasive esophagectomy: A single-center experience

BackgroundAnastomotic leak (AL) after minimally invasive esophagectomy (MIE) is a well-described source of morbidity for patients undergoing surgical treatment of esophageal neoplasm. With improved early recognition and endoscopic management techniques, the long-term impact remains unclear. MethodsA retrospective review was conducted of patients who underwent MIE for esophageal neoplasm between January 2015 and June 2021 at a single institution. Cohorts were stratified by development of AL and subsequent management. Baseline demographics, perioperative data, and post-operative outcomes were examined. ResultsDuring this period, 172 MIEs were performed, with 35 of 172 (20.3%) complicated by an AL. Perioperative factors independently associated with AL were post-operative blood transfusion (leak rate 52.9% versus 16.8%; p = 0.0017), incompleteness of anastomotic rings (75.0% vs 19.1%; p = 0.027), and receiving neoadjuvant therapy (18.5% vs 30.8%; p < 0.0001). Inferior short-term outcomes associated with AL included number of esophageal dilations in the first post-operative year (1.40 vs 0.46, p = 0.0397), discharge disposition to a location other than home (22.9% vs 8.8%, p = 0.012), length of hospital stay (17.7 days vs 9.6 days; p = 0.002), and time until jejunostomy tube removal (134 days vs 79 days; p = 0.0023). There was no significant difference in overall survival between patients with or without an AL at 1 year (79% vs 83%) or 5 years (50% vs 47%) (overall log rank p = 0.758). ConclusionsIn this large single-center series of MIEs, AL was associated with inferior short-term outcomes including hospital length of stay, discharge disposition other than to home, and need for additional endoscopic procedures, without an accompanying impact on 1-year or 5-year survival. Key messageIn this large, single-center series of minimally invasive esophagectomies, anastomotic leak was associated with worse short-term outcomes including hospital length of stay, discharge disposition other than to home, and need for additional endoscopic procedures, but was not associated with worse long-term survival. The significant association between neoadjuvant therapy and decreased leak rates is difficult to interpret, given the potential for confounding factors, thus careful attention to modifiable pre- and peri-operative patient factors associated with anastomotic leak is warranted.

Perioperative Outcomes of Patients Treated in an Anemia Clinic before Spine Surgery

BACKGROUND: Patients with preoperative anemia are at increased risk of postoperative blood transfusion, as well as other adverse outcomes, including infection, prolonged length of stay (LOS), and death. Requirement of intraoperative transfusions may be an independent risk factor for mortality among patients undergoing noncardiac surgery. As such, efforts have emerged internationally to establish clinical decision support tools, dedicated preoperative anemia clinics, and clinical trials studying the effects of preoperative treatment of patients to improve outcomes after surgery. While studies to date have shown mixed results, some suggest that treatment with intravenous (IV) iron improves anemia and decreases transfusion requirements. Treatment with erythropoietin-stimulating agents (ESA) has also been associated with fewer transfusions in patients undergoing orthopedic surgery. METHODS: We established a preoperative clinic in 2019 with a pilot for patients undergoing spine surgery. Patients who were found to have a hemoglobin (Hgb) < 13.0 g/dL on preadmission testing were automatically referred, and when possible, had iron studies reflexively added on to their samples. Patients were offered an appointment with a nurse practitioner or physician in Hematology and treated with IV iron or a combination of IV iron and ESA at the discretion of the provider. Importantly, if time did not allow for a visit or the patient declined an appointment or preoperative treatment, surgeries were not cancelled or delayed. This retrospective study included patients undergoing elective spine surgeries between August 1, 2019 and June 1, 2021 at Thomas Jefferson University Hospital and Jefferson Hospital for Neuroscience. Patients were eligible if they were automatically referred to the preoperative anemia clinic based on preadmission testing results. The primary outcome was postoperative allogeneic red blood cell (RBC) transfusion during the index admission. Secondary outcomes included decrease in Hgb postoperatively, LOS, and 30-day readmission rate. RESULTS: The study included 108 patients (53.7% female) who underwent a total of 112 distinct elective spine surgeries. The median age at the time of surgery was 65 years. The most common surgery was decompression and fusion (73.2%), followed by decompression (17.0%) and fusion (9.8%). 16.1% of surgeries were revisions of a prior surgery. The median preoperative Hgb was 11.6 g/dL. Prior to the 112 surgeries, 45 (40.2%) patients were seen by a Hematology provider and 37 (33.0%) received preoperative treatment for anemia, including 28 (25.0%) who got IV iron plus ESA, 8 (7.1%) IV iron alone, and 1 (0.9%) ESA alone. The final treatment was given a median of 5 days before surgery (IQR 3-9.5 days). There was a nonsignificant trend toward lower mean preoperative Hgb in patients who were treated before surgery and those who were not (mean 11.2 vs 11.6 g/dL, p=.162) and greater mean estimated blood loss during surgery when reported (392 vs 315 mL, p=.462). Compared to untreated patients, those who were treated before surgery were significantly more likely to be iron deficient (ferritin < 30 ng/mL or iron saturation < 15%) (45.9% vs 26.7%, p=.041). The primary outcome of allogeneic RBC transfusion occurred in 18.9% of patients who received pre-treatment and 9.3% of those who did not (p=.149). The degree of initial Hgb drop postoperatively from last pre-op value was significantly lesser in pre-treated patients (-0.93 vs -1.56 g/dL, p=.015), and a nonsignificant improvement was observed in the change from baseline to nadir Hgb during the index admission (-1.54 vs -2.15 g/dL, p=.074). A trend toward shorter LOS was observed in pre-treated patients (3.30 vs 3.47 days, p=.739), though that group also experienced more 30-day inpatient readmissions (18.9 vs 12.0%, p=.325). No deaths were observed during the study period. CONCLUSION: In this preoperative anemia clinic pilot, treatment with IV iron and/or ESA before major spine surgery was not associated with a reduction in allogeneic RBC transfusions or hospital readmission. However, those who received pre-treatment had significantly lesser declines in Hgb after surgery and a trend toward shorter LOS. Patients who received treatment were significantly more likely to be iron deficient before surgery and had lower mean Hgb levels, which confounds the results. Larger prospective studies of preoperative anemia therapy are needed. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Laparoscopic Adenomyomectomy under Real-Time Intraoperative Ultrasound Elastography Guidance: A Case Series and Feasibility Study.

This study aimed to examine the clinical characteristics of 11 patients undergoing laparoscopic adenomyomectomy guided by intraoperative ultrasound elastography and this technique's feasibility. Eleven patients undergoing laparoscopic adenomyomectomy using ultrasound elastography for adenomyosis at Kawasaki Medical School Hospital in Okayama, Japan between March 2020 and February 2021 were enrolled. Operative outcomes included operative time, operative bleeding, resected weight, operation complications, percent change in hemoglobin (Hb) values, and uterine volume pre- and postoperatively. Dysmenorrhea improvement was evaluated by changes in visual analog scale (VAS) scores pre- and 6- and 12-months postoperatively. The median operative time and bleeding volume was 125 min (range, 88-188 min) and 150 mL (10-450 mL), respectively. The median resected weight was 5.0 g (1.5-180 g). No intraoperative or postoperative blood transfusions or perioperative complications were observed. The median changes in uterine volume, Hb value, and VAS score were -49% (-65 to -28%), -3% (-11 to 35%), and -80% (-100 to -50%), respectively. The median follow-up period post-surgery was 14 months (7-30 months). Adenomyosis recurrence was not observed in the patients during the follow-up period. Laparoscopic adenomyomectomy using ultrasound elastography guidance is minimally invasive and resects as many adenomyotic lesions as possible.

Abstract 14448: On-Table Extubation Associated With Lower Resource Utilization and Non-Inferior Outcomes After Coronary Bypass

Introduction: Minimizing the duration of postoperative ventilation facilitates early discharge from the intensive care unit (ICU) thus promoting enhanced recovery after cardiac surgery (ERAS). Hence, we sought to investigate the impact of on-table extubation on outcomes and resource utilization after coronary artery bypass graft (CABG) surgery. Methods: We performed a retrospective review of a prospectively collected local database, including all patients undergoing CABG surgery at a large academic center from January 2020 to December 2021. Patients were stratified into two groups, on-table (before leaving the operating room) extubation versus early (&lt; 6 hours after procedure) extubation. In-hospital mortality and postoperative complications were compared using univariate analyses. Length of stay (LOS), 30-day readmission and high resource utilization (HRU), a binary outcome defined as direct procedure cost of the highest quartile, were investigated. Results: A total of 691 patients were included in our analysis, 267 (38.6%) of which were extubated on-table. The two groups had similar median age and preoperative ejection fractions. However, on-table extubation patients were more likely to be males (86.9% vs 76.6%, p&lt;0.001) with smaller BMIs (27.7% vs 28.5%, p=0.002), lower STS risk scores (0.75% vs 0.95%, p=0.022) and lower cerebrovascular disease prevalence (8.2% vs 14.2%, p=0.017). Compared to early extubation, on-table extubation patients had similar rates of in-hospital mortality (0 % vs 1.4 %, p=0.051), postoperative blood transfusion (7.5% vs 9.0%, p=0.494), reintubation (2.6% vs 3.5%, p=0.499) and pneumonia (1.9% vs 3.3%, p=0.263). As hypothesized, on-table extubation patients had shorter ICU LOS (32hrs vs 39hrs, p=0.02), shorter postoperative LOS (4.9 days vs 5.9 days, p=0.003), and lower incidence of high resource utilization (18.0% vs 29.5%, p&lt;0.001). ICU readmission (3.8% vs 3.5%, p=0.887) and 30-day readmission (5.2% vs 7.3%, p=0.277) were similar in the two groups. Conclusions: On-table extubation is a safe and effective ERAS practice, that is associated with lower ICU LOS, postoperative LOS, and resource utilization, without affecting rates of reintubation, ICU readmission, 30-day readmission or operative mortality.

Increased Severity of Anemia Is Associated with Postoperative Complications following a Adult Spinal Deformity Surgery.

Anemia is a modifiable risk factor for postoperative complications following surgery. This study aimed to determine the impact of preoperative anemia severity on 30-day postoperative complications following adult spinal deformity (ASD) surgery. Adults undergoing spinal fusion for ASD from 2012 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were substratified into 3 cohorts-non-anemia, mild anemia, and moderate-to-severe anemia-based on World Health Organization definitions. We assessed 30-day wound, cardiac, pulmonary, renal, and thromboembolic complications, as well as sepsis, mortality, postoperative transfusions, extended length of stay, and reoperation. Bivariate analyses and multivariable logistic regression were performed. Of 2173 patients, 1694 (78%) had no anemia, 307 (14%) had mild anemia, and 172 (8%) had moderate or severe anemia. Following adjustments, patients with mild anemia were more likely to have postoperative blood transfusions (odds ratio [OR] 1.80, P<0.001) and extended length of stay (OR 1.43, P<0.001). Patients with moderate-to-severe anemia were at increased risk of organ space infection (OR 3.27, P=0.028), death (OR 13.15, P=0.001), postoperative blood transfusion (OR 2.81, P<0.001), and extended length of stay (OR 3.02, P<0.001). We found a stepwise and approximately two-fold increase in the odds ratio of postoperative transfusion and length of stay with increasing severity of anemia. Moderate-to-severe anemia was associated with increased odds of death and organ space infection. Patients with moderate-to-severe anemia should be medically optimized before ASD surgery.

A retrospective analysis of surgical, patient, and clinical characteristics associated with length of stay following elective lumbar spine surgery

BackgroundElective spine surgeries consume significant hospital resources, contributing greatly to the costs of care. Length of stay (LOS) is the major cost driver for most hospitals. This study aimed to describe the demographic, clinical, operative, and postoperative characteristics of patients undergoing elective lumbar spine with wide-ranging rural discharge destinations, and how these characteristics are independently associated with LOS. MethodsThis was a retrospective cohort study of patients at a quaternary institution undergoing surgery for single or two level lumbar degenerative conditions over a two year period. LOS was calculated as the number of days from the date of surgery to the date of discharge. A multiple quasi-Poisson regression was used to describe the characteristics independently associated with LOS. Surgery group was stratified when feasible to explore heterogeneity within the study population. ResultsA total of 473 patients met inclusion criteria. The median LOS was 3.0 days (Interquartile range (IQR) = 1–4) for the entire population, 4.0 days (IQR = 3–6) for 1-level transforaminal lumbar interbody fusion (TLIF) patients, 0 days (IQR = 0–1) for discectomy patients, and 2.0 days (IQR = 1–4) for laminectomy patients. Factors that were statistically significantly associated with LOS in adjusted analyses were age, BMI, preoperative antidepressant use, surgery group, long-acting intraoperative analgesics, operating surgeon, and postoperative blood transfusion. Stratified multivariable analysis showed effect modification by surgery group. ConclusionLOS following elective lumbar spine surgery for degenerative conditions is associated with several patient, clinical, and surgical factors and is highly dependent on the type of surgical procedure performed. Building predictive models for anticipated LOS can help hospitals plan for ideal resource use and scheduling.

8010 Postoperative Abscess Risk with Hemostatic Agent Use in Hysterectomy

<h3>Study Objective</h3> We noticed a trend of increased re-admissions for post-op pelvic abscesses. In an attempt to further investigate causality, we identified use of hemostatic agents as a possible culprit. The study objectives were to determine if intra-operative use of hemostatic agents was associated with postoperative abscess formation in patients undergoing hysterectomy. <h3>Design</h3> Retrospective chart review identified women who underwent hysterectomy by a Gynecologic Oncologist for any indication at a single institution from January 1, 2019, through December 31, 2019. Patient and surgical characteristics were abstracted, and comparisons were made among those who received any hemostatic agent and those that did not. <h3>Setting</h3> Study was performed at an academic institution in rural Virginia. <h3>Patients or Participants</h3> 428 hysterectomies were identified among five providers over a one-year period, with a postoperative pelvic abscess rate of 3.7%. <h3>Interventions</h3> The relationship between intra-operative hemostatic agentuse and post-op pelvic abscess formation was determined using multivariate logistic regression. Secondary outcomes evaluated included the presence of other major post-operative adverse events, such as post-operative blood transfusion, presentation to the emergency room, readmission or re-operation. <h3>Measurements and Main Results</h3> Abscesses were identified in 4 (2.2%)of cases without <i>vs</i> 12 (4.9%) of cases with hemostatic use with a logistic regression model demonstrating no significant difference in the groups (OR=2.10, <i>p</i>=0.22). Data showed an increase in presentation to the ED (OR=3.43, <i>p</i>=0.002 adjusted) and higher odds of readmission to the hospital within 30 days of surgery (OR=3.19, <i>p</i>=0.03) with hemostatic agent use. <h3>Conclusion</h3> There was no association found between the use of hemostatic agent use and abscess formation; however, data showed hemostatic agent use in surgery was associated with increased odds of presentation to the ED and readmission to the hospital within 30 days of surgery.

Coronary artery bypass grafting in non-dialysis dependent chronic renal disease

Background: Renal impairment is associated with increased morbidity and mortality after coronary artery bypass grafting (CABG). Therefore, we aimed to study the risk factors of increased morbidity and mortality after CABG in patients with non-dialysis-dependent mild-to-moderate chronic kidney disease.&#x0D; Methods: This prospective study included 50 patients with non-dialysis-dependent renal impairment (renal disease stage II or III) with off-pump (n= 25) or on-pump (n= 25) CABG. Postoperative outcomes and creatinine levels were compared between both groups.&#x0D; Results: The mean age of all patients was 48.4±12.3 years, and females presented 54% (n= 27). There were no differences in postoperative myocardial infarction (P= 0.923), atrial fibrillation (P= 0.776), blood transfusion (P=0.794), and ICU (P=0.772) and hospital stay (P= 0.698) between groups. Mechanical ventilation was longer in patients with on-pump CABG (16.4 ± 10.9 vs. 6.1 ± 3.2 hours; P˂0.001). Creatinine levels were significantly lower in patients who had off-pump CABG (P˂0.001). The cumulative mortality hazard increases to 56.7% in patients with preoperative creatinine levels above 2 mg/dl. &#x0D; Conclusion: High preoperative creatinine levels could increase mortality in patients undergoing CABG. Off-pump CABG could be a better approach in patients with mild to moderate renal dysfunction.

7542 Post-Operative Complications of Appendectomy in Benign Gynecologic Surgery: National Surgical Quality Improvement Program Analysis

<h3>Study Objective</h3> This study was conducted to assess if concomitant appendectomy in women undergoing laparoscopic surgery for benign gynecologic indications is associated with increased rates of post-operative complications in the 30-day post-operative period. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> National database study. <h3>Patients or Participants</h3> American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was utilized to identify women who underwent laparoscopic surgery by a gynecologist. Patients were excluded if they underwent open abdominal surgeries, bowel resections, urogynecologic surgeries, or if cancer or appendicitis was present. There were 247,700 patients included in population cohort between 2010 and 2020. <h3>Interventions</h3> Patients were identified using Current Procedural Terminology codes. Patients who underwent concomitant appendectomy were compared to patients who did not undergo appendectomy. Demographic variables included age, body mass index, and medical co-morbidities. Post-operative complications included superficial, deep, or organ space infection, sepsis, thromboembolic events, blood transfusion, hospital re-admission, and re-operation. A matched cohort was created by computing propensity scores. Outcomes were compared between groups using Fisher and Mann-Whitney tests. <h3>Measurements and Main Results</h3> 1,815 patients (0.7%) underwent concomitant appendectomy. In the propensity matched sample, there were comparable rates of post-operative surgical site infections at 2.8% in the appendectomy group and 2.4% in the no appendectomy group (p-value 0.469). There were higher rates of sepsis in the appendectomy group with 1.3% of patients being diagnosed with sepsis compared to 0.3% in the no appendectomy group (p-value 0.003). There were higher rates of hospital re-admission in the appendectomy group at 4% compared to 3% in the no appendectomy group (p-value 0.006). There were no differences in the rates of post-operative thromboembolic events, blood transfusion, or re-operation. <h3>Conclusion</h3> Patients undergoing concomitant appendectomy at the time of benign gynecologic laparoscopic surgery have increased risk of post-operative sepsis and hospital re-admission. Additional studies may be conducted to identify patients with optimal risk-benefit profiles when considering concomitant appendectomy.

P-139 THE EFFECTS OF THE INCISION TYPE ON INCISIONAL HERNIA RESULTS OF LIVING DONOR LIVER TRANSPLANT; SINGLE CENTER EXPERIENCE

Abstract Aim We aimed to assess the effects of the chosen incision type on postoperative hernia rates of liver transplantation in this paper. Material-Methods During the period between the 5th September 2018 and 31st March 2022, total 210 liver transplantations were performed in the Liver Transplantation Center of Koç University Hospital. 96 pediatric and 10 deceased donor transplantations were excluded. Living donor liver transplantation (LDLT) cases in only adults were included in the trial. Total 104 patients were included. Patients divided into two groups in the manner of chosen laparotomy incision during the operation. Reverse T incisions (Group A, n=68) and Makuuchi incisions (Group B, n=36) were performed in our center during the trial period. Minimum 3 month-follow up period was performed. Results Demographic data (Table 1) was similar in both groups. Operation and warm ischemia durations were longer in Group B (Table 2). Postoperative immunosuppressive regimens were same protocols contains tacrolimus and prednisolone. Surgical site infection rates, relaparotomy rates, postoperative blood transfusion rates, biliar, vascular and pulmonary complication rates were also similar in both groups (Table 3). While 11 patients diagnosed with incisional hernia in Group A (%16,2), 2 patients diagnosed with incisional hernia in Group B (%5,6, p=0,212). Conclusion Although Makuuchi incision seems to be safer in manner of hernia rates, this couldn't be proved by statistically significance as a result of this retrospective analysis of a single center. The necessity of prospective designed trials is obvious in order to obtain more reliable results.

The Outcome of Minimally Invasive Percutaneous Transpedicular Screw Fixation (TPSF) in Thoracolumbar Spine Fractures

Background &amp; Objective: This study aimed to determine the outcome of percutaneous transpedicular screw fixation (TPSF) in patients with thoracolumbar fractures.&#x0D; Material &amp; Methods: A total of 157 patients with thoracolumbar fractures were included from the Department of Neurosurgery, LGH, PINS, Lahore. Patients were evaluated with plain X-rays, CT, and MRI scans. Neurological status was documented preoperatively and postoperatively. All patients were treated with Minimally Invasive Percutaneous Transpedicular screw fixation. Data for operative time and per-operative blood loss was obtained through the operative notes. The severity of postoperative pain and length of hospital stay were also documented.&#x0D; Results: Out of 157 patients, 69.4% were male and 30.6% were female. The 141 (89.8%) were traumatic from road traffic accidents/falls, and 16 (10.2%) were pathologic. The 128 (81%) patients were discharged on the first day, 23(15%) were discharged on the second day, and 6(3.8%) on the third day. 79% of patients had a single level of spine fracture whereas, 20% had 2 spinal fracture levels. The average operative time for MIS percutaneous TPSF was 55 minutes. Postoperative pain was markedly reduced as compared to traditional open surgery and no patient had any new neurological deficit. The mean blood loss was 25 ml and none of the patients needed a postoperative blood transfusion.&#x0D; Conclusion: Percutaneous transpedicular instrumentation is an ideal surgical approach for thoracolumbar spinal stabilization.&#x0D; Keywords: Thoracolumbar Fractures, Percutaneous Transpedicular Screw Fixation, Minimally Invasive Spine Surgery, Road Traffic Accidents (RTA).

Association of Bleeding Disorders and Risk of Complications Following Open Reduction and Internal Fixation of the Ankle

Category: Ankle; Other Introduction/Purpose: Open reduction and internal fixation (ORIF) of the ankle is a common procedure performed to correct ankle fractures in many different patient populations. Diabetes, peripheral vascular disease, and osteoporosis have been identified as risk factors for postoperative complications following surgery for ankle fractures. To date, there have not been any studies evaluating postoperative outcomes in patients with bleeding disorders undergoing operative treatment for ankle fractures. The aim of this study was to determine the postoperative complication rate following ORIF of the ankle in patients with a bleeding disorder versus those without a bleeding disorder. Methods: From 2006 to 2018, patients undergoing operative treatment for ankle fracture were identified in the National Surgical Quality Improvement Program database. Two patient cohorts were defined: patients with a bleeding disorder and patients without a bleeding disorder. Patients who underwent either inpatient or outpatient ORIF of the ankle were included in this study. In this analysis, demographics, medical comorbidities, and postoperative complications variables were assessed between the two cohorts. Bivariate and multivariate analyses were performed. Results: Of 10,306 patients undergoing operative treatment for ankle fracture, 9,909 patients (96.1%) had no bleeding disorder whereas 397 patients (3.9%) had a bleeding disorder. Following adjustment on multivariate analysis, compared to patients who did not have a bleeding disorder, those with a bleeding disorder had an increased risk of any postoperative complications (OR 1.479; p=0.024), requirement for postoperative blood transfusion (OR 2.863; p=0.001), and extended length of hospital stay greater than 5 days (OR 1.455; p=0.010) (Table 1). Conclusion: Patients with bleeding disorders are at an increased risk of postoperative complications following ORIF for ankle fractures. Our study found that patients with bleeding disorders had greater odds of postoperative complications following ORIF of the ankle. Determining patient risk factors and creating optimal preoperative and perioperative management plans in patients with bleeding disorders undergoing ORIF can be beneficial in reducing postoperative complications, improving patient outcomes, and reducing overall cost.

Factors affecting the need of postoperative blood transfusion in elderly patients with intertrochanteric hip fracture.

We investigated the risk factors that increased the frequency of blood transfusions in elderly patients with intertrochanteric hip fractures to determine blood transfusion risk before surgery and to take selective precautionary measures in the group at high risk for transfusion to ensure safe surgery. We retrospectively reviewed the electronic medical records of 203 patients who underwent surgical fixation of intertrochanteric hip fractures from January 2015 to December 2020. We hypothesized that patient sex, age, body mass index, preoperative hemoglobin, preoperative platelet count, glomerular filtration rate (GFR), preoperative albumin level, American Society of Anesthesiologist score, intraoperative blood loss, duration of surgery, method of anesthesia, and time from injury to surgery would affect the need for blood transfusion. Student's t-test, Chi-squared test, and the one-way analysis of variance test were used to determine whether differences between variables in the transfusion and non-transfusion groups were significant. Unstable fractures (P = 0.002), general anesthesia (P = 0.028), lower preoperative hemoglobin levels (P < 0.001), and lower GFRs (P < 0.001) were identified as related to blood transfusions in univariate analysis. In multivariate logistic analysis, the need for allogeneic blood transfusion in unstable fractures was approximately 2.949 times higher than in stable fractures (P = 0.009). The risk in general anesthesia patients was about 2.953 times higher than in spinal anesthesia patients (P = 0.007). In addition, the need for allogeneic blood transfusion increased by about 1.293 times as preoperative hemoglobin levels decreased by 1 g/dL (P = 0.017) and increased by about 1.017 times as the GFR decreased by 1 mL/min/1.7m2 (P = 0.006). Low preoperative hemoglobin levels, low GFRs, general anesthesia, and unstable fractures in elderly patients with intertrochanteric hip fractures increased the risk of blood transfusion.

Timing of inpatient medical complications after adult spinal deformity surgery: early ambulation matters

BACKGROUNDThe substantial risk for medical complication after adult spinal deformity (ASD) surgery is well known. However, the timing of medical complications during the inpatient stay have not been previously described. Accurate anticipation of complications and adverse events may improve patient counseling and postoperative management. PURPOSE(1) Describe the rate of medical complication and adverse events by postoperative day after ASD surgery and (2) determine whether early ambulation is protective for complications. STUDY DESIGN/SETTINGSingle institution retrospective cohort study. PATIENT SAMPLETwo hundred thirty-five patients with ASD who underwent posterior-only fusion of the lumbar spine (≥5 levels to the pelvis) between 2013 and 2020. OUTCOME MEASURESMedical complications, categorized per the International Spine Study Group-AO system (cardiopulmonary [CP], gastrointestinal [GI], central nervous system [CNS], infectious [nonsurgical site], and renal) and adverse events (postoperative blood transfusion, urinary retention, and electrolyte abnormalities). METHODSPatients were identified from an institutional ASD database. Outcome measures were classified by the first postoperative day the event was recognized. Demographics, year of surgery, surgical factors, radiographic parameters, surgical invasiveness (ASD-S Index), frailty (Modified Frailty Index-5 [mFI-5]), Charlson Comorbidity Index (CCI), obstructive sleep apnea (OSA), smoking, preoperative opioid use, depression, and post-operative day of ambulation were assessed as risk factors for inpatient medical complications. RESULTSAfter exclusions of patients with incomplete medical chart data, 191 patients were available for analysis, mean age 66±10 y, BMI 28±5 kg/m2, PI-LL 24±20°, T1PA 28±13°. Inpatient medical complications occurred in 55 (28.8%) patients; adverse events occurred in 137 (71.7%). Length of stay was higher in patients with medical complications (mean 8.5±3.8 vs. 5.8±2.3 days, p<.001). However, for patients who had an adverse event, but no medical complication, LOS was comparable (p>.05). Most medical complications occurred by POD3 (58% of all complications). Risk (defined as the proportion of patients with that complication out of all inpatients that day) of CNS, CP, and GI complication peaked early in the postoperative course (CNS on POD1 [2.1% risk]; GI on POD2 [3.7%]; CP on POD3 [2.7%]). Risk for infectious and renal complications (infectious POD8 [2.7%]; renal POD7 [0.9%]) peaked later (Figure 1). On univariate analysis, patients with medical complications had higher rates of OSA (9.1% vs. 2.2%, p=.045), ASD-S (45.9 vs. 40.8, p=.04), max coronal cobb (46.9 vs. 36.7°, p=.003), ASA class (2.5 vs. 2.3, p=.01), and POD of ambulation (1.9 vs. 1.3, p=.01). On multivariate logistic regression (c-statistic 0.78), larger coronal cobb and later POD of ambulation were independent risk factors for complications (OR 1.04, 95% CI 1.01–1.07 and OR 2.3, 95% CI 1.2–4.7, respectively). CONCLUSIONSOur data may inform peri-operative management and patient expectations for hospitalization after ASD surgery. Early ambulation may reduce the risk of complications.

Predictors and complications of blood transfusion in rheumatoid arthritis patients undergoing total joint arthroplasty.

Our research investigated predictors of postoperative blood transfusion rate following total joint arthroplasty (TJA) in patients with rheumatoid arthritis (RA) and evaluated the incidence of complications in the transfusion group and non-transfusion group. The authors retrospectively analyzed risk factors among 320 RA patients who underwent elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) from January 2010 to December 2018. Demographic characteristics, laboratory results, medication history, and surgical protocol were gathered from electronic medical records. Univariable and multivariable logistic regression analyses were conducted to measure the impact of relevant variables on the need for transfusions. In addition, we compared the incidence of complications associated with transfusion. The cohort comprised 320 RA patients, aged 57.4 ± 12.0years, of whom 137 required postoperative blood transfusions and 183 did not. BMI, type of surgery, duration of surgery, disease activity score 28 (DAS28-CRP), tranexamic acid (TXA) administration, and preoperative hemoglobin (Hb) were all risk factors for transfusion after adjusting for the planned procedure. Previously published predictors, such as BMI, low preoperative hemoglobin, duration of surgery, procedure type (THA), were also identified in our analysis. Moreover, TXA administration and the DAS28-CRP showed the potential to influence risk. The incidence of postoperative complications was increased in patients who received blood transfusions compared to non-transfusion group. Our findings could help to identify RA patient population requiring blood transfusions, to ensure the necessary steps are adopted to limit blood loss and improve blood management strategies. Key Points • The risk factors for blood transfusion in rheumatoid arthritis patients undergoing total joint arthroplasty were BMI, the type of surgery, duration of surgery, TXA administration, DAS28-CRP, and preoperative hemoglobin. • The incidence of postoperative complications was increased in patients who received blood transfusions compared to non-transfusion group.

Morbidity After Esophagectomy Is Higher for Benign Than Malignant Disease

BackgroundEsophagectomy carries a high risk of morbidity and mortality. The most common indication for esophagectomy is esophageal cancer, with fewer than 5% of esophagectomies performed for benign disease. We hypothesized that esophagectomy for benign disease is associated with a higher risk of operative and postoperative complications. MethodsA retrospective study of The Society of Thoracic Surgeons database was performed to identify all patients who had an esophagectomy from 2010 to 2018. Patients who had an emergent or palliative esophagectomy were excluded. Patients were compared based on the indication for operation, malignant vs benign disease. A 1:1 propensity score matching of The Society of Thoracic Surgeons risk factors was performed and outcomes compared between the matched cohorts. ResultsOf 16,392 patients, 14,871 (91%) had malignant disease and 1521 (9%) had benign disease that met inclusion criteria. Patients with malignant disease were older (P < .001), more likely to be male (83% vs 56%, P < .001), and had more comorbidities (P < .001). There were 1362 propensity-matched pairs. Malignant esophagectomies were more likely to be performed with a minimally invasive vs an open approach (P < .001). Benign operations had more intraoperative blood transfusions (P < .001). Patients undergoing esophagectomy for benign disease had more prolonged intubations (P = .02) and postoperative blood transfusions (P = .001). Benign disease had more major morbidities (P = .001) but similar postoperative mortality (P = .62). ConclusionsEsophagectomy for benign disease is associated with worse perioperative morbidity compared with esophagectomy for malignant disease. Given these findings patients should be counseled on expected outcomes, and this variable should be considered for inclusion in the composite score for risk assessment.

Laparoscopic Radical Hysterectomy Combined with Neoadjuvant Chemotherapy for Cervical Cancer Patients Effectively Improves Immune Function.

Objective To evaluate the clinical efficacy of neoadjuvant chemotherapy plus laparoscopic radical hysterectomy for cervical cancer and the effect on the immune function of patients. Methods Between January 2021 and December 2021, 42 patients with cervical cancer diagnosed and treated at our hospital were recruited and randomly assigned at a 1 : 1 ratio to receive neoadjuvant chemotherapy plus open radical hysterectomy (control group) or neoadjuvant chemotherapy plus laparoscopic radical hysterectomy (treatment group) (study group). Outcome measures included surgical indices, clinical outcomes, and immunological function. Results There were no significant differences in the operative time between the two groups (P > 0.05). Patients receiving laparoscopic surgery had significantly less intraoperative bleeding and shorter time lapse before postoperative anal exhaustion, time lapse before out-of-bed activities, and hospital stay versus patients receiving open surgery (P < 0.05). Laparoscopic surgery resulted in a significantly higher efficacy (90.48%) versus open surgery (57.14%) (P < 0.05). After treatment, patients in the study group showed lower levels of carcinoembryonic antigen (CEA), squamous cell carcinoma antigen (SCC-Ag), and cancer antigen (CA125) than those in the control group (P < 0.05). After treatment, patients given laparoscopic surgery showed significantly lower CD3+, CD4+, and CD8+ levels and higher CD4+/CD8+ levels versus those with open surgery (P < 0.05). The postoperative conditions of the two groups, including recatheterization, postoperative blood transfusion, and secondary anti-inflammation were not significantly different (P > 0.05). The study group showed a significantly lower incidence of complications (19.05%) than the control group (71.43%) (P < 0.05). Patients in the study group had a lower reoperation rate and a higher survival rate (0.00%, 95.24%) than those in the control group (19.05%, 66.67%) (P < 0.05). Conclusion Neoadjuvant chemotherapy plus laparoscopic radical hysterectomy effectively improves clinical efficacy, lowers cancer marker levels, improves patients' immune function, reduces the risk of adverse events, and improves patients' prognosis with less intraoperative bleeding, less trauma, faster postoperative recovery, and shorter hospital stay for cervical cancer patients.

Rationalising pre-operative trauma bloods can lead to significant cost savings.

A full set of pre-operative bloods is being done on nearly all trauma patients who are admitted to our institute for surgery-regardless of variables such as patient age, injury sustained, or co-morbidities. This leads to unnecessary bloods being taken. The primary aims are (1) to calculate the costs associated with routine pre-operative bloods and (2) to examine how much money could be saved by retrospectively applying a more pragmatic pre-operative bloods policy. Trauma theatre cases over a 5-week period were identified with their pre-operative bloods and post-operative transfusions. Labour, material, and processing costs were estimated for each test. An updated pre-operative blood schedule was proposed and applied retrospectively to see if cost savings could be found. Of the 173 orthopaedic procedures performed, 109 (63%) had a group and screen or crossmatch pre-operatively. Fifteen (8.6%) required a post-operative blood transfusion. One hundred and twenty-eight (74%) patients had a full blood count, and renal profile taken pre-operatively. A full set of bloods costs approximately €51.23 to take and process. When the updated pre-operative blood guidelines were retrospectively applied, it would have led to cost savings of €2496 over the 5-week period of this audit, and if extrapolated up to 1year, could lead to potential annual savings of €25,960. We have demonstrated that an excessive amount of unnecessary pre-operative bloods have been taken using the current blood schedule. A pragmatic pre-operative blood schedule can lead to significant actual cost savings.