Anemia and Clinical Outcomes

Bilateral Sudden Hearing Loss in Iron Deficiency Anemia

The present study describes an unusual case of bilateral sudden hearing loss associated with iron deficiency anemia. Although hematologic disorders such as anemia or leukemia have been reported to be associated with sudden hearing loss, bilateral sudden hearing loss, which was presented as the first manifestation of iron deficiency anemia, has not been reported. A 74-year-old man presented with simultaneous bilateral sudden hearing loss without vertigo. A complete blood count test revealed a hemoglobin level of 6.4 g/dL and a ferritin level of 14.5 mg/mL, indicating iron deficiency anemia. Postcontrast 3D FLAIR MRI showed enhancement of the bilateral cochlea, vestibules, and lateral semicircular and posterior semicircular canals. After treatment, the patient's hearing loss partially improved.

Effects of topical tranexamic acid during open reduction and internal fixation of acetabular fractures: A retrospective study

Objective

The aim of this study was to assess the effect of topical tranexamic acid on blood loss and transfusion rates in acetabular fracture surgery.

Methods

The medical records of 61 patients who underwent open reduction and internal fixation for acetabular fracture between 2012 and 2015 were retrospectively reviewed. The patients were divided into two groups: Group I consisted of 31 patients (19 men and 12 women, mean age: 52 ± 19 years) who received intraoperatively a topical tranexamic acid solution of 3 g and Group 2 consisted of 30 control patients (17 men and 13 women, mean age: 48 ± 24 years) who received only 0.9% saline solution. The groups were compared based on their intraoperative blood loss, Postoperative drain output at 24 and 48 h, and postoperative hemoglobin levels, and transfusion rates.

Results

The mean intraoperative blood loss was 410 ± 100 ml in Group 1, compared to 570 ml ± 160 ml of the control group (p < 0.05). The postoperative drain output after 24 h was 210 ± 70 ml in Group 1 compared to 330 ± 90 ml of the control group (p < 0.05). The drain output at 48 h was (50 ± 20 ml) in group 1 compared to 90 ± 40 ml of the control group (p < 0.05). The transfusion rate was significantly low group 1 (42%) than the control group (97%). Hemoglobin drop was again significantly less in tranexamic acid group (2.1 ± 1.1) than the control group (3.2 ± 1.3). The nadir postoperative hemoglobin was higher in the Group 1 (10.4 ± 1.5) than the control group (9.2 ± 1.3).

Conclusion

Topical administration of tranexamic acid reduces intraoperative and postoperative blood loss in acetabular fracture surgery, decreasing transfusion rates.

Level of Evidence

Level III, Therapeutic Study.

Finding the Optimal Regimen for Oral Tranexamic Acid Administration in Primary Total Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Previous studies have confirmed that, compared with intravenous and intra-articular formulations, oral tranexamic acid (TXA) provides equivalent reduction in blood loss, at a substantially reduced cost and greater ease of administration. However, the optimal oral dosage regimen to achieve maximum blood-loss reduction remains unclear. The aim of this study was to assess the efficacy of a regimen of multiple doses of oral TXA on blood loss in primary total hip arthroplasty.

METHODS

In this randomized controlled trial, 200 patients were randomized to 1 of 4 interventions. Group A received a single dose of 2.0 g of TXA orally at 2 hours preoperatively. In addition to this same preoperative dose, Group B received 1.0 g of TXA orally at 3 hours postoperatively, Group C received 1.0 g of TXA orally at 3 and 9 hours postoperatively, and Group D received 1.0 g of TXA orally at 3, 9, and 15 hours postoperatively. All patients received a 1.0-g topical dose of TXA. The primary outcome was total blood loss. Secondary outcomes included hemoglobin reduction, transfusion rate, thromboembolic complications, and adverse events.

RESULTS

The mean total blood loss (and standard deviation) was significantly less in Groups B, C, and D (792.2 ± 293.0, 630.8 ± 229.9, and 553.0 ± 186.1 mL, respectively) than in Group A (983.6 ± 286.7 mL) (p < 0.001). Moreover, Groups C and D had a lower mean reduction in hemoglobin than did Groups A and B. However, no differences were identified between Groups C and D for blood loss and hemoglobin reduction. Additionally, no differences were observed among the groups regarding thromboembolic complications and transfusions.

CONCLUSIONS

The multiple postoperative doses of oral TXA further reduced blood loss compared with a single preoperative bolus. The regimen of a preoperative dose and 3 postoperative doses of oral TXA produced maximum effective reduction of blood loss in total hip arthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The Assessment of Blood Loss During Total Knee Arthroplasty When Comparing Intravenous vs Intracapsular Administration of Tranexamic Acid

BACKGROUND

Administration of tranexamic acid topically and intravenously has demonstrated effectiveness in decreasing blood loss and transfusion rates.

METHODS

We randomized 131 patients undergoing primary total knee arthroplasty to receive either intracapsular (69) or intravenous tranexamic acid (62). Postoperative blood loss was calculated using the formula derived by Nadler et al. The number of units transfused was recorded, as well as length of hospital stay.

RESULTS

We found no statistically significant difference on calculated blood loss (postoperative day [POD] 1: 624 ± 326 vs 644 ± 292; P = .71, POD 2: 806 ± 368 vs 835 ± 319; P = .64, and POD 3: 1076 ± 419 vs 978 ± 343; P = .55). There was no difference in number of blood transfusions, length of stay, or complications.

CONCLUSION

Intracapsular tranexamic acid is not inferior to intravenous tranexamic acid in decreasing blood loss and blood transfusion rate in primary total knee arthroplasty.

Does iron deficiency anemia affect olfactory function?

Conclusion This study found a negative effect of IDA on olfactory function. IDA leads to a reduction in olfactory function, and decreases in hemoglobin levels result in further reduction in olfactory function. Objective This study examined the effects of iron-deficiency anemia (IDA) on olfactory function. Method The study enrolled 50 IDA patients and 50 healthy subjects. Olfactory function was evaluated using the Sniffin' Sticks olfactory test. The diagnosis of IDA was made according to World Health Organization (WHO) criteria. Results Patients with IDA had a significantly lower threshold, discrimination, and identification (TDI) value, and a lower threshold compared with the control group. However, there were no significant differences between the groups in terms of smell selectivity values.

Comparing efficacy of three methods of tranexamic acid administration in reducing hemoglobin drop following total knee arthroplasty

The ideal method of providing tranexamic acid (TXA) for decreasing hemoglobin drop after TKA is still controversial. In this clinical trial, 200 patients were randomly allocated to four groups. In group 1,500 mg TXA was administered intravenously. In group 2, the joint irrigated with 3 g of TXA in 100 cc of saline. In group 3, 1.5 g of TXA was injected through the drain. Group 4 did not take TXA. Albeit all methods had a statistical effect on hemoglobin drop, drainage and number of transfused units when compared to controls, but intravenous injection of TXA seems to be much more effective in terms of reducing hemoglobin drop and transfused units; and what's more TXA injection by drain is more effective regarding to reducing postoperative drainage.

Topical tranexamic acid reduces blood loss and transfusion rates associated with primary total hip arthroplasty

BACKGROUND

Systemic tranexamic acid can decrease blood loss and rates of transfusion in patients undergoing total hip arthroplasty (THA). However, the efficacy of topical tranexamic acid in THA has only recently been characterized in a small number of studies.

QUESTIONS/PURPOSES

The purpose of this study was to compare (1) the greatest hemoglobin decrease after surgery; (2) transfusion rates; and (3) symptomatic thromboembolic events among patients undergoing THA who did and did not receive topical tranexamic acid.

METHODS

We retrospectively compared 135 patients (154 THAs) who received 10 mL 5% tranexamic acid added in a topical cocktail solution during surgery between January 2009 and July 2011 with 211 patients (234 THAs) who received only the topical cocktail solution (analgesic and antibiotic agent) between January 2005 and December 2008. Contraindications for the use of tranexamic acid included a documented history of a venous thromboembolic event, an allergy to tranexamic acid, thrombophilia, or a high risk of venous thromboembolism based on the guidelines of the American Academy of Orthopaedic Surgeons; the 135 patients who received it during that period represented 99.4% of the patients undergoing THA during that time. We compared changes in Hb, transfusion rates, estimated blood loss, surgical results, and complications between the groups. The transfusion threshold was the same, when the Hb values were < 10 g/dL. Patients were screened for thromboembolic disease if symptoms or signs appeared.

RESULTS

Hb decreased less in the tranexamic acid group (1.87 ± 1.10 g/dL) than in the control group (2.2 ± 1.36 g/dL; p = 0.01) on the first postoperative day. The frequency of transfusion was lower in patients receiving tranexamic acid (17% as compared with 35% in the control group; p < 0.001). There was only one nonfatal pulmonary embolism in the control group during the study period.

CONCLUSIONS

Use of topical tranexamic acid in patients undergoing THA reduces postoperative bleeding and decreases blood transfusion rates. No increase in major complications was identified in patients managed with topical tranexamic acid. This retrospective study confirms the results of a smaller randomized trial on the same topic by another group.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Association between ischemic stroke and iron-deficiency anemia: a population-based study

Background

Very little is known about the relationship between non-sickle cell anemia and stroke. The purpose of this study is to evaluate the association of iron-deficiency anemia (IDA) with stroke based on a nationwide coverage database in Taiwan.

Methods

The case-control study subjects were obtained from the Taiwanese Longitudinal Health Insurance Database 2000. We included 51,093 subjects with stroke as cases and randomly selected 153,279 controls (3 controls per case) in this study.Separate conditional logistic regression analyses were used to calculate the odds ratio (OR) for having been previously diagnosed with IDA between cases and controls.We further analyzed the association between stroke and IDA by stroke subtype.

Results

Results showed that 3,685 study subjects (1.81%) had been diagnosed with IDA prior to the index date; of those subjects, 1,268 (2.48%) were cases and 2,417 (1.58%) were controls (p<0.001). Conditional logistic regression shows that the OR of having previously received an IDA diagnosis among cases was 1.49 (95% CI: 1.39~1.60; p < 0.01) that of controls after adjusting for monthly income, geographic region, hypertension, diabetes, coronary heart disease, atrial fibrillation, heart failure, hyperlipidemia, tobacco use disorder, and alcohol abuse/alcohol dependency syndrome. Furthermore, the adjusted OR of prior IDA for cases with ischemic stroke was found to be 1.45 (95% CI: 1.34~1.58) compared to controls. However, we did not find any significant relationship between IDA and subarachnoid/intracerebral hemorrhage even adjusting for other confounding factors (OR=1.17, 95% CI=0.97~1.40).

Conclusion

There is a significant association between prior IDA and ischemic stroke.

Evaluation of effectiveness and analysis of goal-directed blood transfusion in peri-operation of major orthopedic surgery in elderly patients

Through the establishment of blood transfusion-effectiveness assessment criteria, we aimed to evaluate and analyze the effectiveness of peri-operative red blood cell transfusion for major orthopedics in elderly patients. Male and female patients (n=106) with American Society of Anesthesiologists (ASA) stage II-III, aged 60-80 years and scheduled for elective orthopedic surgery were randomly divided into 2 groups: group I (n=52), received the traditional method of red blood cell transfusion and group II (n=54) received hemoglobin (Hb) and hematocrit (Hct) goal-directed red blood cell (RBC) transfusion. We compared the changes in Hb, Hct, RBC, platelet (PLT), prothrombin time (PT), activated partial thromboplastin time (APTT), alveolar-arterial oxygen partial pressure [P(A-a)O(2)], oxygenation index (OI) and Vigileo monitoring indicators following RBC composition transfusion before and after surgery. We also monitored wound healing time, number of hospitalization days and intensive care unit (ICU) transfer rate. Blood transfusion-effectiveness assessment criteria were used to evaluate the efficacy and safety of Hb and Hct goal-directed RBC transfusion in orthopedic elderly patients. The two groups demonstrated an efficiency of 61.5 and 72.2%, respectively (P>0.05). The P(A-a)O(2) and OI in the two groups were not significantly different (P>0.05). Compared with the traditional RBC transfusion group, the Hb and Hct goal-directed RBC transfusion group presented increased RBC, Hb and Hct, as well as decreased PT and APTT and shorter wound healing time. The number of days of hospitalization and ICU transfer rate also decreased (P<0.05). The Hb and Hct goal-directed method for RBC transfusion was found to be more effective as a form of peri-operative RBC transfusion for major orthopedics in elderly patients.

Transfusion in the critically ill: does it affect outcome?

Anemia and red blood cell (RBC) transfusions are common in critically ill and injured, trauma, and surgical patients. Tolerance of anemia is highly variable, depending on the presence of cardiovascular and other comorbid diseases that may diminish the hemodynamic response to a lower hemoglobin (Hb) level. The quest to define a minimum threshold Hb concentration at which patients achieve significant benefit to improve outcome has not yet been identified. Complications related to RBC transfusion are related to RBC storage and intrinsic properties of donor allogeneic RBCs, including bacterial contamination, transfusion-related acute lung injury, and transfusion-related immunomodulation. The best evidence related to transfusion-related outcome involves titrating transfusion requirements to parameters of severity of illness rather than arbitrarily defined Hb levels.

Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial

BACKGROUND

Topical application of tranexamic acid to bleeding wound surfaces reduces blood loss in patients undergoing some major surgeries, without systemic complications. The objective of the present trial was to assess the efficacy and safety of the topical application of tranexamic acid on postoperative blood loss in patients undergoing primary unilateral total knee arthroplasty with cement.

METHODS

In a prospective, double-blind, placebo-controlled trial, 124 patients were randomized to receive 1.5 or 3.0 g of tranexamic acid in 100 mL of normal saline solution or an equivalent volume of placebo (normal saline solution) applied into the joint for five minutes at the end of surgery. The primary outcome was blood loss calculated from the difference between the preoperative hemoglobin level and the corresponding lowest postoperative value or hemoglobin level prior to transfusion. The safety outcomes included Doppler ultrasound in all patients and measurement of plasma levels of tranexamic acid one hour after release of the tourniquet.

RESULTS

Twenty-five patients were withdrawn for various reasons; therefore, ninety-nine patients were included in the intention-to-treat analysis. The postoperative blood loss was reduced in the 1.5 and 3-g tranexamic acid groups (1295 mL [95% confidence interval, 1167 to 1422 mL] and 1208 mL [95% confidence interval, 1078 to 1339 mL], respectively) in comparison with the placebo group (1610 mL [95% confidence interval, 1480 to 1738 mL]) (p < 0.017). The postoperative hemoglobin levels were higher in the 1.5 and 3.0-g tranexamic acid groups (10.0 g/dL [95% confidence interval, 9.5 to 10.4 g/dL] and 10.1 g/dL [95% confidence interval, 9.8 to 10.5 g/dL], respectively) in comparison with the placebo group (8.6 g/dL [95% confidence interval, 8.2 to 9 g/dL]) (p < 0.017). With the numbers studied, there was no difference in the rates of deep-vein thrombosis or pulmonary embolism between the three groups. Minimal systemic absorption of tranexamic acid was observed.

CONCLUSIONS

At the conclusion of a total knee arthroplasty with cement, topical application of tranexamic acid directly into the surgical wound reduced postoperative bleeding by 20% to 25%, or 300 to 400 mL, resulting in 16% to 17% higher postoperative hemoglobin levels compared with placebo, with no clinically important increase in complications being identified in the treatment groups.

Influence of early re-infusion of autologous shed mediastinal blood on clinical outcome after cardiac surgery

Various strategies have been proposed to decrease allogeneic blood transfusion requirements after cardiac surgery. The aim of the study was to evaluate the efficacy of collected and re-infused autologous shed mediastinal blood on a patient's postoperative course. Ninety patients who underwent heart surgery with cardiopulmonary bypass (CPB) were studied. The patients were divided into two groups: Group 1 (n=41) received the centrifuged autologous shed mediastinal blood collected from the cardiotomy reservoir 4 hours after surgery; in Group 2 (n=49) all shed mediastinal blood was discarded (control group). Haemoglobin (Hb), haematocrit (Hct), C-reactive protein values, and leucocyte count were compared before surgery, at 4 h and 20 h after surgery, and on the fifth postoperative day. We have measured serum procalcitonin (PCT) concentration at 4 h and 20 h after CPB. We assessed drained blood loss within 20 postoperative hours. Leucocyte count, Hb, Hct values, C-reactive protein, and procalcitonin concentration did not differ between the groups before and at 4 h after surgery. Hb, Hct level, and leucocyte count were similar at 20 hours and on the fifth day after surgery. At 20 hours after surgery, an increase of serum PCT concentration (>0.5-2 ng/mL) was more frequent in Group 2 (58.3% vs. 33.3%; p = 0.03). On the fifth postoperative day, C-reactive protein concentration was lower in Group 1 (71.74 +/- 15.23; p <0.01) compared to Group 2 (93.53 +/- 20.3). Postoperative blood loss did not differ between the groups. Requirement for allogeneic blood transfusion was significantly lower in Group 1 (14.6% vs. 38.8%; p < 0.02). Patients in Group 1 developed less infective complications compared with Group 2 (2.4% and 16.3%, respectively; p < 0.05). The length of postoperative in-hospital stay was shorter in Group 1 compared with Group 2 (9.32 +/- 2.55 and 16.45 +/- 6.5, respectively; p < 0.05). We conclude that postoperative re-infusion of autologous red blood cells processed from shed mediastinal blood did not increase bleeding tendency and systemic inflammatory response and was effective in reducing the requirement for allogeneic transfusion, the rate of infective complications and the length of postoperative in-hospital stay.

Red blood cell arginase suppresses Jurkat (T cell) proliferation by depleting arginine

BACKGROUND

Transfusion of packed red blood cells (PRBC) suppresses immunity, but the mechanisms are incompletely understood. PRBCs contain arginase, an enzyme which converts arginine to ornithine and depletes arginine in vitro. Arginine depletion suppresses proliferation of Jurkat T cells in other models. We hypothesize that PRBC arginase-mediated arginine depletion will suppress proliferation of T cells.

METHODS

A transfusion model was designed adding PRBC to culture RPMI media with or without an irreversible arginase blocker (nor-NOHA), incubating for 6-48 hours and then removing the PRBCs. Amino acid concentrations in the media were measured using liquid chromatography mass spectrometry. T cells were then added to the pre-conditioned media, cultured for 24 hours, and proliferation was measured.

RESULTS

PRBC depleted arginine significantly and increased ornithine in media compared to baseline PRBC treated wells and significantly decreased T cell proliferation. These effects were enhanced with volume of PRBC exposure. Nor-NOHA inhibition of arginase restored T cell proliferation in PRBC treated cultures.

CONCLUSIONS

Jurkat T cell proliferation was impaired by PRBC in clinically relevant volumes. The mechanism influencing T cell impairment appears to result from arginine depletion by arginase. Arginine depletion by PRBC arginase may be a novel mechanism for immunosuppression after transfusion.

Perioperative Anemia

Perioperative anemia is common and is associated with increased need for blood transfusion in the perioperative period. Perioperative anemia has also been linked to increased morbidity and mortality in surgical patients. Anemia may impede a patient's ability to recover fully and participate in postoperative rehabilitation. Pre-operative treatment of anemia is associated with a reduction in the need for blood transfusion in the perioperative period. Additional advances in surgical technology that reduce blood loss intraoperatively are associated with a reduction in postoperative anemia and should be used whenever possible. All strategies to prevent anemia in the perioperative period should be considered in an effort to minimize exposure of surgical patients to blood transfusion.