Total Hemoglobin Loss Research Articles

Dose Comparison of Flowable Gelatin Hemostatic Matrix for Bleeding Loss in Primary Total Knee Arthroplasty.

Introduction Intraoperative and postoperative bleeding in total knee arthroplasty (TKA) affects postoperative outcomes. Although the hemostatic effect of a flowable gelatin hemostatic matrix (FGHM) is known across several surgical fields, its effectiveness on TKA remains controversial. This study aimed to compare the amount of bleeding across three groups treated with different doses of FGHM in TKA. Methods Overall, 122 knee joints of patients who underwent unilateral primary TKA were included and divided into three groups according to FGHM dose: absence of FGHM (control group, N=48), administration of 5 mL of FGHM (5 mL group, N=46), and administration of 8 mL of FGHM (8 mL group, N=38). Total hemoglobin (Hb) loss, drain output, hidden blood loss (HBL), calculated total blood loss (TBL) on the first postoperative day (POD1) and one week postoperatively (POD7), postoperative flexion angle at one week and discharge, and incidence of postoperative deep venous thrombosis (DVT) were assessed. Results At POD1, the mean total Hb losses were 6.3±3.1g (control group), 5.5±3.3g (5 mL group), and 5.3±2.5g (8 mL group), with no significant differences. At POD7, the mean Hb losses were 9.1±4.6g (control), 8.7±3.6g (5 mL), and 8.3±4.0g (8 mL), also with no significant differences. Mean drain outputs and HBLs showed no significant differences among groups. While there was a decreasing trend in TBL with higher FGHM doses, it was not statistically significant at either POD1 or POD7. There were no statistically significant differences in the mean postoperative flexion angle at POD7 or discharge among the groups (99.7±12.6°, 95.7±12.5°, 98.3±13.8° at POD7; 115.9±9.7°, 113.8±9.6°, 116.6±9.2° at discharge). Of these, only one patient in the 8 mL group developed proximal DVT. Conclusion Despite a trend towards decreased bleeding with FGHM, no significant differences were found among the three groups. However, the clinical utility of this hemostatic agent for reducing blood loss after primary TKA remains still unclear.

Comparison of clinical outcomes between unilateral biportal endoscopic discectomy and percutaneous endoscopic interlaminar discectomy for migrated lumbar disc herniation at lower lumbar spine: a retrospective controlled study

BackgroundBoth Unilateral Biportal Endoscopic Discectomy (UBED) and Percutaneous Endoscopic Interlaminar Discectomy (PEID) have resulted in favorable clinical outcomes in the management of LDH. The aim of this study is to comprehensively compare the efficacy of UBED and PEID in treating migrated LDH in the lower lumbar spine, with a specific focus on high-grade migrated LDH.Methods96 patients who underwent UBED (31 cases) and PEID (65 cases) procedures were enrolled in the study. All patients received a minimum follow-up period of 6 months. Clinical outcomes of the patients were assessed with incision length, operation time, total hemoglobin loss, hospital stay, intraoperative fluoroscopy times, visual analogue scale (VAS) for lower back and leg pain, Oswestry disability index (ODI), modified MacNab criteria, complications, area of lamina loss and increased intervertebral height.ResultsThe VAS scores for lower back and leg pain and ODI significantly decreased in both groups after the operation. Preoperatively, at 1 day, 1 month, and 6 months after the procedure, the VAS and ODI scores exhibited no significant differences between the two groups. There was no significant difference in terms of modified MacNab criteria, area of lamina loss, and increased intervertebral height. The UBED group had a longer incision length, operation time and postoperative hospital stay, and fewer intraoperative fluoroscopy times than to the PEID group. Complications were noted in both groups throughout the follow-up period, but there was no significant difference in the rate of complications. Moreover, there were no notable differences in clinical outcomes between the two groups in the high-grade migrated LDH.ConclusionsBoth UBED and PEID could achieve favorable clinical outcomes for treating migrated LDH at the lower lumbar spine. Despite the longer operative time and postoperative hospital stay associated with the UBED group, UBED remains safe and innovative for treating migrated LDH at the lower lumbar spine.

A Comparison of Oral vs Intravenous Tranexamic Acid in Patients Undergoing Staggered Bilateral Total Knee Arthroplasty.

All previous studies comparing the blood sparing efficacy oral and intravenous tranexamic acid (TXA) in total knee arthroplasty have involved two or more patient cohorts, outcomes of which may be limited by inter-individual variability in human drug response. The purpose of this study was to evaluate if both oral and intravenous preparations of TXA are equivalent at reducing blood loss in the same patients undergoing staggered bilateral total knee arthroplasty. 40 patients undergoing staggered bilateral total knee replacement were recruited. They received 2 g of oral TXA 2 hours preoperatively for the first knee and 1 g of bolus intravenous TXA 15 minutes before skin incision for the second knee. 7 patients were excluded for protocol deviation, leaving 33 participants for the study. The second knee was operated within 5-6 days of the first knee. The primary outcome was reduction in hemoglobin. Equivalence was tested with a two one-sided test (TOST) and a P < 0.05 indicated equivalence between oral and intravenous modes of TXA administration. The mean reduction in hemoglobin was similar between oral and intravenous mode of TXA administration (2.18 and 2.16 g/dl respectively, P<0.0001, equivalence). There was no significant difference in the total hemoglobin loss and total red blood cell volume loss {(104 and 102 g, P=0.86) and (865 and 863 ml, P=0.53) respectively}. Oral and intra venous TXA have equal blood sparing properties in patients undergoing staggered bilateral total knee arthroplasty.

Blood loss and transfusion rate compared among different dosing regimens of tranexamic acid administration in patients undergoing hip hemiarthroplasty for femoral neck fracture: A randomized controlled trial

BackgroundIntravenous tranexamic acid (TXA) administration is a proven safe and effective method for reducing both blood loss and transfusion in total joint arthroplasty. However, data specific to its efficacy in hip hemiarthroplasty (HHA) for femoral neck fracture are scarce. Furthermore, no study has investigated the efficacy of an additional dose of TXA administration. Accordingly, this study aimed to assess blood loss and the transfusion rate compared among different regimens of TXA administration in patients undergoing HHA for femoral neck fracture. MethodsBetween January 2019 to December 2020, 90 HHA patients were randomized into one of three groups (30 patients/group). Control group patients received intravenous normal saline solution (NSS) 20 mL before skin incision, and NSS 20 mL at 3 hours after surgery. one-dose (1D) group patients received 750 mg of intravenous TXA before skin incision, and NSS 20 mL at 3 hours after surgery. Two-dose (2D) group patients received 750 mg of intravenous TXA before skin incision, and 750 mg of TXA at 3 hours after surgery. The primary outcome was blood transfusion rate. Intraoperative blood loss, hemoglobin levels at 24- and 48-hours postoperation, and calculated total blood loss were compared among the three groups. ResultsThe mean age of the study population was 79.7 years, and 76.7% of participants were women. The transfusion rate in the control, 1D and 2D groups was 43.3%, 16.7%, and 3.3%, respectively. Total hemoglobin loss; total red blood cell loss; intraoperative blood loss; hemoglobin level at 24- and 48-hours postoperation; change in hemoglobin level between 0 and 24 hours, and between 0 and 48 hours; blood transfusion rate; and, the number of patients who did not require blood transfusion were all significantly improved in the 2D group compared to baseline. No parameters were significantly improved in the 1D group compared to controls. ConclusionsThe results of this study demonstrate both the efficacy of TXA administration in HHA, and the superiority of two-dose TXA administration over one-dose TXA administration in HHA for femoral neck fracture.

Tranexamic acid in total shoulder arthroplasty under regional anesthesia: a randomized, single blinded, controlled trial

PurposeThe purpose of this study was to determine whether Tranexamic Acid (TXA) can significantly reduce perioperative blood loss in Total Shoulder Arthroplasty (TSA) performed under regional anesthesia. MethodsWe performed a randomized, single blinded, controlled study. Forty-five patients were submitted to TSA under regional anesthesia to treat cuff tear arthropathy, proximal humeral fractures, chronic instability, primary osteoarthrosis, and failures of previous prosthesis. Patients were randomized to either group TXA therapy (TXA), with 1 g intravenous (IV), or no Intervention (NTXA). Postoperative total drain output, hemoglobin variation, total blood loss, hemoglobin loss, and need for transfusion were measured. Pain-related variables were also assessed: postoperative pain assessment by visual analog scale, inpatient pain breakthrough, quality of recovery, length of stay, and coagulation function testing. ResultsParticipants presented a mean age of 76 years, 15.6% were male, 82.2% were American Society of Anesthesiologists (ASA) physical status I or II. There were no differences between groups concerning transfusions, operative time, Post-Anesthesia Care Unit (PACU) length of stay and in-hospital stay, and QoR-15 or postoperative pain. Bleeding measured by drain output at 2, 24 and 48 hours was significantly less in the TXA group at each timepoint. There was a difference in Hb variation – TXA: median (IQR) -1.4 (1.3) g.dL-1 vs. NTXA: -2.2 (1.3) g.dL-1; median difference: 0.80 (0.00–1.20); p = 0.047. aPTT was lower in TXA administered patients – TXA: median (IQR) 29.6 (14.0)s vs. NTXA: 33 (5.8)s; difference in medians: -4.00 (-6.50–-1.00); p = 0.012. ConclusionTXA use significantly decreased blood loss measured by drain output and Hb drop in TSA under regional anesthesia.

Does the correction angle affect hidden blood loss in HTO?

BackgroundHigh tibial osteotomy (HTO) has a history of nearly 60 years and has been widely used in clinical practice. Biplanar open wedge high tibial osteotomy (BOWHTO), which evolved from HTO, is an important therapy for the knee osteoarthritis. In our previous research, we found that the decrease of hemoglobin levels after high tibial osteotomy ranges from between 17 to 41 g/L, but this is highly inconsistent with the intraoperative bleeding and postoperative drainage observed in clinical practice. The purpose of this study was to investigate the perioperative hidden blood loss (HBL) after biplanar open wedge high tibial osteotomy (BOWHTO), as well as to study the effect of the actual correction angle on blood loss.MethodsA retrospective analysis was performed on 21 patients who underwent BOWHTO for osteoarthritis of the knee due to proximal tibia deformity. Gross equation was used to calculate the perioperative total blood loss (TBL) and HBL. The actual correction angle was measured by postoperative anteroposterior radiograph. The correlation between HBL and correction angle was determined through correlation analysis.ResultsThe TBL was 823.5 ± 348.7 mL and the HBL was 601.6 ± 297.3 mL, total hemoglobin loss was 25.0 ± 10.7 g/L, and the mean HBL/patient’s blood volume (H/P) was 13.19 ± 5.56% for 21 patients. The correlation coefficient of correction angle and H/P is statistically significant (|r| = 0.678, P = 0.001).ConclusionsThe actual total blood loss after BOWHTO was significantly higher than the observed, and the HBL was objective existent after BOWHTO. The proportion of H/P is positively correlated with the correction angle.

Does a Single Low Dose Preoperative Intravenous Erythropoietin Affect Postoperative Blood Loss and Transfusion in Elderly Hip Fracture Patients Receiving Intravenous Iron Therapy: A Randomized Controlled Trial

Background: Combined recombinant human erythropoietin (rHuEPO) and iron therapy significantly reduced postoperative blood loss (PBL) and allogeneic blood transfusion (ABT) in elderly hip fracture (HF) patients. However, the minimum effective rHuEPO dosage and route had not been studied before.&#x0D; Objective: To evaluate the efficacy of single low dose preoperative intravenous rHuEPO on PBL and ABT in elderly HF.&#x0D; Methods: A randomized controlled trial (RCT) in 32 elderly HF underwent surgical intervention was conducted. The patients were randomly assigned to receive a single dose of 10 000 IU rHuEPO (EPO group, n = 16) or placebo (control group, n = 16) on admission. All patients were given 200-mg iron sucrose intravenously for 3 days after admission. Perioperative data, outcome related to PBL, ABT, rHuEPO adverse effects, and functional outcome during 1-year period were collected and analyzed.&#x0D; Results: There was no significant difference in demographic data, postoperative complication, and functional outcome between both groups (P &lt; .05). Total hemoglobin loss (THL) and the number of patients receiving ABT in EPO group (2.1 ± 1.0 g/dL and 12 patients) did not significant differ from those in control group (2.2 ± 0.8 g/dL and 10 patients) (P = .81 and P = .44, respectively). However, EPO group demonstrated a nonsignificant greater in hemoglobin recovery (P = .07) and increase in reticulocyte count (P = .10).&#x0D; Conclusion: Combined single low dose preoperative intravenous rHuEPO with iron therapy does not significantly reduce PBL and ABT in elderly HF compared to who received intravenous iron therapy alone. However, this adjunct rHuEPO may hasten the hemoglobin recovery and helpful for the patients’ outcome.

What is the Ideal Route of Administration of Tranexamic Acid in TKA? A Randomized Controlled Trial.

TKA commonly involves substantial blood loss and tranexamic acid has been used to reduce blood loss after TKA. Numerous clinical trials have documented the efficacy and safety of intravenous (IV) or intraarticular (IA) use of tranexamic acid. Combined administration of tranexamic acid also has been suggested; however, there is no consensus regarding the ideal route of tranexamic acid administration. (1) To compare the efficacy of tranexamic acid in terms of total blood loss and the allogeneic transfusion rate among three routes of administration: IV alone, IA alone, and combined IV and IA. (2) To compare these regimens in terms of venous thromboembolism (VTE) and the frequency of wound complications. In total, 376 patients undergoing TKA between March 2014 and March 2015 were randomized to four groups by the route of tranexamic acid administration: IV only, IA only, low-dose combined (IV + IA injection of 1 g), and high-dose combined (IV + IA injection of 2 g). The calculated total blood loss, allogeneic transfusion rate, decrease in hemoglobin, the frequency of symptomatic deep vein thrombosis and pulmonary embolism, wound complications, and periprosthetic joint infection were compared among the groups. Total blood loss was calculated using estimated total body blood volume and hemoglobin loss. The decision regarding when to transfuse was determined based on preset criteria. The high- and low-dose combined groups and the IA-only group had lower total blood loss (564 ± 242 mL, 642 ± 242 mL, and 633 ± 205 mL, respectively) than the IV-only group (764 ± 217 mL; mean differences = 199 mL [95% CI, 116-283 mL], p < 0.001; 121 mL [95% CI, 38-205 mL], p = 0.001; 131 mL [95% CI, 47-214 mL], p < 0.001); no differences were found among the other three groups. No patients in any study group received an allogeneic transfusion. One patient in the IV-only group had a symptomatic pulmonary embolism develop, but no other symptomatic VTE events occurred in any group. In addition, no differences were observed in wound complications, such as superficial wound necrosis (one patient in the IV-only and the high-dose combined group, respectively) and oozing (IV-only, IA-only, low-dose combined, high-dose combined = 3%, 4%, 4%, and 7%; p = 0.572) between the groups. No patients had a periprosthetic joint infection. IA tranexamic acid administration further reduces blood loss after TKA in comparison to IV use alone; no additional effect in further reducing blood loss was found in combination with IV tranexamic acid. Appropriately powered studies are needed to confirm the safety of this route of administration as the preferred route of administration in TKA. Level I, therapeutic study.

Predicting Factors for Allogeneic Blood Transfusion and Excessive Postoperative Blood Loss after Single Low-Dosage Intra-Articular Tranexamic Acid Application in Total Knee Replacement.

Background. Recently, intra-articular tranexamic acid (IA-TXA) application has become a popular method for perioperative blood loss (PBL) reduction in total knee replacement (TKR). Nevertheless, through our knowledge, no previous studies had shown the correlation perioperative factors and the risk of excessive PBL or need of blood transfusion (BT) after IA-TXA. Materials and Methods. A retrospective study was conducted in patients underwent 299 primary TKRs, using IA-TXA, during 2-year period (2013-2014). Patient's characteristic and perioperative data were reviewed and collected. PBL was measured as total hemoglobin loss (THL), estimated total blood loss (ETBL), and drainage volume per kg (DV/kg). Excessive PBL was defined as PBL that exceeded 90th percentile. Results. From multivariate analysis, low preoperative hemoglobin (Hb) level and body mass index (BMI) were the significant predictors of postoperative BT (p < 0.0001 and 0.003, resp.). Excessive THL significant associated with preoperative Hb (p < 0.0001). Excessive ETBL significantly associated with preoperative Hb, height, preoperative range-of-motion, and creatinine clearance (p < 0.05 all). Low BMI and large prosthesis size were the significant predictors of excessive DV/kg (p = 0.0001 and 0.002, resp.). Conclusions. Low preoperative Hb and BMI were the significant risks of postoperative transfusion after TKR with IA-TXA. Moreover, multiple perioperative factors could result in higher PBL.

Closed Suction Drainage Has No Benefits in Anterior Hip Arthroplasty: A Prospective, Randomized Trial

BackgroundMany studies have challenged routine drain placement in patients undergoing total hip arthroplasty. Some studies suggest increased transfusion rate with the use of closed suction drains. The use of tranexamic acid to control surgical bleeding and aspirin for venous thromboembolism prophylaxis has gained popularity. No study has evaluated the use of drains in patients undergoing direct anterior total hip arthroplasty under these conditions. MethodsWe performed a prospective, randomized study in patients undergoing direct anterior total hip arthroplasty to evaluate whether closed suction drain placement provides any clinical benefit. Patients randomly assigned to the control group had closed suctions drains placed; patients randomly assigned to the treatment group had no drains placed. The primary outcome measures were hematoma formation, wound complications, and transfusion rates. The secondary outcome measures were estimated blood loss, decrease in hemoglobin and hematocrit levels, total hemoglobin loss, calculated blood loss, hidden blood loss, and total length of hospital stay. Differences in outcomes between groups were considered to be significant at P ≤ .05. ResultsThere were no significant differences between groups in transfusion rate (P = .49), postoperative decrease in hemoglobin levels (P = .95), average calculated blood loss (P = .65), complications (P = .49), or length of hospital stay (P = .14). There was no hematoma formation observed in either group. ConclusionOur study showed no clinical benefit or disadvantage to closed suction drainage in anterior hip arthroplasty with the concomitant use of tranexamic acid for surgical hemostasis and aspirin for venous thromboembolism prophylaxis.

En-Bloc Technique With Anteroposterior Dissection Holmium Laser Enucleation of the Prostate Allows a Short Operative Time and Acceptable Outcomes

To simplify anteroposterior dissection holmium laser enucleation of the prostate by combining it with a novel en-bloc enucleation technique that omits median lobe enucleation and removes the adenoma en-bloc in benign prostatic hyperplasia patients. Between September 2013 and May 2014, 65 patients with benign prostatic hyperplasia underwent holmium laser enucleation of the prostate with the en-bloc technique we developed at our institution. Twenty-six patients who underwent surgery performed by the same experienced surgeon were included in our study. We evaluated the surgical parameters, including total operative time, enucleation time, morcellation time, and hemoglobin loss. Peak flow rate and postvoid residual urine volume were assessed 3 months postoperatively, and urinary incontinence was assessed 1 day after catheter removal and at 1 and 3 months postoperatively in all patients. Mean total operating time and mean enucleation time were 56.4 and 26.5 minutes, respectively. Peak flow rate and postvoid residual urine volume significantly improved. The incidence of postoperative incontinence at 3 months was 3%. Our en-bloc enucleation method required a short operating time and may address concerns regarding the complexity of the enucleation procedure. We believe the incidence of postoperative incontinence can be further reduced with additional refinements of this procedure.

Efficacy of low-dose intra-articular tranexamic acid in total knee replacement; a prospective triple-blinded randomized controlled trial

BackgroundRecently, a number of studies using intra-articular application of tranexamic acid (IA-TXA), with different dosage and techniques, successfully reduced postoperative blood loss in total knee replacement (TKR). However, best of our knowledge, the very low dose of IA-TXA with drain clamping technique in conventional TKR has not been yet studied. This study aimed to evaluate the effectiveness and dose-response effect of two low-dose IA-TXA regimens in conventional TKR on blood loss and blood transfusion reduction.MethodsBetween 2010 and 2011, a triple-blinded randomized controlled study was conducted in 135 patients undergoing conventional TKR. The patients were allocated into three groups according to intra-articular solution received: Control group (physiologic saline), TXA-250 group (TXA 250 mg), and TXA-500 group (TXA 500 mg). The solution was injected after wound closure followed by drain clamping for 2 hours. Blood loss and transfusion were recorded. Duplex ultrasound was performed. Functional outcome and complication were followed for one year.ResultsThere were forty-five patients per groups. The mean total hemoglobin loss was 2.9 g/dL in control group compared with 2.2 g/dL in both TXA groups (p > 0.001). Ten patients (22%, control), six patients (13%, TXA-250) and none (TXA-500) required transfusion (p = 0.005). Thromboembolic events were detected in 7 patients (4 controls, 1 TXA-250, and 2 TXA-500). Functional outcome was non-significant difference between groups.ConclusionsCombined low-dose IA-TXA, as 500 mg, with 2-hour clamp drain is effective for reducing postoperative blood loss and transfusion in conventional TKR without significant difference in postoperative knee function or complication.Trial registrationClinicalTrials.gov NCT01850394.

Postoperative blood loss reduction in computer-assisted surgery total knee replacement by low dose intra-articular tranexamic acid injection together with 2-hour clamp drain: a prospective triple-blinded randomized controlled trial

A high-dose local tranexamic acid has been introduced in total knee arthroplasty for bleeding control. We are not sure about the systemic absorption and side effects. The aim of this study was to evaluate the effect of low dosage of intra-articular tranexamic acid injection combined with 2-hour clamp drain in minimally bleeding computer-assisted surgery total knee replacement (CAS-TKR). A prospective randomized controlled trial was conducted in a total of 48 patients underwent CAS-TKR. The patients were randomly assigned to receive either of a mixed intra-articular solution of tranexamic acid 250 mg with physiologic saline (TXA group), or physiologic saline (control group) and then followed by clamp drain for 2 hours. Postoperative blood loss was measured by three different methods as drainage volume, total hemoglobin loss and calculated total blood loss. Transfusion requirement and postoperative complications were recorded. All patients were screened for deep vein thrombosis and the functional outcomes were evaluated at 6 months after surgery. The mean postoperative drainage volume, total hemoglobin loss and calculated total blood loss in TXA group were 308.8 mL, 2.1 g/dL and 206.3 mL compared to 529.0 mL, 3.0 g/dL and 385.1 mL in the control group (P=0.0003, 0.0005 and <0.0001 respectively). Allogenic blood transfusion was needed for one patient (4.2%) in TXA group and for eight patients (33.3%) in the control group. Postoperative knee scores were not significantly different between groups. No deep vein thrombosis, infection or wound complication was detected in both groups. In this study, low dose intra-articular tranexamic acid injection combined with 2-hour clamping drain was effective for reducing postoperative blood loss and transfusion requirement in CAS-TKR without significant difference in postoperative complications or functional outcomes.

BPH Tranexamic acid decreases blood loss during transurethral resection of the prostate (TUR-P)

IntroductionPostoperative blood loss after prostate surgery is thought to be associated with an increase in urinary fibrinolytic activity. Tranexamic acid (TXA) is both a potent inhibitor of plasminogen and urokinase activators and a low molecular weight substance that is excreted unchanged in the urinary tract and can be administered both orally and intravenously. We investigated the effect of TXA on the amount of blood loss during transurethral resection of the prostate (TURP).Materials and methodsForty patients with registry numbers ending in even numbers were allocated to the treatment group; those ending in odd numbers were used as controls and received no treatment. The treatment group received 10 mg/kg TXA by intravenous infusion during the first half hour of the operation, while the control group of patients received no medication. Serum hemoglobin was measured before and after surgery. The volume and hemoglobin concentration of the irrigation fluid, resected prostate weight, and duration of resection were recorded.ResultsThe mean loss of hemoglobin per gram of resected prostate tissue was 1.25 g in the TXA group and 2.84 g in the control group. Total hemoglobin loss in the irrigating fluid and hemoglobin loss per 1 gram of prostate tissue was lower in the group of patients given TXA than in the control group (p = 0.018 and p <0.001).ConclusionReduced bleeding during TURP as a result of TXA treatment may lead to better surgical conditions and, as a consequence, shorter operative times and lower irrigating fluid volumes.

Amelioration of the bleeding tendency of preoperative aspirin after aortocoronary bypass grafting

Background. Aspirin therapy is widely used in the treatment of cardiac disease. It has been recognized as a causative factor for increased bleeding and blood loss after open heart operations.Methods. To determine whether high-dose aprotinin maintained its efficacy in reducing blood loss in the presence of aspirin pretreatment in patients undergoing aortocoronary bypass, we performed a double blind study on 60 adult patients. Half received high-dose aprotinin (Trasylol) and half placebo.Results. Total hemoglobin loss, the primary efficacy variable was reduced from 36.1 ± 31.4 g (mean ± SD) to 14.1 ± 16.0 g (p = 0.002). Blood loss was reduced intraoperatively and total loss was reduced from 837.3 mL ± 404.9 mL to 368.7 mL ± 164.3 mL (p < 0.001). The number of patients who did not receive any donor blood products was significantly higher in the aprotinin-treated patients (56.7% versus 23.3%, p = 0.008). Activation of the clotting cascade was significantly less in the treated patients toward the end of cardiopulmonary bypass both by measurement of thrombin–antithrombin III complex (p < 0.0001) and prothrombin fragment 1 + 2 (p < 0.0001). d-Dimer generation was significantly less from the onset of bypass and after reversal of heparin in the aprotinin-treated patients (p < 0.0001).Conclusions. High-dose aprotinin was highly effective in reducing bleeding in this high-risk group of patients. Biochemical analyses suggest the mechanism by which aspirin increases blood loss after cardiopulmonary bypass is different from the blood-preserving effects of aprotinin, which is acting as an antifibrinolytic agent.

The effect of three different doses of tranexamic acid on blood loss after cardiac surgery with mild systemic hypothermia (32°C)

Objective: Prophylactic administration of tranexamic acid (TA), an antifibrinolytic agent, decreases bleeding after cardiac surgery with systemic hypothermia (25°C to 29°C). Warmer systemic temperatures during cardiopulmonary bypass (CPB) may reduce bleeding and thus alter the requirement for TA. The effect of three different doses of TA on bleeding after cardiac surgery with mild systemic hypothermia (32°C) is evaluated. Design: Double-blind, prospective, randomized study. Setting: University hospital. Participants: One hundred fifty adult patients undergoing aortocoronary bypass or valvular cardiac surgery. Interventions: Patients received TA, 50 (n = 50), 100 (n = 50), or 150 (n = 50) mg/kg intravenously before CPB with mild systemic hypothermia. Measurements and Main Results: Blood loss through chest drains over 6, 12, and 24 hours after surgery and total hemoglobin loss were measured. Autotransfused blood, transfused banked blood and blood products, and coagulation profiles were measured. Analysis of variance on log-transformed data for blood loss and confidence intervals (Cis) of 0.95 were calculated and transformed to milliliters of blood. No patient was re-explored for bleeding. Blood loss at 6 hours was statistically greater in the 50-mg/kg group compared with the other two groups ( p = 0.03; p = 0.02). Total hemoglobin loss was statistically greater in the 50-mg/kg group compared with the 150-mg/kg group ( p = 0.04). There was no statistical difference in blood transfusion rate or coagulation profiles among the three groups. However, preoperative hemoglobin level was statistically lower in the 150-mg/kg group compared with the other two groups ( p = 0.01). Conclusion: Of the three doses of TA studied, the most efficacious and cost-effective dose to reduce bleeding after cardiac surgery with mild hypothermic systemic perfusion is 100 mg/kg.

Consistent non-pharmacologic blood conservation in primary and reoperative coronary artery bypass grafting

Because much interest has been focused on blood conservation using different drugs and complicated blood cell processing devices, we analyzed our results with the use of a non-pharmacologic, simple and inexpensive program for blood salvage in 2326 patients undergoing myocardial revascularization. The material was divided into two groups: patients undergoing a primary coronary bypass operation (Group P, n = 2298) and a smaller subset of patients undergoing repeat coronary bypass operation (Group R, n = 28). At least one internal mammary artery was grafted in 99% of the patients, with supplemental saphenous vein grafts. Intraoperatively, autologous heparinized blood was removed before bypass and retransfused at the conclusion of extracorporeal circulation. The volume remaining in the extracorporeal circuit was returned without cell processing or hemofiltration. Autotransfusion of the shed mediastinal blood was continued hourly up to 18 h after surgery in all patients. The mean postoperative mediastinal drainage in group R was 543 +/- 218 ml, compared to 703 +/- 340 ml in Group P (P = 0.01). In Group R, 1 patient (3.6%) received packed red cells and no patients were given other homologous blood products, compared to 33 patients (1.4%) given red cells and 35 patients (1.5%) given plasma transfusion in Group P (NS). Thus, in total, 2257 patients (97.0%) were not exposed to any homologous blood products during hospitalization. Total hemoglobin loss was significantly higher in Group R, resulting in a mean hemoglobin concentration at discharge of 109 +/- 13 g/l, compared to 121 +/- 14 g/l in Group P (P = 0.0002).(ABSTRACT TRUNCATED AT 250 WORDS)

Reduction in blood loss and blood use after cardiopulmonary bypass with high-dose aprotinin versus autologous fresh whole blood transfusion

Ninety patients undergoing cardiac surgery were randomly divided into three groups of 30 patients to compare the effects on bleeding and transfusion requirements of either intraoperative infusion of high-dose aprotinin (Gpl) or reinfusion of autologous fresh whole blood (GpII) versus a control group (GpIII). Standardized anesthetic, perfusion, and surgical techniques were used. Platelet counts, hemoglobin concentration, hematocrit, fibrinogen, and Ivy-Nelson bleeding times determined at fixed times perioperatively did not differ among the three groups. The total loss from the chest drains was significantly reduced in GpI (328 ± 28 mL; mean ± SEM) as compared with the loss in GpII and GpIII (775 ± 75 mL and 834 ± 68 mL, respectively). There was a threefold difference in the total hemoglobin loss (GpI,14.2 ± 1.7 g; GpII, 50.1 ± 5.0 g; GpIII, 45.0 ± 5.2 g). GpI patients also received less banked blood: 250 ± 53 mL versus 507 ± 95 mL in GpII and 557 ± 75 mL in GpIII. No GpI patient required transfusion of platelets or fresh frozen plasma. Fresh whole autologous blood transfusions had no significant hemostatic effect and failed to reduce the homologous blood requirement. Conversely, high-dose aprotinin reduced blood loss and transfusion requirements.

Reduction in blood loss and blood use after cardiopulmonary bypass with high dose aprotinin (Trasylol)

The effect of high dose aprotinin (Trasylol) was evaluated in three groups of patients undergoing cardiopulmonary bypass. In a prospective, placebo-controlled, double-blind study, 80 patients having primary aorta-coronary bypass grafting received aprotinin (700 mg approximately) or saline placebo from the beginning of the procedure until skin closure. Standardized anesthetic, perfusion, and surgical techniques were used. The total loss from the thoracic drains was significantly reduced in the aprotinin group as compared with the loss in the placebo group (309 +/- 133 ml versus 573 +/- 166 ml, p less than 0.01; mean +/- standard deviation). There was a threefold difference in the total hemoglobin loss into the chest drains (aprotinin 12.0 +/- 12.6 gm versus placebo 37.7 +/- 18.3 gm). Patients of the aprotinin group received remarkably less bank blood postoperatively: 13 units total compared with 75 units. Of the 40 patients in the aprotinin group, 32 received no bank blood compared with 2 of 37 patients in the placebo group. Venous hemoglobin levels preoperatively, on day 1, and on day 7 postoperatively did not differ between the groups. At day 7 the values were 13.1 +/- 1.4 gm/dl versus 12.5 +/- 1.2 gm/dl in the aprotinin group and the placebo group, respectively. Platelet counts determined at fixed times perioperatively did not differ between the two groups. In contrast, template bleeding time measured in 32 study patients was distinctly different between groups, with a postoperative rise of 6.2 +/- 2.1 minutes in the placebo group opposed to only 1.5 +/- 1.1 minutes in the aprotinin group.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of preoperative total parenteral nutrition on surgery outcomes

The effect of preoperative total parenteral nutrition (TPN) on morbidity and mortality was studied in medical records of discharged surgical patients. Patients were classified into two groups on the basis of their ability to meet established criteria for malnutrition and the use of preoperative or postoperative TPN. The control group consisted of 44 patients who received TPN only after surgery or for less than 5 days preoperatively. The experimental group consisted of 26 patients who received treatment for at least 5 days before surgery and/or after surgery. Nutrition parameters measured included serum albumin, total lymphocyte count, hemoglobin, weight, and percent weight loss. Major septic complications (MSC) considered were intra-abdominal sepsis, wound dehiscence, septicemia, and pneumonia. Other complications included respiratory failure, congestive heart failure, fistulas, urinary tract infection, shock, and death. The experimental group showed improvements after surgery in the nutritional parameters listed and had a lower incidence of morbidity and mortality. Deficits in serum albumin, total lymphocyte count, and weight losses greater than or equal to 10% have been significantly (p less than .01) linked to the incidence of MSC. MSC also has been more frequently noted among patients who did not have TPN prior to surgery and who died following surgery. Therefore, preoperative TPN does appear to make a difference in the outcome of surgery.