Strategies to minimize intraoperative blood loss during major surgery

Optimizing Dual Antiplatelet Therapy in the Perioperative Period for Spine Surgery After Recent Percutaneous Coronary Intervention: A Comprehensive Review, Synthesis, and Catalyst for Protocol Formulation

The increased incidence of spine surgery within the past decade has highlighted the importance of robust perioperative management to improve patient outcomes overall. Coronary artery disease is a common medical comorbidity present in the population of individuals who receive surgery for spinal pathology that is often treated with dual antiplatelet therapy (DAPT) after percutaneous coronary intervention. Discontinuation of DAPT before surgical intervention is typically indicated; however, contradictory evidence exists in the literature regarding the timing of DAPT use and discontinuation in the perioperative period. We review the most recent cardiac and spine literature on the intricacies of percutaneous coronary intervention and its associated risks in the postoperative period. We further propose protocols for DAPT use after both elective and urgent spine surgery to optimize perioperative care.

The impact of paravertebral nerve blockade on postoperative surgical site wound pain management in patients undergoing video-assisted thoracoscopic surgery for pulmonary carcinoma resection

Management of postoperative pain is of vital importance for patients undergoing Video-Assisted Thoracoscopic Surgery (VATS) for Pulmonary Carcinoma Resection. The study evaluates the impact of Paravertebral Nerve Blockade (PNB) in conjunction with general anaesthesia on postoperative pain relief, as compared with general anaesthesia alone. A retrospective analysis was carried out from May 2020 to May 2023, involving 100 patients with pathologically confirmed pulmonary carcinoma. The patients were divided into two groups: a control group that received general anaesthesia and an observation group that received a combination of general anaesthesia and PNB. The intensity of postoperative pain was assessed at various time intervals using the visual analogue scale (VAS), while the effectiveness of patient-controlled analgesia was also evaluated. Additionally, the study examined the incidence rates of chronic pain in the postoperative period. Statistical analysis was performed using IBM SPSS version 27.0. Significant reductions in VAS scores for both resting and cough-induced pain were observed in the observation group at 2 and 6 h post-operation (p < 0.01). However, the difference diminished over time. The observation group had fewer patient-controlled analgesia activations and required lower dosages of hydromorphone at both 24- and 48-h post-operation. The incidence of chronic pain was also significantly lower in the observation group (24.00%) compared with the control group (54.00%) (p < 0.01). PNB, when administered in combination with general anaesthesia, significantly reduces immediate postoperative pain and the requirement for additional analgesics in patients undergoing VATS for pulmonary carcinoma resection. The effect diminishes over time but has a lasting impact on reducing the incidence of chronic postoperative pain.

Intraoperative Performance with the Exoscope in Spine Surgery: An Institutional Experience

BACKGROUND

Exoscope use in spinal neurosurgery has become a promising surgical option providing enhanced operative field visibility and ergonomics. However, data on its use in spine surgery are underreported in the literature. We aimed to assess the intraoperative outcomes in exoscope-assisted spine surgery compared with similar procedures performed using the operative microscope.

METHODS

A retrospective review was performed of all spinal surgeries performed using an exoscope and, subsequently, an equal number of operative microscope cases performed by 2 senior surgeons at a single institution from 2016 to 2023. The variables included demographics, clinical presentation, surgical treatment, and operative outcomes.

RESULTS

A total of 123 exoscope spinal surgeries were performed on 116 unique patients with a mean age of 67 ± 14 years, of whom 60 (52%) were women. The microscope group included 126 surgeries on 120 unique patients with a mean age of 62 ± 14 years, of whom 53 (45%) were women. The mean blood loss (28 mL vs. 132 mL; P = 0.0009), operative time (83 minutes vs. 103 minutes; P = 0.006), and length of stay (1.04 days vs. 1.73 days; P = 0.02) were significantly less for the exoscope group than for the microscope group.

CONCLUSIONS

The use of the exoscope resulted in a shorter operative time, less blood loss, a shorter length of stay, and favorable clinical outcomes compared with the use of the operative microscope. Neurosurgeons should consider this seemingly efficacious and ergonomically favorable visual technology for spinal surgeries.

Desmopressin to reduce periprocedural bleeding and transfusion: a systematic review and meta-analysis

We systematically reviewed the literature to investigate the effects of peri-procedural desmopressin in patients without known inherited bleeding disorders undergoing surgery or other invasive procedures. We included 63 randomized trials (4163 participants) published up to February 1, 2023. Seven trials were published after a 2017 Cochrane systematic review on this topic. There were 38 trials in cardiac surgery, 22 in noncardiac surgery, and 3 in non-surgical procedures. Meta-analyses demonstrated that desmopressin likely does not reduce the risk of receiving a red blood cell transfusion (25 trials, risk ratio [RR] 0.95, 95% confidence interval [CI] 0.86 to 1.05) and may not reduce the risk of reoperation due to bleeding (22 trials, RR 0.75, 95% CI 0.47 to 1.19) when compared to placebo or usual care. However, we demonstrated significant reductions in number of units of red blood cells transfused (25 trials, mean difference -0.55 units, 95% CI - 0.94 to - 0.15), total volume of blood loss (33 trials, standardized mean difference - 0.40 standard deviations; 95% CI - 0.56 to - 0.23), and the risk of bleeding events (2 trials, RR 0.45, 95% CI 0.24 to 0.84). The certainty of evidence of these findings was generally low. Desmopressin increased the risk of clinically significant hypotension that required intervention (19 trials, RR 2.15, 95% CI 1.36 to 3.41). Limited evidence suggests that tranexamic acid is more effective than desmopressin in reducing transfusion risk (3 trials, RR 2.38 favoring tranexamic acid, 95% CI 1.06 to 5.39) and total volume of blood loss (3 trials, mean difference 391.7 mL favoring tranexamic acid, 95% CI - 93.3 to 876.7 mL). No trials directly informed the safety and hemostatic efficacy of desmopressin in advanced kidney disease. In conclusion, desmopressin likely reduces periprocedural blood loss and the number of units of blood transfused in small trials with methodologic limitations. However, the risk of hypotension needs to be mitigated. Large trials should evaluate desmopressin alongside tranexamic acid and enroll patients with advanced kidney disease.

Surgical Experience from the STASEY Study of Emicizumab Prophylaxis in People with Hemophilia A with Factor VIII Inhibitors

Background  Guidelines surrounding emicizumab prophylaxis and perioperative treatment for people with hemophilia A (PwHA) with factor (F)VIII inhibitors undergoing surgeries are limited. The phase IIIb multicenter, single-arm STASEY study evaluated safety and tolerability of emicizumab prophylaxis in PwHA aged ≥12 years with FVIII inhibitors. This analysis assesses surgeries during study conduct, associated hemophilia medications, and postoperative bleeds (treated and untreated). Methods  PwHA with FVIII inhibitors received emicizumab 3.0 mg/kg/week for 4 weeks, then 1.5 mg/kg/week until 2 years. Surgeries were managed and documented by treating physicians. Bleeds and treatments were recorded by physicians and participants. Results  Forty-six participants had ≥1 on-study surgery, 37 underwent 56 minor surgeries, and 13 underwent 22 major surgeries. Four participants underwent both minor and major surgeries. Of 18 (81.8%) and 4 (18.2%) major surgeries managed with/without additional hemostatic medication, 33.3 and 25.0% were associated with a treated postoperative bleed, respectively. Of 24 (42.9%) and 32 (57.1%) minor surgeries managed with/without additional hemostatic medication, 15.6 and 25.0% were associated with a treated postoperative bleed, respectively. Recombinant activated FVII was the most common medication for prophylaxis and bleed treatment. There were no thrombotic microangiopathies (TMAs). One hypertrophic clot, considered unrelated to emicizumab, occurred following tooth extraction. Conclusion  In this challenging population with a high bleeding risk, major surgeries were performed in PwHA receiving emicizumab with/without additional hemostatic medication. Postoperative bleeds occurred following 59.1% of major surgeries; 53.8% were treated. No arterial/venous thrombotic events or TMAs occurred due to concomitant emicizumab and bypassing agents. Trial registration  This trial is registered at ClinicalTrials.gov (NCT03191799).

Intraoperative blood pressure: could less be more?

Retrospective observational studies have reported a significant association between intraoperative hypotension and postoperative morbidity. However, association does not imply causation, and whether preventing intraoperative hypotension can improve patient outcome remains to be demonstrated. In this issue of the British Journal of Anaesthesia, D'Amico and colleagues meta-analysed 10 prospective randomised trials comparing low (≤60 mm Hg) and higher mean arterial pressure targets during anaesthesia and surgery. They did not observe an increase in postoperative morbidity and mortality in the low target group. In contrast, they reported a statistically significant (but not clinically relevant) reduction in postoperative cardiac arrhythmia and hospital length of stay when targeting mean arterial pressure ≤60 mm Hg. These findings suggest that during most surgical cases, intraoperative hypotension is a marker of the severity, frailty, or both rather than a mediator of postoperative complications.

Construction and validation of a risk prediction model for intraoperative hypothermia in elderly patients undergoing total hip arthroplasty

AIMS

To construct and validate an intraoperative hypothermia risk prediction model for elderly patients undergoing total hip arthroplasty (THA).

METHODS

We collected data from 718 patients undergoing THA in a tertiary hospital from January 2021 to December 2022. Of these patients, 512 were assigned to the modeling group from January 2021 to April 2022, and 206 participants were assigned to the validation group from May 2022 to December 2022. A logistic regression analysis was performed to construct the model. The area under the curve (AUC) was used to test the model's predictive ability.

RESULTS

The incidence rate of intraoperative hypothermia was 51.67%. The risk factors entered into the risk prediction model were age, preoperative hemoglobin level, intraoperative blood loss, postoperative hemoglobin level, and postoperative systolic blood pressure. The model was constructed as follows: logit (P) = - 10.118 + 0.174 × age + 1.366 × 1 (preoperative hemoglobin level) + 0.555 × 1 (postoperative hemoglobin level) + 0.009 × 1 (intraoperative blood loss) + 0.066 × 1 (postoperative systolic blood pressure). Using the Hosmer-Lemeshow test, the P value was 0.676 (AUC, 0.867). The Youden index, sensitivity, and specificity were 0.602, 0.790, and 0.812, respectively. The incidence rates of intraoperative hypothermia in the modeling and validation groups were 53.15% and 48.06%, respectively. The correct practical application rate was 89.81%. This model had good application potential.

CONCLUSIONS

This risk prediction model has good predictive value and can accurately predict the occurrence of intraoperative hypothermia in patients who undergo THA, which provides reliable guidance for clinical work and has good clinical application value.

A hybrid neural network based model for blood donation forecasting

OBJECTIVE

To develop a hybrid neural network-based blood donation prediction method, via this predictive model, we can obtain the best estimate of whole blood in Beijing Tongzhou District Central Blood Station and help managers smoothly solve the allocation problem under fluctuating hospital demand and limited resources.

METHOD

Inspired by the practical problems faced by blood stations providing transfusion services to several hospitals, a hybrid model based on a time-series prediction method and neural network, SARIMAX-TCN-LSTM is proposed for the prediction of daily whole blood donations. The experiment was performed at the central blood station in Tongzhou district, where we used whole blood donations from January 1, 2015, to November 14, 2021, as the subject, supplemented by meteorological and epidemic factors affecting blood donation, to predict daily blood donations for the next two weeks.

RESULT

The hybrid model significantly outperformed the traditional time series forecasting method on multiple regression metrics, with twice as effective fitting as the baseline and a 33% reduction in Root Mean Squared Error (RMSE). Results indicate that the proposed model can improve the prediction accuracy of daily blood donations, and the co-validity of the structure was evidenced in an ablation experiment.

CONCLUSION

Development and evaluation of a hybrid neural network-based model structure improve the prediction of daily blood donations. This intelligent forecasting method can help managers to overcome the challenges of sudden blood demand and contribute to the optimization of resource allocation tasks.

Cell salvage for minimising perioperative allogeneic blood transfusion in adults undergoing elective surgery

BACKGROUND

Concerns regarding the safety and availability of transfused donor blood have prompted research into a range of techniques to minimise allogeneic transfusion requirements. Cell salvage (CS) describes the recovery of blood from the surgical field, either during or after surgery, for reinfusion back to the patient.

OBJECTIVES

To examine the effectiveness of CS in minimising perioperative allogeneic red blood cell transfusion and on other clinical outcomes in adults undergoing elective or non-urgent surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two clinical trials registers for randomised controlled trials (RCTs) and systematic reviews from 2009 (date of previous search) to 19 January 2023, without restrictions on language or publication status.

SELECTION CRITERIA

We included RCTs assessing the use of CS compared to no CS in adults (participants aged 18 or over, or using the study's definition of adult) undergoing elective (non-urgent) surgery only.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 106 RCTs, incorporating data from 14,528 participants, reported in studies conducted in 24 countries. Results were published between 1978 and 2021. We analysed all data according to a single comparison: CS versus no CS. We separated analyses by type of surgery. The certainty of the evidence varied from very low certainty to high certainty. Reasons for downgrading the certainty included imprecision (small sample sizes below the optimal information size required to detect a difference, and wide confidence intervals), inconsistency (high statistical heterogeneity), and risk of bias (high risk from domains including sequence generation, blinding, and baseline imbalances). Aggregate analysis (all surgeries combined: primary outcome only) Very low-certainty evidence means we are uncertain if there is a reduction in the risk of allogeneic transfusion with CS (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.59 to 0.72; 82 RCTs, 12,520 participants). Cancer: 2 RCTs (79 participants) Very low-certainty evidence means we are uncertain whether there is a difference for mortality, blood loss, infection, or deep vein thrombosis (DVT). There were no analysable data reported for the remaining outcomes. Cardiovascular (vascular): 6 RCTs (384 participants) Very low- to low-certainty evidence means we are uncertain whether there is a difference for most outcomes. No data were reported for major adverse cardiovascular events (MACE). Cardiovascular (no bypass): 6 RCTs (372 participants) Moderate-certainty evidence suggests there is probably a reduction in risk of allogeneic transfusion with CS (RR 0.82, 95% CI 0.69 to 0.97; 3 RCTs, 169 participants). Very low- to low-certainty evidence means we are uncertain whether there is a difference for volume transfused, blood loss, mortality, re-operation for bleeding, infection, wound complication, myocardial infarction (MI), stroke, and hospital length of stay (LOS). There were no analysable data reported for thrombosis, DVT, pulmonary embolism (PE), and MACE. Cardiovascular (with bypass): 29 RCTs (2936 participants) Low-certainty evidence suggests there may be a reduction in the risk of allogeneic transfusion with CS, and suggests there may be no difference in risk of infection and hospital LOS. Very low- to moderate-certainty evidence means we are uncertain whether there is a reduction in volume transfused because of CS, or if there is any difference for mortality, blood loss, re-operation for bleeding, wound complication, thrombosis, DVT, PE, MACE, and MI, and probably no difference in risk of stroke. Obstetrics: 1 RCT (1356 participants) High-certainty evidence shows there is no difference between groups for mean volume of allogeneic blood transfused (mean difference (MD) -0.02 units, 95% CI -0.08 to 0.04; 1 RCT, 1349 participants). Low-certainty evidence suggests there may be no difference for risk of allogeneic transfusion. There were no analysable data reported for the remaining outcomes. Orthopaedic (hip only): 17 RCTs (2055 participants) Very low-certainty evidence means we are uncertain if CS reduces the risk of allogeneic transfusion, and the volume transfused, or if there is any difference between groups for mortality, blood loss, re-operation for bleeding, infection, wound complication, prosthetic joint infection (PJI), thrombosis, DVT, PE, stroke, and hospital LOS. There were no analysable data reported for MACE and MI. Orthopaedic (knee only): 26 RCTs (2568 participants) Very low- to low-certainty evidence means we are uncertain if CS reduces the risk of allogeneic transfusion, and the volume transfused, and whether there is a difference for blood loss, re-operation for bleeding, infection, wound complication, PJI, DVT, PE, MI, MACE, stroke, and hospital LOS. There were no analysable data reported for mortality and thrombosis. Orthopaedic (spine only): 6 RCTs (404 participants) Moderate-certainty evidence suggests there is probably a reduction in the need for allogeneic transfusion with CS (RR 0.44, 95% CI 0.31 to 0.63; 3 RCTs, 194 participants). Very low- to moderate-certainty evidence suggests there may be no difference for volume transfused, blood loss, infection, wound complication, and PE. There were no analysable data reported for mortality, re-operation for bleeding, PJI, thrombosis, DVT, MACE, MI, stroke, and hospital LOS. Orthopaedic (mixed): 14 RCTs (4374 participants) Very low- to low-certainty evidence means we are uncertain if there is a reduction in the need for allogeneic transfusion with CS, or if there is any difference between groups for volume transfused, mortality, blood loss, infection, wound complication, PJI, thrombosis, DVT, MI, and hospital LOS. There were no analysable data reported for re-operation for bleeding, MACE, and stroke.

AUTHORS' CONCLUSIONS

In some types of elective surgery, cell salvage may reduce the need for and volume of allogeneic transfusion, alongside evidence of no difference in adverse events, when compared to no cell salvage. Further research is required to establish why other surgeries show no benefit from CS, through further analysis of the current evidence. More large RCTs in under-reported specialities are needed to expand the evidence base for exploring the impact of CS.

The effect of tranexamic acid on intraoperative blood loss in patients undergoing brain meningioma resections: Study protocol for a randomized controlled trial

INTRODUCTION

Tranexamic acid (TXA) has been proven to prevent thrombolysis and reduce bleeding and blood transfusion requirements in various surgical settings. However, the optimal dose of TXA that effectively reduce intraoperative bleeding and blood product infusion in patients undergoing neurosurgical resection of meningioma with a diameter ≥ 5 cm remains unclear.

METHODS

This is a single-center, randomized, double-blinded, paralleled-group controlled trial. Patients scheduled to receive elective tumor resection with meningioma diameter ≥ 5 cm will be randomly assigned the high-dose TXA group, the low-dose group, and the placebo. Patients in the high-dose TXA group will be administered with a loading dose of 20 mg/kg TXA followed by continuous infusion TXA at a rate of 5 mg/kg/h. In the low-dose group, patients will receive the same loading dose of TXA followed by a continuous infusion of normal saline. In the control group, patients will receive an identical volume of normal saline. The primary outcome is the estimated intraoperative blood loss calculated using the following formula: collected blood volume in the suction canister (mL)-the volume of flushing (mL) + the volume from the gauze tampon (mL). Secondary outcomes include calculated intraoperative blood loss, intraoperative coagulation function assessed using thromboelastogram (TEG), intraoperative cell salvage use, blood product infusion, and other safety outcomes.

DISCUSSION

Preclinical studies suggest that TXA could reduce intraoperative blood loss, yet the optimal dose was controversial. This study is one of the early studies to evaluate the impact of intraoperative different doses infusion of TXA on reducing blood loss in neurological meningioma patients.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05230381. Registered on February 8, 2022.

Influencing factors of hidden blood loss after primary total hip arthroplasty through the posterior approach: a retrospective study

BACKGROUND

Total hip arthroplasty (THA) is an excellent treatment for the end-stage hip disease, and perioperative blood management strategies have been effectively applied to this procedure. However, many patients still experience anemia after the operation, which is usually overlooked by orthopedic surgeons due to the hidden blood loss (HBL) in the perioperative period. Therefore, the objective of this study was to evaluate HBL in patients undergoing primary THA using the posterior approach and to explore its influencing factors.

METHODS

A retrospective analysis of 707 patients who underwent primary THA through the posterior approach was conducted in our hospital from January 2020 to January 2022. By applying Gross's and Nadler's formula, the HBL was calculated. Six quantitative variables (age, body mass index, surgical duration, albumin loss, preoperative hemoglobin, and hemoglobin loss) as well as four qualitative variables (gender, American Society of Anesthesiologists class, major preoperative diagnosis, and hypertension) of patients were analyzed using multivariate linear regression.

RESULTS

The HBL was recorded at 700.39 ± 368.59 mL. As a result of multivariate linear regression analysis, it was determined that body mass index, surgical duration, and hemoglobin loss were all significant risk factors for HBL, whereas preoperative hemoglobin was considered a protective factor. It has been demonstrated that HBL is not significantly correlated with age, albumin loss, gender, ASA class, or major preoperative diagnosis, but it also did not differ from HBL by hypertension.

CONCLUSIONS

Hidden blood Loss (HBL) in patients after primary total hip arthroplasty (THA) using the posterior approach is large and significant. When optimizing the perioperative management of THA, orthopedic surgeons should keep in mind HBL and its influencing factors, especially for patients with high body mass indexes, long surgical durations, and low preoperative hemoglobin levels.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100053888) in 02/12/2021, http://www.chictr.org.cn .

Effect of Anesthesia on Endoscopic Sinus Surgery Hemostasis: A State-of-the-Art Review

Endoscopic sinus surgery (ESS) is the gold standard for the management of chronic rhinosinusitis, nasal polyposis, and other pathology involving paranasal sinus as tumors. Intraoperative bleeding during ESS can be challenging due to the narrow sinonasal surgical field, single working hand, and the use of endoscopic instruments, which may affect hemostasis. There is a role for the type of anesthesia technique used for intraoperative bleeding control. Total intravenous anesthesia (TIVA) and inhalational anesthesia (IA) are some of the techniques available for anesthetic purposes. While both techniques have their advantages and disadvantages, there is a need to compare their efficacy and safety to determine which technique is more appropriate for ESS. In this review, our main focus was to summarize the current evidence about the different techniques of anesthesia used during ESS. A systematic review of the PubMed/MEDLINE database was performed using specific English terms related to TIVA and IA/volatile anesthesia used during ESS. A total of 548 publications were considered. Among these, 329 studies did not fulfill the criteria for inclusion in the systematic review, resulting in the inclusion of only 132 publications: 13 systematic reviews, 32 reviews, 92 randomized controlled trials, and 13 meta-analyses. The state of the art favors the use of TIVA during ESS due to its significant improvement in the intraoperative surgical field with less blood loss. Further studies aim to compare long-term nasal status with objective tools, ideally in similar pathology with the same surgeon.

Systematic review highlights high risk of bias of clinical prediction models for blood transfusion in patients undergoing elective surgery

BACKGROUND

Blood transfusion can be a lifesaving intervention after perioperative blood loss. Many prediction models have been developed to identify patients most likely to require blood transfusion during elective surgery, but it is unclear whether any are suitable for clinical practice.

STUDY DESIGN AND SETTING

We conducted a systematic review, searching MEDLINE, Embase, PubMed, The Cochrane Library, Transfusion Evidence Library, Scopus, and Web of Science databases for studies reporting the development or validation of a blood transfusion prediction model in elective surgery patients between January 1, 2000 and June 30, 2021. We extracted study characteristics, discrimination performance (c-statistics) of final models, and data, which we used to perform risk of bias assessment using the Prediction model risk of bias assessment tool (PROBAST).

RESULTS

We reviewed 66 studies (72 developed and 48 externally validated models). Pooled c-statistics of externally validated models ranged from 0.67 to 0.78. Most developed and validated models were at high risk of bias due to handling of predictors, validation methods, and too small sample sizes.

CONCLUSION

Most blood transfusion prediction models are at high risk of bias and suffer from poor reporting and methodological quality, which must be addressed before they can be safely used in clinical practice.

Chitosan-Based Biomaterials for Hemostatic Applications: A Review of Recent Advances

Hemorrhage is a detrimental event present in traumatic injury, surgery, and disorders of bleeding that can become life-threatening if not properly managed. Moreover, uncontrolled bleeding can complicate surgical interventions, altering the outcome of surgical procedures. Therefore, to reduce the risk of complications and decrease the risk of morbidity and mortality associated with hemorrhage, it is necessary to use an effective hemostatic agent that ensures the immediate control of bleeding. In recent years, there have been increasingly rapid advances in developing a novel generation of biomaterials with hemostatic properties. Nowadays, a wide array of topical hemostatic agents is available, including chitosan-based biomaterials that have shown outstanding properties such as antibacterial, antifungal, hemostatic, and analgesic activity in addition to their biocompatibility, biodegradability, and wound-healing effects. This review provides an analysis of chitosan-based hemostatic biomaterials and discusses the progress made in their performance, mechanism of action, efficacy, cost, and safety in recent years.

Safety and Performance of Hemostatic Powders

Background

Hemorrhage, a sudden and severe leakage of blood due to the disruption of blood vessels, is one of the most common causes of death from injuries worldwide. Severe bleeding accounts for more than 35% of pre-hospital deaths and about 40% of deaths recorded within 24 hours of injury. One of the methods for achieving homeostasis is the use of hemostatic powders. This study compares the basic safety and performance of the most popular hemostatic powders.

Methods

Basic safety of commercially available products were evaluated using MTT, MEM elution assay, and endotoxin testing. The in vitro performance was evaluated using water absorption capacity, water absorption rate, and adhesion strength assays.

Results

4Seal, Starsil, and 4DryField extracts did not cause cytotoxicity in MTT and MEM elution assays. PerClot and SuperClot extracts demonstrated cytotoxic potential in MTT assay, while Arista extract was cytotoxic in both MEM elution and MTT assays. 4Seal has the lowest endotoxin contamination, followed by PerClot, 4DryField, SuperClot, Arista, and Starsil. 4Seal and Starsil showed significantly highest WAR among the tested samples, followed by 4DryField, Arista, PerClot, and SuperClot. Adhesion force is highest for 4Seal, followed by Starsil, PerClot, 4DryField Arista, and SuperClot.

Conclusion

4Seal is the most versatile in terms of safety and functional properties compared to 4DryField, Arista, PerClot, Starsil, and SuperClot.

Tranexamic acid use in meningioma surgery - A systematic review and meta-analysis

Tranexamic Acid (TXA) has been used in medical and surgical practice to reduce haemorrhage. The aim of this review was to evaluate the effect of TXA use on intraoperative and postoperative outcomes of meningioma surgery. A systematic review and meta-analysis was conducted in accordance with the PRISMA statement and registered in PROSPERO (CRD42021292157). Six databases were searched up to November 2021 for phase 2-4 control trials or cohort studies, in the English language, examining TXA use during meningioma surgery. Studies ran outside of dedicated neurosurgical departments or centres were excluded. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Random effects meta-analysis were performed to delineate differences in operative and postoperative outcomes. Four studies (281 patients) were included. TXA use significantly reduced intraoperative blood loss (mean difference 315.7 mls [95% confidence interval [CI] -532.8, -98.5]). Factors not affected by TXA use were transfusion requirement (odds ratio = 0.52; 95% CI 0.27, 0.98), operation time (mean difference = -0.2 h; 95% CI -0.8, 0.4), postoperative seizures (Odds Ratio [OR] = 0.88; 95% CI 0.31, 2.53), hospital stay (mean difference = -1.2; 95% CI -3.4, 0.9) and disability after surgery (OR = 0.50; 95% CI 0.23, 1.06). The key limitations of this review were the small sample size, limited data for secondary outcomes and a lack of standardised method for measuring blood loss. TXA use reduces blood loss in meningioma surgery, but not transfusion requirement or postoperative complications. Larger trials are required to investigate the impact of TXA on patient-reported postoperative outcomes.

A comparative high-resolution physicochemical analysis of commercially available fibrin sealants: Impact of sealant osmolality on biological performance

Fibrin sealants are well-established components of the surgical toolbox, especially in procedures that harbor a high risk of perioperative bleeding. Their widespread use as hemostats, sealants or tissue-adhesives in various surgical settings has shown that the choice of the appropriate sealant system affects the clinical outcome. While many studies have compared the hemostatic efficiency of fibrin sealants to that of other natural or synthetic sealants, there is still limited data on how subtle differences in fibrin sealant formulations relate to their biological performance. Here, we performed an in-depth physicochemical and biological characterization of the two most commonly used fibrin sealants in the US and Europe: TISSEEL™ ("FS") and VISTASEAL™/VERASEAL™ ("FS+Osm"). Our chemical analyses demonstrated differences between the two sealants, with lower fibrinogen concentrations and supraphysiological osmolality in the FS+Osm formulation. Rheological testing revealed FS clots have greater clot stiffness, which strongly correlated with network density. Ultrastructural analysis by scanning electron microscopy revealed differences between FS and FS+Osm fibrin networks, the latter characterized by a largely amorphous hydrogel structure in contrast to the physiological fibrillar network of FS. Cytocompatibility experiments with human fibroblasts seeded on FS and FS+Osm fibrin networks, or cultured in presence of sealant extracts, revealed that FS+Osm induced apoptosis, which was not observed with FS. Although differential sealant osmolality and amounts of fibrinogen, as well as the presence of Factor XIII or additives such as antifibrinolytics, may explain the mechanical and structural differences observed between the two fibrin sealants, none of these substances are known to cause apoptosis at the respective concentrations in the sealant formulation. We thus conclude that hyper osmolality in the FS+Osm formulation is the primary trigger of apoptosis-a mechanism that should be evaluated in more detail, as it may affect the cellular wound healing response in situ.

Reducing Blood Loss in a Burn Care Unit: A Review of Its Key Determinants

Patients with a major burn injury differ considerably from the typical critical ill and trauma population. Very often, burn patients suffer from anemia throughout their hospital stay. This is caused both by combination of persistent blood loss with decreased erythropoiesis. Therefore, burn patients do have major transfusion requirements. However, transfusion is not devoid of risks or costs. We hereby review the best surgical techniques and medical approaches, aiming to reduce blood loss in a burn patient and optimize red cell production, so that we can reduce the need of RBC transfusion. The implementation of a combination of surgical techniques aiming to reduce blood loss and medical care approaches to prevent anemia, rather than single attitudes, should be adopted in burn care. There is an urgent need for clear guidelines that can easily be accepted, applied, and spread across different burn units to methodically implement measures to reduce blood loss and transfusion needs, and ultimately improve burn patients' outcome and the health care financial status.

A Multi-Task Convolutional Neural Network for Semantic Segmentation and Event Detection in Laparoscopic Surgery

The current study presents a multi-task end-to-end deep learning model for real-time blood accumulation detection and tools semantic segmentation from a laparoscopic surgery video. Intraoperative bleeding is one of the most problematic aspects of laparoscopic surgery. It is challenging to control and limits the visibility of the surgical site. Consequently, prompt treatment is required to avoid undesirable outcomes. This system exploits a shared backbone based on the encoder of the U-Net architecture and two separate branches to classify the blood accumulation event and output the segmentation map, respectively. Our main contribution is an efficient multi-task approach that achieved satisfactory results during the test on surgical videos, although trained with only RGB images and no other additional information. The proposed multi-tasking convolutional neural network did not employ any pre- or postprocessing step. It achieved a Dice Score equal to 81.89% for the semantic segmentation task and an accuracy of 90.63% for the event detection task. The results demonstrated that the concurrent tasks were properly combined since the common backbone extracted features proved beneficial for tool segmentation and event detection. Indeed, active bleeding usually happens when one of the instruments closes or interacts with anatomical tissues, and it decreases when the aspirator begins to remove the accumulated blood. Even if different aspects of the presented methodology could be improved, this work represents a preliminary attempt toward an end-to-end multi-task deep learning model for real-time video understanding.

Implementation of a patient blood management in an Italian City Hospital: is it effective in reducing the use of red blood cells?

To evaluate the effect of patient blood management (PBM) since its introduction, we analyzed the need for transfusion and the outcomes in patients undergoing abdominal surgery for different types of tumor pre- and post-PBM. Patients undergoing elective gastric, liver, pancreatic, and colorectal surgery between 2017 and 2020 were included. The implementation of the PBM program was completed on May 1, 2018. The patients were grouped as follows: those who underwent surgery before the implementation of the program (pre-PBM) versus after the implementation (post-PBM). A total of 1302 patients were included in the analysis (445 pre-PBM vs. 857 post-PBM). The number of transfused patients per year decreased significantly after the introduction of PBM. A strong tendency for a decreased incidence of transfusion was evident in gastric and pancreatic surgery and a similar decrease was statistically significant in liver surgery. With regard to gastric surgery, a single-unit transfusion scheme was used more frequently in the post-PBM group (7.7% vs. 55% after PBM; p = 0.049); this was similar in liver surgery (17.6% vs. 58.3% after PBM; p = 0.04). Within the subgroup of patients undergoing liver surgery, a significant reduction in the use of blood transfusion (20.5% vs. 6.7%; p = 0.002) and a decrease in the Hb trigger for transfusion (8.5, 8.2-9.5 vs. 8.2, 7.7-8.4 g/dl; p = 0.039) was reported after the PBM introduction. After the implementation of a PBM protocol, a significant reduction in the number of patients receiving blood transfusion was demonstrated, with a strong tendency to minimize the use of blood products for most types of oncologic surgery.

EFFECT OF IRRIGATION FLUID COMPOSITION ON HEMOSTASIS IN MOUSE BLEEDING MODELS

ABSTRACT

Introduction: Intraoperative irrigation, usually with normal saline (NS), aids in bleeding identification and management. We investigated the effect of different irrigation fluids, with additives, on hemostasis using two bleeding models. Methods: C57BL/6 J mice were subjected to a tail bleed model or uncontrolled abdominal hemorrhage via liver laceration followed by abdominal cavity irrigation. We compared NS, lactated Ringer's (LR), and PlasmaLyte. We examined NS and LR at different temperatures. Normal saline or LR with calcium (Ca 2+ ) or tranexamic acid (TXA) was studied. Results: Compared with room temperature (RT), increasing the temperature of the irrigation fluid to 37°C and 42°C reduced tail vein bleeding times substantially in both NS and LR (all P < 0.001), with no significant differences between the two fluids. At RT, LR, but not PlasmaLyte, substantially reduced bleeding times in comparison to NS ( P < 0.0001). Liver injury blood loss was lower with LR ( P < 0.01). Normal saline supplemented with 2.7 mEq/L of Ca 2+ decreased bleeding time and blood loss volume ( P < 0.001 and P < 0.01, respectively) to similar levels as LR. Normal saline with 150 mg/mL of TXA markedly reduced bleeding time ( P < 0.0001), and NS with 62.5 mg/mL TXA decreased blood loss ( P < 0.01). Conclusion: Whereas Ca 2+ - and TXA-supplemented NS reduced bleeding, LR remained superior to all irrigation fluid compositions. As LR contains Ca 2+ , and Ca 2+ -supplemented NS mirrored LR in response, Ca 2+ presence in the irrigation fluid seems key to improving solution's hemostatic ability. Because warming the fluids normalized the choice of agents, the data also suggest that Ca 2+ -containing fluids such as LR may be more suitable for hemostasis when used at RT.

Patient Blood Management in Vascular Surgery

Patient blood management (PBM) is an evidence-based, multidisciplinary approach aimed at appropriately allocating blood products to patients requiring transfusion while simultaneously minimizing inappropriate transfusions. The 3 pillars of patient blood management are optimizing erythropoiesis, minimizing blood loss, and optimizing physiological reserve of anemia. Benefits seen from PBM include limiting hospital costs and mitigating harm from numerous risks of transfusion.

Efficacy of electrocoagulation hemostasis: a study on the optimal usage of the very-low-voltage mode

BACKGROUND

The very-low-voltage (VLV) mode in electrosurgery can stably and deeply energize tissues even if the local electrical resistance changes with energization. Therefore, in electrosurgical hemostasis, the VLV mode is more reliable than other coagulation modes. In clinical practice, the appropriate use of combined saline drip and blood suction under the VLV mode can further enhance coagulation ability. However, the detailed mechanism is not known. The current study aimed to evaluate the association between electrosurgical activation time (ET) and hemostatic tissue effect (HTE) under the VLV mode. Further, the effect of saline drip and suction on power consumption and HTE was validated.

METHODS

Twelve female pigs weighing 35 kg were included in the experiment. A liver hemorrhage model was established via an open abdominal procedure, and hemostasis in the hemorrhagic lesion was attempted using the VLV mode under different conditions (ET: 3, 6, 9, and 12 s, with/without saline drip and/or continuous suction). Electrical data (such as voltage, current, and resistance) during coagulation were extracted. Then, the vertical/horizontal extent of HTE was assessed, and the hemostasis outcome (successful or failed) was recorded.

RESULTS

The vertical/horizontal HTE, power consumption, and integrated current value were positively correlated with the ET. The coagulation depth deepened with saline drip (p < 0.01). However, it was not affected by continuous suction (p = 0.20). The HTE area increased with saline drip (p < 0.01) and decreased with suction (p < 0.01). The power consumption and integrated current increased with saline drip (p < 0.01) and decreased with suction (p < 0.01). The success rate of hemostasis decreased with saline drip alone (31of 48 trials [success rate = 64.5%] in the saline drip group and 44/48 trials (success rate = 91.7%) in the control group). However, it improved with continuous suction (46/48 trials [success rate = 95.8%]).

CONCLUSION

The electrosurgical activation time was positively correlated with hemostatic tissue effect. Saline drip increased heat transfer efficiency but decreased the success rate of hemostasis. Therefore, the use of continuous suction in addition to saline drip increased hemostatic efficiency.

Gastro-intestinal emergency surgery: Evaluation of morbidity and mortality. Protocol of a prospective, multicenter study in Italy for evaluating the burden of abdominal emergency surgery in different age groups. (The GESEMM study)

Gastrointestinal emergencies (GE) are frequently encountered in emergency department (ED), and patients can present with wide-ranging symptoms. more than 3 million patients admitted to US hospitals each year for EGS diagnoses, more than the sum of all new cancer diagnoses. In addition to the complexity of the urgent surgical patient (often suffering from multiple co-morbidities), there is the unpredictability and the severity of the event. In the light of this, these patients need a rapid decision-making process that allows a correct diagnosis and an adequate and timely treatment. The primary endpoint of this Italian nationwide study is to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18. Secondary endpoints will be to evaluate to analyze the prognostic role of existing risk-scores to define the most suitable scoring system for gastro-intestinal surgical emergency. The primary outcomes are 30-day overall postoperative morbidity and mortality rates. Secondary outcomes are 30-day postoperative morbidity and mortality rates, stratified for each procedure or cause of intervention, length of hospital stay, admission and length of stay in ICU, and place of discharge (home or rehabilitation or care facility). In conclusion, to improve the level of care that should be reserved for these patients, we aim to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18, to analyze the prognostic role of existing risk-scores and to define new tools suitable for EGS. This process could ameliorate outcomes and avoid futile treatments. These results may potentially influence the survival of many high-risk EGS procedure.

Total Knee Arthroplasty: Superiority of Intra-Articular Tranexamic Acid Over Intravenous and Cell Salvage as Blood Sparing Strategy – A Retrospective Study

Purpose

Total knee arthroplasty is associated with considerable perioperative hemorrhage. The decrease in hemoglobin concentration and the need for allogenic blood transfusion are related to increased morbidity and mortality. Strategies for minimizing perioperative bleeding are used, such as tranexamic acid and cell salvage. The study aimed to compare intravenous, intra-articular tranexamic acid and cell salvage protocols regarding perioperative hemoglobin variation. Secondary outcomes included blood loss; allogenic transfusions; complications and in-hospital stay.

Patients and Methods

Patients submitted to unilateral total knee arthroplasty between January and December 2018 were retrospectively evaluated. After excluding 62 patients, 204 were subdivided into 3 groups according to the protocol used. Statistical analysis was performed with SPSS version 26.0. One-way ANOVA and Kruskal–Wallis tests were used. Considered a p-value of <0.05 for statistical significance.

Results

Variation of hemoglobin in the intra-articular tranexamic acid group was significantly lower than that of intravenous (p < 0.001) and cell salvage (p = 0.001) groups. Blood loss, variation of hematocrit, need for blood transfusion and in-hospital stay were also statistically significantly lower in the intra-articular tranexamic acid group. The only related complications were in the intravenous tranexamic acid group. No thromboembolic complications were identified which further solidifies the safety of tranexamic acid administration.

Conclusion

This data shows superiority of the intra-articular administration of tranexamic acid over the other techniques in total knee arthroplasty. We propose this protocol as an efficient, low-risk blood-sparing strategy.

“Bloodless” Major Pulmonary Resection in Two Jehovah’s Witnesses Patients with Non-Small Cell Lung Carcinoma

Background

Methods

Results

Conclusion

In vivo study for the hemostatic efficacy and foreign body reaction of a new powder-type polysaccharide hemostatic agent

Purpose

Various hemostatic agents have been introduced in therapy as postoperative bleeding is a poor prognostic factor for postoperative outcomes. These products can be divided into those that directly promote the hemostatic cascade and those that physically form a barrier by absorbing blood. The latter, powder-type hemostatic agents have the advantages of being inexpensive and more absorbable with less foreign body reactions (FBRs) and are applicable to a relatively wide area. This study was conducted to verify the safety and efficacy of a newly invented polysaccharide product (OOZFIX, Theracion Biomedical), which improves blood absorption and hemostatic effects.

Methods

Two separate animal experiments were performed. The first evaluated FBRs histologically at 3 days, 2 weeks, and 4 weeks, after implantation of OOZFIX in rats, and the second compared hemostatic performance of OOZFIX and Arista AH (Bard) in the porcine liver punch biopsy model.

Results

We found minimal FBRs in the 3-day group and no reactions in both the 2-week and 4-week groups after implantation of hemostatic agents. The time to hemostasis of OOZFIX was not significantly different from that of Arista AH (median [interquartile range]: 9 [6–10] minutes vs. 8 [6–10] minutes, respectively; P = 0.522). When comparing the serial bleeding grade tendency, there was no statistical difference between OOZFIX and Arista AH (P = 0.656).

Conclusion

OOZFIX caused a minimal FBR that disappeared within 2 weeks in vivo, and its hemostatic performance was comparable with that of an existing agent, Arista AH. Further clinical studies are required in the future.

Comparison of intra operative hemorrhage by blunt and sharp expansion of uterine incision at cesarean section

Objectives:

To compare the effect of blunt and sharp incision of uterus at cesarean section on intra-operative haemorrhage.

Methods:

This trial was conducted at the Department of Obstetrics and Gynaecology, Pakistan Ordinance Factory Hospital, Wah Cantt from 14^th January to 13^th July 2012. Total 80 women planned for lower segment cesarean section through Pfannensteil incision were randomized to either blunt uterine incision (Group-A, n=40) or sharp uterine incision (Group-B, n=40). The fall in Haemoglobin and HCT was compared in two groups and analyzed with help of SPSS version 10.

Results:

Both groups were similar in terms of demographic features like age, parity, gestational age and indication for cesarean section. The participants in Group-A reveled significantly less drop of mean Hb concentration as compared to Group-B (1.47±1.08 and 1.95±0.85 respectively, P value 0.031). Similarly, the fall in mean HCT was significantly less in Group-A in comparison to Group-B (3.21±1.3 and 4.21±2.17 respectively, P-value 0.015)

Conclusion:

Blunt expansion of uterine incision during caesarean section is associated with less fall in Haemoglobin and HCT as compared to sharp expansion.

Hemoglobin matters: Perioperative blood management for oncology patients

As the number of cancer cases rise each year in Canada, so does the number of surgical oncology cases. Surgery presents a unique and heightened stressor for the body already experiencing volatility from factors such as disease and treatments. Perioperative red blood cell (RBC) transfusions are critical to stabilize hemoglobin levels and correct anemia, as well as provide a buffer against anticipated intraoperative blood loss. Thoroughly examining and anticipating risk factors related to the potential need for perioperative blood transfusions is necessary to improve outcomes. Research evidence in recent years related to perioperative blood management of oncology patients has specifically recommended active, coordinated programs to reduce the need and amount of blood transfusions administered pre-, intra-, and post-surgery. Coordination between surgical oncologists and a local or provincial patient blood management (PBM) program is an important strategy that allows patients at risk of perioperative complications to be identified and receive early interventions and ongoing observation.

L’importance de l’hémoglobine : gestion périopératoire du sang pour les patients en oncologie

Au Canada, le nombre de cas de cancer augmente chaque année et, par conséquent, le nombre de patients en oncologie qui subissent une opération. La chirurgie cause un stress particulièrement intense à l’organisme déjà fragilisé par la maladie et les traitements. Les transfusions périopératoires de globules rouges sont essentielles pour stabiliser le taux d’hémoglobine et soigner l’anémie, ainsi que pour gérer la perte de sang attendue pendant l’opération. Il est nécessaire d’examiner en profondeur et d’anticiper les facteurs de risque associés aux transfusions sanguines périopératoires pour améliorer le devenir des patients. Ces dernières années, la recherche sur la gestion périopératoire du sang des patients en oncologie recommande tout spécialement la création de programmes d’intervention coordonnés pour réduire la nécessité et le nombre de transfusions sanguines administrées avant, pendant et après l’opération. Pour recenser les patients à risque de complications périopératoires et leur faire bénéficier d’interventions rapides et d’une observation continue, la bonne stratégie est de mettre en lien les chirurgiens oncologues avec un programme local ou provincial de conservation du sang.

Safety and Efficacy of Tranexamic Acid to Minimise Perioperative Bleeding in Hepatic Surgery: A Systematic Review and Meta-Analysis

INTRODUCTION

Perioperative bleeding poses a major risk during liver surgery, which can result in increased transfusion requirements, morbidity, and mortality. Tranexamic acid (TXA) effectively reduces perioperative bleeding and transfusion requirements in trauma patients. However, there remains a lack of evidence of its use in liver surgery. This meta-analysis of randomised controlled trials evaluated the efficacy and safety of TXA in liver resection and transplantation.

METHOD

A comprehensive search of Medline, Embase, CENTRAL and Clinicaltrials.gov databases was undertaken to identify studies from January 1947 to September 2021. The outcomes of the need for blood transfusion, thromboembolic events and mortality were extracted from the included studies. Quantitative pooling of data was based on the random effects model.

RESULTS

Six studies reporting on 429 patients were included. TXA reduced the need for perioperative blood transfusion in liver resection and transplantation (OR 0.09; 95% CI 0.01 to 0.72). More importantly, TXA did not increase the incidence of thromboembolic events (OR 2.22; 95% CI 0.47 to 10.43) and mortality (OR 0.60; 95% CI 0.13 to 2.76).

CONCLUSION

TXA safely reduces the need for blood transfusion in patients undergoing liver resection and transplantation.

Demonstration of a U.S. nationwide reduction in transfusion in general surgery and a review of published transfusion reduction methodologies

BACKGROUND

Red blood cell transfusions in surgical procedures can be lifesaving. However, recent studies show transfusions are associated with a dose-dependent increase in postoperative morbidity and mortality; hospitals and physicians have attempted to reduce them. We sought to determine the success of these efforts and review and summarize published reduction methods employed.

STUDY DESIGN/METHODS

An analysis of transfusion data from ACS-NSQIP public use files of general surgical procedures for 2012 and 2018; a retrospective review of the literature surrounding general surgical transfusion reduction from 2008 to 2018.

RESULTS

The rate of general surgical transfusion in the NSQIP dataset decreased from 5.5% in 2012 to 4.0% in 2018, a 27% relative reduction in transfusion. After extensive multivariable adjustment for patient risk and operative complexity, this effect remained (Odds ratio 0.65, 95% CI 0.63-0.67, p < .001). Furthermore, there was a positive correlation between specific procedure decreases in transfusion and decreases in 30-day morbidity (rho =0.41, p = .003) and mortality (rho = 0.37, p = .007). There were 866 published studies matching our search term "red blood cell transfusion reduction." Forty-four were relevant to general surgery. Seven dominant strategies for transfusion reduction by descending frequency of report included restrictive transfusion thresholds, management of preoperative anemia, perioperative interventions, educational programs, electronic clinical decision support, waste reduction, and audits of transfusion practices.

CONCLUSION

Our study demonstrates a 27% decrease in general surgery transfusion between 2012 and 2018 with associated reductions in morbidity and mortality, suggesting published employed strategies have been successful and safely implemented.

The role of intraoperative cell salvage for musculoskeletal sarcoma surgery

•

Musculoskeletal sarcoma surgery involving the lower limb is associated with significant intraoperative blood loss, with more than 500 ml in 96% of patients.

•

Salvaged blood was processed and re-infused in 94% of patients.

•

An estimated one-fourth of intraoperative blood loss was returned to the patient through (Intraoperative cell salvage) ICS.

•

Cytological analysis of imprints from leucodepletion filters(LDF) and reinfused blood did not reveal evidence of tumour cells.

Background

The efficacy and safety of cell salvage for musculoskeletal sarcoma surgery have not been reported, and concerns over re-infusion of tumour cells remain. This study aims to i) describe the intra-operative blood loss and cell salvage reinfusion volumes for lower limb sarcoma and pelvic sarcoma procedures ii) and explore whether there is evidence of tumour cells in reinfused blood.

Methods

Retrospective analysis of 109 consecutive surgical procedures for biopsy-proven sarcoma or bone metastasis performed between 1 July 2015 and 30 October 2019. Salvaged blood was processed and reinfused when intraoperative blood loss exceeded 500 ml. Primary bone tumour (n = 86(79%)) and metastasis (n = 23(21%) constituted the study group and surgeries were classified under hemipelvectomy (n = 43(39%)), lower limb endoprosthesis replacement (LLE) (n = 50(46%)) and wide excision surgery (WE) (n = 16(15%)). Microscopic examination of imprint cytology of leuco-depletion(LD) filters, and peripheral smear examination was performed for reinfused blood.

Results

Median (IQR) intra-operative blood loss was 1750 (600–3000) ml for hemipelvectomy, 850 (600–1200) ml for LLE, and 1000 (550–2000) ml for WE. Salvaged blood was re-infused in 102 of 109 (94%) patients. The mean (SD) volume of re-infusion was 445(4 2 5) ml for hemipelvectomy, 206(1 3 1) ml for LLE, and 184(1 0 6) ml for WE. In total, 64 of 109 (59%) patients received an allogeneic red blood transfusion within 72 h of surgery. Cytology analysis of imprints taken from the filtered blood available in 95(87%) patients and peripheral smear examination of reinfused blood available in 32(29%) patients did not reveal evidence of tumour cells on microscopic examination of any samples.

Conclusion

Our study demonstrates that musculoskeletal sarcoma surgery is associated with significant blood loss, and cell salvage permits reinfusion of autologous blood in most patients. The cytological analysis did not reveal evidence of tumour cells in reinfused blood, consistent with other studies where cell salvage is used for cancer surgery.

Models to predict the probability for intraoperative RBC transfusion during lumbar spinal stenosis and femoral fracture surgeries in aged patients

OBJECTIVE

The goal of this study was to predict the probability of transfusion of red blood cells and the volume of blood consumption based on the clinical characteristics of patients before surgery.

METHODS

The medical records of 565 patients over 65 years old who underwent posterior lumbar surgery and 586 patients over 65 years old receiving femoral fracture surgery were reviewed. The clinical characteristics of the patients were subjected to multivariate regression analysis. The scores of these factors' influences on intraoperative red blood cells infusion were based on the odds ratio of each multivariate risk factor. Non-linear regression was performed to predict the probability of intraoperative blood transfusion and the volume of blood used for patients with different scores.

RESULTS

The factors that significantly influenced blood use during lumbar spinal stenosis and femoral fracture surgery in aged patients(P < 0.05) included age, body mass index, abnormal coagulation function, preoperative hemoglobin, administration of antithrombotic drugs, multisegmental lesions of the lumbar spine, femoral shaft fracture, secondary lumbar surgery and the time from fracture to surgery exceeding 48 h. According to our risk scoring system, patients of posterior lumbar surgery scored 0-10 and patients of femoral fracture had a score of 0-12. More than 50 % of patients receiving an intraoperative red blood cells transfusion during surgery scored>1.

CONCLUSION

The scoring system can be used as a predictive model for the probability of red blood cells transfusion and the blood volume in aged patients undergoing lumbar spinal stenosis and femoral fracture surgeries.

Common haemostatic techniques used in surgical practice

Intraoperative bleeding can be difficult to manage and is associated with worse patient outcomes. Good intraoperative haemostasis by the surgeon is a key factor in ensuring a bloodless field and reducing intraoperative blood loss. There is a myriad of mechanical, thermal and energy-based techniques available to use, each of which has their own benefits and drawbacks. The decision of which to use will depend on patient and procedural factors as well as the surgeon's preference. This article reviews techniques commonly used in surgical practice to maintain intraoperative haemostasis.

Safety and efficacy of tranexamic acid in minimizing perioperative bleeding in extrahepatic abdominal surgery: meta-analysis

BACKGROUND

Perioperative bleeding is associated with increased morbidity and mortality in patients undergoing elective abdominal surgery. The antifibrinolytic agent tranexamic acid (TXA) has been shown to reduce perioperative bleeding and mortality risk in patients with traumatic injuries, but there is a lack of evidence for its use in elective abdominal and pelvic surgery. This meta-analysis of RCTs evaluated the effectiveness and safety of TXA in elective extrahepatic abdominopelvic surgery.

METHODS

PubMed, Embase, and ClinicalTrial.gov databases were searched to identify relevant RCTs from January 1947 to May 2020. The primary outcome, intraoperative blood loss, and secondary outcomes, need for perioperative blood transfusion, units of blood transfused, thromboembolic events, and mortality, were extracted from included studies. Quantitative pooling of data was based on a random-effects model.

RESULTS

Some 19 studies reporting on 2205 patients who underwent abdominal, pelvic, gynaecological or urological surgery were included. TXA reduced intraoperative blood loss (mean difference -188.35 (95 per cent c.i. -254.98 to -121.72) ml) and the need for perioperative blood transfusion (odds ratio (OR) 0.43, 95 per cent c.i. 0.28 to 0.65). TXA had no impact on the incidence of thromboembolic events (OR 0.49, 0.18 to 1.35). No adverse drug reactions or in-hospital deaths were reported.

CONCLUSION

TXA reduces intraoperative blood loss during elective extrahepatic abdominal and pelvic surgery without an increase in complications.

Short-Periods of Pre-Warming in Laparoscopic Surgery. A Non-Randomized Clinical Trial Evaluating Current Clinical Practice

Background: Pre-warming prevents perioperative hypothermia. We evaluated the current clinical practice of pre-warming and its effects on temperature drop and postoperative complications; Methods: This prospective, observational pilot study examines clinical practice in a tertiary hospital on 99 patients undergoing laparoscopic urological surgery. Pre-warming was performed in the pre-anesthesia room. Patients were classified into three groups: P 0 (non-prewarmed), P 5–15 (pre-warming 5–15 min) and P > 15 (pre-warming 15–30 min). Tympanic temperature was recorded in the pre-anesthesia room, prior to anesthesia induction, and in the PACU. Esophageal temperature was recorded intraoperatively. The occurrence of shivering, pain intensity, length of stay in PACU, and postoperative complications during hospital stay were also recorded; Results: After pre-warming, between-group difference in body temperature was higher in P > 15 than in P 0 (0.4 °C, 95% CI 0.14–0.69, p = 0.004). Between P 5–15 and P 0 difference was 0.2 °C (95% CI 0.04–0.55, p = 0.093). Temperature at the end of surgery was higher in pre-warmed groups [mean between-group difference 0.5 °C (95% CI 0.13–0.81, p = 0.007) for P 5–15; 0.9 °C (95% CI 0.55–1.19, p < 0.001) for P > 15]. Pain and shivering was less common in pre-warmed groups. Postoperative transfusions and surgical site infections were lower in P > 15; Conclusion: Short-term pre-warming prior to laparoscopic urological surgery decreased temperature perioperative drop and postoperative complications.

Transfusion in critical care: Past, present and future

Anaemia and coagulopathy are common in critically ill patients and are associated with poor outcomes, including increased risk of mortality, myocardial infarction, failure to be liberated from mechanical ventilation and poor physical recovery. Transfusion of blood and blood products remains the corner stone of anaemia and coagulopathy treatment in critical care. However, determining when the benefits of transfusion outweigh the risks of anaemia may be challenging in some critically ill patients. Therefore, the European Society of Intensive Care Medicine prioritised the development of a clinical practice guideline to address anaemia and coagulopathy in non-bleeding critically ill patients. The aims of this article are to: (1) review the evolution of transfusion practice in critical care and the direction for future developments in this important area of transfusion medicine and (2) to provide a brief synopsis of the guideline development process and recommendations in a format designed for busy clinicians and blood bank staff. These clinical practice guidelines provide recommendations to clinicians on how best to manage non-bleeding critically ill patients at the bedside. More research is needed on alternative transfusion targets, use of transfusions in special populations (e.g., acute neurological injury, acute coronary syndromes), use of anaemia prevention strategies and point-of-care interventions to guide transfusion strategies.