Substantial Blood Loss Research Articles

Management of anticoagulant-related soft tissue bleeding

Spontaneous, severe, and life-threatening soft tissue bleeding (STB) in patients taking anticoagulants is associated with high morbidity and mortality due to the substantial blood loss and nonspecific clinical symptoms. The optimal management of these predominantly older patients with multiple comorbidities has not yet been unanimously clarified. This work comprises aliterature search and analysis of the pertinent retrospective studies and case series. Structured diagnostic workup with contrast-enhanced computed tomography (CT) is essential for planning transarterial embolization (TAE). Contrast agent extravasation, the signal flare phenomenon, and the hematocrit effect are all indicative of active bleeding or an anticoagulant-related hematoma. For TAE, coils, particles, and liquid embolic agents can be used alone or in combination. Aback door/front door embolization should be strived for. Transarterial embolization is the method of choice for managing anticoagulant-related localized or diffuse spontaneous soft tissue bleeding in the context of hemodynamic stabilization of the patient.

Minimally Invasive Surgery for Posterior Atlantoaxial Lateral Mass Joint Fusion (MIS-PALF): A Muscle-Sparing Procedure for Atlantoaxial Instability or Dislocation.

Conventional surgical procedures for atlantoaxial instability or dislocation (AAI/D) have been associated with a high prevalence of postoperative occipitocervical pain and dysfunction, as well as substantial perioperative blood loss. We hypothesized that minimally invasive surgery for posterior atlantoaxial lateral mass joint fusion (MIS-PALF), a procedure that can largely avoid disruption of suboccipital musculature, would be superior to the standard Goel-Harms technique in terms of postoperative pain and perioperative blood loss. This was a prospective cohort study of patients undergoing MIS-PALF for AAI/D at Peking University Third Hospital's Department of Orthopaedics from January 2021 to December 2021 and a historical control group of patients with the same diagnoses who were treated with the Goel-Harms technique. The duration of surgery, perioperative blood loss, postoperative length of hospital stay, postoperative body temperature, pain, supplementary use of narcotics, spinal cord function/improvement (assessed using the Japanese Orthopaedic Association [JOA] scores), reduction of AAI/D (determined based on radiographic parameters), rate of successful fusion, and complication rate were all compared between the 2 groups. No significant differences were noted between the groups (43 MIS-PALF cases, 86 control cases) regarding baseline data, operative time, spinal cord function or improvement, reduction of AAI/D, rate of successful fusion, and complication rate. MIS-PALF was associated with significantly less perioperative blood loss, a shorter postoperative hospital stay (decreased by 30.8%), lower intensity and frequency of postoperative pain (decreased by 10.6% and 61.9%, respectively), less need for supplementary narcotics, and less frequent postoperative fever (decreased by 48.7%). This was the first prospective cohort study of which we are aware on minimally invasive procedures for atlantoaxial fusion. Clinical efficacy (AAI/D reduction, rate of successful atlantoaxial fusion, JOA score improvement), efficiency (operative time), and safety (complications) of MIS-PALF appeared to be noninferior to those of the Goel-Harms technique. MIS-PALF was superior in terms of postoperative occipitocervical pain and length of hospital stay, both of which directly affect overall patient satisfaction and postoperative recovery of quality of life. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Low-temperature plasma-treated polyethylene oxide for hemostasis and skin wound healing

The development of a hemostatic material capable of controlling substantial blood loss in wound healing scenarios remains a critical challenge in clinical practice. Herein, we treated polyethylene oxide (PEO) with low-temperature plasma irradiation (LTPI) technology in the air, and the modified PEO (CAPEO) was obtained with carboxyl (–COOH) and amine (–NH2) groups. Notably, CAPEO exhibited excellent hydrophilicity, great cytocompatibility, and blood compatibility. Platelets could be activated more and clotting time could be shorter with the treatment of CAPEO than with PEO. More importantly, in the rat liver hemorrhage model, the blood loss in CAPEO (95.8 mg) was less than in PEO (144.2 mg). Moreover, in vivo investigation of skin wound repair, CAPEO could promote epidermal regeneration and collagen deposition, thereby accelerating wound healing. These findings disclose that CAPEO holds great potential for hemostasis and wound healing.

Maternal Outcomes of Placental Abruption With Intrauterine Fetal Death and Delivery Routes: A Nationwide Observational Study

(Acta Obstet Gynecol Scand. 2023;102:708–715) Both maternal and neonatal morbidity and mortality are associated with placental abruption (PA), a condition where the placenta prematurely separates from the uterine wall before or during labor. PA and intrauterine fetal death (IUFD) can co-occur, making a delivery more complex as well as high risk, as shown through increased maternal morbidity rates. Worldwide, delivery for mothers with PA and IUFD varies between vaginal delivery (VD) and cesarean delivery (CD), although various sources cite VD as the preferred method. Frequent complications of VD for PA with IUFD includes a longer delivery time, uterine rupture, and substantial blood loss. CD is associated with hemorrhagic shock and hematoma formation due to a greater increase in blood loss. Limited, small-scale studies have been performed comparing VD and CD and the effect on maternal morbidity in cases with IUFD and PA; however, this study uses a large data set to understand the relationship between delivery method and morbidity in cases of PA with IUFD.

To Study Perioperative Changes in Plasma Phenytoin Levels in Patients with Brain Tumor Undergoing Craniotomy and Its Correlation with Postoperative Seizures

Abstract Introduction Phenytoin, although commonly used for postoperative seizure prophylaxis, exhibits variable results in mitigating seizure frequency following craniotomy. These discrepancies may be linked to a reduction in plasma phenytoin levels subsequent to the surgical intervention. Aims This prospective study aims to characterize changes in plasma phenytoin levels after craniotomy and their relationship with intraoperative blood loss. Methods Fifty consecutive patients were enrolled in this study after obtaining written informed consent. These patients had either been on oral phenytoin for at least 7 days or had received an intravenous loading dose before undergoing craniotomy. Serum phenytoin levels were measured 24 hours preoperatively, immediately before craniotomy (prior to skin incision), postcraniotomy (after skin closure), and 24 hours postcraniotomy. Additionally, intraoperative blood loss was calculated using a modified Gross formula. Results Immediately following craniotomy, there was a statistically significant mean decline of 28.16% in serum phenytoin levels. Furthermore, the analysis revealed a robust positive correlation between the decrease in phenytoin concentration level and several factors, including blood loss during surgery, the duration of the surgical procedure, intravenous fluids administered during surgery, and the occurrence of postoperative seizures. Conclusion This study underscores the potential utility of routinely measuring perioperative serum phenytoin levels in high-risk patients to prevent postcraniotomy seizures. Moreover, it suggests that patients with substantial intraoperative blood loss may benefit from an additional bolus dose of phenytoin toward the end of the surgical procedure.

Analysis of Risk Factors for Post-Extraction Bleeding and Study on Emergency Intervention Strategies.

The objective of this investigation is to delineate the distributional attributes of factors correlated with post-tooth extraction bleeding and to scrutinize corresponding strategies for emergency prevention and intervention. The chi-squared test and rank sum test were deployed to evaluate fluctuations in blood loss. Univariate and multivariate binary logistic regression methodologies were employed to compute the odds ratio (OR) and its associated 95% confidence interval (95% CI). Furthermore, we delved into the relationship between each contributing factor and blood loss. Concurrently, univariate and multivariate logistic regression techniques were utilized to probe the nexus between blood loss and treatment modalities. Following adjustments for pertinent factors, the outcomes of multivariate analyses unveiled an escalated susceptibility to bleeding among male patients and individuals aged 60 years or older. The adjusted OR values and their corresponding 95% CI were determined as follows: OR = 1.54 (95% CI: 1.34-1.77, P < 0.001), OR = 0.74 (95% CI: 0.59-0.91, P = 0.005), OR = 0.58 (95% CI: 0.42-0.80, P = 0.001). Additionally, the results of multivariate logistic regression analysis indicated that, in contrast to individuals experiencing minimal blood loss, the OR values associated with treatment modalities for patients encountering substantial blood loss, namely iodoform gauze strips, sutures, collagen, and compression, were noted as follows: OR = 220.80 (95% CI: 151.43-321.95, P < 0.001), OR = 69.40 (95% CI: 46.11-104.44, P < 0.001), OR = 52.78 (95% CI: 34.66-80.38, P < 0.001), OR = 12.85 (95% CI: 9.46-17.45, P < 0.001). It is imperative to prioritize the scrutiny of risk factors associated with post-tooth extraction hemorrhage, with the aim of preemptively averting incidences of bleeding subsequent to tooth extraction. Moreover, it is paramount to offer expert and tailored emergency interventions designed to address diverse case scenarios.

Full endoscopic resection of ventral thoracic osteophyte and repair of spontaneous CSF leak.

Spontaneous CSF leaks frequently cause headaches, meningismus, and nausea due to intracranial hypotension. When conservative treatment fails, surgical repair is indicated. Especially ventral leaks necessitate invasive approaches with substantial blood loss and tissue trauma. Full endoscopic spine surgery (FESS) enables circumferential access via the transforaminal approach. Here, the authors show the successful repair of a ventral CSF leak in the thoracic spine after removal of bony osteophytes utilizing FESS with placement of a dural substitute and sealant. Lasting symptom relief was reported. These results suggest that FESS is safe and efficient for the repair of spontaneous and incidental CSF leaks. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23209.

Comparison of blood loss between intra-articular microporous polysaccharide hemospheres powder and tranexamic acid following primary total knee arthroplasty

Total knee arthroplasty (TKA) is associated with substantial blood loss and tranexamic acid (TXA) effectively reduces postoperative bleeding. Although it is known that there is no difference between intravenous or intra-articular (IA) injection, the general interest is directed towards topical hemostatic agents regarding thromboembolic events in high-risk patients. This study aimed to compare the blood conservation effects of IA MPH powder and TXA in patients undergoing primary TKA. We retrospectively analyzed 103 patients who underwent primary TKA between June 2020 and December 2021. MPH powder was applied to the IA space before capsule closure (MPH group, n = 51). TXA (3 g) was injected via the drain after wound closure (TXA group, n = 52). All patients underwent drain clamping for three postoperative hours. The primary outcome was the drain output, and the secondary outcomes were the postoperative hemoglobin (Hb) levels during the hospitalization period and the perioperative blood transfusion rates. An independent Student’s t-test was used to determine differences between the two groups. The drain output in the first 24 h after surgery was significantly higher in the MPH group than in the TXA group. The postoperative Hb levels were significantly lower in the MPH group than in the TXA group. In patients with simultaneous bilateral TKA, there was a significant difference in the blood transfusion volumes and the rates between groups. It is considered that IA MPH powder cannot replace IA TXA because of an inferior efficacy in reducing blood loss and maintaining postoperative Hb levels in the early postoperative period after primary TKA. Moreover, in the case of simultaneous bilateral TKA, we do not recommend the use of IA MPH powder because it was notably less effective in the field of transfusion volume and rate.

En Bloc Surgery in the Thoracic Spine: Indications, Results, and Complications in a Series of Eighty-Five Patients Affected by Primary and Secondary Malignant Bone Tumors

BackgroundEn-bloc resection remains the cornerstone treatment for malignant bone tumors affecting the spine. The thoracic spine poses unique challenges due to the proximity of crucial structures. This study assesses outcomes of patients who underwent en-bloc spondylectomy for malignant bone tumors at the thoracic level. MethodsWe retrospectively reviewed 85 cases of primary and secondary bone tumors in the thoracic spine, undergoing en-bloc spondylectomy from 1996 to 2016. Evaluation encompassed clinical presentation, tumor characteristics, surgical outcomes, complications, survival rates, and recurrence. ResultsOf 85 patients, 40 presented directly, while 45 had undergone prior intralesional surgery. Chondrosarcoma and chordoma comprised the most prevalent primary histological types; thyroid and kidney carcinomas were the most frequent secondary tumors. Pain was reported in 75 patients at diagnosis. Margins were adequate in 54 cases and intralesional in 31. Immediate postoperative deaths amounted to four. Major complications included substantial blood loss, neurological deterioration, and paraplegia. The 5-year Local Recurrence-Free Survival rate was 58.7%, significantly influenced by the surgical margin: patients with wide margins experienced a 5-year LRFS of 85.7%, while those with marginal and intralesional margins had rates of 56.7% and 45.6%, respectively; overall recurrence was 22.3% with no notable disparities between previously treated and untreated patients. The 5-year Overall Survival (OS) rates were 63.2% and 56.2% for primary and secondary tumors, respectively. The OS was not significantly influenced by surgical margins. ConclusionsManaging malignant thoracic bone tumors poses significant challenges. This study underscores the criticality of achieving adequate margins, particularly following previous intralesional approaches.

Analysis of high-risk factors for early pulmonary bacterial infection after lung transplantation and their correlation with long-term mortality.

To investigate the high-risk factors for early pulmonary bacterial infection following lung transplantation and their association with long-term mortality. A retrospective analysis was conducted on 142 lung transplant recipients treated at Wuxi People's Hospital between January 2018 and July 2022. After applying predefined inclusion and exclusion criteria, 111 cases were analyzed. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for early pulmonary infection post-transplantation. Additionally, univariate and multivariate Cox regression analyses were used to identify independent prognostic factors affecting one-year survival post-transplantation. Univariate analysis identified age, bacterial infection in donor lungs, and operation duration as risk factors for early pulmonary infection (all P < 0.05). Multivariate analysis was confirmatory for these as independent risk factors (all P < 0.05). Univariate analysis also showed that intraoperative blood loss and oxygenation index impacted one-year survival (P < 0.05). Multivariate analysis was confirmatory for these as independent risk factors (P < 0.05). Early pulmonary bacterial infection was not found to be an independent factor affecting 1-year survival. However, substantial intraoperative blood loss and a reduced oxygenation index were identified as independent risk factors associated with increased mortality within 1 year post-transplantation.

Evaluating the Efficacy and Safety of Combined Administration of Systemic and Topical Tranexamic Acid in Total Knee Arthroplasty.

Tranexamic acid (TXA) is an antifibrinolytic agent, thatagent that reduces substantial blood loss in total knee arthroplasty (TKA) surgeries without increasing the risk of thromboembolic complications. The purpose of our study was to assess the effectiveness and safety of the combined use of intravenousIV and topical TXAtranexamic acid in uncomplicated primary Total knee Arthroplasty (TKA) without complications. In this prospective study, we enrolled 61 patients who underwent unilateral primary TKR and were randomly divided into two groups: Group I received intravenous (IV) TXA and Group II received both IV and intraarticular (IA) TXA. Patients assigned to Group I received IV TXA preoperatively 30 mins before surgery and postoperatively at 3 and 6 hours after surgery, whereas in the combined group, in addition to IV doses, topical TXA was applied as mop 2 g of TXA diluted in 30 mL of isotonic sodium chloride solution) intraarticularly for about 5 minutes before closing the arthrotomy. We measured total blood loss (TBL), ) and mean reduction in haemoglobin (Hb) levels as primary outcomes. Transfusion rates, incidence of thromboembolic events (TE), and other adverse effects as secondary outcomes. Total blood loss TBL and Hb drops was were noted on the 3rd post-operative day. All the patients were followed-up for 6 months to note the incidence of deep venous thrombosisDVT and Thromboembolic Events (TE). An Iindependent t-test was used to evaluate between--group differences. P < 0.05 as is the cut-off for statistically significant differences. The Total blood loss (TBL) in Group I was 780.05 ± 158.05 mL, compared to 660.80 ± 156.45 mL in Group II. (P < 0.001). The Hb drop was significantly lower in IV TXA group (2.3 ± 0.37) than the combined TXA group (1.40 ± 0.32). Furthermore, both groups required no transfusions. No thromboembolic complications was were noted postoperatively and at 6 6-month follow-up. TXATranexamic acid in total knee replacement surgery effectively decreases blood loss and significantly reduces the need for blood transfusions. Based on our study, the combined use of intravenous (IV) and IAintraarticular TXA in total knee replacement was found to be superior in reducing blood loss and significantly reducing the need for blood transfusions in TKA.

Evaluation of Parameters Affecting the Occurrence of Systemic Inflammatory Response Syndrome in Patients Operated on Due to Kidney Tumors.

The application and prognostic nature of systemic inflammatory reaction syndrome (SIRS) is still being researched, as using SIRS parameters to predict patient status is cheap, efficient, fast, and easy. The study aimed to determine SIRS markers and postoperative complications occurrence in patients undergoing kidney tumor surgery, and to verify if SIRS occurrence depends on age, sex, BMI (body mass index), comorbidities, patients' general condition before the surgery, type of surgery, intraoperative blood loss, or intraoperative ischemia time. Body temperature, heart rate, respiratory rate, and leukocyte count were measured in patients (n = 285) operated on due to a kidney tumor on the first (T0) and third (T3) postoperative day. Univariable and multivariable logistic regression were used to analyze the factors affecting postoperative SIRS and complications occurrence. T0: SIRS developed in patients with higher BMI, >2 ASA points, and more substantial intraoperative blood loss. T3: SIRS developed in obese or overweight patients, with >2 ASA points, significantly higher relative HR change, lower relative body temperature change, respiratory rate, and leukocyte count. BMI values, preoperative general health status, and the amount of intraoperative blood loss in patients undergoing surgery due to a kidney tumor can contribute to SIRS occurrence. Patient's sex, age, tumor size, type of surgery, operated side, and time of intraoperative ischemia do not affect SIRS occurrence.

Computed Tomography Perfusion Combined With Preoperative Embolization for Reducing Intraoperative Blood Loss in Separation Surgery for Thoracolumbar Metastases.

A prospective consecutive case study. This study aimed to assess the accuracy of computed tomography perfusion (CTP) in evaluating the vascularity of thoracolumbar metastases and to determine the impact of combining CTP with preoperative embolization on reducing intraoperative blood loss during separation surgery. Surgery for thoracolumbar metastases is a complex procedure with the potential for substantial blood loss. Therefore, assessing tumor vascularity before surgery and taking measures to minimize intraoperative blood loss is essential. A total of 62 patients with thoracolumbar metastases were prospectively enrolled. All patients underwent separation surgery using the posterior approach. Before surgery, the vascularity of the metastases was evaluated using CTP. On the basis of the CTP results, patients were categorized into hypervascular and hypovascular groups. Preoperative angiography and embolization were performed for the hypervascular group. Clinical data were abstracted, including intraoperative blood loss, perioperative complications, visual analog scale score, neurological status, and the accuracy of vascularity evaluation by CTP confirmed by angiography. χ 2 testing was used to compare categorical variables, whereas independent sample t tests were used to compare continuous variables, with paired t tests used to assess differences from preoperative to postoperative time points. The mean intraoperative blood loss was 485±167 and 455±127.6mL in the two groups, respectively. The accuracy of vascularity evaluation by CTP was 100%. In the hypervascular group, 80.6% of the patients experienced at least one level of improvement in neurological status, while the hypovascular group had 81.5% of patients with similar improvement. None of the patients experienced neurological deterioration. There was a significant reduction in visual analog scale scores in both groups after the operation. The vascularity of thoracolumbar metastases could be accurately evaluated using noninvasive CTP. When combined with preoperative embolization, this approach effectively and safely reduced intraoperative blood loss in the setting of separation surgery.

Team Approach: The Unstable Trauma Patient.

» A multidisciplinary, integrated, and synergistic team approach to the unstable polytrauma patient is critical to optimize outcomes, minimize morbidity, and reduce mortality.» The use of Advanced Trauma Life Support protocols helps standardize the assessment and avoid missing critical injuries» Effective and open dialog with consulting specialists is paramount for effective team-based care.» Orthopaedic surgeons should play an important role in the rapid assessment of potentially life-threatening and/or limb-threatening injuries including pelvic ring disruption, open fractures with substantial blood loss, and dysvascular limbs.

Pneumatic tourniquet versus no tourniquet in transfemoral amputation – a study protocol for a randomized controlled trial

BackgroundLower extremity amputation patients represent a frail group with extensive comorbidity. Transfemoral amputation is a high-risk procedure with 37–50% risk of mortality in the first year. Substantial blood loss during surgery increases the risk of anemic complications and death for these already weakened patients. The use of tourniquet during surgery may reduce blood loss, the need for blood transfusions, the related complications as well as the length of the surgery. However the use of tourniquet may be related to impaired wound healing and hence the use should be investigated in a randomized controlled trial.The primary aim of this study is to investigate the total blood loss and secondary to investigate differences in complications after transfemoral amputation between patients operated with or without tourniquet.MethodsThe total blood loss is calculated using Nadlers approach. Based on data from a pilot series, the sample size was calculated to 124, allocated 1:1 in two groups of 62 participants to ensure detection of at least 200 mL difference in the total blood loss. The primary outcome is the total blood loss. Secondary outcomes are blood transfusions, duration of surgery, length of hospital stay and risk of complications within 90 days (re-admissions, re-operations and mortality). Explorative outcomes are 1 year mortality and re-operation risk. Further explorative outcomes are postoperative quality of life (questionnaire EQ-5D-5L) and evaluation of number of prosthesis users including evaluation of prosthesis-specific function measured 3, 6, and 12 months postoperatively.DiscussionThe possibility to enhance patient safety is highly relevant and this trial will provide data for evidence based recommendations of best practice in amputation surgery.Trial registrationThe trial is registered on ClinicalTrials.gov with ID: NCT05550623. Initial release: 13/09 2022.

Treatment of thoracolumbar fractures: comparison of the clinical and radiological outcomes of percutaneous versus open surgery.

Retrospective study. Spinal fractures are common trauma that can be treated by a range of techniques, from functional to surgical. Spine surgery has been around for many years. The first procedures were done open but have been plagued by numerous complications-sometimes severe-and substantial intraoperative blood loss. Percutaneous surgery was developed to help reduce the complications while providing similar clinical and radiological outcomes to open surgery. We conducted a study to compare open and percutaneous surgery and to evaluate other complications as well as short- and medium-term clinical and radiological results. Retrospective, single-center study comparing two cohorts of patients suffering from an isolated vertebral fracture who were operated using either an open or percutaneous technique. Included were patients who had an isolated vertebral fracture between T10 and L3 and were operated between 01/01/2016 and 31/12/2018 at the Reims university hospital. These patients were reviewed in person after a minimum of 18months postoperative for clinical and radiological assessments. The Mercuriali and Brecher formula was used to calculate intraoperative blood loss based on pre- and postoperative hematocrit; the total blood volume was determined with the Nadler formula. The study cohort consisted of 79 patients operated by percutaneous surgery and 55 patients operated by open surgery. The blood loss in the percutaneous surgery group was 176mL versus 220mL in the open surgery group (p = 0.02). The length of hospital stay was shorter after percutaneous surgery (mean of 3.6days) than after open surgery (mean of 5.5days) (p < 0.001). Also, the pedicle screw placement was optimal in 88% of percutaneous procedures versus 67% of open procedures (p < 0.001). Percutaneous surgery for thoracolumbar fractures causes less blood loss than conventional open surgery. The clinical and radiological results are on par with conventional open surgery. The mean length of hospital stay is shorter and the accuracy of pedicular screw placement is higher with percutaneous surgery. Thus, we can conclude that percutaneous surgery is the preferred treatment for thoracolumbar fractures when no neurological deficit is present. IV.

Blood loss in total en bloc spondylectomy for primary spinal bone tumours: a comparison of estimated blood loss versus actual blood loss in a single centre over 10 years.

BackgroundTotal en bloc spondylectomy (TES) is a widely accepted surgical technique for primary spinal bone tumours but is frequently accompanied by substantial peri-operative blood loss. Prior studies have reported estimated blood loss (EBL) can reach up to 3,200 mL. The aim of this study is to estimate the blood loss during TES procedures performed in the last ten years at our tertiary referral centre and compare EBL with actual blood loss (ABL).MethodsWe performed a retrospective review of all cases managed surgically with TES referred to our centre between 2005 and 2015. We recorded the oncological characteristics of each tumour and surgical management in terms of resection margins, operative duration and instrumentation. Data relating to peri-operative blood loss was also recorded including an estimation of total blood loss, the use of cell salvage where applicable and transfusion rates.ResultsA total of 21 patients were found to meet our inclusion criteria. There were 11 men and 10 women, with a median age of 40 years. The mean total ABL was 3,310 mL. Total operation time ranged from 6.53 to 19.7 h. Compared to ABL, in 59% of cases EBL had been underestimated by an average of 78% by volume. The EBL of the remaining 41% cases had been overestimated by 43%. This was not statistically significant (P=0.373). Cell salvage was used in 62% patients with a mean blood loss of 2,845 mL (884–4,939 mL) and transfusion of 3.8 units (0–12 units) versus 4,069 mL (297–8,335 mL) and 9.3 units (0–18 units) in those not managed with cell salvage. There was no significant difference in ABL between the cell salvage and non-cell salvage groups.ConclusionsWe report one of the largest case series in TES for primary bone tumours. EBL is not a reliable predictor for ABL. A large blood loss should be anticipated and use of cell salvage is recommended.

The physiologic responses to a fluid bolus administration in old and young healthy adults

BackgroundOrgan function is known to decline with age. Optimizing cardiac, pulmonary and renal function in older adults has led to significant improvements in perioperative care. However, when substantial blood loss and fluid shifts occur, perioperative outcomes still remains poor, especially in older adults. We suspect that this could be due to age-related changes in endothelial function—an organ controlling the transport of fluid and solutes. The capillary filtration coefficient (CFC) is an important determinant of fluid transport. The CFC can be measured in vivo, which provides a tool to estimate endothelial barrier function. We have previously shown that the CFC increases when giving a fluid bolus resulting in increased vascular and extravascular volume expansion, in young adults. This study aimed to compare the physiologic determinants of fluid distribution in young versus older adults so that clinicians can best optimize perioperative fluid therapy.MethodsTen healthy young volunteers (ages 21–35) and nine healthy older volunteers (ages 60–75) received a 10 mL/kg fluid bolus over the course of twenty minutes. Hemodynamics, systolic and diastolic heart function, fluid volumetrics and microcirculatory determinants were measured before, during, and after the fluid bolus.ResultsDiastolic function was reduced in older versus younger adults before and after fluid bolus (P < 0.01). Basal CFC and plasma oncotic pressure were lower in the older versus younger adults. Further, CFC did not increase in older adults following the fluid bolus, whereas it did in younger adults (p < 0.05). Cumulative urinary output, while lower in older adults, was not significantly different (p = 0.059). Mean arterial pressure and systemic vascular resistance were elevated in the older versus younger adults (p < 0.05).ConclusionOlder adults show a less reactive CFC to a fluid bolus, which could reduce blood to tissue transport of fluid. Diastolic dysfunction likely contributes to fluid maldistribution in older adults.

Treatment and contemporary outcomes associated with adjunct tourniquet use during phlebectomy of complex, voluminous truncular varicosities

ObjectivePhlebectomy of large voluminous varicose veins comes with a risk of substantial blood loss. The purpose of the present study was to investigate the outcomes associated with the use of an adjunct tourniquet during varicose vein surgery of complex and large truncular varicosities. MethodsThe prospectively collected registry data included anatomic and outcomes details for patients who presented with complex and large truncular varicosities with a CEAP clinical class of C2, or higher (indicating more serious venous disease) from December 2014 to December 2021. Of all patients, those treated with an adjunct tourniquet for large complex varicosities (largest diameter varicosity ≥1 cm by visual inspection) were selected for analysis. The venous clinical severity scores (VCSSs) and patient-reported outcomes (PROs) were obtained. Additional parameters, including operative time, tourniquet time, and blood loss, were obtained retrospectively via a review of the medical records. Univariate descriptive statistics of the demographic and procedural data were performed pre- and postoperatively, with comparisons performed using the Student two-tailed t test. ResultsThe data from 19 patients (22 limbs; 7 women and 12 men) were analyzed. Of the 22 limbs, 11 (50%) had advanced venous disease of C4 or higher preoperatively. A review of the preoperative duplex ultrasound scans confirmed the presence of large varicosities (average, 1.0 ± 0.54 cm; n = 18). All the limbs were treated using radiofrequency ablation of axial reflux and phlebectomy (a combination of powered and stab) under tourniquet control (82%) or phlebectomy under tourniquet control alone (18%). The average tourniquet time was 40 ± 12 minutes, with a median blood loss of 50 mL (interquartile range, 30-100 mL). The average follow-up was 332 ± 422 days after 19 procedures for 16 patients (2 patients moved out of state during the immediate postoperative period and 1 patient was lost to follow-up). Of the patients who completed >3 months of follow-up, 14 limbs experienced improvement in the CEAP class, 5 limbs had no change, and 3 were limbs of patients who moved or were lost to follow-up. The VCSSs significantly improved (8.8 ± 2.8 vs 3.9 ± 1.9; P < .0001). The PROs also improved significantly (16.1 ± 5.0 vs 2.2 ± 2.3; P < .0001). ConclusionsTourniquet use in the treatment of varicosities has only been described in the setting of high ligation and stripping. Our data suggest that in the modern era of minimally invasive endovenous treatment of axial reflux and phlebectomy, adjunct tourniquet use during the treatment of large complex varicosities can result in significant improvements in the VCSSs and PROs, with minimal blood loss.

Bone Density May Be a Promising Predictor for Blood Loss during Total Hip Arthroplasty

Background: Total hip arthroplasty (THA), which is performed mostly in elderly individuals, can result in substantial blood loss and thereby imposes a significant physical burden and risk of blood transfusion. The femoral neck cut and reamed acetabulum are the main sites of intraoperative bleeding. Whether the bone density in that region can be used to predict the amount of blood loss in THA is unknown. Methods: We retrospectively analyzed adult patients undergoing primary THA in the Department of Orthopedics, Peking Union Medical College Hospital, from January 2018 to January 2020. All these patients underwent primary unilateral THA. Patients had their bone mineral density (BMD) recorded within the week before surgery and were stratified and analyzed for perioperative blood loss. Multivariable regressions were utilized to adjust for differences in demographics and comorbidities among groups. Results: A total of 176 patients were included in the study. Intraoperative blood loss was 280.1 ± 119.56 mL. Pearson correlation analysis showed a significant correlation between blood loss and preoperative bone density of both the femoral greater trochanter (R = 0.245, p = 0.001) and the Ward’s triangle (R = 0.181, p = 0.016). Stepwise multiple linear regression showed that preoperative bone density of the greater trochanter (p = 0.015, 95% CI: 0.004–0.049) and sex (p = 0.002) were independent risk factors for THA bleeding. The area under the receiver operating characteristic curve (AUROC) of the greater trochanter and Ward’s triangle was 0.593 (95% CI: 0.507–0.678, p = 0.035) and 0.603 (95% CI: 0.519–0.688, p = 0.018), respectively. The cutoff T value on the femoral greater trochanter for predicting higher bleeding was −1.75. Conclusions: In THA patients, preoperative bone density values of the femoral greater trochanter and sex could be promising independent predictors for bleeding during surgery. Osteoporosis and female patients might have lower blood loss in the THA operation.