Safety and Efficacy of Tranexamic Acid in Hip Hemiarthroplasty for Fracture Neck Femur: a Systematic Review and Meta-analysis

Purpose

Although numerous systematic reviews and meta-analyses have established the efficacy of tranexamic acid (TXA) in hip fracture surgeries, the included studies in those reviews have included all types of surgical interventions ranging from fixation to arthroplasty. Hip hemiarthroplasty is usually indicated in the elderly patients with femoral neck fracture and these patients have associated severe comorbidities and cognitive impairment. These subsets of patients with femoral neck fracture needs appropriate perioperative care and judicious use of antifibrinolytics. There is no meta-analysis evaluating the safety and efficacy of intravenous TXA in these patients.

Methods

Searches of PubMed, Embase and Cochrane Central Register of Controlled Trials databases revealed 102 studies on TXA in hip fracture surgeries. After screening, eight studies were found to be suitable for review. The primary objective of this meta-analysis was to compare blood transfusion rate between TXA vs. control in hip hemiarthroplasty. The secondary objectives were total blood loss, postoperative haemoglobin, surgical duration, length of hospital stay and side effects (VTE, readmission and 30 days mortality).

Results

There were one RCT, one prospective cohort study and six retrospective studies. All studies recruited the elderly patients. Intravenous (IV) TXA administration resulted in significant reduction in requirement of blood transfusion (12.7% vs. 31.9%; OR 0.28; 95% CI 0.17-0.46; p < 00,001; I 2 = 73%). The TXA group had significantly decreased total blood loss (MD - 100.31; 95% CI - 153.79, - 46.83; p < 0.0002). The postoperative Hb in the TXA group was significantly higher than the control group (MD 0.53; 95% CI 0.35, 0.71; p < 0.00001). There was no significant difference in the incidences of VTE (0.97% vs. 0.73%, OR 1.27; p = 0.81; I 2 = 64%) and readmission rate (9.2% vs. 9.64%; OR 0.79; p = 0.54), but 30-d mortality rate was significantly lower in the TXA group (3.41% vs. 6.04%; OR 0.66; p = 0.03).

Conclusions

Intravenous TXA is efficacious in the reduction of blood loss and transfusion need in hip hemiarthroplasty surgery for hip fracture, without increased risk of VTE. The blood conservation protocol led to decreased 30 days mortality in these fragile elderly patients.

Level of evidence

III.

Management of cesarean scar pregnancy: Importance of gestational age at diagnosis and disease type-A single center's 5 years of experience involving 223 cases

Objective

This study aims to evaluate the importance of the gestational age at diagnosis and the types of cesarean scar pregnancy (CSP) for treatment outcomes and to identify the optimal treatment based on both the gestational age at diagnosis and the CSP type.

Methods

A retrospective cohort study included 223 pregnant women diagnosed with CSP at Peking University First Hospital, Beijing, China, between 2014 and 2018. All CSP cases underwent ultrasound-guided vacuum aspiration followed by supplementary curettage. Adjuvant treatment modalities included intramuscular injection of systemic methotrexate, uterine artery embolization, and hysteroscopy before ultrasound-guided vacuum aspiration. Linear regression was used to determine the relationship between intraoperative blood loss and gestational age at diagnosis, CSP type, highest β-human chorionic gonadotropin level, and management procedures.

Results

None of the patients required blood transfusions or hysterectomies. Patients presenting at <8, 8-10, and >10 weeks had median estimated blood loss of 5, 10, and 35 ml, respectively. Patients with type I CSP, type II CSP, and type III CSP had median blood loss of 5, 5 and 10 ml, respectively. Multivariate linear regression analysis demonstrated that the gestational age at diagnosis (p < 0.001) and type of CSP (p = 0.023) were independent predictors of intraoperative estimated blood loss. For type I CSP patients, ultrasound-guided vacuum aspiration followed by supplementary curettage alone was performed in 15 of 34 (44.1%) patients, including 12/27 (44.4%) diagnosed at <8 weeks, 2/6 (33.3%) at 8-10 weeks, and 1/1 for >10 weeks. In type II CSP patients, fewer cases were managed by ultrasound-guided vacuum aspiration followed by supplementary curettage alone as the gestational age at diagnosis increased [18/96 (18.8%) for <8 weeks, 7/41 (17.1%) for 8-10 weeks, none for >10 weeks]. Most type III CSP patients (41/45, 91.1%) needed treatments in addition to the ultrasound-guided vacuum aspiration regardless of the gestational age at diagnosis. All CSP patients were treated successfully and did not require readmission or further medical interventions.

Conclusion

Gestational age at diagnosis of CSP and its type show a strong correlation with estimated blood loss during ultrasound-guided vacuum aspiration. With careful management, CSPs may be treated at any gestational week, regardless of their type, with minimal intraoperative bleeding.

Estimation of the intraoperative blood loss in dogs undergoing enucleation

PURPOSE

To quantify the surgical blood loss during canine enucleation and to investigate the relationship between this and any patient, surgical, and anesthetic factors.

METHODS

A prospective observational analysis was conducted on 121 client-owned dogs (130 eyes) undergoing enucleation at a referral ophthalmology clinic. Blood loss was estimated by the gravimetric method (weight difference between dry and blood-containing surgical materials) to provide absolute blood loss (ABL) in milliliters, expressed as a percentage of circulating blood volume, to establish relative blood loss (RBL).

RESULTS

Median ABL was 12 ml (1.6-116 ml), and median RBL was 1.3% (0.1%-6.7%). A higher RBL was associated with the following: use of a bupivacaine splash block versus retrobulbar nerve block (1.9 vs. 1%; p < .001), transpalpebral versus subconjunctival approach (2.2 vs. 1.3%; p = .003), and small versus large breed dogs (1.7% vs. 1.1%; p = .001). Both ABL and RBL differed significantly between surgeons. There was no significant difference in hemorrhage associated with the presence of ocular hypertension, systemic illness, surgical time, administration of meloxicam or choice of pre-medicant (acepromazine vs medetomidine). No dog required supportive intervention in response to surgical hemorrhage.

CONCLUSIONS

This study has established a surgical blood loss estimate for dogs undergoing enucleation at an ophthalmology referral centre. Subconjunctival enucleation may be preferred for patients at greater risk of haemodynamic complications.

Tranexamic acid is associated with improved hemostasis in elderly patients undergoing coronary-artery surgeries in a retrospective cohort study

Background

More elderly patients undergo coronary artery bypass surgery (CABG) than younger patients. Whether tranexamic acid (TA) is still effective and safe in elderly patients undergoing CABG surgeries is still unclear.

Methods

In this study, a cohort of 7,224 patients ≥70 years undergoing CABG surgery were included. Patients were categorized into the no TA group, TA group, high-dose group, and low-dose group according whether TA was administered and the dose administered. The primary endpoint was blood loss and blood transfusion after CABG. The secondary endpoints were thromboembolic events and in-hospital death.

Results

The blood loss at 24 and 48 h and the total blood loss after surgery in patients in the TA group were 90, 90, and 190 ml less than those in the no-TA group, respectively (p < 0.0001). The total blood transfusion was reduced 0.38-fold with TA administration compared to that without TA (OR = 0.62, 95% CI 0.56-0.68, p < 0.0001). Blood component transfusion was also reduced. High-dose TA administration reduced the blood loss by 20 ml 24 h after surgery (p = 0.032) but had no relationship with the blood transfusion. TA increased the risk of perioperative myocardial infarction (PMI) by 1.62-fold [p = 0.003, OR = 1.62, 95% CI (1.18-2.22)] but reduced the hospital stay time in patients who were administered TA compared to that of patients who did not receive TA (p = 0.026).

Conclusion

We revealed that elderly patients undergoing CABG surgeries had better hemostasis after TA administration but increased the risk of PMI. High-dose TA was effective and safe compared with low-dose TA administration in elderly patients undergoing CABG surgery.

A Comparison Between the Perioperative Outcomes of Female Adolescent Idiopathic Scoliosis (AIS) Versus Adult Idiopathic Scoliosis (AdIS) Following Posterior Spinal Fusion: A Propensity Score Matching Analysis Involving 425 Patients

STUDY DESIGN

Retrospective propensity score matching (PSM) study.

OBJECTIVE

To investigate the perioperative outcomes comparing adolescent idiopathic scoliosis (AIS) and adult idiopathic scoliosis (AdIS) patients following posterior spinal fusion (PSF).

METHODS

425 female AIS and AdIS patients who were operated (between January 2015 to March 2020) using a dual attending surgeon strategy were stratified into G1 (AIS aged 10-16 years old) and G2 (AdIS > 20 years old). PSM analysis with one-to-one, nearest neighbor matching technique with match tolerance of 0.001 was used to matched 357 AIS patients to 68 AdIS patients. Operation duration, intraoperative blood loss (IBL), blood loss percentage, hemoglobin drift, blood salvaged, postoperative wound length, allogenic blood transfusion requirement, postoperative hospital stay, postoperative Cobb, correction rate and postoperative complications were documented and reported.

RESULTS

Following PSM, G1 and G2 each had 50 patients with comparable and balanced covariates. As anticipated, G2 patients were heavier, taller and had higher body mass index compared to G1 patients (P < 0.05). We could not find any significant differences in the perioperative outcome comparing this 2 groups. AIS and AdIS patients had similar operation duration (125.9 ± 27.2 min vs 127.3 ± 37.8 min), IBL (749.8 ± 315.7 ml vs 723.8 ± 342.1 ml) and length of hospital stay (3.3 ± 0.4 days vs 3.5 ± 0.8 days) (P > 0.05). Hemoglobin drift and amount of blood salvaged were comparable (P > 0.05). G2 had stiffer curves. There was a trend toward a lower correction rate in G2 in the immediate postoperative period, however it did not reach statistical significance (61.8 ± 11.2% vs. 66.3 ± 11.6%, P = 0.051). No patients required blood transfusion and none had any postoperative complications.

CONCLUSION

Adolescent and adult female scoliosis patients had comparable perioperative outcome following PSF surgery that was carried out using a dual attending surgeon strategy.

Impact of intra-articular injection with tranexamic acid on total blood loss and postoperative pain after arthroscopic rotator cuff repair surgery

Objectives

To evaluate the impact of intra-articular injection with tranexamic acid (TXA) on total blood loss (TBL) and postoperative pain after arthroscopic rotator cuff repair (ARCR).

Methods

This study retrospectively included patients with full-thickness rotator cuff tears who underwent shoulder ARCR surgery in Taizhou hospital, China, between January 2018 and December 2020. Patients received 10 ml (100 mg/ml) of intra-articular TXA injection (TXA group) or 10 ml of normal saline (non-TXA group) after the incision was sutured. The primary variable was the type of drug injected into the shoulder joint at the end of the operation. The primary outcome were perioperative TBL and postoperative pain [measured by visual analog scale (VAS)]. The secondary outcomes were differences in red blood cell count, hemoglobin count, hematocrit, platelet count.

Results

A total of 162 patients were included, 83 patients in TXA group and 79 patients in non-TXA group. Notably, patients in TXA group were more likely to have lower TBL volume [261.21 (175.13-506.67) ml vs. 382.41 (236.11-593.31), P = 0.025], and postoperative VAS score ≤ 2 within 24 h (P = 0.031) compared with those in non-TXA group. In addition, the median hemoglobin count difference was significantly lower in TXA group than that of in non-TXA group (P = 0.045), while, the differences in median counts of red blood cell, hematocrit, and platelet between the two groups were comparable (all P > 0.05).

Conclusion

Intra-articular injection of TXA might reduce the TBL and degree of postoperative pain within 24 h after shoulder arthroscopy.

Evaluation of the Safety and Effectiveness of Topical Intrapleural Application of Tranexamic Acid in Thoracic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

Bleeding remains a common complication post-thoracic surgery. Although intravenous tranexamic acid (TXA) has been shown to decrease blood loss, its use has been associated with adverse effects. Accordingly, topical TXA has been proposed as an alternative to reduce bleeding with fewer systemic complications.

METHODS

We searched Medline, Embase, and Cochrane Central databases for randomized controlled trials (RCTs) comparing topical TXA versus control (i.e., placebo) in patients undergoing thoracic procedures. The primary outcome was total postoperative blood loss at 24 hours. Secondary outcomes included were the number of red blood cell (RBC) transfusions, and hospital length of stay (LOS). Meta-analyses were pooled using mean difference with inverse-variance weighting and random-effects.

RESULTS

Out of the 575 unique studies that were screened, we identified three randomized controlled trials (RCTs) involving 399 patients. Out of the three RCTs analyzed, two studies, accounting for 67% of the total, were found to have a low risk of bias. The primary outcome of 24-h post-operative blood loss was significantly lower in patients who received TXA (mean difference [MD] -93.6 ml, 95% CI -121.8 to -65.4 ml, I2 = 45%). In addition, the need for RBC transfusion was significantly lower in the topical TXA group compared to control (MD -0.5 units, 95% CI -0.8 to -0.3 units, I2 = 60%). However, there was no significant difference in the hospital length of stay (LOS) (MD -0.3 days, 95% CI -0.9 to 0.4 days, I2 = 0%). These results remained consistent after several sensitivity analyses. The use of topical intrapleural tranexamic acid has also been found to be safe without any significant safety concerns.

CONCLUSION

Topical intrapleural TXA reduces blood loss and the need for blood transfusions during thoracic surgery. In addition, there is no evidence of the increased safety concerns associated with its use. Larger trials are necessary to validate these findings and evaluate the safety and efficacy of different dosages.

The effects of continuing aspirin on blood loss and postoperative outcomes in percutaneous nephrolithotomy

BACKGROUND

Percutaneous nephrolithotomy (PCNL) is an effective surgery for complex kidney stones yet with inherent bleeding risks. It remains unclear whether aspirin should be discontinued prior to PCNL. We aimed to further substantiate the safety of continuing aspirin during PCNL surgery and to determine whether aspirin status affects postoperative outcomes following PCNL.

METHODS

We retrospectively queried our endourology database for patients who underwent PCNL from October 2017 to December 2022 at our high-volume tertiary referral center. The three groups were based on aspirin status at the time of PCNL: no aspirin (NA), discontinued aspirin (DA), and continued aspirin (CA). Data collected included demographics, preoperative characteristics, operative parameters, pre and postoperative lab values, transfusions, and complications.

RESULTS

A total 648 patients were divided into these study groups: 525 NA patients (81.0%), 55 DA (8.5%), and 68 CA (10.5%). The DA and CA groups were of similar comorbidities, and both were more comorbid at baseline than NA. Postoperative change in lab values and complications did not differ significantly. Rates of postoperative blood transfusion were higher in the CA and DA groups compared to NA and approached statistical significance. There were no significant differences in any postoperative outcomes between the DA and CA groups alone.

CONCLUSIONS

In patients on chronic aspirin therapy, continuing aspirin appears equally safe to discontinuing aspirin prior to PCNL. Most patients should not forego the benefits of continuous aspirin for the theoretical risk of bleeding. Patients on prolonged aspirin therapy may be more likely than those who are not on chronic aspirin therapy to require blood transfusions. However, regardless of whether aspirin use is stopped, this may be caused by patient comorbidities rather than higher rates of blood loss.

Preoperative embolization in the treatment of patients with metastatic epidural spinal cord compression: A retrospective analysis

Purpose

The purpose of the study was to assess the effectiveness and safety of preoperative embolization in the treatment of patients with metastatic epidural spinal cord compression (MESCC).

Methods

A retrospective analysis of 138 MESCC patients who underwent decompressive surgery and spine stabilization was performed in a large teaching hospital. Among all enrolled patients, 46 patients were treated with preoperative embolization (the embolization group), whereas 92 patients did not (the control group). Patient's baseline clinical characteristics, surgery-related characteristics, and postoperative neurological status, complications, and survival prognoses were collected and analyzed. Subgroup analysis was performed according to the degree of tumor vascularity between patients with and without preoperative embolization.

Results

Patients with severe hypervascularity experienced more mean blood loss in the control group than in the embolization group, and this difference was statistically significant (P=0.02). The number of transfused packed red cells (PRC) showed a similar trend (P=0.01). However, for patients with mild and moderate hypervascularity, both blood loss and the number of PRC transfusion were comparable across the two groups. Regarding decompressive techniques, the embolization group (64.29%, 9/14) had a higher proportion of circumferential decompression in comparison to the control group (30.00%, 9/30) among patients with severe hypervascularity (P=0.03), whereas the rates were similar among patients with mild (P=0.45) and moderate (P=0.54) hypervascularity. In addition, no subgroup analysis revealed any statistically significant differences in operation time, postoperative functional recovery, postoperative complications, or survival outcome. Multivariate analysis showed that higher tumor vascularity (OR[odds ratio]=3.69, 95% CI [confident interval]: 1.30-10.43, P=0.01) and smaller extent of embolization (OR=4.16, 95% CI: 1.10-15.74, P=0.04) were significantly associated with more blood loss.

Conclusions

Preoperative embolization is an effective and safe method in treating MESCC patients with severe hypervascular tumors in terms of intra-operative blood loss and surgical removal of metastatic tumors. Preoperative tumor vascularity and extent of embolization are independent risk factors for blood loss during surgery. This study implies that MESCC patients with severe hypervascular tumors should be advised to undergo preoperative embolization.

Can trajectory nor-epinephrine infiltration reduce blood loss during percutaneous nephrolithotomy? A double-blinded randomized controlled trial

PURPOSE

To determine the efficacy and safety of trajectory infiltration with 1:150 000 Norepinephrine (NE) in reducing blood loss during percutaneous nephrolithotomy (PCNL).

MATERIALS AND METHODS

This is a prospective randomized double-blinded placebo-controlled trial. In all, 140 consecutive patients underwent PCNL for the management of large renal calculi. They were randomly assigned (1:1) to one of either study groups, the NE-PCNL group (70 patients whose PCNL-trajectory was infiltrated by NE) or the Placebo group (saline PCNL) (70 patients whose PCNL tracts were infiltrated by normal saline). Procedure-related blood loss (the primary outcome) was assessed and statistically analyzed. Also, all other procedure-related events and complications were recorded and compared.

RESULTS

The median blood loss was 378 ml (IQR: 252-504) in the NE-PCNL group versus 592 ml (IQR: 378-756) in the S-PCNL group (p < 0.0001). In addition, Hemoglobin and Hematocrit deficits were lower in NE-PCNL (p < 0.05). Patients who were randomized to the NE-PCNL group had a higher immediate stone-free rate (SFR) (80%) compared with those of the S-PCNL group (70%) (p = 0.034). However, no statistical differences were found in the final SFR. The reported overall complications between the 2 groups were similar (p > 0.05). Indeed, bleeding-related complications were 1 (1.4%) versus 10 (14.3%) for NE-PCNL and S-PCNL, respectively (p = 0.009).

CONCLUSIONS

Trajectory infiltration of PCNL tracts by NE was found to be effective and safe in mitigation of PCNL-related blood loss. This step is a timeless and cost-effective as NE is readily available in surgical theaters and of very low cost.

Tranexamic acid for the prevention of blood loss after cesarean among women with twins: a secondary analysis of the TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery randomized clinical trial

BACKGROUND

Although prophylactic tranexamic acid administration after cesarean delivery resulted in a lower incidence of calculated estimated blood loss of >1000 mL or red cell transfusion by day 2, its failure to reduce the incidence of hemorrhage-related secondary clinical outcomes (TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial) makes its use questionable. The magnitude of its effect may differ in women at higher risk of blood loss, including those with multiple pregnancies.

OBJECTIVE

This study aimed to compare the effect of tranexamic acid vs placebo to prevent blood loss after cesarean delivery among women with multiple pregnancies.

STUDY DESIGN

This was a secondary analysis of the TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial data, a double-blind, randomized controlled trial from March 2018 to January 2020 in 27 French maternity hospitals, that included 319 women with multiple pregnancies. Women with a cesarean delivery before or during labor at ≥34 weeks of gestation were randomized to receive intravenously 1 g of tranexamic acid (n=160) or placebo (n=159), both with prophylactic uterotonics. The primary outcome was a calculated estimated blood loss of >1000 mL or a red blood cell transfusion by 2 days after delivery. The secondary outcomes included clinical and laboratory blood loss measurements.

RESULTS

Of the 4551 women randomized in this trial, 319 had a multiple pregnancy and cesarean delivery, and 298 (93.4%) had primary outcome data available. This outcome occurred in 62 of 147 women (42.2%) in the tranexamic acid group and 67 of 152 (44.1%) receiving placebo (adjusted risk ratio, 0.97; 95% confidence interval, 0.68-1.38; P=.86). No significant between-group differences occurred for any hemorrhage-related clinical outcomes: gravimetrically estimated blood loss, provider-assessed clinically significant hemorrhage, additional uterotonics, postpartum blood transfusion, arterial embolization, and emergency surgery (P>.05 for all comparisons).

CONCLUSION

Among women with a multiple pregnancy and cesarean delivery, prophylactic tranexamic acid did not reduce the incidence of any blood loss-related outcomes.

The incidence, complications, and treatment of iron deficiency in pregnancy

Iron deficiency and/or iron deficiency anemia (IDA) complicate nearly 50% of pregnancies globally, negatively impacting both maternal and fetal outcomes. Iron deficiency can cause a range of symptoms that range from aggravating to debilitating including fatigue, poor quality of life, pagophagia, and restless leg syndrome. Iron deficiency and IDA are also associated with maternal complications including preterm labor, increased rates of cesarean delivery, postpartum hemorrhage, and maternal death. Fetal complications include increased rates of low birth weight and small for gestational age newborns. Prenatal maternal anemia has also been associated with autism spectrum disorders in the neonate, although causation is not established. Deficiency in the newborn is associated with compromised memory, processing, and bonding, with some of these deficits persisting into adulthood. Despite the prevalence and consequences associated with iron deficiency in pregnancy, data show that it is routinely undertreated. Due to the physiologic changes of pregnancy, all pregnant individuals should receive oral iron supplementation. However, the bioavailability of oral iron is poor and it is often ineffective at preventing and treating iron deficiency. Likewise, it frequently causes gastrointestinal symptoms that can worsen the quality of life in pregnancy. Intravenous iron formulations administered in a single or multiple dose series are now available. There is increasing data suggesting that newer intravenous formulations are safe and effective in the second and third trimesters and should be strongly considered in pregnant individuals without optimal response to oral iron repletion.

Total Hip Arthroplasty Patients with Distinct Postoperative Fibrinolytic Phenotypes Require Different Antifibrinolytic Strategies

Bleeding patients exhibit different fibrinolytic phenotypes after injury, and the universal use of tranexamic acid (TXA) is doubted. We aimed to evaluate the efficacy of postoperative antifibrinolytic treatment in total hip arthroplasty (THA) patients with different fibrinolytic phenotypes. A retrospective analysis was conducted in 238 patients who underwent THA. Patients were divided into two groups by different fibrinolytic phenotypes (non-fibrinolytic shutdown and fibrinolytic shutdown), determined by the LY30 level on postoperative day 1 (POD1). The two groups were further stratified into four sub-groups based on different postoperative TXA regimens (Group A received no TXA postoperatively, while Group B did). Hidden blood loss (HBL), decline of hemoglobin (ΔHb), D-dimer (D-D), fibrinogen/fibrin degradation product (FDP), prothrombin time (PT), activated partial thromboplastin time (APTT), and demographics were collected and compared. The clinical baseline data were comparable between the studied groups. In patients who presented non-fibrinolytic shutdown postoperatively, Group B suffered significantly lower HBL and ΔHb than Group A on POD3 and POD5. In patients who presented postoperative fibrinolytic shutdown, Group B failed to benefit from the postoperative administration of TXA when compared to Group A. No difference was found in postoperative levels of D-D, FDP, PT, and APTT. Postoperative antifibrinolytic therapy is beneficial for THA patients who presented non-fibrinolytic shutdown postoperatively, while the efficacy and necessity should be considered with caution in those with fibrinolytic shutdown. LY30 is a promising parameter to distinguish different fibrinolytic phenotypes and guide TXA administration. However, further prospective studies are needed to confirm these findings.

Influence of Obesity and Fluid Balance on Operative Outcomes in Hepatic Resection

As the number of obese patients requiring hepatic resection is increasing, efforts to understand their operative risk and determine proper perioperative management are necessary. A total of 175 patients who underwent hepatic resection between March 2015 and July 2021 were evaluated. The patients were divided into two groups by their body mass index (BMI) using the World Health Organization definition of obesity for Asians: obese patients (BMI ≥ 25 kg/m2, n = 84) and non-obese patients (BMI < 25 kg/m2, n = 91). The operative duration (195.7 ± 62.9 min vs. 176.0 ± 53.6 min, p = 0.027) was longer and related to a higher estimated blood loss (EBL) ≥ 500 mL (61.9% vs. 40.7%, p = 0.005) in the obese patients than in the non-obese patients. Obesity (odds ratio (OR), 2.204; 95% confidence interval (CI), 1.177−4.129; p = 0.014) and central venous pressure (CVP) ≥ 5 (OR, 2.733; 95% CI, 1.445−5.170; p = 0.002) at the start of the surgery were significant risk factors for EBL ≥ 500 mL. Obese patients with low CVP showed significantly lower EBL than those with high CVP, but a similar EBL to non-obese patients (p = 0.003). In conclusion, fluid restriction before hepatic resection would be important, especially in obese patients, to improve their operative outcomes.

Peripartum outcomes after combined myo-inositol, probiotics, and micronutrient supplementation from preconception: the NiPPeR randomized controlled trial

BACKGROUND

Evidence that nutritional supplementation before and during pregnancy improves peripartum outcomes is sparse. In the Nutritional Intervention Preconception and During Pregnancy to Maintain Healthy Glucose Metabolism and Offspring Health (NiPPeR) trial, we previously reported that a combined myo-inositol, probiotics, and micronutrient supplement started at preconception showed no difference in the primary outcome of gestational glycemia, but did reduce the risk of preterm delivery, preterm prelabor rupture of membranes, and major postpartum hemorrhage.

OBJECTIVE

This study aimed to examine the hypothesis that a reduction in major postpartum hemorrhage following a combined nutritional (myo-inositol, probiotics, and micronutrients) intervention is linked with promotion of labor progress and reduced operative delivery.

STUDY DESIGN

This double-blind randomized controlled trial recruited 1729 women from the United Kingdom, Singapore, and New Zealand, aged 18 to 38 years, and planning conception between 2015 and 2017. The effects of the nutritional intervention compared with those of a standard micronutrient supplement (control), taken at preconception and throughout pregnancy, were examined for the secondary outcomes of peripartum events using multinomial, Poisson, and linear regression adjusting for site, ethnicity, and important covariates.

RESULTS

Of the women who conceived and progressed beyond 24 weeks' gestation with a singleton pregnancy (n=589), 583 (99%) provided peripartum data. Between women in the intervention (n=293) and control (n=290) groups, there were no differences in rates of labor induction, oxytocin augmentation during labor, instrumental delivery, perineal trauma, and intrapartum cesarean delivery. Although duration of the first stage of labor was similar, the second-stage duration was 20% shorter in the intervention than in the control group (adjusted mean difference, -12.0 [95% confidence interval, -22.2 to -1.2] minutes; P=.029), accompanied by a reduction in operative delivery for delayed second-stage progress (adjusted risk ratio, 0.61 [0.48-0.95]; P=.022). Estimated blood loss was 10% lower in the intervention than in the control group (adjusted mean difference, -35.0 [-70.0 to -3.5] mL; P=.047), consistent with previous findings of reduced postpartum hemorrhage.

CONCLUSION

Supplementation with a specific combination of myo-inositol, probiotics, and micronutrients started at preconception and continued in pregnancy reduced the duration of the second stage of labor, the risk of operative delivery for delay in the second stage, and blood loss at delivery.

The Effect of Systemic Tranexamic Acid on Blood Loss and Blood Transfusion Requirement in Elective Total Hip Arthroplasty

BACKGROUND

Although total hip arthroplasty (THA) is one of the most successful surgical procedures of the last century, high rates of bleeding and allogeneic blood transfusion may be required. Tranexamic acid (TXA) is an antifibrinolytic agent that has been increasingly used in THA in recent years to reduce blood loss and the need for transfusion. In this study, the effect of two doses of TXA, which was administered intravenously (iv) before and after surgery in unilateral THA patients, on total blood loss and blood transfusion need was compared retrospectively.

MATERIAL AND METHODS

A total of 327 patients who underwent elective THA at our department between January 2011 and January 2020 were identified. Demographic data, blood parameters before and after surgery and complications seen during a 90-day follow-up period were recorded from patient files. Total blood loss amounts were calculated according to Nadler&apos;s formula. The amount of transfused blood was recorded. 127 patients treated with IV TXA and 119 patients not given TXA were assigned to separate groups and compared.

RESULTS

Total mean blood loss, decrease in hemoglobin levels and amount of blood transfusion were lower in the TXA group compared to the control group (p=0.001; p=0.001; p=0.001, respectively). The length of stay hospital was shorter in the TXA group than the control group (p=0.001).

CONCLUSION

We think that it is an effective and reliable method in THA since giving IV TXA twice, as 15 mg / kg preoperatively and 10 mg / kg after the operation significantly reduces blood loss and the need for blood transfusion without causing an increase in thromboembolic complications.

Comparison between simultaneous bilateral total hip arthroplasty with and without drainage: A retrospective cohort study

Simultaneous bilateral total hip arthroplasty (SBTHA) is an effective procedure for patients with disease bilaterally. But there is concern about increased blood loss and complications of SBTHA than staged total hip arthroplasty (THA). This study aimed to evaluate the differences in the clinical outcomes and complication rate of SBTHA with drainage and without drainage for reducing the concerns. Between October 2015 and April 2019, a retrospective cohort study was conducted with modified minimally invasive 2-incision method and a consecutive series of 41 SBTHA performed with drainage (Group I) were compared to 37 SBTHA performed without drainage (Group II). It was assessed clinically and radiographically for a mean of 2.1 ± 0.8 years (range, 1.0-4.8 years). Postoperative hematologic values (Hgb loss, total blood loss, transfusion rate), pain susceptibility, functional outcome (Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index score) and complication were compared in the drained group and the non-drained group. Postoperative Hgb loss (I: 2163.2 ± 698.7 g, II: 1730.4 ± 572.5 g; P = .002), total blood loss (I: 1528.8 ± 421.7 mL, II: 1237.6 ± 325.9 mL; P = .001) and mean transfusion unit (I: 0.7 ± 1.0 IU, II: 0.1 ± 0.3 IU; P < .001) were significantly lower in the without drainage group than in the with drainage group. But the morphine equivalent (I: 132.7 ± 314.1 mg, II: 732.2 ± 591.5 mg; P < .001) was significantly larger in the without drainage group. No significant difference was found between the drainage group and without drainage group in Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index score at final follow-up. SBTHA without drainage can reduce postoperative blood loss and the requirement for transfusion without increasing other complication. But SBTHA without drainage is more painful method than SBTHA with drainage. Therefore, SBTHA without drainage will be a good option to reduce the burden on the patient by reducing postoperative bleeding if it can control pain well after surgery. III, Retrospective case-control study.

Delayed femoral vein ligation reduces operative time and blood loss during hip disarticulation in patients with extremity tumors

This study aimed to evaluate the effects of delayed femoral vein ligation on the clinical outcomes of hip disarticulation. We retrospectively reviewed 20 patients with extremity tumors (10 bone tumors and 10 soft tissue sarcomas [STS]) who underwent hip disarticulation. Patients treated for hip disarticulation with synchronous femoral vein ligation (n = 10, regular surgery group) and hip disarticulation with delayed femoral vein ligation (n = 10, delayed ligation group), respectively, were enrolled in this study. The operative time and blood loss were used to evaluate the clinical outcomes. The delayed ligation group had significantly lower operative times than the regular surgery group (P < 0.05). Total, hidden, and intraoperative blood loss were all significantly lower in the delayed ligation group than in the regular surgery group (P < 0.05). However, there were no significant differences in postoperative blood loss. In conclusion, delayed femoral vein ligation could significantly reduce the operative time, hidden blood loss, and intraoperative blood loss in patients undergoing hip disarticulation.

Perioperative Red Cell Line Trend following Robot-Assisted Radical Prostatectomy for Prostate Cancer

Background and Objective: Blood loss represents a long-standing concern of radical prostatectomy (RP). This study aimed to assess how red line cell values changed following robot-assisted radical prostatectomy (RARP) for prostate cancer (PCa). Materials and Methods: The blood panels of 453 consecutive PCa patients undergoing RARP at a single tertiary academic referral center, from September 2020 to April 2022, were reviewed. Data from 363 patients with the blood panel available for the following timeframe: within seven days before surgery, six hours after surgery, and the first three postoperative days, were analyzed. Specifically, hemoglobin (Hb, g/dL), red blood cells (RBCs, ×106/μL), and hematocrit (HCT, %) trends were collected. Results: Considering the Hb trend, the median values in the preoperative day, postoperative day (POD) 2, and POD 3 are 14.7 (interquartile range (IQR) = 13.9−15.4), 12.1 (IQR = 11.2−12.9), and 12.2 (IQR = 11.2−13.1), respectively. The ∆ between preoperative day and POD 2 is 2.5 (IQR = 1.8−3.2) (p < 0.001). Considering the RBCs trend, the median values in the preoperative day, POD 2, and POD 3 are 4.9 (IQR = 4.7−5.3), 4.1 (IQR = 3.8−4.4), and 4.1 (IQR = 3.8−4.5), respectively. The ∆ between preoperative day and POD 2 is 0.9 (IQR = 0.6−1.1) (p < 0.001). Considering the HCT trend, the median values in the preoperative day, POD 2, and POD 3 are 44.4 (IQR = 41.7−46.6), 36.4 (IQR = 33.8−38.9), and 36.1 (IQR = 33.5−38.7), respectively. The ∆ between preoperative day and POD 2 is 7.8 (IQR = 5.2−10.5) (p < 0.001). Conclusions: Overall, patients undergoing RARP experience a significant, but clinically limited, decline in red line cell values between the preoperative time and the second day post-surgery. These observations are important to provide physicians with knowledge of the expected postoperative course and, thus, to improve the quality of patient care.

Use of tranexamic acid may reduce the need for routine tourniquet use in total knee arthroplasty

OBJECTIVES

The aim of this study was to evaluate the effects of tranexamic acid (TXA) administration on bleeding control and to compare its utilization with and without simultaneous use of conventional pneumatic tourniquets during total knee arthroplasty (TKA).

PATIENTS AND METHODS

Between January 2017 and December 2017, a total of 204 patients (23 males, 181 females; mean age: 66±6.9 years; range, 45 to 86 years) who underwent TKA for Stage 4 gonarthrosis were retrospectively analyzed. The patients were divided into two groups as those with (n=110) and without (n=94) pneumatic tourniquet use. Tranexamic acid (1 g) was administered intravenously to all patients in both study groups. Intra- and postoperative blood loss were calculated, and postoperative pain was evaluated by a Visual Analog Scale. Demographic and clinical data were compared between the study groups.

RESULTS

The amount of total blood loss and postoperative blood loss were significantly higher in the tourniquet group than that in the no-tourniquet group (589.4±69.5 mL vs. 490.8±55.2 mL and 326±56 mL vs. 164±35.5 mL, respectively; p<0.001 for both). Intraoperative blood loss was significantly higher in the no-tourniquet group (326.9±42.9 mL vs. 263.5±53.8 mL, respectively; p<0.001). The pain score at 24 h was significantly higher in the tourniquet group (p<0.001).

CONCLUSION

Total blood loss and postoperative pain were significantly higher among patients in whom a tourniquet was used during TKA. Therefore, the routine use of tourniquets with TXA should be reconsidered.

Effects of colloid-based (hydroxyethylstarch 6% 130/0.42, gelafundin 4%) and crystalloid-based volume regimes in cardiac surgery: a retrospective analysis

BACKGROUND

The restriction of hydroxyethylstarch (HES) necessitated changes in volume management in cardiac surgery, increasing the use of gelatin (GELA) and crystalloid (CRYS) mono strategies.

METHODS

This retrospective study evaluated the effects of changed volume replacement management to a GELA or CRYS mono therapy on mortality, acute kidney injury (AKI), blood loss, and transfusion in cardiac surgery patients with at least one coronary artery bypass grafting (CABG) at a university hospital. Three groups (HES n=938, GELA n=397, CRYS n=205) were derived from 1,540 patients with complete data sets. Data were analyzed by multiple regression models.

RESULTS

Patients had similar risk profiles, comorbidities, and preoperative routine diagnostics prior to surgery. No difference was observed in mortality and AKI. HES treated patients showed highest blood loss, followed by GELA while CRYS patients had the lowest (P<0.0001). Patients in the HES group had highest transfusion of packed red blood cells (PRBCs) and platelet concentrates (PCs), followed by GELA, whereas CRYS had the lowest (P<0.0001). Fresh frozen plasma (FFP) transfusion, administration of fibrinogen, and prothrombin complex concentrates (PCCs) were highest in HES group. CRYS showed the shortest time of mechanical ventilation (P<0.0001) and left the intensive care unit (ICU) significantly earlier (P<0.0001). Multivariable regression analysis found that colloid volume significantly predicted hospital mortality and renal replacement therapy (RRT), but not AKI.

CONCLUSIONS

Administration of crystalloids without any colloid showed no differences in mortality or AKI, but less blood loss and transfusion. Colloids should be considered critically and further studies should investigate effects of GELA in cardiac surgery.

Impact of tranexamic acid on clinical and hematologic outcomes following total shoulder arthroplasty

Background

The purpose of this study is to evaluate the impact of intravenous tranexamic acid on clinical and hematologic outcomes after total shoulder arthroplasty.

Methods

Retrospective review was conducted for 282 consecutive patients undergoing either anatomic shoulder arthroplasty or reverse total shoulder arthroplasty. Univariate analysis and multivariate linear regression were used to compare outcomes for patients receiving intravenous tranexamic acid with those who did not.

Results

Of the 282 patients included in this study, 78 patients received intravenous tranexamic acid and 204 did not. Patients who received intravenous tranexamic acid had significantly lower pre- to postoperative change in hemoglobin and hematocrit, and decreased postoperative drain output. In addition, patients receiving intravenous tranexamic acid were significantly less likely to have a postoperative hematocrit <30. There were no significant differences in length of stay, rate of 30 day hematoma, surgical site infection, deep vein thrombosis, or readmission between groups.

Conclusion

Intravenous tranexamic acid is associated with a significant reduction in change in hematocrit and hemoglobin and postoperative drain output after both anatomic and reverse total shoulder arthroplasty. Despite improving hematologic outcomes for these patients, tranexamic acid appears to have little impact on clinical outcomes such as length of stay and 30-day complication rates.

Does the clamping method in local and systemic TXA applications in total knee arthroplasty change the game?: A retrospective comparative cohort study

Many different methods and drain clamping periods have been described in systemic and local tranexamic acid (TXA) applications, and the superiority of the methods to each other has not been clearly demonstrated. The method of local infusion in combined TXA applications may not alter the Hb drop or total or hidden blood loss. We aim to compare two different combined TXA application methods. We retrospectively analyzed 182 patients who underwent total knee arthroplasty between 2018 and 2021. Patients over 40 years of age who underwent TKA for degenerative knee arthritis were included in the study. Unicondylar, revision, or bilateral arthroplasties and patients with the cardiovascular or cerebrovascular disease were excluded from the study. All patients in the study received 1 g TXA intravenously half an hour before the incision. For the first group, 1 g TXA was given intra-articularly at the drain site after closure, and the clamp was kept closed for 1 hour. In the second group, the drain was clamped for an additional 6 hours, and a 1 g intravenous dose was administered at the 5th hour postoperatively. No local applications were used in the control group. Total, hidden, and visible blood loss (total blood loss, hidden blood loss, visible blood loss), postoperative decreases in hemoglobin and hematocrit level (ΔHgb, ΔHtc), blood transfusion rates, and hospital stay durations were evaluated. There were 72 patients in the first group, 52 in the second, and 58 in control. A total of 37 patients received one or more blood transfusions postoperatively, and there was no statistical difference in the need for blood transfusions between the groups (P = .255). Although a statistically significant difference (P = .001) in total blood loss, hidden blood loss, visible blood loss and ΔHgb values was observed between the groups, the difference between the first and second groups was insignificant (P = .512). The duration of hospital stay was observed to be less in the first and second groups (P = .024). Local and systemic TXA applications were observed to be more effective than only systemic applications in reducing blood loss after total knee arthroplasty, regardless of the local method.

Liver hanging maneuver is suitable in major hepatectomy for liver malignancies over 5 cm

Objectives

Hepatic transection through an anterior approach is required to successfully complete anatomical hepatectomy for large liver malignancies. The liver hanging maneuver (LHM) is an alternative procedure for transection on an adequate cut plane and may reduce intraoperative bleeding and transection times.

Material and Methods

We examined the medical records of 24 patients with large liver malignancies (>5 cm) who had undergone anatomical hepatic resection with LHM (n= 9) or without LHM (n= 15) between 2015 and 2020. Patient demographics, preoperative hepatic function, surgical records, and post-hepatectomy outcomes were retrospectively compared between the LHM and non-LHM groups.

Results

The prevalence of tumors >10 cm was significantly higher in the LHM group than in the non-LHM group (p <0.05). Furthermore, LHM was significantly performed to right and extended right hepatectomies in the background normal liver (p <0.05). Although transection times did not significantly differ between the two groups, the amount of intraoperative blood loss was slightly lower in the LHM group than in the non-LHM group (1.566 mL vs. 2.017 mL), and blood transfusion was not needed for patients in the LHM group. Post-hepatectomy liver failure and bile leakage were not observed in LHM. However, the length of hospitalization was slightly shorter in the LHM group than in the non-LHM group.

Conclusion

LHM is useful for transecting an adequately cut plane in hepatectomy for liver tumors over 5 cm-in-size located on the right side and achieves better outcomes.

Postoperative outcomes of pedicle screw instrumentation for adolescent idiopathic scoliosis with and without a subfascial wound drain: a multicentre randomized controlled trial

AIMS

The aim of this study was to evaluate whether, after correction of an adolescent idiopathic scoliosis (AIS), leaving out the subfascial drain gives results that are no worse than using a drain in terms of total blood loss, drop in haemoglobin level, and opioid consumption.

METHODS

Adolescents (aged between 10 and 21 years) with an idiopathic scoliosis (major curve ≥ 45°) were eligible for inclusion in this randomized controlled noninferiority trial (n = 125). A total of 90 adolescents who had undergone segmental pedicle screw instrumentation were randomized into no-drain or drain groups at the time of wound closure using the sealed envelope technique (1:1). The primary outcome was a drop in the haemoglobin level during first three postoperative days. Secondary outcomes were 48-hour postoperative oxycodone consumption and surgical complications.

RESULTS

All 90 patients were included in the primary outcome analysis (no drain = 43; drain = 47). The mean total postoperative blood loss (intraoperative and drain output) was significantly higher in the group with a subfascial drain than in the no-drain group (1,008 ml (SD 520) vs 631 ml (SD 518); p < 0.001). The drop in haemoglobin level did not differ between the study groups over the postoperative timepoints (p = 0.290). The 48-hour opioid consumption was significantly higher in the no-drain group (2.0 mg/kg (SD 0.9) vs 1.4 (SD 0.6); p = 0.005). Two patients in the no-drain and one patient in the drain group developed a surgical site infection.

CONCLUSION

Leaving the subfascial drain out after pedicle screw instrumentation for AIS is not associated with higher postoperative haemoglobin levels. Patients treated without a subfascial drain needed 30% more opioids during the first 48 hours than those who had a drain.Cite this article: Bone Joint J 2022;104-B(9):1067-1072.

Therapeutic effect of Internal iliac artery ligation and uterine artery ligation techniques for bleeding control in placenta accreta spectrum patients: A meta-analysis of 795 patients

Placenta accreta spectrum (PAS) can cause complications like hysterectomy or death due to massive pelvic bleeding. We aim to evaluate the efficacy of two different arterial ligation techniques in controlling postpartum haemorrhage and minimizing bleeding complications. We searched six databases. 11 studies were finally included into our review and analysis. We graded their quality using the Cochrane tool for randomized trials and the NIH tool for retrospective studies. Our analysis showed that internal iliac artery ligation has no significant effect on bleeding control (MD = -248.60 [-1045.55, 548.35] P = 0.54), while uterine artery ligation significantly reduced the amount of blood loss and preserved the uterus (MD = -260.75, 95% CI [-333.64, -187.86], P < 0.00001). Uterine artery ligation also minimized the need for blood transfusion. Bleeding was best controlled by combining both uterine artery ligation with uterine tamponade (MD = 1694.06 [1675.34, 1712.78], P < 0.00001). This combination also showed a significant decrease in hysterectomy compared to the uterine artery ligation technique alone. Bilateral uterine artery ligation in women with placenta accreta spectrum can effectively reduce the amount of bleeding and the risk of complications. The best bleeding control tested is a combination of both, uterine artery ligation and cervical tamponade. These techniques may offer an easy and applicable way to preserve fertility in PAS patients. Larger randomized trials are needed to define the best technique.

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

Background

Total 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).

Methods

We 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.

Results

A 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.

Conclusions

We 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.

Cemented Total Knee Arthroplasty Shows Less Blood Loss but a Higher Rate of Aseptic Loosening Compared With Cementless Fixation: An Updated Meta-Analysis of Comparative Studies

BACKGROUND

The aim of this study was to update the current evidence on functional outcomes, complications, and reoperation rates between cemented and cementless total knee arthroplasty (TKA) by evaluating comparative studies published over the past 15 years.

METHODS

The PubMed, MEDLINE, Scopus, and the Cochrane Central databases were used to search keywords and a total of 18 studies were included. Random and fixed effect models were used for the meta-analysis of pooled mean differences (MDs) and odds ratios (ORs).

RESULTS

A total of 5,222 patients were identified with a mean age of 64.4 ± 9.4 and 63 ± 8.6 years for the cemented and cementless TKA groups, respectively. The mean follow-up was 107.9 ± 30 and 104.3 ± 10 months for the cemented and cementless TKA groups, respectively. Cemented TKA showed a significantly greater postoperative Knee Society Score (MD = -0.95, 95% CI [-1.57, 0.33], P = .003) and range of motion (MD = -1.09, 95% CI [-1.88, -0.29], P = .0007), but no differences in other outcome scores were found. The incidence of periprosthetic joint infection, radiolucent lines, instability, and polyethylene wear was also comparable. Cemented TKA showed less perioperative blood loss (SMD = -438.41, 95% CI [-541.69, -35.14], P < .0001) but a higher rate of manipulation under anesthesia (OR = 3.39, 95% CI [1.64, 6.99], P = .001) and aseptic loosening (OR = 1.62, 95% CI [1.09, 2.41], P = .02) than cementless TKA. No differences were found in terms of the reoperation rate.

CONCLUSION

When cemented and cementless fixations are compared in primary TKA, comparable functional outcomes and reoperation rates can be achieved. Cemented TKA showed less blood loss but a higher rate of manipulation under anesthesia and aseptic loosening.

Acute Postoperative Anemia After Unilateral Primary Total Joint Arthroplasty: Restrictive Transfusion Thresholds are Safe for Discharge Regardless of Delta Hemoglobin

BACKGROUND

Primary unilateral total joint arthroplasty (TJA) is associated with acute postoperative anemia that may require blood transfusion. Clinicians may worry about discharging patients after surgery who experience substantial decreases in hemoglobin (Hgb), even if their Hgb is above restrictive transfusion thresholds. The purpose of this study was to determine whether differences between preoperative and postoperative Hgb values (Delta) correlate with 90-day readmission in patients who did not receive perioperative transfusions.

METHODS

A retrospective review of patients undergoing primary unilateral TJA between 2015 and 2020 was performed. The primary outcome was whether a specific cutoff delta Hgb was predictive of readmission within 90 days due to anemia-related causes. Secondary outcomes included the presence of acute postoperative anemia and transfusion during readmission.

RESULTS

Six thousand seven hundred and ninety one patients had a median delta Hgb of 2.80. In total, 268 patients (3.95%) were readmitted within 90 days postoperatively, with two patients requiring transfusion during readmission. A significantly higher rate of readmission was found in patients with cardiovascular disease (5.16% versus 3.68%; P = .020). When constructing receiver operating characteristic curves, a cutoff value of 3.20 resulted in an area under curve of 0.595 (0.486-0.704). In patients with cardiovascular disease, a cutoff value of 3.10 resulted in an area under curve of 0.626 (0.466-0.787).

CONCLUSION

The magnitude of Hgb change was not predictive of anemia-related readmission within 90 days in patients who did not receive a perioperative transfusion. Patients experiencing higher delta Hgb values but remaining above the transfusion threshold may have a greater physiologic reserve.

Prehabilitation of Cardiac Surgical Patients, Part 1: Anemia, Diabetes Mellitus, Obesity, Sleep Apnea, and Cardiac Rehabilitation

The concept of "prehabilitation" consists of screening for and identification of pre-existing disorders followed by medical optimization. This is performed for many types of surgery, but may have profound impacts on outcomes particularly in cardiac surgery given the multiple comorbidities typically carried by these patients. Components of prehabilitation include direct medical intervention by preoperative specialists as well as significant care coordination and shared decision making. In this two-part review, the authors describe existing evidence to support the optimization of various preoperative problems and present a few institutional protocols utilized by our center for cardiac presurgical care. This first installment will focus on the management of anemia, obesity, sleep apnea, diabetes, and cardiac rehabilitation prior to surgery. The second will focus on frailty, malnutrition, respiratory disease, alcohol and smoking cessation, and depression.

The effects of a new protocol on blood loss in total knee arthroplasty

The aim of study was to evaluate the efficacy of blood loss prevention with Tranexamic acid in patients undergoing total knee arthroplasty (TKA). The Authors defined a new protocol that foresees the use of Tranexamic acid both pre-intra and post-operatively. Seventy patients indicated for TKA were enrolled. Thirty-five patients (control group) followed standard protocol without Tranexamic acid and the other 35 patients (study group) followed standard protocol with Tranexamic acid. We analyzed the values of hemoglobin (Hb), hematocrit (HCT) and red blood cells (RBCs) both pre-operatively (T0) and post-operatively: immediately after surgery (T1), at one day (T2) and three days post-op (T3). We observed statistical differences at T0 and T3 regarding the Hb, HT and RBCs value between the two groups. Moreover, 11.4% in the study and 28.5% in the control group required blood transfusion. No thrombotic or thrombo-embolic events were reported. We conclude that Tranexamic acid use, as in our protocol, reduces postoperative bleeding in primary knee arthroplasty, with the absence of thrombo-embolic events.

Association of In-Hospital Hemoglobin Drop With Decreased Myocardial Salvage and Increased Long-Term Mortality in Patients With Acute ST-Segment-Elevation Myocardial Infarction

Background

Anemia and blood loss occur often in patients with ST‐segment–elevation myocardial infarction (STEMI). In‐hospital hemoglobin drop is associated with 1‐year mortality in patients with acute coronary syndrome. However, data on the effect of hemoglobin reduction on myocardial salvage and long‐term outcomes are scarce. We investigated the impact of in‐hospital hemoglobin drop on myocardial salvage and 5‐year mortality in patients with STEMI treated with primary percutaneous coronary intervention.

Methods and Results

In‐hospital hemoglobin drop was defined as a decrease in hemoglobin levels from admission and nadir hemoglobin values. Patients were categorized as having the following: no drop, minimal drop (<3 g/dL), minor drop (≥3 to <5 g/dL), and major drop (≥5 g/dL). Myocardial area at risk and infarct size were measured using serial single‐photon emission computerized tomography imaging. The co‐primary outcomes were myocardial salvage and 5‐year all‐cause mortality. Of 1204 patients, 1169 (97.1%) showed a hemoglobin drop during hospitalization: minimal, minor, and major drop occurred in 894 (74.3%), 214 (17.8%), and 61 (5.1%) patients, respectively. Myocardial salvage was reduced in patients with minimal (median, 0.53 [interquartile range, 0.27–0.83]), minor (median, 0.40 [interquartile range, 0.18–0.62]), and major (median, 0.40 [interquartile range, 0.14–0.77]) drop compared with patients without drop (median, 0.70 [interquartile range, 0.44–1.0], P<0.001). After adjusting for covariates, hemoglobin drop remained an independent correlate of poor myocardial salvage. A drop of ≥3 g/dL was associated with reduced left ventricular function at 6 months and with increased mortality at 5‐year follow‐up after STEMI.

Conclusions

In patients with STEMI undergoing primary percutaneous coronary intervention, in‐hospital hemoglobin drop was associated with reduced myocardial salvage, left ventricular function, and increased long‐term mortality.

Pre-operative Blood Loss Prediction Formulas in Burn Surgeries: A Review

Extensive burn surgeries lead to a considerable amount of blood loss. Predicting pre-operative blood loss is essential for blood ordering and crossmatching. Accurate amount of ordered blood units ensures patients' safety and minimizes cost. However, blood loss estimation is complicated due to a variety of factors influencing blood loss, including patient and operative-related variables. Currently, no standard method to predict blood loss exists prior to surgery. Our goal is to review factors influencing blood loss and formulas that can predict blood loss. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and MEDLINE databases for studies investigating blood loss in burn surgeries with a clear quantitative outcome. Fifteen studies were included, comprising 1613 subjects. All studies calculated blood loss and assessed possible related factors, and four studies proposed preoperative blood loss prediction formulas. Larger areas of tissue excised and grafted, younger age, and delayed surgery were correlated with increased blood loss. Varying decrease in blood loss was observed with tumescent usage and other bleeding control methods. Other variables produced inconsistent results. From four prediction formulas, only one formula, Dye's Formula, had been applied and proven effective in reducing unused blood units clinically by up to 40% of cross-matched blood. Various confounding factors and dissimilarities between studies make reliable prediction method construction challenging. With consideration of diverse patient characteristics, some study develops formulas to achieve optimal patient care and avoid unnecessary hospital expenditure. Further research with consistent variables should be done to construct a standardized blood loss estimation formula.

Comparison of carbon fibre and titanium intramedullary nails in orthopaedic oncology

Aims

Due to their radiolucency and favourable mechanical properties, carbon fibre nails may be a preferable alternative to titanium nails for oncology patients. We aim to compare the surgical characteristics and short-term results of patients who underwent intramedullary fixation with either a titanium or carbon fibre nail for pathological long-bone fracture.

Methods

This single tertiary-institutional, retrospectively matched case-control study included 72 patients who underwent prophylactic or therapeutic fixation for pathological fracture of the humerus, femur, or tibia with either a titanium (control group, n = 36) or carbon fibre (case group, n = 36) intramedullary nail between 2016 to 2020. Patients were excluded if intramedullary fixation was combined with any other surgical procedure/fixation method. Outcomes included operating time, blood loss, fluoroscopic time, and complications. Fisher’s exact test and Mann-Whitney U test were used for categorical and continuous outcomes, respectively.

Results

Patients receiving carbon nails as compared to those receiving titanium nails had higher blood loss (median 150 ml (interquartile range (IQR) 100 to 250) vs 100 ml (IQR 50 to 150); p = 0.042) and longer fluoroscopic time (median 150 seconds (IQR 114 to 182) vs 94 seconds (IQR 58 to 124); p = 0.001). Implant complications occurred in seven patients (19%) in the titanium group versus one patient (3%) in the carbon fibre group (p = 0.055). There were no notable differences between groups with regard to operating time, surgical wound infection, or survival.

Conclusion

This pilot study demonstrates a non-inferior surgical and short-term clinical profile supporting further consideration of carbon fibre nails for pathological fracture fixation in orthopaedic oncology patients. Given enhanced accommodation of imaging methods important for oncological surveillance and radiation therapy planning, as well as high tolerances to fatigue stress, carbon fibre implants possess important oncological advantages over titanium implants that merit further prospective investigation.

Level of evidence: III, Retrospective study

Cite this article: Bone Jt Open 2022;3(8):648–655.

The effect of tranexamic acid in open reduction and internal fixation of pelvic and acetabular fracture: A systematic review and meta-analysis

BACKGROUND

Pelvic bone fractures may cause extensive bleeding; however, the efficacy of tranexamic acid (TXA) usage in pelvic fracture surgery remains unclear. In this systematic review and meta-analysis, we aimed to evaluate the efficacy of TXA in open reduction and internal fixation surgery for pelvic and acetabular fracture.

METHODS

MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before April 22, 2020, that investigated the effect of TXA in the treatment of pelvic and acetabular fracture with open reduction and internal fixation. A pooled analysis was used to identify the differences between a TXA usage group and a control group in terms of estimated blood loss (EBL), transfusion rates, and postoperative complications.

RESULTS

We included 6 studies involving 764 patients, comprising 293 patients who received TXA (TXA group) and 471 patients who did not (control group). The pooled analysis showed no differences in EBL between the groups (mean difference -64.67, 95% confidence interval [CI] -185.27 to -55.93, P = .29). The study period transfusion rate showed no significant difference between the groups (odds ratio [OR] 0.77, 95% CI 0.19-3.14, P = .71, I2 = 82%), nor in venous thromboembolism incidence (OR 1.53, 95% CI 0.44-5.25, P = .50, I2 = 0%) or postoperative infection rates (OR 1.15, 95% CI 0.13-9.98, P = .90, I2 = 48%).

CONCLUSIONS

Despite several studies having recommended TXA administration in orthopedic surgery, our study did not find TXA usage to be more effective than not using TXA in pelvic and acetabular fracture surgery, especially in terms of EBL reduction, transfusion rates, and the risk of postoperative complications.

Hospital-Acquired Anemia in Patients Hospitalized in the Intensive Care Unit: A Retrospective Cohort Study

Hospital-acquired anemia (HAA) is prevalent in patients hospitalized in the intensive care unit (ICU). Iatrogenic blood loss (IBL) may aggravate existing anemia or lead to a need for red blood cell (RBC) transfusion. The aim of our study was to analyze hemoglobin (Hb) concentration changes in up to 14 days, as well as all potential sources of IBL, in consecutive patients admitted to the intensive care unit (ICU) in the years 2020−2021. Patients admitted due to bleeding were excluded. Anemia on admission was present in 218 (58.8%) patients—47 (48.9%) surgical and 171 (62.2%) non-surgical (p = 0.02). Gradual decrease in Hb was seen in all ICU patients. Eighty-one (21.8%) patients required RBC transfusion. The first unit of RBC was transfused on day 7 (IQR 2−13) and the second on day 11 (IQR 4−15) of ICU hospitalization. The median admission Hb in patients who required RBC transfusion was 10.2 (IQR 8.5−11.8) and, in those who did not require transfusion, it was 12.0 (IQR 10.2−13.6) g/dL (p < 0.01). Anemia on admission was associated with a need for RBC transfusion (p < 0.01). Average decrease in Hb during the first week of ICU hospitalization in patients with and without anemia on admission was 1.2 (IQR 0.2−2.3) and 2.8 (IQR 1.1−3.8) g/dL (p < 0.01), respectively. Percentage of patients who bled at the insertion site of invasive devices was as follows: percutaneous tracheostomy—46.7%, therapeutic plasma exchange (TPE) catheter—23.8%, dialysis catheter—13.3%, gastrostomy—9.5%, central venous catheter—7.8%. Moreover, circuit clotting occurred in 17.7 and 9.5% of patients undergoing dialysis and TPE, respectively. Median blood loss for repeated laboratory testing in our study population was 13.7 (IQR 9.9−19.3) mL per patient daily. Anemia is highly prevalent among medical and surgical patients on admission to ICU and is associated with RBC transfusion. Patients who required RBC transfusion had significantly lower daily Hb concentrations. Severity of disease did not seem to have impact on Hb concentration. IBL associated with invasive devices and extracorporeal therapies is frequent in ICU patients and may lead to a gradual decrease in Hb concentration. Further studies are required to analyze causes of HAA in the ICU.

Avoiding Femoral Canal Instrumentation in Computer-Assisted Total Knee Arthroplasty With Contemporary Blood Management Had Minimal Differences in Blood Loss and Transfusion Rates Compared to Conventional Techniques

BACKGROUND

Computer-assisted surgery that does not utilize femoral canal instrumentation is theorized to have less blood loss. However, there is a paucity of data on this, particularly in the era of tranexamic acid use. We sought to analyze the association of computer navigation with total calculated blood loss and transfusion rate in patients undergoing primary total knee arthroplasty (TKA).

METHODS

We identified 14,890 patients who underwent unilateral primary TKA at a single institution from 2016 to 2020. Computer-assisted surgery in the form of an accelerometer or robotics was utilized in 4,165 TKAs (28%). Drains were utilized in 4,860 TKAs (32%). We used multivariate logistic regression analysis to determine if computer navigation reduced the rate of blood transfusion and linear regression analysis to determine the impact of computer navigation on blood loss.

RESULTS

In total, 542 patients (3.6%) underwent a transfusion. The average change in hemoglobin (Hgb) was 2.1 g/dL (standard deviation [SD] 0.91) and average total calculated blood loss was 310 mL (SD = 154). In a multivariate regression model, computer navigation was not protective of transfusion (odds ratio [OR] 1.04, P = .73). Preoperative Hgb <10 (OR 10.5, P < .0001) and drain use (OR 2.25, P < .0001) were the most significant risk factors for transfusion. In a linear regression model, computer navigation reduced blood loss by 19 mL (SD 2.94, P < .0001) per case.

CONCLUSION

In this large retrospective cohort analysis of contemporary TKA patients, computer-assisted surgery that eliminates intramedullary femoral canal instrumentation during primary TKA was not associated with reduced transfusion rates and had minimal differences in overall blood loss.

Impact of "natural" cesarean delivery on peripartum blood loss: a randomized controlled trial

BACKGROUND

Early skin-to-skin contact after vaginal delivery increases milk production and may increase oxytocin release, leading to a reduction in the rate of postpartum hemorrhage.

OBJECTIVE

This study aimed to examine the effect of "natural" cesarean deliveries on perioperative maternal blood loss.

STUDY DESIGN

This was a randomized controlled trial conducted at a single university-affiliated medical center, between August 2016 and February 2018. Term singleton pregnancies scheduled for a planned cesarean delivery under spinal anesthesia were included. Women were randomized at a ratio of 1:1 to natural cesarean delivery (study group) or traditional cesarean delivery (control group) during the routine preoperative assessment. Women in the study group watched fetal extraction, had early skin-to-skin contact, and breastfed until the end of surgery. Neonates in the control group were presented to the mother for a few minutes. Blood samples were drawn from all women, during fascia closure, to determine oxytocin levels using an enzyme-linked immunosorbent assay kit. The laboratory component was performed after recruitment completion and was accomplished in February 2019. The primary outcome was postpartum hemoglobin levels. To detect a difference of 0.5 g/dL between the groups with α=0.05 and β=80%, 214 women were needed.

RESULTS

Of 214 randomized women, 23 were excluded. There was no difference in demographic and obstetrical variables between the groups. Postpartum hemoglobin levels were 10.1±1.1 and 10.3±1.3 g/dL in the study and control groups, respectively (P=.19). There was no difference in the rates of postpartum hemorrhage and blood transfusion. Maternal pain scores, satisfaction, and exclusive breastfeeding were comparable. Maternal oxytocin blood levels were 389.5±183.7 and 408.5±233.6 pg/mL in the study and control groups, respectively (P=.96). The incidence of neonatal hypothermia was comparable between the groups (P=.13).

CONCLUSION

Natural cesarean delivery did not affect perioperative hemoglobin level or maternal oxytocin blood concentration.

Impact of capsular preservation on patient-reported outcomes and complication rates in total hip arthroplasty using the direct anterior approach

AIMS

It is not known whether preservation of the capsule of the hip positively affects patient-reported outcome measures (PROMs) in total hip arthroplasty using the direct anterior approach (DAA-THA). A recent randomized controlled trial found no clinically significant difference at one year postoperatively. This study aimed to determine whether preservation of the anterolateral capsule and anatomical closure improve the outcome and revision rate, when compared with resection of the anterolateral capsule, at two years postoperatively.

METHODS

Two consecutive groups of patients whose operations were performed by the senior author were compared. The anterolateral capsule was resected in the first group of 430 patients between January 2012 and December 2014, and preserved and anatomically closed in the second group of 450 patients between July 2015 and December 2017. There were no other technical changes between the two groups. Patient characteristics, the Charlson Comorbidity Index (CCI), and surgical data were collected from our database. PROM questionnaires, consisting of the Oxford Hip Score (OHS) and Core Outcome Measures Index (COMI-Hip), were collected two years postoperatively. Data were analyzed with generalized multiple regression analysis.

RESULTS

The characteristics, CCI, operating time, and length of stay were similar in both groups. There was significantly less blood loss in the capsular preservation group (p = 0.037). The revision rate (n = 3, (0.6%) in the resected group, and 1 (0.2%) in the preserved group) did not differ significantly (p = 0.295). Once adjusted for demographic and surgical factors, the preserved group had significantly worse PROMs: + 0.24 COMI-Hip (p < 0.001) and -1.6 OHS points (p = 0.017). However, the effect sizes were much smaller than the minimal clinically important differences (MCIDs) of 0.95 and 5, respectively). The date of surgery (influencing, for instance, the surgeon's age) was not a significant factor.

CONCLUSION

Based on the MCID, the lower PROMs in the capsular preservation group do not seem to have clinical relevance. They do not, however, confirm the expected benefit of capsular preservation reported for the posterolateral approach. Cite this article: Bone Joint J 2022;104-B(7):826-832.

Low-dose morphine reduces tolerance to central hypovolemia in healthy adults without affecting muscle sympathetic outflow

Hemorrhage is a leading cause of preventable battlefield and civilian trauma deaths. Low-dose (i.e., an analgesic dose) morphine is recommended for use in the prehospital (i.e., field) setting. Morphine administration reduces hemorrhagic tolerance in rodents. However, it is unknown whether morphine impairs autonomic cardiovascular regulation and consequently reduces hemorrhagic tolerance in humans. Thus, the purpose of this study was to test the hypothesis that low-dose morphine reduces hemorrhagic tolerance in conscious humans. Thirty adults (15 women/15 men; 29 ± 6 yr; 26 ± 4 kg·m-2, means ± SD) completed this randomized, crossover, double-blinded, placebo-controlled trial. One minute after intravenous administration of morphine (5 mg) or placebo (saline), we used a presyncopal limited progressive lower-body negative pressure (LBNP) protocol to determine hemorrhagic tolerance. Hemorrhagic tolerance was quantified as a cumulative stress index (mmHg·min), which was compared between trials using a Wilcoxon matched-pairs signed-rank test. We also compared muscle sympathetic nerve activity (MSNA; microneurography) and beat-to-beat blood pressure (photoplethysmography) during the LBNP test using mixed-effects analyses [time (LBNP stage) × trial]. Median LBNP tolerance was lower during morphine trials (placebo: 692 [473-997] vs. morphine: 385 [251-728] mmHg·min, P < 0.001, CI: -394 to -128). Systolic blood pressure was 8 mmHg lower during moderate central hypovolemia during morphine trials (post hoc P = 0.02; time: P < 0.001, trial: P = 0.13, interaction: P = 0.006). MSNA burst frequency responses were not different between trials (time: P < 0.001, trial: P = 0.80, interaction: P = 0.51). These data demonstrate that low-dose morphine reduces hemorrhagic tolerance in conscious humans. Thus, morphine is not an ideal analgesic for a hemorrhaging individual in the prehospital setting.NEW & NOTEWORTHY In this randomized, crossover, placebo-controlled trial, we found that tolerance to simulated hemorrhage was lower after low-dose morphine administration. Such reductions in hemorrhagic tolerance were observed without differences in MSNA burst frequency responses between morphine and placebo trials. These data, the first to be obtained in conscious humans, demonstrate that low-dose morphine reduces hemorrhagic tolerance. Thus, morphine is not an ideal analgesic for a hemorrhaging individual in the prehospital setting.

Transfusion Guidelines in Brain Tumor Surgery: A Systematic Review and Critical Summary of Currently Available Evidence

OBJECTIVE

Red blood cell (RBC) transfusion is commonly indicated in brain tumor surgery due to risk of blood loss. Current transfusion guidelines are based on evidence derived from critically ill patients and may not be optimal for brain tumor surgeries. Our study is the first to synthesize available evidence to suggest RBC transfusion thresholds in brain tumor patients undergoing surgery.

METHODS

A systematic review was conducted using PubMed, EMBASE, and Google Scholar databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to critically assess RBC transfusion thresholds in adult patients with brain tumors and complications secondary to transfusion following blood loss in the operating room (OR) or the perioperative period.

RESULTS

Seven (7) articles meeting our search criteria were reviewed. Brain tumor patients who received blood transfusions were older, had greater rates of ASA class 3 or 4, and presented with increased number of comorbidities including diabetes, hypertension, and cardiovascular diseases. In addition, transfused patients had a prolonged surgical time. Transfusions were associated with multiple postoperative major and minor complications, including longer hospital length of stay (LOS), increased return to the OR, and elevated 30-day mortality. Analysis of transfusion thresholds showed that a restrictive hemoglobin (Hb) threshold of 8 g/dL is safe in patients, as evidenced by a reduction in LOS, mortality, and complications (Level C Class IIa).

CONCLUSIONS

A restrictive Hb threshold of 8 g/dL appears to be safe and minimizes potential complications of transfusion in brain tumor patients.

LEVEL OF EVIDENCE

Class C Level IIa.

Risk factors and clinical characteristics associated with a ruptured ectopic pregnancy: A 19-year retrospective observational study

Ectopic pregnancy is the most common cause of maternal mortality in the first trimester of pregnancy. The aim of this study was to find risk factors and clinical characteristics associated with ruptured ectopic pregnancies at a medical center in eastern Taiwan in a 19-year period. This was a retrospective observational study that included patients diagnosed with ectopic pregnancy between August 1999 and December 2018. Data about the demographic variables, initial presentation, pre-treatment beta-human chorionic gonadotropin levels, treatment routes (laparoscopy or laparotomy), surgical methods (salpingostomy or salpingectomy), operation time, blood loss amount, the status of ectopic pregnancy (ruptured or unruptured), the requirement for transfusion, and duration of hospital stay were collected. The categorical and continuous variables were analyzed using the correlation coefficients. This study included 225 women who were diagnosed as having an ectopic pregnancy. There were 49 and 176 women with unruptured and ruptured ectopic pregnancies, respectively. The beta-human chorionic gonadotropin levels, history of previous ectopic pregnancy, pelvic inflammatory disease, tubal surgery, abdominal history, and vaginal bleeding were not significantly different between the 2 groups. The ratio of women with abdominal pain was significantly higher in the ruptured ectopic pregnancy group than in the unruptured group (89.1% vs. 63.8%, respectively, P < .001). Preoperative hemoglobin was lower in the ruptured group compared with the unruptured group (P < .001). Blood loss, postoperative hemoglobin, and blood transfusion were significantly higher in the ruptured group than in the unruptured group (P = .000 and P = .001 for blood loss and blood transfusion, respectively). Multiple logistic regression analysis revealed that abdominal pain and blood loss were associated with ruptured tubal pregnancies (adjusted odds ratio [95% confidence intervals]: 3.42 {1.40, 8.40}; 1.01 {1.005, 1.014}, respectively). In conclusion, early pregnancy with abdominal pain, more parity, and lower preoperative hemoglobin should be aware of the possibility of ruptured ectopic pregnancy. More blood loss, transfusion and lower postoperative hemoglobin were also noted with ruptured ectopic pregnancy.

A randomised controlled trial of tranexamic acid versus misoprostol in reducing blood loss during caesarean section

OBJECTIVE

To determine the efficacy of intravenous tranexamic acid versus rectal misoprostol in decreasing intraoperative blood loss during caesarean section (C/S).

DESIGN AND SETTING

Randomised controlled study involving pregnant women undergoing C/S at Alex Ekwueme Federal University Teaching Hospital, Abakaliki in Nigeria.

PARTICIPANTS AND INTERVENTIONS

Five hundred and fourteen women undergoing elective C/S were assigned randomly (257 patients per group) to receive either pre-operative 1000 µg rectal misoprostol or 1000mg intravenous tranexamic acid after spinal anaesthesia. Data from 248 patients were analysed in the misoprostol group, while data from 250 patients were analysed in the tranexamic acid group. Sixteen patients were excluded from analysis; nine had incompletely filled proforma, while seven were lost to follow-up.

MAIN OUTCOME

Intraoperative blood loss.

RESULTS

The mean intraoperative blood loss was not significantly different between the misoprostol group and the tranexamic acid group (547 ± 183.75ml vs. 551.66 ± 21.74ml, P = 0.157). The mean difference in pack cell volume (PCV) changes was not significant between the groups (2.41±0.95% vs. 2.36±0.56%, P = 0.474). The side effects profile was similar for both groups except for shivering, which was statistically higher among the misoprostol group (RR = 0.70; 95%CI 0.40 - 0.91, P = 0.028).

CONCLUSION

Intravenous tranexamic acid was comparable to rectal misoprostol in the reduction of blood loss during C/S. Tranexamic acid could act as a good alternative to misoprostol for prophylaxis for blood loss during elective C/S.

FUNDING

None declared.

Impact of intravenous tranexamic acid on patients undergoing shoulder arthroplasty surgery

Background

Shoulder arthroplasty surgery carries the risk of blood loss. The antifibrinolytic tranexamic acid (TXA) is effective in reducing blood loss in lower limb arthroplasty. The purpose of this study was to assess blood loss and associated complications following shoulder arthroplasty performed with and without TXA for both elective and trauma indications.

Methods

A cohort study was performed to assess blood loss, transfusion requirements and post-operative venous thromboembolic events (VTE) following shoulder arthroplasty undertaken with and without the use of intravenous TXA.

Results

The study consisted of 67 patients (n = 36 with TXA; n = 31 without TXA). Type of arthroplasty included reverse-shoulder arthroplasty, total-shoulder arthroplasty and hemiarthroplasty. There was no significant difference between TXA and non-TXA groups regarding blood loss (TXA group haemoglobin drop 20.6 mg/dL; non-TXA group haemoglobin drop 20.5 mg/dL; p = 0.978). There was no significant difference in measured outcomes with or without TXA use for elective or trauma indications, nor regarding type of arthroplasty.

Discussion

The use of intravenous TXA in shoulder arthroplasty was not associated with a significant reduction in blood loss or post-operative transfusion rates, nor did it impact on VTE. This result was not affected by the indication being elective or trauma nor the type of arthroplasty surgery performed.

Efficacy and Safety Profile of Tranexamic Acid in Traumatic Thoracolumbar Fracture Management: A Systematic Review and Meta-Analysis

OBJECTIVE

In this article, the authors systematically evaluated the efficacy and safety of tranexamic acid (TXA) in surgeries for spinal trauma.

METHODS

Potentially relevant academic articles were identified from the Cochrane Library, MEDLINE, PubMed, and Google Scholar. Secondary sources were identified from the references of the included literature. RevMan software was used to analyze the pooled data.

RESULTS

A total of 7 randomized controlled trials (RCTs) and 2 non-RCTs were included in the review. There were significant differences in total blood loss (standard mean difference [SMD] = -2.54 [95% CI, -3.72, -1.37], P = 0.0001), intraoperative blood loss (SMD = -0.96 [95% CI, -1.28, -0.64], P < 0.00001), postoperative blood loss (SMD = -1.42 [95% CI, -1.72, -1.11], P < 0.00001), and length of hospital stay (SMD = -3.73 [95% CI, -4.41, -3.06], P = 0.00001). No significant differences were found regarding transfusion requirement, operative duration, deep vein thrombosis, and pulmonary embolism between the 2 groups.

CONCLUSIONS

The present meta-analysis indicates that the use of TXA in spinal surgery decreases blood loss and duration of hospital stay while not increasing the risk of side effects such as deep vein thrombosis and pulmonary embolism.

CLINICAL RELEVANCE

The study aims to provide clinicians who operate on spine trauma with information on the use of tranexamic acid to decrease blood loss and related complications.

LEVEL OF EVIDENCE: 1

Comparison Benefit between Hydrogen Peroxide and Adrenaline in Tonsillectomy: A Randomized Controlled Study

This study aimed to further evaluate the benefit of topical hemostasis agents in tonsillectomy. We compared the clinical effects of topical application between hydrogen peroxide and adrenaline in tonsillectomy. Overall, 60 patients (120 tonsils) were prospectively enrolled for tonsillectomy between February 2018 and December 2020. The patients were randomly assigned to either the hydrogen peroxide or adrenaline group. Then, tonsillectomy was performed using hydrogen peroxide as a hemostatic agent on the assigned side, while adrenaline was applied to the other side. All procedures were performed by a surgeon who was blinded to the randomization. The outcome measurements of operation time, intraoperative blood loss, postoperative pain, and hemorrhage events were analyzed. The intraoperative blood loss was significantly lower in the hydrogen peroxide group than in the adrenaline group (9.99 ± 4.51 mL vs. 13.87 ± 6.32 mL; p = 0.0). The median operation time was also significantly lower in the hydrogen peroxide group (8.02 ± 3.59 min vs. 9.22 ± 3.88 min; p = 0.019). Meanwhile, the visual analogue scale (VAS) scores were significantly higher in the hydrogen peroxide group (4.98 ± 1.94 vs. 4.27 ± 1.97; p = 0.001). The topical application of hydrogen peroxide as a hemostatic agent effectively decreases the operation time and intraoperative blood loss. Thus, hydrogen peroxide can be used as a routine hemostatic agent for bleeding control in tonsillectomy.

The use of FEIBA for refractory bleeding in cardiac surgery - a systematic review

INTRODUCTION

Significant blood loss during cardiac surgery is associated with a significant increase in morbidity and mortality. Factor Eight Inhibitor Bypassing Activity (FEIBA), a hemostatic bypassing agent mainly used in hemophiliac patients, has also been used for intractable surgical bleeding during cardiac surgical procedures in non-hemophiliac patients. However, concerns exist that its use may be linked to increased incidence of perioperative adverse effects including thrombotic complications.

AREAS COVERED

A systematic literature search was performed on MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases for all studies that reported the administration of FEIBA for treatment of bleeding during adult cardiac surgery in non-hemophiliac patients. After selecting of title and abstracts, two authors assessed the methodological quality of the full-text articles prior to final inclusion in the manuscript.

EXPERT OPINION

The safety profile of FEIBA was determined through an aggregate count of adverse events. Major complications included renal failure, re-operation for unresolved bleeding, postoperative mortality, and thromboembolic events. Overall, there is insufficient robust evidence to make a definitive conclusion about the safety or efficacy of using of FEIBA as a hemostatic agent in the setting of cardiac surgery.

Effects of Pre-Donated Autologous Blood Transfusion on Peri-Operative Hemoglobin Concentration and Mid-Term Health Outcomes in Primary Total Knee Arthroplasty

The effects of auto-BT in primary TKA on the perioperative hemoglobin (Hb) concentration and mid-term health outcomes are unknown. This study was performed to analyze the detailed changes in the perioperative Hb concentration before and after the operation (days 0–14 postoperatively), cardiovascular events, and mortality rate within 1 and 5 years postoperatively. One hundred patients undergoing primary TKA with auto-BT using 800 mL of preoperatively collected blood at the authors’ institution were included. The mean Hb concentration before and after autologous blood collection was 12.7 ± 1.1 and 11.7 ± 1.2 g/dL, respectively. After primary TKA with auto-BT, the mean Hb concentration on day 0, 1, 3, 7, and 14 was 10.2 ± 1.2, 9.9 ± 1.2, 10.4 ± 1.3, 10.5 ± 1.3, and 11.0 ± 1.3 g/dL, respectively. Only one (1%) patient required additional allogenic blood transfusion. No patients developed cardiovascular events, and the 1- and 5-year postoperative mortality rate was 1.0% and 2.0%, respectively. Primary TKA with auto-BT showed relatively small perioperative changes in the Hb concentration, a low incidence of cardiovascular events, and a low mortality rate within 1 and 5 years postoperatively. These findings suggest that auto-BT, in which blood is preoperatively collected, is beneficial for patient safety and health, even if its cost-effectiveness may be debatable.

静脉应用不同剂量氨甲环酸对微创小切口经椎间孔腰椎椎间融合术围术期失血量影响的前瞻性随机对照研究

OBJECTIVE

A prospective randomized controlled trial was conducted to study the effectiveness and safety of intravenous different doses tranexamic acid (TXA) in single-level unilateral minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).

METHODS

The patients treated with single-level unilateral MIS-TLIF between September 2019 and October 2020 were enrolled and randomly classified into low-dose TXA (LD) group (n=39), high-dose TXA (HD) group (n=39), and placebo-controlled (PC) group (n=38). The LD, HD, and PC groups received intravenous TXA 20 mg/kg, TXA 50 mg/kg, the same volume of normal saline at 30 minute before skin incision after general anesthesia, respectively. There was no significant difference on baseline characteristics and preoperative laboratory results among 3 groups (P>0.05), including age, gender, body mass index, surgical segments, hematocrit (HCT), hemoglobin (HGB), prothrombin time (PT), international normalized ratio (INR), D-dimer, fibrin degradation products (FDP), activated partial prothromboplastin time (APTT), alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatinine (Cr), urea. The intraoperative blood loss (IBL), postoperative drainage volume, operation time, total blood loss (TBL), hidden blood loss (HBL), blood transfusion, hematological examination indexes on the first day after operation, and the incidence of complications within 1 month were compared among the 3 groups.

RESULTS

There were 3, 2, and 4 patients in the LD, HD, and PC groups who underwent autologous blood transfusion, respectively, and there was no allogeneic blood transfusion patients in the 3 groups. There was no significant difference in IBL, postoperative drainage volume, and operation time between groups (P>0.05). The TBL, HBL, and the decreased value of HGB in LD and HD groups were significantly lower than those in PC group (P<0.05), and TBL and HBL in HD group were significantly lower than those in LD group (P<0.05); the decreased value of HGB between LD group and HD group showed no significant difference (P>0.05). On the first day after operation, D-dimer in LD and HD groups were significantly lower than that in PC group (P<0.05); there was no significant difference between LD and HD groups (P>0.05). There was no significant difference in other hematological indexes between groups (P>0.05). All patients were followed up 1 month, and there was no TXA-related complication such as deep venous thrombosis of lower extremity, pulmonary embolism, and epilepsy in the 3 groups.

CONCLUSION

Intravenous administration of TXA in single-level unilateral MIS-TLIF is effective and safe in reducing postoperative TBL and HBL within 1 day in a dose-dependent manner. Also, TXA can reduce postoperative fibrinolysis markers and do not increase the risk of thrombotic events, including deep venous thrombosis and pulmonary embolism.