Significant Postoperative Blood Loss Research Articles

Role of Absorbable Polysaccharide Hemostatic Powder in the Prevention of Bleeding and Wound Events after Thyroid Surgery.

Bleeding is one of the most fearsome and life-threatening complications after thyroid surgery. Several medical devices and haemostatic agents have been proposed to improve haemostasis during total and hemi-thyroidectomy. Resorbable polysaccharide powder (HaemoCer™) is a plant-based polymer that is helpful in terms of the coagulation cascade becoming a gel and forming a barrier to prevent further bleeding, having tested for haemostasis in different districts. The aim of the current study was the evaluation of drain output, the presence of significant postoperative blood loss and complications in patients treated with or without resorbable polysaccharide powder during thyroid surgery. From January to December 2022, postoperative bleeding, drainage output and the postoperative wound events of patients undergoing thyroid surgery, in a tertiary centre, with haemostasis completion with resorbable polysaccharide powder (Group A) or not (Group B), were retrospectively analysed. Eighty-one patients in Group A received a haemostasis improvement with the use of reabsorbable polysaccharide powder, and 96 patients in Group B received thyroid surgery alone. Patients in Group A presented lower drainage output (0.005), lower incidence of neck haematoma (0.005) and seroma (0.021), confirmed also by multivariate analysis. The resorbable polysaccharide powder, in the current series, appeared to be an effective agent in achieving haemostasis in thyroidectomies, reducing the postoperative drainage output, and also neck events such as neck haematoma and seroma, improving the postoperative comfort of the patients. Further larger comparative studies are needed to address this issue.

Role of Omega-6 Fatty Acid Metabolism in Cardiac Surgery Postoperative Bleeding Risk.

OBJECTIVES:Cardiac surgery is frequently associated with significant postoperative bleeding. Platelet-dysfunction is the main cardiopulmonary bypass (CPB)-induced hemostatic defect. Not only the number of platelets decreases, but also the remaining are functionally impaired. Although lipid metabolism is crucial for platelet function, little is known regarding platelet metabolic changes associated with CPB-dysfunction. Our aim is to explore possible contribution of metabolic perturbations for platelet dysfunction after cardiac surgery.DESIGN:Prospective cohort study.SETTING:Tertiary academic cardiothoracic-surgery ICU.PATIENTS:Thirty-three patients submitted to elective surgical aortic valve replacement.INTERVENTIONS:Samples from patients were collected at three time points (preoperative, 6- and 24-hr postoperative). Untargeted metabolic analysis using high-performance liquid chromatography-tandem mass spectrometry was performed to compare patients with significant postoperative bleeding with patients without hemorrhage. Principal component analyses, Wilcoxon matched-pairs signed-rank tests, adjusted to FDR, and pairwise comparison were used to identify pathways of interest. Enrichment and pathway metabolomic complemented the analyses.MEASUREMENTS AND MAIN RESULTS:We identified a platelet-related signature based on an overrepresentation of changes in known fatty acid metabolism pathways involved in platelet function. We observed that arachidonic acid (AA) levels and other metabolites from the pathway were reduced at 6 and 24 hours, independently from antiagreggation therapy and platelet count. Concentrations of preoperative AA were inversely correlated with postoperative chest tube blood loss but were not correlated with platelet count in the preoperative, at 6 or at 24 hours. Patients with significant postoperative blood-loss had considerably lower values of AA and higher transfusion rates. Values of postoperative interleukin-6 were strongly correlated with AA variability.CONCLUSIONS AND RELEVANCE:Our observations suggest that an inflammatory-related perturbation of AA metabolism is a signature of cardiac surgery with CPB and that preoperative levels of AA may be more relevant than platelet count to anticipate and prevent postoperative blood loss in patients submitted to cardiac surgery with CPB.

Efficacy and safety of systemic tranexamic acid administration in total knee arthroplasty: A case series

IntroductionTotal knee arthroplasty (TKA) are associated with significant postoperative blood loss. Tranexamic acid (TXA) is a potent agent with antifibrinolytic activity, that can be administered via the intravenous (IV) and/or topical (intra-articular, IA) route, which can possibly interrupt the cascade of events due to hemostatic irregularities close to the source of bleeding. However, the literature contains scarce scientific evidence related to IV only TXA usage in TKA. The current study aims to compare the outcome between patients who were administered IV TXA and a control group in terms of blood loss, transfusion rate, and incidence of deep vein thrombosis (DVT) and thromboembolism (TE). Methods110 patients, who underwent TKA were placed into two groups: 1) 34 patients who received IV TXA; and 2) 76 patients in the control group. In the TXA group, patients received an IV TXA dose of 1 g, 30 min before incision. Two drains were placed. ResultsUsage of IV TXA showed better results when compared to the control group in terms of mean blood transfusion (0.5 less transfusion during hospital stay), hemoglobin drop (10%). No cases of DVT or TE were noted among the two study groups. ConclusionUse of IV TXA provided significantly better results compared to no TXA use with respect to all variables related to postoperative blood loss in TKA. Moreover, TXA use is safe in terms of incidence of symptomatic DVT and TE.

Comparison of Efficacy & Safety Between Intravenous and Intraarticular Tranexamic Acid in Reducing Blood Loss after Total Knee Arthroplasty

Total knee arthroplasty (TKA) is associated with significant postoperative blood loss necessitating blood transfusion. Tranexamic acid is an antifibrinolytic drug that has shown good efficacy in reducing this postoperative morbidity. Although, the most commonly used route of administration is intravenous; the optimal route of administration has not been agreed upon. AIM: The aim of this study was to evaluate and compare the efficacy and safety of intravenous and intra-articular administration of tranexamic acid in reducing blood loss following TKA. METHOD: The study was a prospective, interventional; randomized controlled study involving 63 patients who underwent unilateral uncomplicated TKA for severe osteoarthritis of the knee at the National Orthopaedic Hospital, Dala – Kano, Nigeria. The patients were randomized into 3 groups using online random team generator; (1) Intravenous group, (2) Intraarticular group and (3) Control group. RESULTS: The postoperative blood loss was significantly greater in the control group than in intravenous and intraarticular groups (p = 0.02). Also, the postoperative fall in Hb level and the need for blood transfusion were significantly higher in the control group than in intravenous and intraarticular groups (0.00). However, Intravenous and Intraarticular groups did not differ significantly in terms of the measured variables. There was no significant difference between the preoperative and postoperative platelet counts (p = 0.81), INR (p = 0.21) and serum creatinine (p = 0.39) in all the three study groups. CONCLUSION: Intravenous and intraarticular tranexamic acid were equally effective and safe for reducing blood loss after TKA.

Multivariate model for predicting postoperative blood loss in children undergoing cardiac surgery: a preliminary study

Postoperative bleeding and blood product transfusion increase morbidity, mortality, and costs after cardiac surgery. However, factors that could accurately predict bleeding have not been well studied in children undergoing cardiac surgery. This study aims at determining factors that could be used to predict postoperative bleeding in this paediatric population. We included 182 children undergoing congenital heart surgery. Significant bleeding was defined as a blood loss that exceeds 10% of total blood volume within the first 6 postoperative hours. Univariate and multivariate logistic regression analyses were performed to determine variables independently associated with bleeding. These variables were used to calculate a probability for each individual child to develop postoperative bleeding. According to the definition of bleeding, 44 patients were included into the 'bleeder' group and 138 into the 'non-bleeder' group. Factors independently associated with postoperative bleeding were preoperative body weight, the presence of a cyanotic disease, and the time required for wound closure. Based on these three parameters, we calculated the probability of bleeding and found a significant relationship with postoperative bleeding. Finally, a calculated probability of 0.59 can predict significant postoperative blood loss with a sensitivity of 84% and a specificity of 64%. This study shows that preoperative body weight, cyanotic disease, and wound closure duration are best predictors of bleeding in the paediatric population after cardiac surgery. The combination of these three factors could be used at the end of the surgery to estimate the probability of postoperative bleeding.

Unexpected Postpartum Hemorrhage Due to an Acquired Factor VIII Inhibitor

Unexplained postpartum hemorrhage (PPH) refractory to standard hemostatic measures should trigger a heightened clinical suspicion of an acquired bleeding disorder. When hemostatic medical interventions and surgical procedures fail to control the bleeding, then significant postoperative blood loss, debilitating morbidity, loss of fertility, and death may occur. In the setting of an autoantibody inhibitor to factor VIII (FVIII), control of life-threatening PPH and avoidance of subsequent bleeding episodes depends on a timely and accurate diagnosis, prompt hemostatic treatment and eradication of FVIII inhibitors, and appropriate long-term patient care and management. Acquired postpartum hemophilia due to a FVIII inhibitor is a rare cause of PPH; however, delayed treatment can lead to increased maternal morbidity and mortality. Acquired FVIII inhibitors also pose an emerging bleeding threat to the neonate as a result of possible transplacental transfer of FVIII autoantibodies to the fetus during the last trimester of pregnancy. The purpose of this review is to increase awareness among hematologists and obstetricians/gynecologists regarding the occurrence of FVIII neutralizing autoantibodies as a cause of PPH, and emphasize the importance of collaboration between obstetrician/gynecologists and hematology specialists to optimize the diagnostic evaluation, treatment, and long-term management of women who experience PPH due to an acquired FVIII inhibitor.

Sensory Neuropathy Associated With Aggressive Cauterization Using a Bipolar Radiofrequency Device in Primary TKA

Because significant postoperative blood loss can result in many complications, hemostasis remains a critical part of successful joint replacement outcomes. Advanced techniques, such as electrocautery use after optimally timed tourniquet release, focus on desired patient blood loss outcomes. The purposes of this study were to report the incidence of nerve injury, identify associated risk factors following the use of bipolar electrocautery for hemostasis in the posterior knee during primary total knee arthroplasty, and compare that rate with the rate seen using a standard electrocautery device. Clinical and operative data were retrospectively reviewed for an association with postoperative nerve injury in 241 consecutive patients when using bipolar electrocautery between July 2007 and October 2008. A comparison group of 192 demographically similar consecutive patients between November 2008 and October 2009 was also evaluated to establish a surgeon-specific benchmark when using standard electrocautery. Seven (2.9%) of 241 patients in the bipolar electrocautery group reported documented neuropathies compared with 1 (0.52%) of 192 patients using standard electrocautery. In addition, female sex and rheumatoid arthritis were associated with postoperative nerve injury following bipolar electrocautery. Although the bipolar radiofrequency device is effective in achieving hemostasis, the authors recommend judicious use of this procedure in women or patients with rheumatoid arthritis and cautious, nonaggressive use of posterior compartment bipolar radiofrequency ablation in the remaining patient populations.

Fibrin sealants in orthopaedic surgery: practical experiences derived from use of QUIXIL® in total knee arthroplasty

Total knee arthroplasty is associated with a significant postoperative blood loss even without any form of perioperative anticoagulation. The potential role of QUIXIL(®), a fibrin sealant used in orthopaedic surgery to control blood loss and avoid blood transfusions in patients undergoing total knee arthroplasty was evaluated in a prospective randomized trial with twenty-four patients diagnosed with primary osteoarthritis of the knee. Results showed that application of 2ml QUIXIL(®) adds costs to treatment without reducing the number of transfused red blood cell counts and postoperative haemoglobin loss. However, significant lower levels of postoperative fluid loss (P=0.026) was detected in QUIXIL(®) treated patients. Regarding cost effectiveness and benefit no indication for the use of 2ml QUIXIL(®) fibrin sealant in standard knee arthroplasty could be proofed statistically.

Autologous transfusion of drain contents in elective primary knee arthroplasty: its value and relevance.

Total knee arthroplasty is associated with significant post-operative blood loss often necessitating blood transfusions. Blood transfusions may be associated with transfusion reactions and may transmit human immunodeficiency virus, hepatitis C virus and hepatitis B virus, with devastating consequences. After total knee arthroplasty, transfusion of the contents of an autologous drain is becoming common practice. The aim of our study was to look at the effectiveness of these drains in elective primary total knee arthroplasty. A prospective study was conducted including 70 non-randomised patients. A normal suction drain was used in 35 patients (group A), whereas in the other 35 patients, a CellTrans™ drain was used (group B). All the operations were performed by four surgeons using a tourniquet with a medial parapatellar approach. Pre- and post-operative haemoglobin concentrations were recorded in both groups. A Student's t-test was applied to determine the statistical significance of the data collected. The average fall in post-operative haemoglobin was 3.66 g/dL (SD 1.46; range, 0.6-7.0) among patients in whom the simple drain was used (group A) and 2.29 g/dL (SD 0.92; range, 0.6-5.9) among those in whom the CellTrans™ drain was used (group B) (p<0.0001). Twenty-five units of allogeneic blood were required in group A compared to four units in group B. The rate of transfusion was 5.7% (2 patients) in the group in which CellTrans™ drain was used and 25.7% (9 patients) in the group in which a simple suction drain was used. Total knee arthroplasty is associated with significant post-operative blood loss despite best operative technique. Autologous reinfusion of the contents of a CellTrans™ drain significantly reduces the rate of post-operative blood transfusion. This study indicates that the use of an autologous drain could be recommended as routine practice in primary total knee arthroplasty.

Investigation of the Use of Drained Blood Reinfusion after Total Knee Arthroplasty: A Prospective Randomised Controlled Study

To compare the use of a blood salvage and reinfusion system with standard allogeneic blood transfusion after total knee arthroplasty--a procedure associated with significant postoperative blood loss. Between June 2002 and May 2004, 60 patients undergoing total knee arthroplasty were randomly allocated into a reinfusion group (n = 26) or a control group (n = 34). Patients in the reinfusion group had their blood reinfused from drains within 6 hours of surgery. Both groups received allogeneic blood transfusions according to specified transfusion criteria if the haemoglobin level fell below 90 g/l, or in the presence of severe anaemic symptoms. Haemoglobin levels and drain output were recorded daily for 3 consecutive days after surgery. There was no significant difference between the 2 groups in demographic data, drain output, total blood loss, and mean postoperative haemoglobin levels. Significantly more allogeneic blood was required by the control group than by the reinfusion group (p = 0.022). Postoperative reinfusion of drained blood reduced the need for blood transfusion after total knee arthroplasty, while having an effect on postoperative haemoglobin level equivalent to standard allogeneic blood transfusion.

Use of Thromboelastography to Assess Haemostatic Changes during Paediatric Cardiac Surgery and to Predict Post-Operative Bleeding.

The management of post-operative bleeding in paediatric cardiac surgery is difficult because the underlying haemostatic changes have been poorly studied. The thromboelastogram (TEG) provides a real-time, functional measure of haemostasis, quantifying clot formation, strength and lysis. We investigated the use of serial intra-operative TEG to assess perioperative haemostatic changes and as an adjunct to demographic and laboratory variables for the prediction of bleeding following cardiopulmonary bypass (CPB) surgery. Ethical committee approval was obtained to study fifty-one children, median (interquartile) age 6.8 months (0.5 to 10.5) prospectively through CPB and for the first 24 hours after intensive care unit admission. Significant post-operative blood loss was defined as more than 10ml/kg in the first four post-operative hours. TEG readings and traditional coagulation parameters were measured throughout CPB. Forward stepwise logistic regression analysis was used to predict bleeding.The incidence of bleeding was 37% (19/51), with a mean 4-hour blood loss of 24 ml/kg. Both groups showed abnormalities in all TEG parameters (apart from lysis) at the end of CPB, which were more marked among those who bled (all p<0.05).Hyperfibrinolysis was not seen. Addition of heparinase to the TEG samples taken after protamine administration demonstrated a small but consistent heparin effect for all TEG parameters only among patients who bled, however this group exhibited comparable protamine:heparin ratios to those who did not (p = 0.22). Significant multivariate predictors of bleeding included fibrinogen level at induction of anaesthesia; occurrence of circulatory arrest; and two TEG parameters taken at the end of CPB: “k” (the time to maximal clot formation) and “angle” (the rate of clot formation). The final model predicted bleeding well, producing an area under the receiver operating characteristic curve of 0.855 (95% CI 0.750 to 0.960).In summary, the aetiology of bleeding after paediatric cardiac surgery appears to be due to inadequate clot formation rather than fibrinolysis. TEG readings taken at the end of CPB, in conjunction with laboratory and demographic variables may provide a useful predictor of post-operative bleeding.

The effect of preoperative tranexamic acid on blood loss after cardiac operations in children

Children undergoing cardiac operations in which cardiopulmonary bypass is used are at risk of significant postoperative blood loss. The acquired coagulopathy is complex but is thought to be due, in part, to excessive fibrinolysis. We examined the possibility of reducing postoperative blood loss in children by using the antifibrinolytic drug tranexamic acid. Using a prospective, randomized, double-blind study design, we administered a single dose of tranexamic acid (50 mg/kg intravenously) or saline placebo, before skin incision, in 88 children undergoing cardiac operations. Postoperative blood loss and fluid replacement were recorded for the next 24 hours. In addition, hemoglobin, platelet counts, and coagulation measures were recorded every 6 hours. When all patients were examined, there was no significant difference in postoperative blood loss between the treated and placebo groups (21.2 ± 12 ml/kg per 24 hours, tranexamic acid, vs 27.2 ± 20.3 mls/kg per 24 hours, placebo). However, when the children with cyanosis were analyzed separately, there was a highly significant difference in blood loss between the groups during the first 6 hours (11.2 ± 3.7 ml/kg per 6 hours, tranexamic acid, vs 27.2 ± 11.4 mls/kg per 6 hours, placebo; p < 0.002), as well as the overall 24 hour study period (23.7 ± 7.5 mls/kg per 24 hours, tranexamic acid, vs 48.9 ± 27.6 mls/kg per 24 hours, placebo; p < 0.02). Also significantly less blood and blood products were administered to the treated cyanosed group. Tranexamic acid produced a significant reduction in postoperative blood loss and blood product requirements in children with cyanosis undergoing heart operations. The drug had no effect in children without cyanosis or those requiring a second thoracotomy. (J T HORAC C ARDIOVASC S URG 1996;111:982-7)