Perioperative Blood Transfusion Requirements Research Articles

Intravenous administration of desmopressin acetate to reverse acetylsalicylic acid‐induced coagulopathy in three dogs

Acetylsalicylic acid (ie, aspirin) administration inhibits platelet aggregation in dogs and is associated with increased perioperative blood loss and transfusion requirements in people. Desmopressin acetate (DDAVP) is used to control or prevent bleeding in dogs with type 1 von Willebrand disease and is also widely reported in the human literature as an emergency antithrombotic reversal agent. Three dogs undergoing surgery for intervertebral disc disease had marked prolongations in buccal mucosal bleeding time (BMBT) after aspirin administration. DDAVP was given intravenously preoperatively and achieved prompt reversal of the prolongation in BMBT. None of the dogs experienced intraoperative bleeding complications. IV DDAVP corrected prolongations in BMBT in dogs given aspirin and should be considered in dogs requiring prompt reversal of aspirin-induced coagulopathies to reduce the risk of bleeding complications.

A meta-analysis of the effectiveness and safety of using tranexamic acid in primary unilateral total knee arthroplasty

BackgroundTo evaluate the effectiveness and safety of tranexamic acid (TEA) treatment in reducing perioperative blood loss and transfusion for patients receiving primary unilateral total knee arthroplasty (TKA) and to explore the most effective and safe protocol. Materials and methodsThis study was based on Cochrane methodology for conducting meta-analyses. Only randomized controlled trials were eligible for this study. The participants were adults who had undergone primary unilateral TKA. The Review Manager Database (RevMan version 5.0, The Cochrane Collaboration, 2008) was used to analyze selected studies. ResultsNineteen randomized controlled trials involving 1114 patients were included. The use of TEA reduced postoperative drainage by a mean of 290 mL (95% confidence interval [CI] −385 to −196], total blood loss by a mean of 570 mL (95% CI −663 to −478), the number of blood transfusions per patient by 0.96 units (95% CI −1.32 to −0.59), and the volumes of blood transfusions per patient −440 mL (95% CI −518 to −362). TEA led to a significant reduction in the proportion of patients requiring blood transfusion (relative risk 0.39). There were no significant differences in venous thromboembolism or other adverse events among the study groups. ConclusionsIntravenous TEA could significantly reduce perioperative blood loss and blood transfusion requirements following primary unilateral TKA. Its application is not associated with increased risk of venous thromboembolisms or other adverse events.

Novel Temporalis Muscle and Fat Pad Morphomic Analyses Aids Preoperative Risk Evaluation and Outcome Assessment in Nonsyndromic Craniosynostosis

Analytical morphomics is the term we created to describe an innovative, highly automated, anatomically indexed processing of 3D medical imaging data captured during the course of a patients' preoperative CT scan. Our specific aim is to determine the efficacy of craniofacial morphomic indices (CMI) such as temporalis muscle and temporal fat pad morphometric values to predict blood transfusion requirement and hospital stay in a cohort of children with nonsyndromic craniosynostosis (NSC). High-throughput, semi-automated image analysis was used to reconstruct the 3-dimensional anatomy of the temporalis muscle and temporal fat pad and to quantify CMIs. The prognostic effect of CMI on clinical outcomes were evaluated among all NSC patients and compared across various craniosynostosis subtypes using Wilcoxon nonparametric tests and Kendall's τ to determine significance. Using preoperative CT images, we evaluated 117 children with NSC from the University of Michigan Health System. Results demonstrate that increased temporal fat pad volume and local temporalis muscle volume are associated with better clinical outcomes in craniosynostosis patients. More specifically, temporal fat pad volume was shown to be a significant predictor of perioperative blood transfusion requirements (P = 0.0033) and increased temporal muscle volume correlated with decreased hospital stay (P = 0.016) when controlling for other covariates including age, sex, weight, and preoperative hematocrit. In addition, the same significant predictors were found when examining individual subtypes of craniosynostosis. Our findings demonstrate that maxillofacial CT scans provide a useful quantitative index reflecting general patient health, risk stratification, and probabilities of intervention in addition to their previously established ability to determine the specific pathology of the patient. We demonstrate that temporal morphomics predict the incidence of blood transfusion, hospital stay, and serve as a proxy for fitness in patients undergoing craniosynostosis surgery.

The role of fusion in the management of burst fractures of the thoracolumbar spine treated by short segment pedicle screw fixation

The purpose of this study was to determine whether patients with a burst fracture of the thoracolumbar spine treated by short segment pedicle screw fixation fared better clinically and radiologically if the affected segment was fused at the same time. A total of 50 patients were enrolled in a prospective study and assigned to one of two groups. After the exclusion of three patients, there were 23 patients in the fusion group and 24 in the non-fusion group. Follow-up was at a mean of 23.9 months (18 to 30). Functional outcome was evaluated using the Greenough Low Back Outcome Score. Neurological function was graded using the American Spinal Injury Association Impairment Scale. Radiological outcome was assessed on the basis of the angle of kyphosis. Peri-operative blood transfusion requirements and duration of surgery were significantly higher in the fusion group (p = 0.029 and p < 0.001, respectively). There were no clinical or radiological differences in outcome between the groups (all outcomes p > 0.05). The results of this study suggest that adjunctive fusion is unnecessary when managing patients with a burst fracture of the thoracolumbar spine with short segment pedicle screw fixation.

Grafts for Mesenterico-Portal Vein Resections Can Be Avoided during Pancreatoduodenectomy

The aim of this study was to assess whether pancreatoduodenectomy (PD) and en bloc mesenterico-portal resection (PD+VR) could be performed with primary venous reconstruction, avoiding a vascular graft. In addition, the short-term surgical outcomes of this approach were compared with a standard PD (PD-VR). Two hundred twelve patients underwent PD between January 2004 and June 2011. Clinical data, operative results, pathologic findings, and postoperative outcomes were collected prospectively and analyzed. One hundred fifty patients (71%) had PD-VR and 62 patients underwent PD+VR. The majority (82%) of the venous reconstructions were performed with primary end-to-end anastomosis. Only 1 patient had synthetic interposition graft repair. The volume of intraoperative blood loss and the perioperative blood transfusion requirements were significantly greater, and the duration of the operation was significantly longer in the PD+VR group compared with the PD-VR group. There were no significant differences in the length of hospitalization, postoperative morbidity, or grades of complications between the 2 groups. Multivariate logistic regression identified American Society of Anesthesiologists score as the only predictor of postoperative morbidity. Fifty percent of patients with pancreatic adenocarcinoma (n = 101) required VR. A significantly higher rate of positive resection margins (p < 0.001) was noted in the PD+VR subgroup compared with PD-VR subgroup. Furthermore, high intraoperative blood loss and neural invasion were predictive of a positive resection margin. Pancreatoduodenectomy with VR and primary venous anastomosis avoids the need for a graft and has comparable postoperative morbidity with PD-VR. However, it is associated with an increased operative time, higher intraoperative blood loss, and, for pancreatic ductal adenocarcinoma, a higher rate of positive resection margins compared with PD-VR.

Impact of clopidogrel on bleeding complications and survival in off-pump coronary artery bypass grafting

This study investigated the impact of preoperative clopidogrel on bleeding complications and survival during and after off-pump coronary artery bypass grafting (OPCABG) and assessed the possible role of the antifibrinolytic agent aprotinin for attenuating blood loss after clopidogrel exposure. Prospectively collected data of 753 consecutive adult patients undergoing OPCABG were retrospectively reviewed; 139 (18.5%) patients received clopidogrel preoperatively. Statistical methods used were student paired t-test, Mann-Whitney U, Kruskal-Wallis, chi-square analysis and Kaplan-Meier with log-rank analysis. Clopidogrel was associated with a significant increase in perioperative blood loss (P=0.003) and more excessive postoperative haemorrhage (P=0.04). Overall transfusion rates (P=0.02) and the amount of administered blood products (P=0.01) were also higher after clopidogrel exposure. Intraoperative aprotinin reduced postoperative bleeding significantly in patients administered clopidogrel [18.7% after 24h (P=0.006) and 15.2% after 48h (P=0.03)] and attenuated excessive postoperative haemorrhaging. Five-year survival was markedly improved in clopidogrel-treated patients. Preoperative clopidogrel exposure does increase perioperative blood loss and blood transfusion requirements in patients undergoing OPCABG but has an otherwise excellent safety profile with a 94% 5-year survival rate. Aprotinin attenuated this blood loss. Based on these results a recommendation to discontinue clopidogrel prior to coronary artery bypass grafting cannot be maintained, if OPCABG strategies are considered.

Efficacy of Tranexamic Acid in Pediatric Craniosynostosis Surgery

Background: Extensive blood loss is common in pediatric craniosynostosis reconstruction surgery. Tranexamic acid (TXA) is increasingly used to reduce perioperative blood loss in various settings, but data on its efficacy are limited in children. The purpose of this randomized, double-blind, placebo-controlled, parallel trial was to evaluate the efficacy of TXA in pediatric craniosynostosis correction surgery. The primary and secondary outcome variables were reduction in perioperative blood loss and reduction in blood transfusion, respectively. Methods: Forty-three children, ages 2 months to 6 yr, received either placebo or TXA in a loading dose of 50 mg·kg ―1 , followed by an infusion of 5 mg·kg ―1 ·h ―1 during surgery. TXA plasma concentrations were measured. Results: The TXA group had significantly lower perioperative mean blood loss (65 vs. 119 ml·kg ―1 , P < 0.001) and lower perioperative mean blood transfusion (33 vs. 56 ml· kg ―1 , P = 0.006) compared to the placebo group. The mean difference between the TXA and placebo groups for total blood loss was 54 ml·kg ―1 (95% CI for the difference, 23-84 ml·kg ―1 ) and for packed erythrocytes transfused was 23 ml·kg ―1 (95% CI for the difference, 7-39 ml·kg ―1 ). TXA administration also significantly diminished (by two thirds) the perioperative exposure of patients to transfused blood (median, 1 unit vs. 3 units; P < 0.001). TXA plasma concentrations were maintained above the in vitro thresholds reported for inhibition of fibrinolysis (10 μg·ml ―1 ) and plasmin-induced platelet activation (16 μg·ml ―1 ) throughout the infusion. Conclusions: TXA is effective in reducing perioperative blood loss and transfusion requirement in children undergoing craniosynostosis reconstruction surgery.

Efficacy of Tranexamic Acid in Pediatric Craniosynostosis Surgery

Extensive blood loss is common in pediatric craniosynostosis reconstruction surgery. Tranexamic acid (TXA) is increasingly used to reduce perioperative blood loss in various settings, but data on its efficacy are limited in children. The purpose of this randomized, double-blind, placebo-controlled, parallel trial was to evaluate the efficacy of TXA in pediatric craniosynostosis correction surgery. The primary and secondary outcome variables were reduction in perioperative blood loss and reduction in blood transfusion, respectively. Forty-three children, ages 2 months to 6 yr, received either placebo or TXA in a loading dose of 50 mg·kg(-1), followed by an infusion of 5 mg·kg·h(-1) during surgery. TXA plasma concentrations were measured. The TXA group had significantly lower perioperative mean blood loss (65 vs. 119 ml·kg(-1), P < 0.001) and lower perioperative mean blood transfusion (33 vs. 56 ml· kg(-1), P = 0.006) compared to the placebo group. The mean difference between the TXA and placebo groups for total blood loss was 54 ml·kg(-1) (95% CI for the difference, 23-84 ml·kg(-1)) and for packed erythrocytes transfused was 23 ml·kg(-1) (95% CI for the difference, 7-39 ml·kg(-1)). TXA administration also significantly diminished (by two thirds) the perioperative exposure of patients to transfused blood (median, 1 unit vs. 3 units; P < 0.001). TXA plasma concentrations were maintained above the in vitro thresholds reported for inhibition of fibrinolysis (10 μg·ml(-1)) and plasmin-induced platelet activation (16 μg·ml(-1)) throughout the infusion. TXA is effective in reducing perioperative blood loss and transfusion requirement in children undergoing craniosynostosis reconstruction surgery.

Comparison of Blood-Sparing Efficacy of ε-Aminocaproic Acid and Tranexamic Acid in Newborns Undergoing Cardiac Surgery

ε-Aminocaproic acid (EACA) and tranexamic acid (TXA) are used for antifibrinolytic therapy in neonates undergoing cardiac surgery, although data directly comparing their blood-sparing efficacy are not yet available. We compared two consecutive cohorts of neonates for the effect of these two medications on perioperative blood loss and allogeneic transfusions. Data from the EACA group (n = 77) were collected over a 12-month period; data from the tranexamic acid group (n = 28) were collected over a 5-month period. Blood loss, rate of reoperation due to bleeding, and transfusion requirements were measured. There was no significant difference in blood loss at 6 hours (EACA 24 [17-30] mL/kg [median (interquartile range)] vs. TXA 20 [11-34] mL/kg, P = 0.491), at 12 hours (EACA 31 [22-38] mL/kg vs. TXA 27 [19-43] ml/kg, P = 0.496) or at 24 hours postoperatively (EACA 41 [31-47] mL/kg vs. TXA 39 [27-60] mL/kg; P = 0.625) or transfusion of blood products. ε-Aminocaproic acid and tranexamic acid are equally effective with respect to perioperative blood loss and transfusion requirements in newborns undergoing cardiac surgery.

Effect of Hydroxyethyl Starch 130/0.4 on Blood Loss and Coagulation in Patients With Recent Exposure to Dual Antiplatelet Therapy Undergoing Off-Pump Coronary Artery Bypass Graft Surgery

Hydroxyethyl starch (HES) solutions are often used for maintaining intravascular volume and improving microperfusion, while a large amount of HES can cause adverse effects on coagulation. As the indications for clopidogrel expand, an increasing number of patients undergoing off-pump coronary artery bypass surgery (OPCAB) are also undergoing dual antiplatelet therapy (DAPT), with its higher risk of bleeding complications. The aim of the present study was to determine whether a moderate dose of 6% HES 130/0.4 significantly increases perioperative blood loss in patients with continued DAPT within 5 days of OPCAB. Patients who received clopidogrel and aspirin within 5 days of OPCAB were randomly allocated to receive HES 130/0.4 (≤ 30 ml/kg) followed by crystalloid infusion (HES group, n=53), or crystalloid only (crystalloid group, n=53) perioperatively. The amount of perioperative blood loss (sum of bleeding during the intraoperative and postoperative 24-h period), transfusion requirements, modified thromboelastography and coagulation variables, hemodynamic parameters, and fluid balance were recorded. Perioperative blood loss and coagulation profiles were similar between the groups, but the postoperative hemoglobin level was higher in the crystalloid group. Up to 30 ml·kg⁻¹·day⁻¹ of 6% HES 130/0.4 did not increase the perioperative blood loss compared to crystalloid in patients with recent exposure to DAPT undergoing OPCAB. HES 130/0.4 caused a similar degree and duration of coagulation impairment as observed when only crystalloid was given.

Blood Transfusion Prediction in Patients Undergoing Major Head and Neck Surgery With Free-Flap Reconstruction

to develop a clinically useful perioperative blood transfusion prediction model for patients undergoing a major head and neck surgical procedure requiring free-flap reconstruction. retrospective observational study. tertiary care university-affiliated teaching hospital (University Health Network, Toronto, Ontario, Canada). all patients with a head and neck malignant neoplasm undergoing major head and neck surgery requiring free-flap reconstruction. perioperative single-unit red blood cell transfusion. all the preoperative variables were tested for an association with perioperative blood transfusion using univariable and multivariable analyses. After multivariable regression analysis, the following preoperative variables were found to be significantly associated with perioperative transfusion: sex, body mass index, T stage, preoperative hemoglobin level, and type of free-flap reconstruction used (ie, osseous vs nonosseous). The regression model was used to develop a transfusion risk score. Receiver operating characteristic curve analysis confirmed adequate discrimination of risk using the transfusion risk score. we have developed a reliable model for predicting perioperative blood transfusion requirements in patients undergoing major head and neck surgery requiring free-flap reconstruction. This model can be used for accurate preoperative risk stratification.

ROTEM and multiplate – a suitable tool for POC?

The early recognition of perioperative coagulation disorders is essential to identify non-surgical reasons of bleeding, to initiate appropriate haemostatic treatment and finally to reduce perioperative blood loss. Conventional laboratory coagulation tests include prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen levels and platelet counts. Although these parameters are frequently assessed, their value has been challenged at least in the setting of acute perioperative bleeding [1]. PT and aPTT are performed in an artificial ‘in vitro’ system, i.e. in plasma separated from whole blood, which is then warmed to 37 C and buffered to a pH of 7AE4. These standardized conditions often do not reflect the patient’s situation [2]. Plasmatic ‘in vitro’ tests merely reflect the time elapsing until the activation of thrombin, but provide only marginal information about the functional state of the coagulation system (e.g. platelet function, interaction of plasmatic coagulation factors with platelets and red blood cells, clot firmness, fibrinolysis). Routine coagulation tests are mostly performed in the central laboratory, i.e. remote from the operating theatre. As a consequence, test results are often not available in time or with a considerable delay [3]. Current devices designed for point-of-care (POC) monitoring of coagulation have been designed for the assessment of coagulation directly at the bedside, so that results could be available earlier. Moreover, POC tests are usually performed in whole blood, thereby comprising interactions between cellular components (i.e. platelets and red blood cells) and plasmatic coagulation factors. Commonly used POC devices for assessment of plasmatic coagulation and platelet function are listed in Table 1. This review focuses on rotation thrombelastography (ROTEM ) as a global coagulation test and multiple electrode aggregometry (MEA, Multiplate ) for assessment of platelet function. Rotation thrombelastometry (ROTEM )

Blood transfusion requirements in elective breast reconstruction surgery

Introduction Excess-ordering of cross-matched blood in preparation for elective surgery is expensive with associated blood shortages and time-expired wastage. Although, the maximum surgical blood order schedule (MSBOS) for breast reconstruction recommends pre-operative cross-match of 2–6 units of red cell concentrate, there is no data confirming whether this guideline is observed in practice or whether compliance results in improved outcome. The aim of this study was to examine the utility of this MSBOS in clinical practice by assessing its performance in a validation set of patients. Materials and Methods Over a three year period, 49 patients undergoing 50 consecutive elective breast reconstruction surgery were assessed for demographic data, surgical information and hematological/transfusion data to compare the number of units of blood cross-matched with those subsequently transfused for elective breast reconstruction surgery. This was in lieu of updating the current maximal surgical blood order schedule of cross-matching 2–6 units pre-operatively. Results Fifty elective operations were undertaken during the study period with a zero peri-operative blood transfusion requirement and a 8% post-operative blood transfusion requirement. Pre-operative cross-match to transfusion ratio was unacceptably high with a time-expired blood wastage of 8.7%. Discussion These data thus indicate that adoption of a type and screen policy is satisfactory for haemorrhage risk management of elective breast reconstruction. The MSBOS is not designed to predict post-surgery blood needs and a requirement based blood ordering protocol will optimise blood utilisation efficiency.

Antifibrinolytics in Major Orthopaedic Surgery

Total joint arthroplasty and deformity surgery of the spine can require complex reconstructive procedures accompanied by the potential for major blood loss. In an attempt to minimize the perioperative blood loss associated with these procedures, recent focus has concentrated on the efficacy of pharmacologic agents. Antifibrinolytics such as epsilon-aminocaproic acid, tranexamic acid, and aprotinin have been shown to reduce perioperative blood loss, autologous blood donation, transfusions, and associated costs in cardiac as well as major orthopaedic surgery. These agents reduce perioperative blood loss by inhibition of clot breakdown. Prospective, randomized studies have shown that the use of these agents can be effective in reducing the perioperative blood loss and transfusion requirements in total joint arthroplasty, pediatric scoliosis surgery, and adult reconstructive surgery of the spine. Aprotinin, however, is currently under suspension from use pending further evaluation of a trial. Although concerns exist about increased thrombotic events with the use of these agents, large meta-analyses suggest that antifibrinolytics can be safely and efficaciously employed to decrease perioperative blood loss and transfusion requirements.

Perioperative outcomes after transition from conventional to minimally invasive Ivor-Lewis esophagectomy in a specialized center

Minimally invasive techniques are now increasingly adopted for the treatment of esophageal cancers. Benefits such as earlier functional recovery and less need for transfusion and intensive care stay should be balanced by a determination to avoid compromise to the oncologic integrity of the procedure, especially in the early phase of transition from open to laparoscopic surgery. This study aimed to compare primary outcomes including oncologic clearance, complications, and functional recovery between open and laparoscopic esophagectomy in a single center. This prospective study recruited 75 consecutive patients undergoing Ivor-Lewis esophagectomy, all treated by a single surgeon. These patients were divided into three groups. The 24 patients in group A underwent open Ivor-Lewis esophagectomy. The remaining patients underwent laparoscopic Ivor-Lewis esophagectomy in two groups: 25 patients in an early cohort (group B) and 26 patients in a later cohort (group C). All the patients were treated according to the same protocol. The three groups were adequately matched. The findings showed trends toward a reduction in median operative time, with group A requiring 260 min, group B requiring 249 min, and group C requiring 223 min (p = 0.06), and a significant reduction in the requirement for perioperative blood transfusion between groups A (65%) and C (27%) (p = 0.02). The median lymph node yield was significantly less in group B (n = 13) than in group A (n = 24) or group C (n = 22) (p = 0.003). There was no significant difference between the three groups in the length of hospital stay (median stay, 14-16 days) or the requirement for critical care beds (median stay, 3-4 days). The in-hospital mortality rate was zero, and the morbidity rate did not differ between the three groups. This study shows that laparoscopic Ivor-Lewis esophagectomy is associated with a reduced need for blood transfusion, a shorter operative time, and an adequate lymph node harvest. Oncologic principles are not compromised during the transition phase from open to laparoscopic esophagectomy.

Perioperative Blood Transfusion Requirements in Pediatric Scoliosis Surgery

Previous studies have noted that the use of antifibrinolytic medications can help reduce blood loss and transfusion requirements during cardiac, total joint arthroplasty, and spine surgery. Tranexamic acid (TXA) has been investigated in these patient groups but consensus with respect to the dosing regimen has not been achieved, especially in the pediatric scoliosis literature. The purpose of this study was to compare the effects of 2 TXA dosing regimens on reducing transfusion requirements. A retrospective chart review was performed on all idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion from 2005 to 2006 to determine total perioperative transfusion requirements. Transfusion requirements for those patients receiving either a low (10 mg/kg loading, 1 mg/kg/h infusion) or high (20 mg/kg loading, 10 mg/kg/h infusion) dose of TXA were compared. High-dose TXA (n = 11) showed a trend toward a reduction in transfusion requirements compared with the low dose (n = 15) for idiopathic scoliosis patients undergoing posterior only instrumentation and fusion (687.9 +/- 778.1 mL vs 1372.6 +/- 1077.3 mL; P = 0.07; 95% confidence interval for the mean difference, -66.3 mL to 1435.7 mL). Although substantial, this difference was underpowered to show a difference. The use of the higher dose of TXA resulted in a 50% reduction in transfusion requirements for idiopathic scoliosis patients. Given previous studies, there appears to be a dose-response effect. A prospective dose-ranging study is now required to determine the optimal dose for pediatric patients with idiopathic scoliosis. III, retrospective cohort study.

Preoperative use of epoietin beta in total hip replacement: a prospective study

Epoietin (EPO) effectively decreases perioperative blood transfusion requirements. We evaluated the feasibility of using EPO beta to increase haemoglobin levels before total hip replacement (THR) and reduce transfusion. One hundred and seventy-one patients undergoing primary THR were included in this prospective observational study. Patients with initial haemoglobin level <130 g l−1 received EPO beta subcutaneously in a four-dose regimen. Haemoglobin levels were measured at baseline, before surgery, and at postoperative days 1 and 5. Twenty-eight patients received EPO beta preoperatively, 143 were not treated including 42 with initial haemoglobin level <130 g l−1. Haemoglobin increased by 29 ± 9 g l−1 in the low Hb + EPO group versus 2 ± 1 g l−1 for the other patients. In the low Hb + EPO group 3.6% were transfused, in the low HB group 45.2% (P = 0.001) and in the normal Hb group 11.9% (P = 0.2). Preoperative EPO beta increases haemoglobin level and reduces transfusion frequency in anaemic patients before total joint replacement. It could play a major role in the management of perioperative blood loss in orthopaedic surgery.

Role of Amicar in Surgery for Neuromuscular Scoliosis

A retrospective case-control study. Evaluate the effectiveness of Amicar in decreasing perioperative blood loss in patients with neuromuscular scoliosis undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI). Previously, a preliminary prospective; prospective randomized double-blind; same-day anterior and posterior spinal fusion; and fibrinogen studies have demonstrated Amicar to be effective in decreasing total perioperative blood loss and transfusion requirements in surgery for idiopathic scoliosis. Increased fibrinogen secretion is a possible explanation. We are now analyzing its effectiveness in neuromuscular scoliosis. Amicar was administered at 100 mg/kg over 15 minute not to exceed 5 g after anesthesia induction. Maintenance is 10 mg/kg/h until wound closure. There were 2 study groups: group 1 (n = 34), no Amicar and group 2 (n = 62) who received Amicar. The majority of patients in both groups had cerebral palsy. Total perioperative blood loss was determined from the estimated intraoperative blood loss and measured postoperative suction drainage. Total perioperative blood loss and transfusion requirements (cell saver and allogeneic) were compared using chi or Fisher exact test. There was statistically less estimated intraoperative blood loss, total perioperative blood loss, and transfusion requirements in group 2. Postoperative suction drainage was also less but did not reach statistical significance. In group 1, estimated intraoperative blood loss, measured postoperative suction drainage, and total perioperative blood loss were 2194 +/- 1626 mL, 903 +/- 547 mL, and 3055 +/- 1852 mL, whereas in group 2, it was 1125 +/- 715 mL, 695 +/- 489 mL, and 1805 +/- 940 mL. Transfusion requirements were 1548 +/- 962 mL in group 1 but only 660 +/- 589 mL in group 2 (P < 0.0001). Amicar was equally effective in all diagnoses. There were no complications related to the use of Amicar. Amicar was highly effective in decreasing perioperative blood loss and transfusion requirements in patients with neuromuscular scoliosis undergoing PSF and SSI. It was most effective in decreasing estimated intraoperative blood loss. This results in decreased transfusion requirements, costs, and potential transfusion-related complications.

The Role of Amicar in Same-Day Anterior and Posterior Spinal Fusion for Idiopathic Scoliosis

A retrospective study of the effectiveness of Amicar (epsilon aminocaproic acid). Evaluate the effectiveness of Amicar in decreasing perioperative blood loss and transfusion requirements in same-day anterior (ASF) and posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI) for idiopathic scoliosis. Preliminary prospective, prospective randomized double-blind, and fibrinogen studies have demonstrated Amicar to be effective in decreasing perioperative blood loss in patients with idiopathic scoliosis undergoing PSF with SSI. Increased fibrinogen secretion is a possible explanation. There were 73 consecutive patients divided into 3 study groups based on the administration of Amicar: Group 1 (n = 16), no Amicar; Group 2 (n = 18), Amicar for the PSF with SSI only; and Group 3 (n = 39), Amicar for both ASF and PSF with SSI. All patients were managed using the same general anesthesia technique, intraoperative procedure, postoperative care path, and indications for transfusion (hemoglobin <7 g/dL). Total perioperative blood loss (estimated intraoperative blood loss for both procedures and measured postoperative chest tube and PSF wound suction drainage) and total transfusion requirements between groups were compared using one-way ANOVA. There were statistically significant decreases in mean estimated intraoperative PSF with SSI, total perioperative blood loss, and transfusion requirements in the 2 Amicar groups. However, Amicar had no significant effect on estimated intraoperative ASF blood loss, chest tube drainage, or PSF wound suction drainage. Total perioperative blood loss and transfusion requirements (cell saver, autologous, directed, and allogeneic blood) were: 3442.8 +/- 1344.0 mL and 1537.1 +/- 905.1 mL in Group 1; 2089.8 +/- 684.0 mL and 485.2 +/- 349.8 mL in Group 2; and 2184.1 +/- 1163.7 mL and 531.5 +/- 510.5 mL in Group 3. There were no Amicar related complications. Amicar was highly effective in decreasing total perioperative blood loss and transfusion requirements in same-day ASF and PSF with SSI for idiopathic scoliosis. It results in less preoperative autologous blood donation, perioperative blood transfusion, costs, and potential transfusion-related complications. It was most effective in decreasing intraoperative estimated PSF with SSI blood loss. It had no significant effect during the ASF, postoperative chest tube, or PSF wound suction drainage. We now recommend that it be used for the PSF with SSI procedure only.

Outcomes of surgical management for popliteal artery aneurysms: An analysis of 583 cases

This study aimed to analyze outcomes of surgical management for popliteal artery aneurysms (PAA). This is a retrospective analysis of prospectively collected data regarding operations for PAA obtained from 123 United States Veterans Affairs Medical Centers as part of the National Surgical Quality Improvement Program. Univariate analyses and multivariate logistic regression were used to characterize 33 risk factors and their associations with 30-day morbidity and mortality. Survival and amputation rates, observed at one and two years after surgery, were subject to life-table and Cox regression analyses. There were 583 operations for PAA in 537 patients during 1994-2005. Almost all were in men (99.8%) and median age was 69 years (range, 34 to 92 years). Most had multiple co-morbidities, 88% were ASA (American Society of Anesthesiologists) class 3 or 4, and 81% were current or past smokers (median pack-years = 50). Only 16% were diabetic. Serious complications occurred in 69 (11.8%) cases, of which 37 (6.3%) required arterial-specific reinterventions. Eight patients died within 30 days, a mortality of 1.4%. Risk factors associated with increased complications included: African-American race (odds ratio [OR] 2.8 [95% confidence interval 1.5-5.2], P = .002), emergency surgery (OR 3.8 [2.0-7.0], P < .0001), ASA 4 (OR 1.9 [1.1-3.5], P = .04), dependent functional status (OR 2.5 [1.4-4.7], P = .004), steroid use (OR 3.2 [1.2-8.7], P = .03), and need for intraoperative red blood cell transfusion of any quantity (OR 6.3 [3.5-11.2], P < .0001). Independent predictors for complications in the multivariate model were dependent functional status (adjusted OR 2.1 [1.1-4.3], P = .049) and intraoperative transfusion (adjusted OR 4.5 [2.3-8.9], P = .0002). Postoperative bleeding complications within 72 hours independently predicted early amputation (adjusted OR 25.5 [1.7-393], P = .02). Unadjusted patient survival was 92.6% at one year and 86.1% at two years. Limb salvage in surviving patients was 99.0% at 30 days, 97.6% at one year, and 96.2% at two years. Dependent preoperative functional status was the only factor predictive of worse two-year limb salvage (adjusted OR 4.6 [1.9-10.9], P = .001), but remained high at 88.2% versus 97.1% in independent patients. Surgical intervention for PAA is associated with low operative mortality and offers excellent two-year limb salvage, even in high-risk patients. Patients' preoperative functional status and perioperative blood transfusion requirements were the most predictive indicators of negative outcomes.