Reduce Transfusion Requirements Research Articles

S2804 Refractory Bleeding From Nodular Gastric Antral Vascular Ectasia (GAVE): Is Combination Therapy of Sclerotherapy and Band Ligation the Solution?

Introduction: Gastric antral vascular ectasia (GAVE) is a rare condition that presents in the distal stomach as dilated longitudinal columns of blood vessels prone to bleeding. Nodular GAVE is an even rarer variant and is often refractory to standard therapy for GAVE. Endoscopic treatment options widely varies and include rubber band ligation, radiofrequency ablation (RFA), argon plasma coagulation (APC), and resection with hot snare. We present a case study of successful treatment of nodular GAVE of a patient who has been refractory to repeated APC with combination therapy of band ligation and sclerotherapy. Case Description/Methods: 63-year-old female with history of alcoholic cirrhosis and pancreatitis who has had persistent iron deficiency anemia thought secondary to chronic blood loss requiring constant transfusions. Initial EGD was performed at age of 60 with evidence of small grade I esophageal varices, portal hypertensive gastropathy, and innumerable gastric polyps in the gastric body and antrum that on biopsy was consistent with nodular GAVE. She then underwent 5 repeat EGDs over a span of 6 months with a combination RFA, APC, snare resection followed by hemostatic clipping, and banding, with continued recurrence of nodular GAVE and transfusion dependent anemia, with total of 17 units of packed red blood cell (pRBC) transfusions required over the same 6 month period. On her seventh EGD, she then underwent combination therapy of sclerotherapy (1% sodium tetradecyl sulfate (STS), 20mL total), which were injected at the base of the nodular areas, along with placement of 12 bands. Her transfusion requirements subsequently subsided after the initial sclerotherapy and band ligation combination session, and the patient received additional 6 EGD sessions with repeat combination therapy over the next 12 months, with notable visual improvement endoscopically subsequent to 2 sclerotherapy plus banding sessions. She only required a total of 3 units of pRBC transfusion over the same period. (Figure) Discussion: We described the first known case of combination sclerotherapy and band ligation therapy for treatment of refractory nodular GAVE. The treatment resulted in significant reduction in transfusion requirements with concomitant improvement of the appearance of nodular GAVE even after just 2 sessions, and may be particularly useful in patients who have failed more conventional treatments. Additional studies will need to be performed to determine the safety and efficacy of this combination treatment modality.Figure 1.: endoscopic images of nodular GAVE before and after serial treatments, along with a timeline of hemoglobin level, transfusions, and endoscopic sessions/therapies over the patient's follow up period of 1.5 years.

Factor eight inhibiting bypass activity for refractory bleeding in acute type A aortic dissection repair: A propensity-matched analysis.

Perioperative bleeding and transfusion have been associated with adverse outcomes after cardiac surgery. The use of factor eight inhibiting bypass activity (FEIBA) in managing bleeding after repair of acute Stanford type A aortic dissection (ATAAD) has not previously been evaluated. We report our experience in utilizing FEIBA in ATAAD repair. A retrospective review was undertaken of all consecutive patients who underwent repair of ATAAD between July 2014 and December 2019. Patients were divided into two groups, dependent upon whether or not they received FEIBA intraoperatively: "FEIBA" (n= 112) versus "no FEIBA" (n= 119). From this, 53 propensity-matched pairs of patients were analyzed with respect to transfusion requirements and short-term clinical outcomes. Thirty-day mortality for the entire cohort was 11.7% (27 deaths), not significantly different between patient groups. Those patients who received FEIBA demonstrated reduced transfusion requirements for all types of blood products in the first 48 h after surgery as compared with the "no FEIBA" cases, including red blood cells, platelets, plasma, and cryoprecipitate (p< .0001). There was no significant difference in major postoperative morbidity between the two groups. The FEIBA cohort did not demonstrate an increased incidence of thrombotic complications (stroke, deep venous thrombosis, pulmonary thromboembolism). When used as rescue therapy for refractory bleeding following repair of ATAAD, FEIBA appears to be effective in decreasing postoperative transfusion requirements whilst not negatively impacting clinical outcomes. These findings should prompt further investigation and validation via larger, multi-center, randomized trials.

Tranexamic Acid Administration at Hospital Admission Decreases Transfusion Rates in Geriatric Hip Fracture Patients Undergoing Surgery.

IntroductionThe timing of tranexamic acid (TXA) administration in fragility hip fracture patients is controversial. Prior studies have demonstrated reduction in transfusion requirements using the two-dose arthroplasty model. However, unlike arthroplasty patients whose bleeding starts at the time of surgical incision, hip fractures have an onset of bleeding at the time of the injury. The primary goal of this study was to evaluate the optimal timing of TXA administration and to determine its effect on red blood cell transfusions in fragility hip fracture patients.MethodsAll patients admitted to the fragility hip fracture service from April 1, 2019 to September 30, 2019 were prospectively screened for inclusion in the study. Eligible patients received 4 intravenous doses of TXA: Ineligible patients received no TXA. Patients with medical conditions precluding the use of TXA were deemed ineligible: allergy to TXA; creatinine clearance <30 mL/min; active malignancy; vascular event in the past year; anticoagulant use; fracture >48 hours prior to presentation. A subset of patients received only admission TXA dosing and a separate subset of patients received only incision and post op TXA dosing. Red blood cell transfusions, major adverse vascular events, and minor drug and infusion-related adverse events were recorded for all subgroups of patients.ResultsA total of 508 patients were eligible for analysis. In total, 180 patients received no TXA, 32 patients only received the admission doses of TXA, 112 patients received only the arthroplasty based (incision and post op) doses of TXA, and 183 patients received all 4 doses of TXA. The transfusion rate was significantly lower in patients who received all 4 doses of TXA (8.7%) and in those who only received one dose of TXA at admission (9.4%) compared to patients who received TXA at incision and recovery room (25.7%) or those patients who did not receive TXA prophylaxis (29.4%) (P = 0.001). Additionally, the transfusion rate for intramedullary nailing was higher compared to patients undergoing any other procedure (27% vs 13.8%, P < 0.001).ConclusionsPatients with fragility hip fractures who received IV TXA at hospital admission have significantly lower transfusion rates compared to those who received no tranexamic acid or those who received two dose-TXA (at the operative incision and in the post-operative recovery room). These findings suggest that isolated dosing of TXA at hospital admission may be more effective at reducing post-operative bleeding than the traditional arthroplasty dosing (incision and post-op doses) and is equally as effective as the 4-dose TXA protocol in hip fracture patients undergoing surgery.

Field tourniquets in an austere military environment: A prospective case series

ObjectiveField tourniquets are often used for battlefield extremity injuries. Their effectiveness has been documented by a large combat theater trauma center. However, their use and effectiveness by an austere forward surgical team has not been reported. Aims of this study were to determine: Whether field tourniquets: (1) Were placed for appropriate indications; (2) significantly reduced hemorrhage as measured by transfusion requirements; (3) influenced vital signs and injury severity scores; and (4) did they cause limb amputation, changed amputation level, or other complications. MethodsTwenty-five patients with 30 involved extremities presenting to a forward surgical team in Iraq met the inclusion criteria. We prospectively collected data regarding the presence, indications for, and effectiveness of field tourniquets based on the need for blood transfusion. We recorded any complications associated with their use. ResultsTourniquets significantly reduced hemorrhage from penetrating injuries as measured by transfusion requirements. Those having major vascular injuries with effective tourniquets, a total of 12 units of blood were transfused (1.7 units/vascular injury; 2 units/patient). However, 19 units were transfused in patients (3.3 units/vascular injury; 3.8 units/patient) who had an ineffective or no tourniquet (p = 0.0006). Transfusion requirements were related the presence of an effective tourniquet regardless of concomitant injuries. The group with effective tourniquets and compressed hemorrhage presented with higher mean systolic (p = 0.003) and diastolic (p = 0.023) blood pressures than the group with no tourniquets or ineffective ones. Complications included one peroneal nerve palsy and no amputations resulted from tourniquet application. ConclusionField tourniquets applied for penetrating injuries with severe bleeding can significantly reduce transfusion requirements and help maintain adequate blood pressure. Tourniquets were not the proximate cause of amputation and did not determine the choice of immediate amputation level.

Fibrinogen supplementation for the trauma patient: Should you choose fibrinogen concentrate over cryoprecipitate?

Trauma-induced coagulopathy is frequently associated with hypofibrinogenemia. Cryoprecipitate (Cryo), and fibrinogen concentrate (FC) are both potential means of fibrinogen supplementation. The aim of this study was to compare the outcomes of traumatic hemorrhagic patients who received fibrinogen supplementation using FC versus Cryo. We performed a 2-year (2016-2017) retrospective cohort analysis of the American College of Surgeons Trauma Quality Improvement Program database. All adult trauma patients (≥18 years) who received FC or Cryo as an adjunct to resuscitation were included. Patients with bleeding disorders, chronic liver disease, and those on preinjury anticoagulants were excluded. Patients were stratified into those who received FC, and those who received Cryo. Propensity score matching (1:2) was performed. Outcome measures were transfusion requirements, major complications, hospital, and intensive care unit lengths of stay, and mortality. A matched cohort of 255 patients who received fibrinogen supplementation (85 in FC, 170 in Cryo) was analyzed. Overall, the mean age was 41 ± 19 years, 74% were male, 74% were white and median Injury Severity Score was 26 (22-30). Compared with the Cryo group, the FC group required less units of packed red blood cells, fresh frozen plasma, and platelets, and had shorter in-hospital and intensive care unit length of stay. There were no significant differences between the two groups in terms of major in-hospital complications and mortality. Fibrinogen supplementation in the form of FC for the traumatic hemorrhagic patient is associated with improved outcomes and reduced transfusion requirements as compared with Cryo. Further studies are required to evaluate the optimal method of fibrinogen supplementation in the resuscitation of trauma patients. Therapeutic/Care Management; Level III.

Single-dose intravenous ferric carboxymaltose infusion versus multiple fractionated doses of intravenous iron sucrose in the treatment of post-operative anaemia in colorectal cancer patients: a randomised controlled trial.

Recent clinical guidelines suggest that treatment of postoperative anaemia in colorectal cancer surgery with intravenous iron reduces transfusion requirements and improves outcomes. The study aimed at comparing two intravenous iron regimens in anaemic patients after colorectal cancer surgery. This was a single-centre, open-label, randomised, controlled trial in patients undergoing elective colorectal cancer surgery. Patients with moderate to severe anaemia (haemoglobin [Hb] <11 g/dL) after surgery were randomly assigned 1:1 to receive ferric carboxymaltose (FC; 1,000 mg, single dose) or iron sucrose (IS; 200 mg every 48 hours until covering the total iron deficit or discharge). Randomisation was stratified by Hb level: <10 g/dL (Group A) or ≥10-10.9 (Group B). The primary endpoint was the change in Hb concentration at postoperative day 30. Secondary endpoints included iron status parameters, transfusion requirements, complications, and length of hospital stay. From September 2015 to May 2018, 104 patients were randomised (FC 50, IS 54). The median intravenous iron dose was 1,000 mg and 600 mg in the FC and IS groups, respectively. There were no between-group differences in mean change in Hb from postoperative day 1 to postoperative day 30 (FC: 2.5 g/dL, 95% CI: 2.1-2.9; IS: 2.4 g/dL, 95% CI: 2.0-2.8; p=0.52), in transfusion requirements or length of stay. The infection rate was lower in the FC group compared with the IS group (9.8% vs 37.2%, respectively). The administration of approximately 500 mg of IS resulted in an increase in Hb at postoperative day 30 similar to that of 1,000 mg of FC, but it was associated with a higher infection rate. Future research will be needed to confirm the results, and to choose the best regime in terms of effectiveness and side effects to treat postoperative anaemia in colorectal cancer patients.

The Effects of Preoperative Administration of Erythropoietin in Pediatric Patients Undergoing Cranial Vault Remodeling for Craniosynostosis.

Over 90% of patients undergoing cranial vault remodeling for craniosynostosis receive blood transfusions to compensate for intraoperative blood loss. However, transfusions are not without risk and can lead to allergic and immune transfusion reactions as well as rare cases of infectious transmissions. Preoperative use of erythropoietin in cranial vault remodeling has been demonstrated to be safe and to reduce transfusion requirements in prior studies. This study's purpose is to add to the body of data supporting the safe use of a protocolized erythropoietin alfa regimen before cranial vault remodeling and strip craniectomy procedures with decreased blood transfusion requirements and other favorable outcomes. A retrospective chart review was performed on patients who underwent cranial vault remodeling between 2006 and 2021 at our tertiary care center. Two groups were identified: in the first, preoperative erythropoietin was administered under protocol; and in the second, preoperative erythropoietin was not administered. The groups were compared with respect to age, perioperative hemoglobin levels, estimated blood loss during surgery, packed red blood cell transfusion volume, length of hospital stay, and length of surgery. Demographics were not significantly different in terms of age, weight, diagnosis, gender, and type of procedure. Patients who were administered preoperative erythropoietin were found to have significantly increased preoperative hemoglobin levels (13.6 versus 12.3 g/dL), as well as decreased estimated intraoperative blood loss (376 versus 1099 mL), the volume of packed red blood cells transfused (316 versus 897 mL), length of hospital stay, and length of surgery. Postoperative hemoglobin levels were not found to be significantly different. In this study, preoperative administration of erythropoietin with elemental iron was beneficial for patients undergoing cranial vault remodeling for craniosynostosis. Specifically, it decreased the need for red blood cell transfusion, intraoperative blood loss, and length of hospital stay. No adverse events were recorded in the treatment arm. Further studies may include a separate group administered iron alone.

Eculizumab treatment in pregnant women with paroxysmal nocturnal hemoglobinuria: A Polish experience.

Eculizumab is an antibody targeting the C5 complement protein. Clinical trials suggest that eculizumab significantly reduces transfusion requirements and prevents disease complications in patients with paroxysmal nocturnal hemoglobinuria (PNH). To analyze the outcome of pregnancies among Polish women with PNH treated with eculizumab as a part of the Polish National Health Fund program. We report the outcomes of 3 pregnancies among women treated with eculizumab between 2017 and 2020. For 1 of these woman, it was the 1st pregnancy, while the remaining 2 patients had previously had 1 previous successful pregnancy each. All 3 mothers survived pregnancy, and all children were born alive. One of the patients had a vaginal delivery. Another required cesarean delivery at the 34th week due to a decreasing platelet count. In 1 case, premature rupture of the fetal membranes occurred at week 36, followed by artificial labor induction. All children were born without any inborn defects. The 2 prematurely born babies required a prolonged hospital stay. Treatment with eculizumab seems to reduce the risk to a mother and a child associated with PNH. However, more data are necessary to confirm this notion.

Effectiveness and Safety of E-aminocaproic Acid in Overall and Less-Invasive Cardiac Surgeries

To examine E-aminocaproic acid effectiveness in reducing transfusion requirements in overall and less-invasive cardiac surgery, and to assess its safety. Retrospective cohort study. Single-center tertiary academic medical center. A total of 19,111 adult patients who underwent elective surgery requiring cardiopulmonary bypass from January 1, 2008, through December 31, 2016. None. Propensity matching was used to create well-balanced groups and separately compare both overall cohort and less-invasive surgery with and without E-aminocaproic acid. Supplementary zero-inflated negative binomial regression analysis was used because outcome data were zero-inflated. Effectiveness was assessed by transfusion requirements, and safety by comparison of in-hospital outcomes. In the overall cohort, patients receiving E-aminocaproic acid received fewer red blood cells postoperatively and fewer intra- and postoperativel blood products. In a less-invasive cohort, there was no significant difference in red blood cell transfusion either intra- or postoperatively, but the E-aminocaproic group received fewer intra- and postoperative platelets, intraoperative cryoprecipitate, and postoperative plasma. There were no significant differences for in-hospital outcomes in both less-invasive and overall cohorts. The reduction of postoperative red blood cell requirement observed when analyzing the overall cohort did not translate to less-invasive cardiac surgery in the authors' patient population; however, both overall and less-invasive cohorts had lower requirements for other blood components with E-aminocaproic acid. There was no association with major Society of thoracic surgeons (STS)-defined morbidity and mortality in both groups.

Preintervention Computed Tomography Improves the Performance of Endovascular Intervention in Patients with Abdominopelvic Trauma

PurposeTo evaluate the role of computed tomography (CT) and CT angiography in guiding endovascular arteriography (EA) and embolization in hemodynamically (HD) stable and unstable patients with abdominal and/or pelvic (AP) trauma. Materials and MethodsA retrospective review was performed of patients with AP trauma who underwent EA with or without embolization (from January 2012 to August 2020) at an urban, level I trauma center. Patients aged <18 years or those undergoing EA outside of the abdomen and/or pelvis were excluded. Demographics, imaging findings, procedure length, contrast agent administration, laboratory values, and outcomes were compared on the basis of preprocedural imaging technique and hemodynamic status. ResultsA total of 190 patients with AP trauma underwent EA with or without embolization; among them, 123 were HD stable and underwent CT/CT angiography, whereas 67 were initially HD unstable and underwent operative management prior to EA. Of these patients, 38 underwent CT/CT angiography after hemodynamic stability was achieved prior to postoperative EA. The incidence of therapeutic embolization for arterial injury on EA was significantly higher in patients with preprocedural CT/CT angiography (65.8% vs 44.8%, P = .04). The positive and negative predictive values of CT angiography for arterial injury at the time of EA were 92.3% and 100%, respectively. Prior imaging was associated with a reduced contrast agent requirement at the time of EA and reduced transfusion requirement (P = .05 and P = .02). No significant differences were observed in adverse outcomes for patients undergoing preprocedural imaging. ConclusionsCT or CT angiography prior to EA for HD stable and unstable patients with AP trauma may improve the likelihood of therapeutic embolization and enable improved procedure metrics without increasing adverse outcomes.

Effect of Initial Anticoagulation Targets on Bleeding and Thrombotic Complications for Patients With Acute Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation

ObjectiveTo evaluate the effect of anticoagulation targets and intensity on bleeding events, thrombotic events, and transfusion requirements in patients with acute respiratory distress syndrome (ARDS) receiving venovenous extracorporeal membrane oxygenation (ECMO) and continuous-infusion heparin.DesignA retrospective cohort study.SettingAt a single-center, large academic medical center.ParticipantsOne hundred thirty-six critically ill patients.InterventionsThe following three therapeutic targets were implemented over time and evaluated: (1) no protocol (September 2013-August 2016): no standardized anticoagulation protocol or transfusion thresholds; (2) <50 seconds (September 2016-January 2018): standardized activated partial thromboplastin time (aPTT) goal of <50 seconds, maximum heparin infusion rate of 1,200 units/h, transfusion threshold of hemoglobin (Hgb) <8 g/dL; and (3) 40-to-50 seconds (February 2018-December 2019): aPTT goal of 40-to-50 sec, no maximum heparin infusion rate, transfusion threshold of Hgb <7 g/dL.Measurements and Main ResultsContinuous variables were compared using the Kruskal-Wallis test, and categorical variables were compared using Fisher exact tests. The primary endpoint, an incidence of at least 1 bleeding event, was highest in the no-protocol group though not statistically different among groups (39.3% v 26.7% v 34%, p = 0.5). Thrombotic complications were similar. The median units of packed red blood cells transfused were highest in the no-protocol group (3 v 2 v 0.5, p < 0.001).ConclusionAnticoagulation protocols standardizing aPTT goals to <50 or 40-to-50 seconds may be a reasonable strategy for patients receiving venovenous ECMO for ARDS. More restrictive hemoglobin transfusion thresholds, in combination with lower aPTT targets, may be associated with a reduction in transfusion requirements.

Effects of crystalloid and colloid priming strategies for cardiopulmonary bypass on colloid oncotic pressure and haemostasis: a meta-analysis.

OBJECTIVESColloid oncotic pressure (COP) is an important factor in cardiac surgery, owing to its role in haemodilution. The effect of cardiopulmonary bypass prime fluids on the COP is unknown. In this study, the effect of crystalloid and colloid prime fluids, with or without retrograde autologous priming (RAP), on the COP during elective cardiac surgery was evaluated.METHODSRandomized controlled trials and prospective clinical trials comparing crystalloid and colloid priming fluids or with RAP were selected. The primary outcome was the COP; secondary outcomes were fluid balance, fluid requirements, weight gain, blood loss, platelet count and transfusion requirements.RESULTSFrom 1582 records, 29 eligible studies were identified. COPs were comparable between gelofusine and hydroxyethyl starch (HES) during bypass [mean difference (MD): 0.69; 95% confidence interval (CI): −2.05, 3.43; P = 0.621], after bypass (MD: −0.11; 95% CI: −2.54, 2.32; P = 0.930) and postoperative (MD: −0.61; 95% CI: −1.60, 0.38; P = 0.228). Fluid balance was lower with HES than with crystalloids. RAP reduced transfusion requirements compared with crystalloids. Blood loss was comparable between groups.CONCLUSIONSCOPs did not differ between crystalloids and colloids. As a result of increased transcapillary fluid movement, fluid balance was lower with HES than with crystalloids. Haematocrit and transfusion requirements were comparable between groups. However, the latter was lower when RAP was applied to crystalloid priming compared with crystalloids alone. Finally, no differences in blood loss were observed between the groups.

Transfusion in Root Replacement for Aortic Dissection: The STS Adult Cardiac Surgery Database Analysis

BackgroundTransfusion in acute aortic syndromes has been studied in a limited fashion. We sought to describe contemporary transfusion practice for root replacement in acute (Stanford) type A aortic dissection. MethodsThe Society of Thoracic Surgeons Adult Cardiac Surgery Database was interrogated to identify patients who underwent primary aortic root replacement for acute (Stanford) type A aortic dissection (July 2014 to June 2017). Patients (n = 1558) were stratified by type of root replacement. Multivariate regression was used to determine those variables associated with transfusion and postoperative morbidity. ResultsTransfusion was required in 90.5% of cases (n = 1410). Operative mortality for all patients was 17.3% (261 deaths). Intraoperative red blood cell transfusion portended reduced short-term survival (odds ratio [OR] 2.00, P = .025). Massive postoperative transfusion was associated with prolonged ventilation (OR 13.47, P < .001), sepsis (OR 4.13, P < .001), and new dialysis-dependent renal failure (OR 2.43, P < .001). Women were more likely to require transfusion (OR 3.03, P < .001), as were patients who had coronary artery bypass (OR 1.57, P = .009), and those in shock (OR 2.27, P < .001). Valve-sparing aortic root replacement was associated with reduced transfusion requirements vs composite roots. Institutional case volume was not appreciably correlated with transfusion. ConclusionsMost patients undergoing root replacement for aortic dissection require blood products. Composite root replacement is associated with a greater likelihood of transfusion than a valve-sparing operation. Transfusion independently foreshadows greater operative mortality.

Improving Outcomes after Allograft Nephrectomy through Use of Preoperative Angiographic Kidney Embolization.

Allograft nephrectomy (AN) has been associated with considerable perioperative morbidity. We aimed to determine if preoperative angiographic kidney embolization (PAKE) to induce graft thrombosis before AN improves outcomes. We reviewed adult kidney transplant alone patients who underwent AN at a single center from 2002 to 2020 and compared perioperative outcomes for patients with and without PAKE. Eighty patients underwent AN, including 54 (67.5%) with PAKE before AN and 26 (32.5%) with AN alone. PAKE was associated with significantly reduced blood loss (PAKE: mean 266 ± 292 mL vs AN alone: 495 ± 689 mL; p = 0.04) and reduced transfusion requirements (PAKE: mean 0.5 ± 0.8 packed red blood cell units vs AN alone: 1.6 ± 2.6 units; p = 0.004) despite similar preoperative hemoglobin levels. Mean operating time (PAKE: 142 ± 43 minutes vs AN alone: 202 ± 111 minutes; p = 0.001) and length of hospital stay (PAKE: 4.3 ± 2.0 days vs AN alone: 9.3 ± 9.4 days; p = 0.0003) also favored PAKE, as did the surgical complication rate (PAKE: 6/54 [11%] vs AN alone: 9/26 [35%], p = 0.02). Long-term patient survival after AN was comparable in both groups. PAKE was associated with lower intraoperative blood loss, fewer transfusions, reduced operating time, shorter length of stay, and fewer surgical complications compared with AN alone at our center.

Viscoelastic haemostatic point-of-care assays in the management of postpartum haemorrhage: a narrative review.

Viscoelastic haemostatic assays provide rapid testing at the bed-side that identify all phases of haemostasis, from initial fibrin formation to clot lysis. In obstetric patients, altered haemostasis is common as pregnancy is associated with coagulation changes that may contribute to bleeding events such as postpartum haemorrhage, as well as thrombosis events. In this narrative review, we examine the potential clinical utility of viscoelastic haemostatic assays in postpartum haemorrhage and consider the current recommendations for their use in obstetric patients. We discuss the clinical benefits associated with the use of viscoelastic haemostatic assays due to the provision of (near) real-time readouts with a short turnaround, coupled with the identification of coagulation defects such as hypofibrinogenaemia. The use of viscoelastic haemostatic assay-guided algorithms may be beneficial to diagnose coagulopathy, predict postpartum haemorrhage, reduce transfusion requirements and monitor fibrinolysis in women with obstetric haemorrhage. Further studies are required to assess whether viscoelastic haemostatic assay-guided treatment improves clinical outcomes, and to confirm the utility of prepartum viscoelastic haemostatic assay measurements for identifying patients at risk of postpartum haemorrhage.

Minimally invasive mitral valve surgery versus conventional sternotomy mitral valve surgery: A systematic review and meta-analysis of 119 studies.

Whether minimally invasive mitral valve surgery (MMVS) leads to better outcomes remains unclear. We conducted a systematic review and meta-analysis comparing various MMVS approaches with conventional sternotomy. We searched Cochrane CENTRAL, MEDLINE, EMBASE, ClinicalTrials. gov, and the ISRCTN Register for studies comparing minimally invasive approach (thoracotomy, port access, partial sternotomy, or robotic) with median sternotomy for mitral valve surgery. We performed title and abstract, full-text screening, and data extraction independently and in duplicate. We pooled data using random effect models. Quality assessment was performed using validated tools. Certainty of evidence was established using the GRADE framework. One hundred and nineteenstudies (n = 38,106) met eligibility criteria: eight randomized controlled trials (RCTs) and 111 observational studies. MMVS was associated with fewer days in hospital (RCT: MD: -2.2 days, 95% CI, [-3.7 to -0.8]; observational: MD:-2.4 days, 95% CI, [-2.7 to -2.1]). Observational studies suggested that MMVS reduced transfusion requirements with fewer units transfused per patient (MD: -1.2; 95% CI, [-1.6 to -0.9]) and fewer patients transfused (RR, 0.7; 95% CI, [0.6-0.7]). Observational data also suggested lower mortality with MMVS (RR, 0.6; 95% CI, [0.5-0.7], p < .001, I2 = 0%), but this was not corroborated by RCT data. The risk of postoperative mitral regurgitation (≥2+ or requiring re-intervention) did not differ between the two groups. MMVS may be associated with shorter length of hospital stay with no significant difference in short-term morbidity and mortality. There is a paucity of high-quality data on the long-term outcomes of MMVS when compared with conventional sternotomy.

Risk Factors for High Blood Product Use in Patients with Stanford Type A Dissection.

Intraoperative and postoperative bleeding associated with allogeneic blood transfusion and reoperation is still a common and feared complication in patients undergoing surgery due to acute Type A Aortic Dissection (aTAAD). The aim of our study was to identify risk factors for higher transfusion rates. In this retrospective single center study we evaluated pre -, intra-, and postoperative data of 121 patients with aTAAD. Depending on the median of received packed red blood cells (PRBCs), patients were divided into Group A (<8 PRBC, n = 53) and Group B (≥8 PRBC n = 68). Statistical analyses (descriptive statistics, univariable and multivariable logistic regression) were performed using SPSS software 25.0. Statistical significance was assumed at p-value <0.05. A total of 120 patients received a blood product during their perioperative course. Among others we identified age, hemorrhagic pericardial effusion, and dual antiplatelet therapy as preoperative risk factors, low rectal temperature as intraoperative risk factor and low body temperature, positive fluid balance, high lactate level and beginning development of acute renal failure as postoperative risk factors. Our study identifies several factors which predict a higher likelihood of bleeding and consecutive blood transfusion. Knowledge of these factors could influence the therapy to reduce transfusion requirements and lead to a targeted and more efficient use of coagulation products.

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

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

Key points in reducing transfusion requirements in perioperative period

Surgical intervention can lead to blood loss either through perioperative complications, or through disease severity until surgery. For this reason, mastering the main strategies to improve surgical patients’ hematological status, to reduce transfusion rate, and to correct hemoglobin level represent the state of art in surgical patient management. In the last period, due to COVID-19 pandemic and the blood shortage crisis across hospitals, applying principles meant to reduce blood loss, and therefore the rate of blood transfusion, have become even more important.

Short-term high-dose intravenous iron reduced peri-operative transfusion after staggered bilateral total knee arthroplasty: A retrospective cohort study.

Staggered bilateral total knee arthroplasty, two procedures performed 4-7 days apart during a single hospitalization, has an increased risk of blood transfusion. This observational study aimed to evaluate whether immediate post-operative single, high-dose intravenous iron supplementation could reduce transfusion requirements and facilitate anaemia recovery in patients. We retrospectively analysed 131 patients who underwent staggered bilateral total knee arthroplasty. The ferric carboxymaltose (FCM) group received 1000 mg of FCM after the first operation. The non-FCM group did not receive intravenous iron. The transfusion rate and post-operative complications were compared between the groups. The anaemia rate was evaluated pre-operatively, during hospitalization, and 5 weeks after the second total knee arthroplasty. The FCM group comprised 78 patients (59.5%). The rate (21.8% vs. 47.2%, p= 0.004) and amount of transfusion (0 [0-2] vs. 0 [0-0], p= 0.001) was significantly lower in the FCM group than in the non-FCM group. Although both groups' pre-operative haemoglobin concentrations were not significantly different, the FCM group demonstrated higher haemoglobin values 5 weeks post surgery (12.25 ± 0.83 mg/dl vs. 11.48 ± 1.36 mg/dl, p< 0.001). More non-FCM patients developed moderate to severe anaemia at 5 weeks post surgery (p< 0.001). The mortality and complication rates were not significantly different. Immediate post-operative, high-dose, intravenous iron treatment may contribute to reduced transfusion rates, facilitate haemoglobin recovery after staggered bilateral total knee arthroplasty, and minimize the development of moderate to severe anaemia.