Postoperative Hemoglobin Concentration Research Articles

Two novel classification systems for uterine fibroids and subsequent uterine reconstruction after myomectomy

Laparoscopic approaches are the gold standard surgical treatment for intramural and subserous fibroids, whereas submucosal myomas can be treated via hysteroscopy. Removal of intramural myomas often requires a subsequent reconstruction of the uterine wall that ranges from single- to multiple-layer sutures to complex reconstructions. Several classification systems are currently used to characterize uterine fibroids, all of which focus on the assessment of submucosal fibroids during hysteroscopic myomectomy. There are no classification systems for the comprehensive localization of fibroids or for uterine reconstruction after myomectomy. Therefore, the aim of this study was to validate a new scoring system developed by our group to classify uterine leiomyoma as well as a standardized assessment scoring system for uterine reconstruction after surgical myomectomy. To validate the uterine fibroid and uterine reconstruction classification systems, a retrospective review of 136 patients undergoing surgical myomectomy and uterine reconstruction at a single tertiary institution was performed. The age of the patient, duration of surgery, number, size, and location of excised fibroids, number of uterine incisions, level of uterine reconstruction, desire for future pregnancies, pre- and postoperative hemoglobin concentrations, duration of postoperative hospitalization, and operating surgeon were obtained by medical chart review. For each patient, a specific fibroid score and the level of uterine reconstruction were determined according to the classification systems. Correlations between the uterine fibroid and reconstruction scores, as well as between the classification scores and perioperative parameters, were analyzed. The newly developed classification system for uterine fibroids incorporates the number, location, and size of myomas, as well as the number of uterine incisions required for myomectomy. The uterine reconstruction scoring system comprises four levels of reconstruction, ranging from no reconstruction to advanced reconstruction. Outcomes from 136 patients showed a correlation between uterine fibroid and uterine reconstructive scores. High fibroid scores were correlated with higher levels of reconstruction. Both scoring systems showed associations with the duration of surgery, intraoperative blood loss, and days of hospitalization. This study presents the first scoring system for uterine fibroids that incorporates all possible fibroid locations and a standardized assessment of uterine reconstruction. Scoring systems were validated in a large cohort, and a correlation was identified between uterine fibroid and uterine reconstruction scores. In daily clinical practice, this scoring system allows a better planning of surgery, specifically of the estimated duration of surgery, blood loss, and time of hospitalization.

Efficiency and Safety of Intravenous Tranexamic Acid in Simultaneous Bilateral Total Knee Arthroplasty: A Systematic Review and Meta-analysis.

The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of i.v. tranexamic acid (TXA) in simultaneous bilateral total knee arthroplasty (TKA). Potentially relevant published reports were identified from the following electronic databases: Medline, PubMed, Embase, ScienceDirect and Cochrane Library. RevMan v5.3was used to pool data. Two randomized controlled trials and four case-control studies met the inclusion criteria. The current meta-analysis identified significant differences between TXA group and control groups in terms of postoperative hemoglobin concentration (P < 0.01), drainage volume (P < 0.01), transfusion rate (P < 0.01) and units transfused (P = 0.006). There were no significant differences in length of stay (P = 0.66), operation time (P = 0.81) or and incidence of adverse effects such as infection (P = 0.42), deep venous thrombosis (DVT) (P = 0.88) and pulmonary embolism (PE) (P = 0.11). Our results show that i.v. administration of TXA in simultaneous bilateral TKA reduces postoperative drops in hemoglobin concentration, drainage volume, and transfusion requirements and does not prolong length of stay or operation time. Moreover, no adverse effects, such as infection, DVT or PE, were associated with TXA.

An evaluation of intra-operative and post-operative blood loss in total knee arthroplasty at the national orthopaedic hospital, Lagos

Total knee replacement is a rewarding and reliable procedure, producing a lasting relief to severe knee pains. However, significant blood loss usually in the post-operative period may be a challenge, necessitating prompt restoration of circulating blood volume to minimize morbidity and mortality. The aim of this study was to evaluate blood loss after total knee replacement.A prospective study of blood loss after Total Knee Arthroplasty in 53 patients in the National Orthopaedic Hospital, Lagos. Consecutive patients with established indications, presenting for total knee arthroplasty were recruited into the study after obtaining their consent.The mean intra-operative blood loss was 342.4 mls, with a range of 50 - 1500 mls. The mean post-operative blood loss and total blood loss were 603.6 mls and 940.3 mls respectively, showing a strong positive correlation (r = 0.884, p < 0.01). The average pre-operative and post-operative haemoglobin concentration were 12.5 ± 1.2 g/dl and 9.8 ± 0.9 g/dl, respectively. The mean haemoglobin loss was 2.6 ± 1.2 g/dl (r = 0.46, p < 0.001).Post-operative blood loss as measured by suction drainage, is a good predictor of total blood loss, showing a strong and positive correlation.

Monopolar versus bipolar transurethral resection of prostate for benign prostatic hyperplasia: Operative outcomes and surgeon preferences, a real-world scenario.

Context:Monopolar transurethral resection of prostate (M-TURP) is considered the gold standard for the management of bladder outlet obstruction due to benign prostatic hyperplasia. Its newly introduced modification, bipolar TURP (B-TURP), promises to overcome its most prominent shortcomings, namely bleeding and dilutional hyponatremia. Literature is conflicting regarding merits of B-TURP over M-TURP.Aims:To find a difference, if any, in perioperative outcomes between M-TURP and B-TURP in a real-wold setting.Settings and Design:Prospective nonrandomized study.Subjects and Methods:Operative outcomes of patients undergoing M-TURP and B-TURP from February 2014 to October 2015 were compared.Statistical Analysis Used:Categorical data were compared by Fischer exact test and numerical data were compared by independent samples Mann–Whitney U-test. P <0.05 was considered statistically significant.Results:The mean size of prostate operated by bipolar technology was significantly greater than those operated by monopolar technology (38.12 ± 9.59 cc vs. 66.49 ± 22.95 cc; P < 0.001). The mean fall in postoperative serum sodium concentration was 0.99 ± 0.76 mEq/L for the B-TURP group as compared to 3.60 ± 2.89 mEq/L for the M-TURP group (P < 0.001). The mean drop in postoperative hemoglobin concentration (P = 0.28) was statistically insignificant, even though larger glands were operated by B-TURP. There were three instances of the transurethral resection (TUR) syndrome in the M-TURP group whereas no TUR syndrome occurred in the B-TURP group.Conclusions:In spite of various contrary viewpoints in literature, surgeons prefer to operate on larger prostates using bipolar technology. B-TURP definitely reduces the incidence of bleeding and dilutional hyponatremia, making it a contender to replace M-TURP as the new gold standard.

Prophylactic abdominal aorta balloon occlusion during caesarean section: a retrospective case series

BackgroundThe management of patients with morbidly adherent placenta has been described using vascular balloon catheters placed in the iliac arteries, but rarely in the aorta. This case series presents our experience with prophylactic lower abdominal aorta balloon occlusion in 45 women. MethodsThe records of patients in our centre who underwent caesarean section between May 2013 and June 2014 were retrospectively analysed for the use of prophylactic lower abdominal aorta balloon occlusion. ResultsForty-five cases were identified. All patients had a morbidly adherent placenta, including placenta accreta (n=22), placenta increta (n=20) and placenta percreta (n=3). A subtotal hysterectomy was performed in four cases. Eleven of the 45 patients received red blood cell transfusion of a mean of 1.7 units. Mean preoperative and postoperative haemoglobin concentrations were 10.1g/dL and 9.4g/dL, respectively. Mean estimated blood loss was 835mL [range 200–6000mL]. The incidence of complications was 4.4% (2/45), including one case of lower extremity arterial thrombosis and one case of ischaemic injury to the femoral nerve. Follow up at one year was completed in 22 patients at which time all babies were well. ConclusionsProphylactic lower abdominal aorta balloon occlusion has the potential to reduce intraoperative blood loss, transfusion and hysterectomy rate in patients with morbidly adherent placenta undergoing caesarean section. Careful patient selection is critical as the technique may be associated with potentially serious complications.

Universal tranexamic acid therapy to minimize transfusion for major joint arthroplasty: a retrospective analysis of protocol implementation.

Tranexamic acid (TXA) therapy can reduce red blood cell (RBC) transfusion; however, this therapy remains underutilized in many surgical patient populations. We assessed whether implementation of a protocol to facilitate universal administration of TXA in patients undergoing total hip or knee arthroplasty would reduce the incidence of RBC transfusion without increasing adverse clinical outcomes. We implemented a quality of care policy to provide universal administration of intravenous TXA at a dose of 20 mg·kg(-1) iv to all eligible patients undergoing total hip or knee arthroplasty from October 21, 2013 to April 30, 2014. We compared data from an equal number of patients before and after protocol implementation (n = 422 per group). The primary outcome was RBC transfusion with secondary outcomes including postoperative hemoglobin concentration (Hb) and length of hospital stay. Adverse events were identified from the electronic medical records. Data were analyzed by a Chi square test and adjusted logistic and linear regression analysis. Implementation of the protocol resulted in an increase in TXA utilization from 45.8% to 95.3% [change 49.5%; 95% confidence interval (CI), 44.1 to 54.5; P < 0.001]. This change was associated with a reduction in the rate of RBC transfusion from 8.8% to 5.2%, (change -3.6%; 95% CI, -0.1 to -7.0; P = 0.043). Pre- and post-protocol mean [standard deviation (SD)] Hb values were similar, including the nadir Hb prior to RBC transfusion [72 (8) g·L(-1) vs 70 (8) g·L(-1), respectively; mean difference -1 g·L(-1); 95% CI, -3 to 5; P = 0.569]. Length of stay was not altered, and no increase in adverse events was observed. Implementation of a perioperative TXA protocol was associated with both an increase in TXA use and a reduction in RBC transfusion following hip or knee arthroplasty. Adverse events and length of hospital stay were not influenced by the protocol.

Comparison of pterygomaxillary dysjunction with tuberosity separation in isolated Le Fort I osteotomies: a prospective, multi-centre, triple-blind, randomized controlled trial

The aim of this trial was to compare two techniques of maxillary dysjunction, with 10mg/kg tranexamic acid as an adjuvant, in isolated non-segmented Le Fort I procedures. Two hundred patients were randomized to one of four groups: group A, pterygomaxillary dysjunction+saline; group B, tuberosity separation+saline; group C, pterygomaxillary dysjunction+tranexamic acid; and group D, tuberosity separation+tranexamic acid. Primary outcome measures were intraoperative blood loss and operating time, while the secondary outcome measures were surgical field assessment, need for blood transfusion, and duration of hospitalization. The data were analyzed using one-way analysis of variance (SPSS v. 17.0), and the level of significance was set at P<0.05. Results revealed that group D (tuberosity separation+tranexamic acid) had the least blood loss (mean 172ml) and shortest operating times (mean 49min), with the best surgical field. This group also exhibited the lowest drop in postoperative haemoglobin concentration (Hbgm/dl) and packed cell volume (PCV). Five patients, all in group A, required a blood transfusion and had an extra 24h of hospitalization. This trial revealed that the tuberosity separation technique with the use of tranexamic acid was the best protocol in producing the least blood loss, minimizing the operating time, and providing the best surgical field.

Hospital audit of delayed transfusion after orthopaedic surgery

Background and objectivesTo understand the mechanisms related to both the onset and correction of severe anaemia after orthopaedic surgery, we analysed all the full blood counts (FBCs) for patients on one orthopaedic ward during a one-year period in an academic hospital. MethodsFBCs were screened and the medical records of those patients for whom a postoperative haemoglobin (Hb) concentration below 8g/dL was recorded at least once were reviewed. The onset of postoperative anaemia was determined by calculating the various time intervals delineated by surgery, the time at which the transfusion threshold was reached and the time at which the lowest Hb level (nadir) and transfusion (if any) occurred. ResultsA total of 6573 FBCs drawn from 1255 patients were screened. The medical records of 74 consecutive patients with at least one Hb value<8g/dL were analysed. The postoperative Hb nadir was 7.4 (± 0.6) g/dL (mean – SD). The medians (IQR 25–75) of the calculated intervals were: (surgery – nadir): 72 (48–144) h, (nadir – transfusion): 7 (5–21) h and (transfusion threshold – transfusion): 26 (11–51) h. ConclusionsDelayed transfusion (defined as>12hours between the time at which the transfusion threshold was reached and actual transfusion) was observed in 57% of severely anaemic patients after orthopaedic surgery.

Liberal versus restrictive blood transfusion strategy: 3-year survival and cause of death results from the FOCUS randomised controlled trial

Blood transfusion might affect long-term mortality by changing immune function and thus potentially increasing the risk of subsequent infections and cancer recurrence. Compared with a restrictive transfusion strategy, a more liberal strategy could reduce cardiac complications by lowering myocardial damage, thereby reducing future deaths from cardiovascular disease. We aimed to establish the effect of a liberal transfusion strategy on long-term survival compared with a restrictive transfusion strategy. In the randomised controlled FOCUS trial, adult patients aged 50 years and older, with a history of or risk factors for cardiovascular disease, and with postoperative haemoglobin concentrations lower than 100 g/L within 3 days of surgery to repair a hip fracture, were eligible for enrolment. Patients were recruited from 47 participating hospitals in the USA and Canada, and eligible participants were randomly allocated in a 1:1 ratio by a central telephone system to either liberal transfusion in which they received blood transfusion to maintain haemoglobin level at 100 g/L or higher, or restrictive transfusion in which they received blood transfusion when haemoglobin level was lower than 80 g/L or if they had symptoms of anaemia. In this study, we analysed the long-term mortality of patients assigned to the two transfusion strategies, which was a secondary outcome of the FOCUS trial. Long-term mortality was established by linking the study participants to national death registries in the USA and Canada. Treatment assignment was not masked, but investigators who ascertained mortality and cause of death were masked to group assignment. Analyses were by intention to treat. The FOCUS trial is registered with ClinicalTrials.gov, number NCT00071032. Between July 19, 2004, and Feb 28, 2009, 2016 patients were enrolled and randomly assigned to the two treatment groups: 1007 to the liberal transfusion strategy and 1009 to the restrictive transfusion strategy. The median duration of follow-up was 3·1 years (IQR 2·4-4·1 years), during which 841 (42%) patients died. Long-term mortality did not differ significantly between the liberal transfusion strategy (432 deaths) and the restrictive transfusion strategy (409 deaths) (hazard ratio 1·09 [95% CI 0·95-1·25]; p=0·21). Liberal blood transfusion did not affect mortality compared with a restrictive transfusion strategy in a high-risk group of elderly patients with underlying cardiovascular disease or risk factors. The underlying causes of death did not differ between the trial groups. These findings do not support hypotheses that blood transfusion leads to long-term immunosuppression that is severe enough to affect long-term mortality rate by more than 20-25% or cause of death. National Heart, Lung, and Blood Institute.

A Randomized Clinical Trial of Liberal Versus Restrictive Transfusion Strategy Evaluating Long Term Survival and Cause of Death: Results from the FOCUS Trial

▪IntroductionThere are a large number of randomized clinical trials comparing short-term mortality between liberal and restrictive transfusion strategies. However, transfusion is thought to have long-term consequences related to alteration of immune function. These effects have been hypothesized to increase the risk of subsequent infections and recurrence of cancer. Thus, it is possible that transfusion will increase the risk of long-term mortality by increasing the deaths due to infections and recurrent cancer. Alternatively, more liberal transfusion might reduce cardiac complications by increasing oxygen to vulnerable myocardium and reduce deaths from cardiovascular disease. We hypothesized that liberal transfusion would affect cause specific mortality and might affect all-cause mortality, depending on the predominant impact of transfusion.MethodsWe performed a secondary analysis of the FOCUS trial that randomly allocated patients undergoing hip fracture repair with postoperative hemoglobin concentrations below 10 g/dL within 3 days of surgery. Patients were eligible for the trial if they had underlying cardiovascular disease (coronary artery disease, congestive heart failure, stroke, peripheral vascular disease) or cardiovascular risk factors (diabetes mellitus, hypertension, hyperlipidemia, tobacco use, or renal insufficiency). We randomly allocated patients to liberal transfusion where patients received blood transfusion to maintain hemoglobin 10 g/dL or greater, or restrictive transfusion where patients received blood transfusion when hemoglobin level was less than 8 g/dL or for symptoms. Long-term mortality was determined by linking the study subjects to national death registries in US and Canada. We compared survival time between the two transfusion treatment strategies using the unadjusted log-rank test and Cox proportional hazard models. The underlying cause of death was identified by the national death registries and grouped into seven categories: cardiovascular disease, cancer, infection, stroke, dementia, pulmonary, and other.ResultsThere were 1007 subjects randomly allocated to the liberal transfusion strategy and 1009 to the restrictive transfusion strategy. The baseline clinical status was similar between the two groups; mean age of the study population was 81.6 years (range, 51 to 103). The liberal transfusion group were transfused a total of 1866 units and restrictive transfusion group 652 units. We established long-term survival for 2002 (99.3%) of the study population. The median follow-up was 3.1 years (interquartile range, 2.4 to 4.1 years) and there were 841 (42.0%) deaths. There was no difference in the long-term mortality between the liberal transfusion strategy (N=432 deaths) and restrictive transfusion strategy (N= 409 deaths); hazard ratio =1.09; 95% confidence interval 0.95 to 1.25 (Figure). The results were consistent across all subgroups including demographics and multiple co-morbidities. There was also no difference in the underlying cause of death between the transfusion strategies (p=0.99) (Table); Cardiovascular disease (liberal-32.6%, restrictive-33.5%), Cancer (liberal-12.5%, restrictive-12.0%), Infection (liberal-9.5%, restrictive 9.0%).ConclusionsLiberal transfusion of 10 g/dL did not reduce or increase long-term mortality compared to restrictive transfusion strategy using an 8 g/dL threshold or symptoms in a high risk group of elderly patients with underlying cardiovascular disease or risk factors. The underlying causes of death were similar in both arms of the trial and liberal transfusion did not appear to increase risk of death from infection or cancer or reduce the risk of death from cardiovascular disease. These results do not support the hypotheses that transfusion leads to long-term immunosuppression that is severe enough to influence mortality or cause of death. Our findings suggest that clinicians should primarily consider short-term effects of transfusion when deciding whom to transfuse.TableTotal N (%)LiberalN (%)Restrictive N (%)Cardiovascular Disease278 (33.1)141 (32.6)137 (33.5)Cancer103 (12.2)54 (12.5)49 (12.0)Infection78 (9.3)41 (9.5)37 (9.0)Stroke57 (6.8)27 (6.3)30 (7.3)Dementia108 (12.8)56 (13.0)52 (12.7)Pulmonary58 (6.9)29 (6.7)29 (7.1)Other147 (17.5)79 (18.3)68 (16.6)Unknown12 (1.4)5 (1.2)7 (1.7)Totals841432 409 [Display omitted] DisclosuresMagaziner:Ammonett : Consultancy; Sanofi: Consultancy; Regeneron: Consultancy; Novartis: Consultancy; Eli Lilly: Consultancy; American Orthopedic Association: Consultancy.

English

AIM: Aim of our study to assess the effects of tranexamic acid (TA) in patients undergoing lower limb orthopedic surgeries. OBJECTIVE: Assess the effects of tranexamic acid on prevention of bleeding and requirement of blood transfusion after major lower limb orthopedic surgeries. MATERIAL AND METHOD: 90 patients ASA grade I & II undergoing elective surgery for femoral fracture like open reduction internal fixation, hemiarthroplasty, total hip replacement (THR) under anaesthesia were taken. Patients were classified randomly into 2 groups (forty five patients in each group). Group T: Patients received inj. TA 10 mg/kg body weight. Group P: Patients received normal saline 1 ml/kg body weight 15 min before surgery. Postoperative hemoglobin concentration (on day 0 and day 2) and volume of blood in the drain were measured. The number of units of packed red cells transfused during the hospital stay was recorded and any thromboembolic and other complications were documented. RESULT: Analysis revealed that there were no significant differences between the patients with respect to age, sex, duration and type of surgery and preoperative mean hemoglobin concentration. Neither heart rate nor MABP has statistically significant difference or results (P>0.05). The drains were removed in the evening of the first postoperative day. Mean volume of blood in the drain compared to placebo group showing a highly significant reduction in postoperative blood loss (P=0.01). Mean fall in hemoglobin at day 0 and day 2 was 2 less in the study group as compared to the placebo that has P value 0.01 making it significant finding. CONCLUSION: the present paired study demonstrated that the administration of TA given preoperatively reduces the blood loss in the first 24 h by a highly significant degree as well it causes a significant reduction in postoperative anemia and need for transfusion among these patients.

One-shot dilation in modified supine position for percutaneous nephrolithotomy: experience from over 300 cases.

To evaluate the feasibility, safety and efficacy of one-shot dilation (OSD) in modified supine position percutaneous nephrolithotomy (PCNL). A total of 320 PCNL in a total of 291 patients were performed between October 2008 and July 2011. There were no specific exclusion criteria. Patients with kidney anomalies or solitary kidney, with history of renal surgery or extracorporeal shockwave lithotripsy (SWL), those with staghorn calculi or needing more than one access, were eligible for inclusion. Data collected included patient demographics and stone characteristics, access time, radiation exposure, total operating time, preoperative and postoperative hemoglobin concentrations, tract dilatation failures, complications and transfusions. Mean stone size was 38 mm (16-110 mm). The mean time access was 2.1 min (range 0.7-6.2 min). Tract dilatation fluoroscopy time was 25 ± 17 sec. The targeted calix could be entered with a success rate of 97.81%. The mean hemoglobin decrease was -1.17 g/dL ± 0.84. There were no visceral, pleural, collecting systems or vascular injuries. Major complications included, transfusion in 4 (1.25%) patients, pseudoaneurysm with persistent bleeding necessitating nephrectomy in 1 (0.3%) patient and two deaths (0.62%) after surgery. There was no significant difference in successful access and complications between patients with and without previous open surgery and in those with or without staghorn stones (P > .05). The use of one shot and modified supine position combines the advantages of these both methods including less radiation exposure and shorter access and operative time. The one shot dilation is safe, easy to learn, cost effective and offers a potential alternative to the standard devices particularly in developing countries.

The Effect on Perioperative Bleeding of Placental Extraction From an Exteriorized Uterus During Caesarean Section

ObjectiveTo evaluate the effect on perioperative bleeding of an alternative technique for Caesarean section, in which placental extraction is performed while the uterus is exteriorized. MethodsWe performed a retrospective matched cohort study using data obtained through chart review. Group 1 included women who had CS performed using the technique of placental removal while the uterus was exteriorized, and group 2 included women who had CS performed using the conventional method of placental removal from a non-exteriorized uterus. Women in each group were matched for number of previous Caesarean sections, indications for CS, and gestational age. The primary outcome was the difference between preoperative and postoperative hemoglobin concentrations. Secondary outcomes included the incidence of blood transfusion, estimated blood loss (EBL), operative time, the incidence of postoperative endometritis, and length of hospital stay. ResultsA total of 90 charts were reviewed (45 per group). Baseline clinical characteristics were similar in both groups. The mean decrease in hemoglobin concentration was 22% less in women who had placental extraction from an exteriorized uterus than in those who had the conventional placental extraction (13.2g/L vs. 16.9g/L, P=0.016). Among secondary outcomes, women in group 1 had a lower mean EBL (531.1mL vs. 691.1mL, P<0.05) and a shorter mean duration of surgery (28.0 minutes vs. 40.5 minutes, P<0.05). ConclusionExteriorizing the uterus prior to removal of the placenta during CS may decrease intraoperative and immediate postoperative bleeding compared with the conventional technique. Further studies on this technique are indicated.

A Prospective Randomized Comparative Study of Monopolar and Bipolar Transurethral Resection of the Prostate and Photoselective Vaporization of the Prostate in Patients Who Present with Benign Prostatic Obstruction: A Single Center Experience

The first prospective randomized study to compare the safety and short-term efficacy of monopolar transurethral resection of the prostate (TURP), bipolar TURP, and photoselective vaporization of the prostate (PVP) using GreenLight high-performance system 120W laser in patients who presented with benign prostatic obstruction (BPO). The 186 consecutive patients who presented with BPO and who were planned for surgery were randomized into three groups: Group A, patients who underwent monopolar TURP; group B, patients who underwent bipolar TURP; and group C, patients who underwent PVP. All three groups were subdivided into two subgroups based on prostate volume: Subgroup 1 >20 cc and <50 cc, and subgroup 2, between 50 and 80 cc. Patients preoperative, perioperative, and follow-up data were recorded and analyzed. The baseline characteristics of the three groups and subgroups 1 and 2 were comparable. The number of patients in whom postoperative irrigation was instituted, amount of fluid used for postoperative irrigation, duration of postoperative irrigation, postoperative hemoglobin concentration, and duration of catheterization were significantly in favor of group C patients except for the mean operative time, which was significantly longer among them. All three groups demonstrated an increase in International Prostate Symptom Score, quality of life score, and maximum flow rate and decrease in prostate volume and postvoid residual urine at 12-month follow-up. The mean Intgernational Index of Erectile Function-5 score did not show improvement in any group. The need for blood transfusion and clot retention necessitating intervention were significantly lower among group C patients compared with group A, whereas these values for group B patients did not reach significant level compared with either group A or C. These complications were comparable among subgroup 1 patients, whereas subgroup 2 patients had shown results in favor of subgroup C2. Monopolar TURP, bipolar TURP, and PVP are equally efficacious at 12-month follow-up. PVP has added advantages of lesser blood loss, lesser need for blood transfusion (especially for prostate volume 50-80 cc), and shorter catheterization time.

Effect of a single preoperative dose of sublingual misoprostol on intraoperative blood loss during total abdominal hysterectomy

ObjectiveTo investigate whether use of preoperative misoprostol can reduce blood loss during total abdominal hysterectomy (TAH). MethodsIn a randomized double-blind placebo-controlled trial at a tertiary care hospital in Kolkata, India, between March 2011 and April 2012, women (n=132) undergoing TAH with or without bilateral salpingo-oophorectomy for symptomatic myomas were randomly allocated to receive either 400μg of misoprostol or placebo 30minutes before surgery. The primary outcome measure was intraoperative blood loss was. The secondary outcomes were postoperative drop in hemoglobin, need for blood transfusion, and incidence of adverse effects. ResultsThe 2 groups were similar with regard to demographic and clinical characteristics. There was a significant reduction of blood loss during TAH after sublingual administration of misoprostol compared with placebo before surgery (356mL vs 435mL; P=0.049). The mean postoperative hemoglobin concentration was higher (10.5g/dL vs 9.5g/dL; P<0.001) and the postoperative drop in hemoglobin was smaller (1.1g/dL vs 1.9g/dL; P=0.004) in the misoprostol group than in the placebo group. No significant adverse effects occurred in either group. ConclusionThe results showed that a single dose of misoprostol administered before abdominal hysterectomy resulted in a significant reduction of blood loss with minimal adverse effects.Clinical Trial Registry India (www.ctri.nic.in): CTRI/2011/091/000216.

Continuous Low-Dose Aspirin Therapy in Robotic-Assisted Laparoscopic Radical Prostatectomy Does Not Increase Risk of Surgical Hemorrhage

Withdrawal of oral antiplatelet therapy (OAT) is a major risk factor for stent thrombosis, myocardial infarction, and cerebral strokes. In order to minimize the risk for thrombotic complications, since 2007 robotic-assisted laparoscopic radical prostatectomy (RARP) has taken place under continuous OAT with aspirin at our institution. In this retrospective study we analyzed the risk for perioperative bleeding and surgical outcome after RARP with OAT. All patients who underwent RARP with aspirin OAT at our institution since 2007 were included in this analysis. The OAT group was compared with a group that underwent RARP without OAT, which contained twice the number of patients. Matching of the two groups was performed with regard to the tumor stage and whether a lymph node dissection or nerve-sparing was performed. Thirty-eight patients were assigned to the OAT group and 76 to the control group. A difference in the decrease of postoperative hemoglobin concentration was not detectable between the two groups (mean drop of 2.9±1.4 g/dL and 2.9±1.1 g/dL, respectively; P=.93). RARP was completed in all OAT patients without conversion to open surgery. Two of the 38 patients (5.3%) in the OAT group and none in the control group required blood transfusions (P=.11). Equivalent rates of positive surgical margins for pT2 tumors were detected (16% OAT versus 14% control group; P=1.0). No adverse cardiovascular events occurred in either group during the hospitalization. Continued perioperative OAT with aspirin in RARP is safe, feasible, and not associated with increased blood loss.

Supportive treatment of severe anaemia in a Jehovah's Witness with severe trauma.

Supportive treatment of severe anaemia in a Jehovah's Witness with severe trauma.

Effect of postoperative anemia on functional outcome and quality of life after hip and knee arthroplasties: a long term follow-up

Background: Postoperative anemia is frequent in patients undergoing hip and knee arthroplasty. While it is legitimate to think that anemia could decrease postoperative vigor and, consequently, limit the patient’s rehabilitation, our previous study showed that anemia does not impair functional recovery in patients during the immediate postoperative period (10 days). Here we investigate the possible relationship between the postoperative hemoglobin (Hb) concentration and long-term (6 months or more) functional recovery and quality of life (QoL) in patients.Study design and methods: A follow-up, observational study was conducted in the 305 patients 60 years and older who underwent major hip or knee arthroplasty and participated in the Transfusion Requirements in Orthopedic Surgery (TRIOS) study (phase 2). The relationship between postoperative Hb concentration (or variation thereof) and primary outcomes (Functional Status Index (FSI) score, scores in the two categories of the Short Form 36 (SF-36) test and adverse events) was established by linear regression.Results: 160 patients responded to long-term follow-up. There were no significant correlations between the postoperative Hb concentration (or the variation in perioperative Hb) and either the FSI or SF-36 scores or adverse events. Consequently, moderate postoperative anemia does not appear to affect long-term (6 months or more after surgery) functional recovery or QoL in patients undergoing a major arthroplasty.Conclusion: Our results confirm the lack of longer-term effects of anemia on functional recovery observed in the immediate postoperative period in the TRIOS phase 2 study.

Effect of postoperative anemia on functional outcome and quality of life after hip and knee arthroplasties: a long term follow-up

Background: Postoperative anemia is frequent in patients undergoing hip and knee arthroplasty. While it is legitimate to think that anemia could decrease postoperative vigor and, consequently, limit the patient’s rehabilitation, our previous study showed that anemia does not impair functional recovery in patients during the immediate postoperative period (10 days). Here we investigate the possible relationship between the postoperative hemoglobin (Hb) concentration and long-term (6 months or more) functional recovery and quality of life (QoL) in patients. Study design and methods: A follow-up, observational study was conducted in the 305 patients 60 years and older who underwent major hip or knee arthroplasty and participated in the Transfusion Requirements in Orthopedic Surgery (TRIOS) study (phase 2). The relationship between postoperative Hb concentration (or variation thereof) and primary outcomes (Functional Status Index (FSI) score, scores in the two categories of the Short Form 36 (SF-36) test and adverse events) was established by linear regression. Results: 160 patients responded to long-term follow-up. There were no significant correlations between the postoperative Hb concentration (or the variation in perioperative Hb) and either the FSI or SF-36 scores or adverse events. Consequently, moderate postoperative anemia does not appear to affect long-term (6 months or more after surgery) functional recovery or QoL in patients undergoing a major arthroplasty. Conclusion: Our results confirm the lack of longer-term effects of anemia on functional recovery observed in the immediate postoperative period in the TRIOS phase 2 study.

The impact of blood loss during cochlear implantation in very young children

The aim of this study was to investigate if the intraoperative bleeding during cochlear implantation in very young children had any clinical importance and if it should influence the clinical management of such cases. A retrospective chart review of the pre- and postoperative hemoglobin concentration was performed on 14 implantations in children aged 16 months or younger at the time of surgery (11 males and 3 females). A postoperative decrease of the hemoglobin value was noted in 13 cases (93 %), with a mean difference between pre- and postoperative measurement of -1.9 g/dl. The most remarkable case was that of a 2-month-old newborn with a bilateral profound hearing loss caused by bacterial meningitis. In the course of the asynchronous bilateral cochlear implantation and due to a remarkable bleeding, a transfusion of packed red blood cells was performed. The increased loss of blood was reported at the time of detaching and lifting up the muscle-periosteal-flap from the mastoid bone as well as at the time of the mastoidectomy. The special physiological properties of this age can contribute to a rapid cardiovascular decompensation in the case of increased blood loss. The consideration of these aspects is of great importance in the stage of planning the cochlear implantation, which in this group of patients should include the requirement of banked human blood. In addition, the intraoperative bleeding should be taken into account during the decision for a simultaneous bilateral implantation.