Perioperative Blood Transfusion Requirements Research Articles

Reducing Blood Transfusions in Primary Total Hip Replacement Patients: Effectiveness of Near-patient Testing and a Dedicated Preoperative Anemia Clinic.

Objective Preoperative anemia in orthopedic patients is associated with higher allogeneic blood transfusion rates and poorer outcomes. Up to 25% of the patients listed for major orthopedic surgery have some degree of anemia. Good perioperative patient blood management is essential to reduce the sequelae of anemia and the need for transfusions. We assessed the efficacy of rapid near-patient testing in conjunction with a dedicated preoperative anemia clinic for screening and treating primary total hip replacement (THR) patients for anemia. Methods A comparison of overall allogeneic blood transfusion rates was made for patients undergoing primary total hip replacement before and after the implementation of near-patient testing and of a dedicated preoperative anemia clinic over 1 year. A comparison was also performed between anemic patients who were referred to the clinic with those who were not referred. Preoperative hemoglobin levels, allogeneic blood transfusion rates and clinic treatment for 1,095 patients were reviewed. Results There was a significant decrease in transfusion rates in patients undergoing primary THR from 10.0 to 6.2% ( p < 0.05; χ2 test) after the implementation of near-patient testing and of a dedicated preoperative anemia clinic pathway. The allogeneic blood transfusion rate for anemic patients who were treated in the clinic was 6.7% compared with 26.9% for patients who were anemic preoperatively but were not treated in the clinic ( p < 0.05; Fisher exact test). On average, treatment in the pathway increased the hemoglobin of the patients by 20 g/L, from 104 g/L to 124 g/L ( p < 0.001). Conclusions Near-patient testing, in conjunction with a dedicated preoperative anemia clinic, reduces perioperative allogenic blood transfusion requirements for patients undergoing primary THR by providing rapid identification and effective treatment of preoperative anemia.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Is Continuing Anticoagulation or Antiplatelet Therapy Safe Prior to Kidney Transplantation?

BackgroundPatients undergoing kidney transplantation are often placed on anticoagulation or antiplatelet therapy, and their perioperative management is often challenging. This study aimed to determine the safety of continuing anticoagulation or antiplatelet therapy prior to kidney transplantation. The primary outcome was bleeding after transplantation.Material/MethodsPatients who underwent kidney transplantation between January 2017 and July 2019 were included and divided into 3 groups: pretransplant anticoagulation with warfarin (WARF; n=23); pretransplant antiplatelet therapy with clopidogrel/aspirin (ASA/CLOP; n=32); and control (CTL; n=197). Patients received kidneys from live or deceased donors. Preoperative INRs and platelet counts were compared to ensure therapeutic anticoagulation in the warfarin group and no significant platelet count variation among groups. The primary outcome was graft exploration for bleeding at 3 and 6 months after transplantation. Secondary outcomes included perioperative transfusion requirements, prolonged length of stay (>7 days), and outcomes at 3 and 6 months after transplantation, including hemodialysis and rejection rates and creatinine levels.ResultsPretransplant INR was significantly greater in the warfarin group (CTL 1.1, WARF 2.2, ASA/CLOP 1.2; P<0.01). There were no differences in pretransplant platelet count (CTL 202×103, WARF 186×103, ASA/CLOP 194×103; P=0.31), graft exploration for bleeding at 3 (CTL 3%, WARF 0%, ASA/CLOP 3%; P=0.69) and 6 months after transplantation (CTL 1%, WARF 4%, ASA/CLOP 0%; P=0.12), or perioperative blood transfusion requirements (CTL 4%, WARF 4%, ASA/CLOP 14%; P=0.13). Prolonged length of stay was similar (CTL 24%, WARF 26%, ASA/CLOP 44%; P=0.08). There were no significant differences among groups at 3 months in dialysis (CTL 2%, WARF 0%, ASA/CLOP 0%; P=0.71), creatinine (CTL 1.5 mg/dL, WARF 1.7 mg/dL, ASA/CLOP 1.7; P=0.13), or rejection (CTL 6%, WARF 0%, ASA/CLOP 0%) or at 6 months in dialysis (CTL 3%, WARF 0%, ASA/CLOP 0%; P=0.49), creatinine (CTL 1.5 mg/dL, WARF 1.7 mg/dL, ASA/CLOP 1.5; P=0.49), or rejection (CTL 1%, WARF 0%, ASA/CLOP 3%).ConclusionsContinuing anticoagulation or antiplatelet was safe in not increasing bleeding complications or perioperative transfusion requirements. Outcomes were similar at 3 and 6 months among groups. This strategy avoids exposing patients to risk of thrombosis if treatment is held and simplifies proceeding to transplantation.

The Safety and Efficacy of Tranexamic Acid in Oncology Patients Undergoing Endoprosthetic Reconstruction and a ROTEM-Based Evaluation of Their Hemostatic Profile: A Pilot Study.

Simple SummaryTranexamic acid can be an effective and safe way to reduce perioperative bleeding following an endoprosthetic reconstruction of a lower limb after a bone tumor resection. Tranexamic acid does not result in a complete shutdown of the fibrinolysis, supporting its safe use without increasing the risk of thromboembolic complications.Background: An endoprosthetic reconstruction in musculoskeletal oncology patients is associated with significant blood loss. The purpose of this study is to evaluate the safety and efficacy of tranexamic acid (TXA) for these patients and to assess any changes in their hemostatic profile using rotational thromboelastometry (ROTEM). Methods: A retrospective observational study was performed including 61 patients with primary or metastatic bone tumors who underwent surgery. Group A (n = 30) received both intravenous and local TXA whereas Group B (n = 31) was the control group. The primary outcomes were perioperative blood loss and blood unit transfusions and the secondary outcomes included the incidence of thromboembolic complications and a change in blood coagulability as reflected by ROTEM parameters. Results: The median difference in blood loss between the two groups was 548.5 mL, indicating a 29.2% reduction in the 72 h blood loss following TXA administration (p < 0.001). TXA also led to a reduced transfusion of 1 red blood cell (RBC) unit per patient (p < 0.001). The two groups had similar rates of thromboembolic complications (p = 0.99). The antifibrinolytic properties of TXA were confirmed by the significantly higher INTEM, FIBTEM and EXTEM LI60 (p < 0.001, p = 0.005 and p < 0.001, respectively) values in the TXA group. Conclusion: Tranexamic acid was associated with a significant reduction in perioperative blood loss and transfusion requirements without a complete shutdown of the fibrinolysis. Larger studies are warranted to assess the frequency of these outcomes in musculoskeletal oncology patients.

Safety of early surgery for geriatric hip fracture patients taking clopidogrel: a retrospective case-control study of 120 patients in China.

Background:Geriatric hip fracture patients receiving clopidogrel are a surgical challenge. In China, most of these patients undergo delayed surgical treatment after clopidogrel withdrawal for at least 5 to 7 days. However, delayed surgery is associated with increased complications and mortality in the older adults. This retrospective paralleled comparison study investigated the safety of early surgery for geriatric hip fracture patients within 5 days of clopidogrel withdrawal.Methods:Acute hip fracture patients (≥65 years) who were hospitalized in the orthogeriatric co-management ward of Beijing Jishuitan Hospital between November 2016 and April 2018 were retrospectively reviewed. Sixty patients taking clopidogrel before injury and discontinued <5 days before surgery constituted the clopidogrel group. The control group constituted 60 patients not taking antiplatelet or anticoagulant drugs and matched 1:1 with the clopidogrel group for sex, fracture type, operative procedure, and time from injury to operation (±10 h). The primary outcome was perioperative blood loss and the secondary outcomes were transfusion requirement, complications, and mortality. The Student's t test or Wilcoxon signed rank sum test was used for continuous variables and the Chi-square test was used for categorical variables.Results:Age, body mass index, American Society of Anesthesiologists score, and percentage undergoing general anesthesia were comparable between the groups (P > 0.050). The percentages of patients with coronary heart disease (61.7% vs. 18.3%; P < 0.001) and cerebrovascular disease (45.0% vs. 15.0%; P < 0.010) were significantly higher in the clopidogrel vs. control groups, respectively. The median clopidogrel discontinuation time before operation was 73.0 (range: 3.0–120.0) h. There was no significant difference in the estimated perioperative blood loss between the clopidogrel group (median: 745 mL) and control group (median: 772 mL) (P = 0.866). The intra-operative transfusion rate was higher in the clopidogrel group (22/60, 36.7%) than that in the control group (12/60, 20.0%) (P < 0.050). However, there was no significant difference in the blood transfusion rate during the entire perioperative period (26/60, 43.3% vs. 20/60, 33.3%; clopidogrel group vs. control group, respectively; P > 0.050). There was no significant difference in perioperative complications, and 30-day and 1-year mortality rates between the groups.Conclusions:Early hip fracture surgery is safe for elderly patients within 5 days of clopidogrel withdrawal, without increased perioperative blood loss, transfusion requirement, complications, and mortality compared with patients not taking antiplatelet drugs.

A PROSPECTIVE ANALYSIS OF RISK FACTORS, PRESENTATION AND OUTCOME OF LEAKAGE AFTER GASTROINTESTINAL ANASTOMOSES

Background: Despite advancements in modern surgery and postoperative care, disruption of gastrointestinal anastomosis remains the most dreaded complication, even in experienced surgical hands. The cause of leakage is multifactorial consisting of a complete spectrum of pre, intra and postoperative factors. Search for an ideal gastrointestinal anastomosis still remains an unquenched thirst. Study Design: Prospective, hospital based, time bound observational study. Methods: After ethical clearance, 288 consenting adult patients who underwent gastrointestinal anastomosis were observed for risk factors, presentation and outcome of leakage and evaluated using appropriate statistical tools. Results: An overall gastrointestinal anastomotic leak rate of 15.28% with peak incidence at 41-50 years (19.51%) was seen. Peritonitis (p=0.0009, OR=2.9611), COPD (p=0.0181, OR=2.7306), low serum albumin concentration (p=0.0028, OR=3.1442), ASA status of ≥III (p=0.0001, OR=4.0281) and a perioperative blood transfusion requirement of ≥2 units (p=0.0028, OR=3.1442) were the most signicant risk factors associated with leakage. Obstruction (p=0.0160, OR=2.2310), malignancy (p=0.0149, OR=2.6961), steroid therapy (p=0.0176, OR=2.2741), chemoradiation (p=0.0400, OR=2.4889), diabetes (p=0.0427, OR=2.2689), undernutrition (p= 0.0308, OR= 2.1099), anaemia (p=0.0325, OR=2.0183) and sepsis (p=0.0187, OR=2.2702) also showed clear risk augmentation. Risk of leakage was increased with a surgical duration of &gt;4 hours (p=0.0078, OR=2.5610), when anastomosis was done as an emergency procedure (p=0.0427, OR=2.6571) or by a surgeon with expertise of ≤5 years (p=0.0338, OR=2.7733). Neither the level, type, technique of anastomosis; nor the usage of surgical staplers had an impact on leakage. Preoperative bowel preparation and creation of a proximal stoma also had minimal effect on leakage rates; though, the infectious complications that follow were greatly reduced. The most common presentation of anastomotic leak was a suspicious drain output with a mean time of 7.59± 2(2.48) postoperative days; resulting in a prolongation of hospitalization by more than ten days (p&lt;0.0001), along with an increased mortality rate (p&lt;0.0001). Conclusions: Accurately predicting anastomotic leakage still requires more evidence-based information. Even with good risk stratication, many causative factors may not be amenable to immediate correction in the pre-operative period. In such cases, the patient must be considered as a candidate for an enterostomy to help tide the crisis over.

Comparative efficacy and safety of topical hemostatic agents in primary total knee arthroplasty: A network meta-analysis of randomized controlled trials.

Background:Topical hemostatic agents are commonly used for reducing perioperative blood loss and transfusion requirement in primary total knee arthroplasty (TKA), although the optimal option has yet to be defined. This study aimed to evaluate the efficacy and safety of topical hemostatic agents and rank the best intervention using the network meta-analysis (NMA) method.Methods:We searched Web of science, PubMed, and Cochrane Library database up to April 2020, for randomized controlled trials (RCTs) on topical hemostatic agents in primary TKA. The quality of included studies was assessed using the Cochrane “risk of bias” tool. Direct and indirect comparisons were performed for the result of network meta-analysis followed by consistency test.Results:Thirty seven RCTs with 3792 patients were included in this NMA and the pooled results indicated that tranexamic acid plus diluted epinephrine (TXA+DEP) displayed the highest efficacy in reducing total blood loss, hemoglobin drop and transfusion requirement. None of the included treatments was found to increase risk of thromboembolic events compared to placebo. According to the results of ranking probabilities, TXA+DEP had the highest possibility to be the best topical hemostatic agent with regard to the greatest comparative efficacy and a relatively high safety level.Conclusion:Current evidence supports that administration of TXA+DEP may be the optimal topical hemostatic agent to decrease blood loss and transfusion requirement in primary TKA. More direct studies that focused on the topical application of TXA+DEP versus other treatments are needed in the future.

Association between preoperative hemoglobin levels after iron supplementation and perioperative blood transfusion requirements in children undergoing scoliosis surgery.

In this study, we assessed the association between preoperative hemoglobin and red blood cell transfusion in children undergoing spine surgery after the implementation of our preoperative iron supplementation protocol. We performed a retrospective analysis of patients who underwent posterior spinal fusion surgery between January 2013 and December 2017 and received preoperative iron supplementation. We used uni- and multivariable logistic regression to determine the association between preoperative hemoglobin level and red blood cell transfusion in patients receiving iron supplementation. A total of 382 patients treated with preoperative oral iron were included. Of these, 175 (45.5%) patients were transfused intraoperatively. Multivariable logistic regression analysis revealed nonidiopathic etiology of the scoliosis (OR 4.178 [95% CI: 2.277-7.668], P<.001), the Cobb angle (OR 1.025 [95% CI: 1.010-1.040], P=.001), and number of vertebrae fused (OR 1.169 [95% CI: 1.042-1.312], P=.008) were associated with red blood cell transfusion. In addition, patients with a preoperative hemoglobin≥140g/L (OR 0.157 [95% CI: 0.046-0.540], P=.003), and hemoglobin between 130 and 140g/L (OR 0.195 [95% CI: 0.057-0.669], P=.009) were less likely to be transfused compared with patients with preoperative hemoglobin between 120 and 130g/L (OR 0.294 [95% CI: 0.780-1.082], P=.066) or <120g/L (reference). Our study suggests that higher preoperative hemoglobin levels (>130g/L) are associated with a reduced need for red blood cell transfusion in pediatric patients who have received iron supplementation before undergoing posterior spinal fusion in our institution. The effect of iron supplementation, the optimal dosing, and duration of supplemental iron therapy remains unclear at this time.

English

English

Robotic multivisceral pelvic resection: experience from an exenteration unit.

Pelvic exenteration remains a viable and effective treatment option for the management of locally advanced or recurrent pelvic malignancy. The aim of this study was to present an early experience of robotic multivisceral resection of pelvic malignancy, and to compare this experience with similar series through a systematic review of the literature. A retrospective study was performed on patients who had robotic-assisted multi-visceral resection for pelvic malignancy at a single Colorectal Surgical unit based between two tertiary academic hospitals. Primary outcomes observed included operation type, operation time, perioperative complications, and hospital length of stay. Secondary outcomes included R0 resection status, lymph node harvest, and rate of recurrence at clinical follow-up. Eight cases of robotic multivisceral resection were performed for primary locally advanced pelvic malignancy involving a rectal resection as part of their operative management. The median age of patients undergoing resection was 56years (range 29-83years). The male:female ratio was 6:2. The mean total operating time was 8.3h (range 6-10h). Perioperative blood transfusion requirements were minimal. Mean hospital length of stay was 15days (range 7-26days). No patients experienced any serious postoperative morbidity or mortality. All patients had clear margins on histological assessment and no patients have recurrence at 12-month follow-up. Robotic multivisceral resection for malignant disease of the pelvis is a safe and feasible minimally invasive approach in highly selected cases.

Comparação entre duas doses de ácido tranexâmico intra‐articular no sangramento pós‐operatório de artroplastia total do joelho: estudo clínico randomizado

IntroductionTranexamic Acid (TXA), an antifibrinolytic that inhibits the fibrinolytic activity of plasmin is used to decrease perioperative blood loss and transfusion requirements in orthopedic surgery. The aim of our study was to compare postoperative bleeding in two intra‐articular doses (1g and 2g) of tranexamic acid in adult patients undergoing unilateral total knee replacement. MethodWe conducted a single‐operator, randomized, and controlled, double‐blind study in two groups. The G1 group received 1g of intra‐articular TXA and the G2 group 2g of intra‐articular TXA. Both groups received 15mg.kg‐1 IV before the surgical incision (TXA induction dose) and then 10mg.kg‐1, orally, 6 and 12hours after the induction dose of TXA. The primary endpoint was bleeding measured by blood loss in postoperative drainage. Secondary outcomes were change in hemoglobin and hematocrit levels on the first and third postoperative days, and the need for transfusion during hospitalization. ResultsIn total, 100 patients were randomized, and 100 were included in the analysis. Blood loss in postoperative drainage was similar in both groups (200±50 vs. 250±50mL, G1 and G2 groups respectively). Change in hematocrit and hemoglobin values (% of change) between preoperative and day 3 were not statically significant between groups G1 and G2 (18±5 vs. 21±4; 21±7 vs. 22±5 respectively). No patients received blood transfusion. ConclusionsOur study did not show superiority of 2g of intra‐articular tranexamic acid compared to 1g.ClinicalTrials.gov Identifier NCT04085575

Comparison of two doses of intra-articular tranexamic acid on postoperative bleeding in total knee arthroplasty: a randomized clinical trial

IntroductionTranexamic Acid (TXA), an antifibrinolytic that inhibits the fibrinolytic activity of plasmin is used to decrease perioperative blood loss and transfusion requirements in orthopedic surgery. The aim of our study was to compare postoperative bleeding in two intra-articular doses (1g and 2g) of tranexamic acid in adult patients undergoing unilateral total knee replacement. MethodWe conducted a single-operator, randomized, and controlled, double-blind study in two groups. The G1 group received 1g of intra-articular TXA and the G2 group 2g of intra-articular TXA. Both groups received 15mgkg−1 IV before the surgical incision (TXA induction dose) and then 10mgkg−1, orally, 6 and 12hours after the induction dose of TXA.The primary endpoint was bleeding measured by blood loss in postoperative drainage. Secondary outcomes were change in hemoglobin and hematocrit levels on the first and third postoperative days, and the need for transfusion during hospitalization. ResultsIn total, 100 patients were randomized, and 100 were included in the analysis. Blood loss in postoperative drainage was similar in both groups (200±50 vs. 250±50mL, G1 and G2 groups respectively). Change in hematocrit and hemoglobin values (% of change) between preoperative and day 3 were not statically significant between groups G1 and G2 (18±5 vs. 21±4; 21±7 vs. 22±5 respectively). No patients received blood transfusion. ConclusionsOur study did not show superiority of 2g of intra-articular tranexamic acid compared to 1g.ClinicalTrials.gov Identifier NCT04085575

Intraoperative tranexamic acid to decrease blood loss during myomectomy: a randomized, double-blind, placebo-controlled trial

Myomectomy is associated with a significant risk of hemorrhage. Tranexamic acid is a synthetic lysine derivative with antifibrinolytic activity used in other surgical disciplines to reduce blood loss during surgery. However, its utility in gynecologic surgery is not well understood. This study aimed to determine the effect of early administration of intravenous tranexamic acid on perioperative bleeding and blood transfusion requirements in women undergoing myomectomy. This study was a double-blinded, randomized, placebo-controlled trial conducted in an academic teaching hospital. Women with symptomatic fibroids thought to be at risk for large intraoperative blood loss who met the following criteria were included in the study: (1) at least 1 fibroid ≥10 cm, (2) any intramural or broad ligament fibroid ≥6 cm, and/or (3) at least 5 total fibroids based on preoperative imaging. Patients were randomized to receive a single intravenous bolus injection of tranexamic acid 15 mg/kg (intervention group) versus an intravenous bolus injection of saline of equivalent volume (placebo group) 20 minutes before the initial surgical incision. Perioperative bleeding was defined by measuring intraoperative estimated blood loss, change between pre- and postoperative hemoglobin, and frequency of blood transfusions. Estimated blood loss was calculated by combining the blood volume collected within the suction canister and the weight of used sponges. The 2 groups were compared for age; body mass index; perioperative hemoglobin and hematocrit; perioperative blood loss; duration of surgery; blood transfusion requirements; and the number, total weight, and volume of myomas removed. A total of 60 patients (30 per arm) were enrolled into the study between March 1, 2015, and January 29, 2018. Age, body mass index, baseline hemoglobin and/or hematocrit, number and total weight of myomas removed, and size of myomas did not differ between arms. Of 60 patients, 32 (53%) had laparoscopic myomectomy, 24 (40%) had robotic myomectomy, and 4 (7%) had laparotomy. Median estimated blood loss was 200 mL for the tranexamic acid group and 240 mL for the placebo group (P=.88). There was no difference in median duration of surgery (165 vs 164 minutes; P=.64) or change in perioperative hemoglobin (1.00 vs 1.1 g/dL; P=.64). Patients in the tranexamic acid group did not require blood transfusions; however, 4 patients (13.3%) in the placebo group (P=.11) required blood transfusions. Intravenous administration of tranexamic acid in patients undergoing laparoscopic or robotic myomectomies was not associated with decreased blood loss.

A Single Preoperative Dose of Tranexamic Acid Reduces Perioperative Blood Loss: A Meta-analysis.

To review the efficacy and safety of a single dose of intravenous tranexamic acid (TXA) given preoperatively. TXA is a synthetic antifibrinolytic that has been used in various surgical disciplines to reduce blood loss, blood transfusions, ecchymosis, and hematoma formation. However, there is no universal standard on the most effective dose and route of TXA administration, limiting its routine use in many centers. This study evaluates the current evidence for the efficacy and safety of a single preoperative dose of TXA on surgical blood loss in all surgical disciplines. With the guidance of a research librarian, in accordance with the Cochrane Handbook Medline, Cochrane Central and Embase were searched in November 2018. Search terms included "Tranexamic Acid" AND "Intravenous," with studies limited to randomized controlled trails in adult humans. Two independent reviewers and an arbitrator assessed articles for inclusion. Criteria included a single preoperative bolus dose of intravenous TXA, surgical patients, and intraoperative blood loss measurement or perioperative blood loss up to 24 hours postsurgery. Quality assessment was done using the Cochrane Collaboration risk-of-bias tool by 2 reviewers. Statistical analysis was carried out using Cochrane Review Manager 5.3. The primary outcome was surgical blood loss. Secondary outcomes included venous thromboembolic complications, transfusion requirements, and dosing. A total of 1906 articles were screened, 57 met inclusion criteria. The majority of included studies were orthopedic (27), followed by obstetric and gynecological (16), oral maxillofacial and otolaryngology (10), cardiac (3), and 1 plastic surgery study focusing on acute burn reconstruction. Across all surgical specialties (n = 5698), the perioperative estimated blood loss was lower in patients receiving TXA, with a standard mean difference of -153.33 mL (95% CI = -187.79 to -118.87). Overall, surgical patients with TXA had a 72% reduced odds of transfusion (odds ratio = 0.28 [95% CI = 0.22-0.36]). The most frequently used dose of TXA was 15 mg/kg. There was no difference in the incidence of venous thromboembolic events between TXA and control groups. While there is a growing body of evidence to support benefits of perioperative TXA use, this is the first meta-analysis to identify the efficacy and safety of a single preoperative dose of IV TXA. The potential implications for expanding the use of preoperative TXA for elective day surgery procedures is substantial. Preoperative intravenous TXA reduced perioperative blood loss and transfusion requirements in a variety of surgical disciplines without increasing the risk of thromboembolic events. Therefore, it should be considered for prophylactic use in surgery to reduce operative bleeding.

Selective Use of Anticoagulation or Dual Antiplatelet Therapy for Patients with Extra-anatomic Bypasses

The benefit of long-term anticoagulation or dual antiplatelet therapy (DAPT) for patients with extra-anatomic bypasses to the lower extremity remains poorly defined. Our study analyzed the real-world use of antithrombotic therapy in patients with extra-anatomic bypass grafts to the lower extremity and compared graft and patient outcomes by antithrombotic regimen. We studied patients who underwent axillofemoral or femoral-femoral bypass within the Vascular Quality Initiative with one-year follow-up data. Primary exposures were anticoagulation and DAPT, at the time of index procedure and one-year follow-up. Primary outcomes were major adverse limb events (MALE) defined as reintervention or above-ankle amputation, and primary patency. Secondary outcomes included perioperative blood transfusion requirements and the need for reoperation specifically for bleeding. We analyzed outcomes using the Kaplan-Meier estimation and examined factors associated with choice of antithrombotic therapy via logistic regression. Our cohort included 2,760 patients (axillofemoral bypass, n=857; femoral-femoral bypass, n=1,903) across 168 centers from 2009 to 2018. Mean age was 66.5±10.5years and 59% were male. Patients were infrequently prescribed long-term anticoagulation (19%) or DAPT (22%). One-year primary patency was 86% and was similar by anticoagulation (log-rank P=0.12) and DAPT status (log-rank P=0.26). Freedom from MALE was 87% at 1year and was slightly inferior for patients on anticoagulation (88 vs. 83%, log-rank P=0.001) but was similar by DAPT (log-rank P=0.19). Transfusion was more common in patients who were anticoagulated than those who were not (30 vs. 25%, P<0.01), but there was no increase in reoperation because of bleeding (anticoagulation 0.8 vs. 0.8, P=0.98). Anticoagulation was more commonly prescribed according to disease severity, such as rest pain (adjusted odds ratio (OR): 1.6 (95% confidence interval (CI): 1.20-2.20), tissue loss (OR: 1.9, CI: 1.28-2.73), or acute limb ischemia (OR: 1.9, CI: 1.35-2.71) or prior bypass graft (OR: 2.6, CI: 2.07-3.35). Patients were more commonly prescribed DAPT according to comorbidities, including hypertension (OR: 1.4, CI: 1.04-1.94) and coronary artery disease (OR: 1.6, CI 1.26-1.95). Antithrombotics are selectively used in patients with extra-anatomic bypass to the lower extremity, the selection of which appears associated with disease severity for anticoagulants and patient comorbidities for DAPT. Primary patency and MALE rates are similar with focused utilization of anticoagulants or DAPT. Blood transfusions are more common among patients on antithrombotics without a difference in the need for reoperation for bleeding.

Preoperative embolization in surgical treatment of long bone metastasis: a systematic literature review.

Surgery of long bone metastases is associated with a significant risk of perioperative blood loss, which may necessitate blood transfusion.Successful embolization (> 70% obliteration of vascularity) can be achieved in 36–75% of cases.The reported rate of embolization-related complications is 0–9%.Three out of six level III evidence studies showed a reduction in perioperative blood loss and/or blood transfusion requirement after preoperative embolization of renal cell carcinoma metastasis in long bones; three out of six studies did not.One level III evidence study did not show a reduction in perioperative blood loss and/or transfusion requirement after preoperative embolization of hepatocellular carcinoma metastases in long bones.There were no studies found that support preoperative embolization of thyroid metastases or other frequent long bone metastases (e.g. mamma carcinoma, lung carcinoma, or prostate carcinoma).The clinical level of evidence of the studies found is low and randomized studies taking into account primary tumour, location of metastases and type of surgery are therefore desired.Cite this article: EFORT Open Rev 2020;5:17-25. DOI: 10.1302/2058-5241.5.190013

Retraction: Does the preoperative administration of tranexamic acid reduce perioperative blood loss and transfusion requirements after head neck cancer surgery? A randomized, controlled trial.

[This retracts the article on p. 384 in vol. 9, PMID: 26712979.].

Comparison of Blood-Conserving and Allogenic Transfusion-Sparing Effects of Antifibrinolytics in Scoliosis Correction Surgery.

Background:Intraoperative antifibrinolytic drug administration is a safe and effective method of reducing blood loss and allogenic transfusions in patients undergoing spine deformity correction.Aim:This study aimed to compare the effectiveness of two antifibrinolytic drugs tranexamic acid (TXA) and epsilon amino caproic acid (EACA) in reducing peri-operative blood loss and transfusion requirements against a placebo control in patients with idiopathic scoliosis undergoing correction surgery.Setting and Design:This is a prospective, randomized, double-blinded, controlled comparative study.Methodology:Patients in TXA group received 50 mg.kg−1 bolus and 10 mg.kg−1.h−1 infusion as against 100 mg.kg−1 and 10 mg.kg−1.h−1 infusion in EACA group. The placebo group had saline bolus and infusion. Parameters observed included baseline demographic and deformity data, duration of surgery, total peri-operative blood loss, and allogenic packed red cell transfusion requirements.Statistical Analysis:Mean and standard deviation were used to represent the quantitative continuous data, and percentage was used to represent categorical data. The Student's t-test and ANOVA were used to compare means between groups. Bonferroni's multiple comparison test was used to find out the association between categorical variables.Results:A total of 36 patients were enrolled with 12 patients in each group. Peri-operative blood loss was 50.1% lower in patients receiving TXA and 17.7% lower in patients receiving EACA compared with the placebo group. The volume of total packed red cell transfusion was 66.7% lower in patients receiving TXA and 45.6% lower in patients receiving EACA compared with placebo.Conclusion:TXA was more effective in reducing total peri-operative blood loss and allogenic transfusion requirement in idiopathic scoliosis correction surgery compared to EACA.

One stage bilateral total hip arthroplasty in Indian patients

There are few studies which investigate peri-operative safety and surgical outcome of one stage bilateral total hip arthroplasty. Avascular necrosis of hip is the most common indication for total hip arthroplasty which is frequently bilateral. In present study, we studied 30 patients who were operated with one stage bilateral total hip arthroplasty. Most of them (93%) were suffering from avascular necrosis of hip. We analysed intra-operative blood loss, peri-operative blood transfusion requirement, length of hospital stay and peri-operative complications for the aforesaid patients. All patients were followed up for a period of 6 months post-operatively to determine functional outcome using harris hip score. We concluded that one stage bilateral total hip arthroplasty is safe and efficacious treatment modality for our patients. This study also demonstrates brisk rehabilitation in patients operated with single stage bilateral total hip arthroplasty.

Preoperative Vitamin K Reduces Blood Transfusions at Time of Left Ventricular Assist Device Implant

Congestive heart failure patients have hepatic congestion and abnormal coagulation profiles, increasing perioperative bleeding at time of ventricular assist device implantation. This study examined the impact of the preoperative administration of vitamin K on perioperative blood transfusion requirements. Retrospectively, 190 patients met inclusion criteria. Patients received no vitamin K (n= 62) or two 10-mg doses of intravenous vitamin K (n= 128) in the 24 hours before assist device implantation. Primary end points included transfusion requirements and reexploration rates for bleeding. Secondary outcomes were pump thrombosis and in-hospital mortality. Baseline characteristics were similar between the 2 groups, with slight differences (not statistically significant) noted in the Interagency Registry for Mechanically Assisted Circulatory Support profile and total bilirubin levels. The only significant difference noted was the year of implantation (P < .001). Blood product usage was significantly lower in the vitamin K group compared to the no vitamin K group (P < .001). Higher rates of reexploration for bleeding (29.7% vs 13.6%, P= .023) and death at hospital discharge (16.2% vs 2.8%, P= .004) were noted for the no vitamin K group compared with the vitamin K group. After adjusting for age, sex, race, body mass index, Interagency Registry for Mechanically Assisted Circulatory Support profile, total bilirubin, surgeon, and year of operation, reexploration rates and death did not achieve statistical significance. No statistically significant difference was observed in stroke and pump thrombosis rates between the 2 groups. Preoperative vitamin K administration may help reduce blood product use without any increased risk for strokes or pump thrombosis.