Risk Of Intraoperative Blood Loss Research Articles

A comparative study of blood loss during caesarean myomectomy and caesarean section

Background: Uterine enlargement and associated increase in its vascularity during pregnancy are believed to increase the risk of haemorrhage and thus caesarean myomectomy is often avoided. However, some reports have claimed that caesarean myomectomy is safe during caesarean section. Aim: This study aims to compare blood loss during caesarean myomectomy and caesarean section with a view to determine the safety of carrying out a caesarean myomectomy. Methods: A retrospective review of all parturient that had caesarean myomectomy (study group) or caesarean section (control group) in a Cottage Hospital in the Niger Delta from September 2011 to August 2012 was carried out. The patients with incomplete data, those with previous abdominal surgery and placental disease and emergency caesarean section were excluded from the study. Data were collated on intraoperative blood loss, intraoperative blood transfusion and packed cell volume (PCV) change. Data were analysed using the SPSS version 16.0 software. Results: There was no statistical difference in the mean age of the parturient in the study (31.3 ± 3.9 years) and control (30.9 ± 3.4 years; P = 0.72) groups. The mean estimated blood loss between the study group (670.8 ± 227.9 ml) and control group (575.0 ± 226.5 ml) was not statistically significant ( P = 0.15). However, the PCV change between the study group (7.5% ±3.4%) and control group (5.2% ±2.9%) was statistically significant ( P = 0.002), with a higher incidence of post-operative anaemia observed in the study group ( P = 0.035). Conclusion: Caesarean myomectomy significantly increases the risk of intraoperative blood loss which can easily be underestimated, resulting in undertransfusion and anaemia with its associated complications. Caesarean myomectomy should, therefore, be carried out when benefits outweigh the risk and appropriate precaution should be put in place to manage possible intra- and post-operative anaemia.

ДВУСТОРОННЯЯ ОДНОМОМЕНТНАЯ ВИДЕОАССИСТИРОВАННАЯ РЕЗЕКЦИЯ ЛЕГКИХ ИЗ ОДНОСТОРОННЕГО ДОСТУПА У БОЛЬНЫХ ТУБЕРКУЛЕЗОМ

Goal of the study : to compare two surgical tactics for the treatment of bilateral pulmonary tuberculosis. Materials and methods : 189 patients with tuberculous lesions in both lungs underwent lung resections: 91 patients had it done simultaneously on both lungs from the unilateral intercostal-mediastinal access by video-assisted thoracoscopy; 98 patients had resections of the left and right lung done one after another, time period between resections made 20.8 ± 9.4 days on the average. Results . When comparing two tactics – simultaneous bilateral lung resection from a unilateral access and bilateral consecutive resections the following results were obtained respectively: 100 and 96.9% of patients had sputum conversion (p = 0.09, χ2); 100 and 93.8% of patients had healing of lung cavities (p = 0.11, χ2 ). During simultaneous surgery, the risk of intra-operative blood loss exceeding 300 ml was much lower (OR = 9.94; 95% CI 8.60-11.28) as well as the risk of postoperative complications (OR = 2.11; 95% CI 1.89-2.33).

The Role of Permissive and Induced Hypotension in Current Neuroanesthesia Practice.

Induced hypotension (IH) had been used for decades in neurosurgery to reduce the risk for intraoperative blood loss and decrease blood replacement. More recently, this method fell out of favor because of concerns for cerebral and other end-organ ischemia and worse treatment outcomes. Other contributing factors to the decline in its popularity include improvements in microsurgical technique, widespread use of endovascular procedures, and advances in blood conservation and transfusion protocols. Permissive hypotension (PH) is still being used occasionally in neurosurgery; however, its role in current anesthesia practice remains unclear. Our objective was to describe contemporary utilization of IH and PH (collectively called PH) in clinical practice among members of the Society for Neuroscience in Anesthesiology and Critical Care (SNACC). A questionnaire was developed and distributed among SNACC members that addressed practice patterns related to the use of PH. The responses were analyzed based on the number of individuals who responded to each specific question. Of 72 respondents, 67.6% reported over 10 years of clinical experience, while 15.5% reported 5-10 years of post-training experience. The respondents admitted to providing anesthesia for 300 (median) neurosurgical cases per year. PH was applied most commonly during open interventions on cerebral aneurysms (50.8%) and arteriovenous malformations (46%). Seventy-three percent of respondents were not aware of any complications in their practice attributable to PH. PH is still being used in neuroanesthesia practice by some providers. Further research is justified to clarify the risks and benefits of PH in modern neuroanesthesia practice.

An evaluation of laparoscopic hysterectomy alone versus in combination with laparoscopic myomectomy for patients with uterine fibroids

ObjectiveThe purpose of this study was to compare surgical outcomes following conventional laparoscopic hysterectomy (LH) (C-LH) versus the combination method of LH plus laparoscopic myomectomy (LM) (LH+LM) for the treatment of large uterine fibroids. Study designThis study was performed in 56 patients (uterine weights ≥500g) who underwent either C-LH or LH+LM performed by the same surgeon between May 2010 and May 2016. LH+LM was performed when C-LH was problematic because of poor visibility and/or mobility due to uterine fibroids. ResultsThe C-LH and LH+LM groups consisted of 27 (48%) and 29 (52%) patients, respectively. The clinical characteristics of patients differed significantly only in the median sizes of the dominant fibroid. The sizes of the dominant fibroid in the C-LH and LH+LM groups were 9.5cm and 10.7cm (P=0.04), respectively. Regarding the surgical outcomes for the C-LH and LH+LM groups, the median uterine weights were 558g and 737g (P=0.03), respectively, the median operating times were 156min and 173min (P=0.23), respectively, and the median intraoperative blood losses were 150g and 300g (P=0.0004), respectively. In all patients, LH was performed without conversion to laparotomy and there were no cases of bladder, ureteral, or gastrointestinal tract injury. There were no postoperative complications of Clavien-Dindo scale≥III in either group. ConclusionsWhen C-LH cannot be performed because of large uterine fibroids that cause poor visibility and/or mobility, LH+LM may allow the procedure to be successfully completed without conversion to laparotomy. However, the latter approach increases the risk for intraoperative blood loss.

Chronic Antiplatelet Use Associated With Increased Blood Loss in Lumbar Spinal Surgery Despite Adherence to Protocols.

There are conflicting reports regarding postoperative bleeding risks associated with discontinuation of antiplatelet therapy at least 7 days preoperatively. Most of the studies in the spine literature are based on surveys or anecdotal evidence. The majority of surgeons discontinue therapy 7 days preoperatively, but this varies widely from 5 to 21 days. The purpose of this retrospective study was to assess whether chronic antiplatelet use is associated with increased intraoperative blood loss, need for transfusion, and perioperative complications. Of 454 patients who underwent elective lumbar spinal surgery, 85 were on antiplatelet therapy and 369 were not. All patients stopped antiplatelet therapy at least 7 days preoperatively with approval from their cardiologist or primary care provider. Multiple regression analysis was performed and corrected for age, sex, antiplatelet therapy, number of levels decompressed/fused/instrumented, preoperative hematocrit, and postoperative hematocrit. Results showed that preoperative antiplatelet therapy, despite at least 7 days of discontinuation, is a statistically significant predictor (P=.04) of increased intraoperative blood loss. Blood transfusion was not associated with antiplatelet use but was associated with the number of levels fused, age, and low preoperative hematocrit (all P<.01). There were no recorded complications in either group. The authors conclude that antiplatelet therapy is associated with an increased risk of intraoperative blood loss in spine patients despite discontinuation at least 7 days preoperatively, but the clinical significance of this is unclear given the lack of association with blood transfusions and perioperative complications. [Orthopedics. 2016; 39(4):e695-e700.].

Exploring the metabolic syndrome: Nonalcoholic fatty pancreas disease.

After the first description of fatty pancreas in 1933, the effects of pancreatic steatosis have been poorly investigated, compared with that of the liver. However, the interest of research is increasing. Fat accumulation, associated with obesity and the metabolic syndrome (MetS), has been defined as “fatty infiltration” or “nonalcoholic fatty pancreas disease” (NAFPD). The term “fatty replacement” describes a distinct phenomenon characterized by death of acinar cells and replacement by adipose tissue. Risk factors for developing NAFPD include obesity, increasing age, male sex, hypertension, dyslipidemia, alcohol and hyperferritinemia. Increasing evidence support the role of pancreatic fat in the development of type 2 diabetes mellitus, MetS, atherosclerosis, severe acute pancreatitis and even pancreatic cancer. Evidence exists that fatty pancreas could be used as the initial indicator of “ectopic fat deposition”, which is a key element of nonalcoholic fatty liver disease and/or MetS. Moreover, in patients with fatty pancreas, pancreaticoduodenectomy is associated with an increased risk of intraoperative blood loss and post-operative pancreatic fistula.

Utilization and timing of blood transfusions following open and robot-assisted radical prostatectomy.

Radical prostatectomy (RP) is associated with a high risk of intraoperative blood loss and subsequent blood transfusions. The shift in surgical technique from open radical prostatectomy (ORP) to robot-assisted radical prostatectomy (RARP) has resulted in lower operative blood loss, and reduced the need for transfusions. We analyzed the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database to compare real-world, contemporary trends in utilization and timing of blood transfusion following ORP and RARP. We identified men undergoing both RARP and ORP and then queried for patients who received a blood transfusion in the perioperative period. The outcomes of interest were need and timing of perioperative blood transfusion (PBT), which was categorized into early (postoperative day [POD] ≤1) or late (POD ≥2). Logistic regression analysis was used to identify variables associated with the need and timing for PBT. A total of 16,144 men who underwent RP were identified from 2007 to 2012. The overall PBT rate was 3.1%. Highest rate of transfusions occurred on day of surgery for patients undergoing ORP, and first POD for patients undergoing RARP. On multivariate analysis significant predictors of blood transfusion included history of bleeding disorder (OR: 2.8, p=0.002), preoperative dyspnea (odds ratio [OR]: 1.7, p=0.03), starting hematocrit <42% (OR: 1.9, p<0.001), open approach (OR: 0.09, p<0.001), year of surgery (OR: 0.5, p<0.001), resident involvement (OR: 1.6, p=0.003), and operative time (OR: 4.4, p<0.001). The only predictor of receiving a blood transfusion on POD 2 or later was having the procedure performed through a robot-assisted approach (OR: 3.7, p<0.001). In this study we found that the rate of perioperative transfusions is lower than previously published. A clear separation in timing of transfusion exists based on the utilized surgical approach. It is prudent that surgeons performing RARP be aware of the low, but present risk of a delayed blood transfusion.

Impact of Thoracic Epidural Analgesia on Blood Loss in Radical Retropubic Prostatectomy

Introduction: Radical retropubic prostatectomy (RRP) is associated with an increased risk of intraoperative blood loss and the necessity of transfusions. This prospective randomised clinical study evaluates the influence of thoracic epidural analgesia (TEA) on blood loss in RRP. Materials and Methods: 235 patients were randomised: TEA in group 1 (n = 116; general anaesthesia + TEA) comprised continuous administration of 0.25% bupivacaine, while group 2 (n = 119; general anaesthesia alone) received intravenous analgesia with fentanyl (intubation: 2 µg/kg; maintenance: 0.1- 0.3 mg). A restrictive infusion regimen (<1,000 ml until specimen removal) was administered in both groups. Blood loss, infusion rates and anaesthesiological parameters were recorded and analysed using regression models and analyses of variance. Results: Haemoglobin difference between the pre- and the first postoperative day (group 1: 3.35 ± 1.16 g/dl; group 2: 3.56 ± 1.42 g/dl; p = 0.19), overall blood loss (group 1: 665 ± 431.5 ml; group 2: 705 ± 881 ml; p = 0.73) and transfusion rates (0.4% intraoperatively; 2.55% postoperatively; p = 1.0) did not show group differences. In regression analysis blood loss was influenced by preoperative haemoglobin levels (p < 0.0001), patients' weight (p = 0.018) and duration of the operation (p = 0.017). Conclusions: This study did not demonstrate a direct impact of TEA on intraoperative blood loss and transfusion rates in RRP. Further randomised clinical trials are needed to evaluate an impact of the different anaesthetic procedures presented alone or in combination on blood loss.

Preoperative identification of intraoperative blood loss of more than 1,500 mL during elective hepatectomy

Despite recent advances in surgical techniques, hepatectomies remain one of the most hemorrhagic procedures in abdominal surgery. It is important to identify preoperatively patients who are at high risk of suffering massive intraoperative blood loss. The clinical records of 251 patients who underwent an elective hepatectomy for liver tumors between September 2007 and December 2009 were reviewed retrospectively. A multivariate logistic regression analysis of preoperative factors potentially influencing intraoperative blood loss was performed. We set the cut-off value of the amount of blood loss for safe hepatectomy as less than 1,500 mL because no patients with blood loss of less than 1,500 mL received blood transfusion in this study. A scoring system to predict blood loss of more than 1,500 mL was constructed and validated in a cohort of 59 subsequent patients. Intraoperative blood loss of more than 1,500 mL was recognized in 35 of 251 patients (13.9%). Prothrombin activity < 70%, nonperipheral location of the tumor, involvement of hepatic veins, body mass index ≥ 23.0, and major hepatectomy were independently associated with intraoperative blood loss of more than 1,500 mL. The score was calculated by assigning 1 point for each of the 5 risk factors. The area under the receiver operating characteristic curve (AUC) was 0.814 (95% CI 0.731-0.898). This scoring system was highly predictive in the subsequent validation group of 59 patients (AUC = 0.839, 95% CI 0.710-0.969). This predictive scoring system is considered to be useful for identifying before hepatectomy those patients with a high risk of intraoperative blood loss of more than 1,500 mL.

This Month in Anesthesiology

The authors examined the epidemiology of perioperative AIS in three common surgeries in adult patients: hemicolectomy, total hip replacement, and lobectomy/segmental lung resection. Data were extracted from a national database in the United States for the years 2000 to 2004. Patients with perioperative AIS were identified as were comorbid conditions that may be risk factors for perioperative AIS. Those who developed perioperative AIS were as follows: 0.7% of hemicolectomy patients, 0.2% of total hip replacement patients, and 0.6% of lobectomy/segmental lung resection patients. For patients older than 65, AIS rose to 1.0% for hemicolectomy, 0.3% for hip replacement, and 0.8% for pulmonary resection. Perioperative AIS is an important source of morbidity and mortality associated with noncardiac, nonvascular surgery particularly in elderly patients. See the accompanying Editorial View on page 209 Anesthetic requirements of the fruit fly mutant minisleeper and other Drosophila mutants were determined based on the response of the flies at different concentrations of isoflurane and sevoflurane. The average amount of daily sleep in wild-type Drosophila was 965 minutes but only 584 minutes in minisleeper mutant flies. The EC50values in wild-type Drosophila were 0.706 for isoflurane and 1.298 for sevoflurane; however, EC50values in the minisleeper mutant flies for isoflurane and sevoflurane were 1.306 and 2.013, respectively. A single-gene mutation in Drosophila that causes an extreme reduction in daily sleep is responsible for a significant increase in the requirement of volatile anesthetics. This study has implications for sleep and mechanisms of anesthesia and sedation.Hyperglycemia in perioperative patients has been identified as a risk factor for morbidity and mortality. Intensive insulin therapy (IIT) has been shown to reduce morbidity and mortality among the critically ill, decrease infection rates and improve survival after cardiac surgery, and improve outcomes in acute neurological injury and acute myocardial infarction. However, severe hypoglycemia and adverse events associated with IIT are a concern. The authors summarize the mechanisms and rationale of hyperglycemia and IIT, and review the evidence behind the use of IIT in the perioperative period. While avoidance of hyperglycemia is clearly beneficial, the appropriate glucose target and specific subpopulations that might benefit from IIT have yet to be identified. See the accompanying Editorial View on page 204 The authors hypothesized that the use of factor XIII would delay the decrease in clot firmness in high-risk patients with high fibrin monomer levels. This concept was tested in a prospective, randomized, double-blind, placebo-controlled trial in elective cancer surgery. Patients were randomized to receive factor XIII (30 U/kg) or placebo and standard therapy. During the interim analysis, clot firmness was evaluated. Patients receiving placebo lost 38% firmness whereas those receiving factor XIII did not. This proof of concept study confirmed that patients at high risk for intraoperative blood loss showed reduced loss of clot firmness when factor XIII was administered. Further clinical trials are needed to assess this treatment on blood loss and use of blood products. See the accompanying Editorial View on page 212 An updated report by the American Society of Anesthesiologists Task Force on Neuraxial Opioids.In multivariate models, body mass index is a weak but significant predictor of difficult and failed intubation.Tighter glucose control may improve renal function in potential organ donors. See the accompanying Editorial View on page 207 Early transfusion is an independent predictor of adult respiratory distress syndrome in adult trauma. See the accompanying Editorial View on page 216

Factor XIII Substitution in Surgical Cancer Patients at High Risk for Intraoperative Bleeding

Excessive intraoperative bleeding is associated with significant morbidity and mortality. The authors and others have shown that fibrin monomer allows preoperative risk stratification for intraoperative blood loss, likely due to an imbalance between available factor XIII and prothrombin conversion. The authors hypothesized that the use of factor XIII would delay the decrease of clot firmness in high-risk patients. The concept was tested in a prospective, randomized, double-blind, placebo-controlled trial in elective gastrointestinal cancer surgery. Patients were randomized to receive factor XIII (30 U/kg) or placebo in addition to controlled standard therapy. Twenty-two patients were evaluable for a planned interim analysis. For the primary outcome parameter maximum clot firmness, patients receiving factor XIII showed a nonsignificant 8% decrease, and patients receiving placebo lost 38%, a highly significantly difference between the two groups (P = 0.004). A reduction in the nonprimary outcome parameters fibrinogen consumption (-28%, P = 0.01) and blood loss (-29%, P = 0.041) was also observed in the factor XIII group. Three patients experienced adverse events that seemed unrelated to factor XIII substitution. The trial was stopped early after a planned interim analysis with the primary endpoint reached. This proof of concept study confirms the hypothesis that patients at high risk for intraoperative blood loss show reduced loss of clot firmness when factor XIII is administered early during surgery. Further clinical trials are needed to assess relevant clinical endpoints such as blood loss, loss of other coagulation factors, and use of blood products.