Perioperative management of the bleeding patient

Coagulant Protein-Free Blood Coagulation Using Catechol-Conjugated Adhesive Chitosan/Gelatin Double Layer

Since the discovery of polyphenolic underwater adhesion in marine mussels, researchers strive to emulate this natural phenomenon in the development of adhesive hemostatic materials. In this study, bio-inspired hemostatic materials that lead to pseudo-active blood coagulation, utilizing traditionally passive polymer matrices of chitosan and gelatin are developed. The two-layer configuration, consisting of a thin, blood-clotting catechol-conjugated chitosan (CHI-C) layer and a thick, barrier-functioning gelatin (Geln) ad-layer, maximizes hemostatic capability and usability. The unique combination of coagulant protein-free condition with CHI-C showcases not only coagulopathy-independent blood clotting properties (efficacy) but also exceptional clinical potential, meeting all necessary biocompatibility evaluation (safety) without inclusion of conventional coagulation triggering proteins such as thrombin or fibrinogen. As a result, the CHI-C/Geln is approved by the Ministry of Food and Drug Safety (MFDS, Republic of Korea) as a class II medical device. Hemostatic efficacy observed in multiple animal models further demonstrates the superiority of CHI-C/Geln sponges in achieving quick hemostasis compared to standard treatments. This study not only enriches the growing body of research on mussel-inspired materials but also emphasizes the potential of biomimicry in developing advanced medical materials, contributing a promising avenue toward development of readily accessible and affordable hemostatic materials.

Efficacy and safety of intravenous tranexamic acid in microscopic modified radical mastoidectomy: a study protocol for a prospective, randomised, double-blind controlled trial

INTRODUCTION

Radical mastoidectomy is a common procedure for chronic suppurative otitis media, typically performed under a microscope. The smooth operation is closely related to the clarity of the operative field. Our trial is designed to investigate whether the intravenous administration of tranexamic acid (TXA) can improve the clarity of the operative field, reduce the operative time, and increase surgeon satisfaction.

METHODS AND ANALYSIS

This study is a prospective, randomised, double-blinded, controlled trial that aims to investigate the effects of TXA on patients with otitis media. The trial will include patients between the ages of 18 and 65 who will be randomly assigned to either the TXA group or the control group. In the TXA group, patients will receive 1 g of TXA diluted to 20 mL of normal saline before anaesthesia induction while the control group will receive 20 mL of normal saline. The primary outcome measure will be the Modena Bleeding Score, which will assess the clarity of the surgical field. Secondary outcomes will include the surgeon's satisfaction with surgical conditions, operation time, laboratory measurements (prothrombin time, activated partial thromboplastin time, fibrin degradation products, D-dimer) and levels of inflammatory factors (such as IL-6) at 24 hours postoperatively. In addition, the incidence of general adverse reactions such as postoperative nausea, vomiting and dizziness; serious adverse events such as arterial and venous thromboembolism, myocardial infarction and epilepsy within 90 days will be compared between the two groups.

ETHICS AND DISSEMINATION

The protocol was approved by the Ethics Committee of Peking University People's Hospital (2021PHB173-001), on 19 July 2021. The trial results will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ChiCTR2100049183.

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.

TAVAC: comprehensive review of currently available hemostatic products as adjunct to surgical hemostasis

BACKGROUND

The use of hemostatic agents by general surgeons during abdominal operations is commonplace as an adjunctive measure to minimize risks of postoperative bleeding and its downstream complications. Proper selection of products can be hampered by marginal understanding of their pharmacokinetics and pharmacodynamics. While a variety of hemostatic agents are currently available on the market, the choice of those products is often confusing for surgeons. This paper aims to summarize and compare the available hemostatic products for each clinical indication and to ultimately better guide surgeons in the selection and proper use of hemostatic agents in daily clinical practice.

METHODS

We utilized PubMed electronic database and published product information from the respective pharmaceutical companies to collect information on the characteristics of the hemostatic products.

RESULTS

All commercially available hemostatic agents in the US are described with a description of their mechanism of action, indications, contraindications, circumstances in which they are best utilized, and expected results.

CONCLUSION

Hemostatic products come with many different types and specifications. They are valuable tools to serve as an adjunct to surgical hemostasis. Proper education and knowledge of their characteristics are important for the selection of the right agent and optimal utilization.

Noninvasive hemoglobin monitoring for maintaining hemoglobin concentration within the target range during major noncardiac surgery: A randomized controlled trial

STUDY OBJECTIVE

The effect of noninvasive CO-oximetry hemoglobin (SpHb) monitoring on the clinical outcomes of patients undergoing surgery remains unclear. This trial aimed to evaluate whether SpHb monitoring helps maintain hemoglobin levels within a predefined target range during major noncardiac surgeries with a potential risk of intraoperative hemorrhage.

DESIGN

A single-center, prospective, randomized controlled trial.

SETTING

University hospital.

PATIENTS

One hundred and thirty patients undergoing elective noncardiac surgery with a potential risk of hemorrhage.

INTERVENTIONS

Patients were randomly allocated to undergo either SpHb-guided management (SpHb group) or usual care (control group).

MEASUREMENTS

The primary outcome was the rate of deviation of the total hemoglobin concentration (determined from laboratory testing) from a pre-specified target range (8-14 g/dL). This was defined as the number of laboratory tests revealing such deviations divided by the total number of laboratory tests performed during the surgery.

MAIN RESULTS

The primary outcome occurred significantly less frequently in the SpHb group as compared to that in the control group (15/555 [2.7%]) vs. 68/598 [11.4%]; relative risk, 0.24; 95% confidence interval, 0.13-0.41; P < 0.001). Fewer point-of-care blood tests were performed in the SpHb group than in the control group (median [interquartile range], 2 [1-4] vs. 4 [2-5]; P < 0.001). There were no significant intergroup differences in the number of patients who received red blood cell transfusions during surgery (SpHb vs. control, 33.8% vs. 46.2%; P = 0.201). The incidence of unnecessary red blood cell preparation (>2 units) was lower in the SpHb group than in the control group (3.1% vs. 16.9%; P = 0.024).

CONCLUSIONS

Compared with routine care, SpHb-guided management resulted in significantly lower rates of hemoglobin deviation outside the target range intraoperatively in patients undergoing major noncardiac surgeries with a potential risk of hemorrhage.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (identifier: NCT03816514).

Examining Bleeding Risk, Transfusion-related Complications, and Strategies to Reduce Transfusions in Lung Transplantation

Blood product transfusions for bleeding management in lung transplantation affect recipient outcomes. Interventions are needed to reduce perioperative bleeding risk and optimize outcomes.

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.

Collagen-Based Medical Devices for Regenerative Medicine and Tissue Engineering

Assisted reproductive technologies are key to solving the problems of aging and organ defects. Collagen is compatible with living tissues and has many different chemical properties; it has great potential for use in reproductive medicine and the engineering of reproductive tissues. It is a natural substance that has been used a lot in science and medicine. Collagen is a substance that can be obtained from many different animals. It can be made naturally or created using scientific methods. Using pure collagen has some drawbacks regarding its physical and chemical characteristics. Because of this, when collagen is processed in various ways, it can better meet the specific needs as a material for repairing tissues. In simpler terms, collagen can be used to help regenerate bones, cartilage, and skin. It can also be used in cardiovascular repair and other areas. There are different ways to process collagen, such as cross-linking it, making it more structured, adding minerals to it, or using it as a carrier for other substances. All of these methods help advance the field of tissue engineering. This review summarizes and discusses the current progress of collagen-based materials for reproductive medicine.

Improving the Physical Properties of Starch-Based Powders for Potential Anti-Adhesion Applications

Postoperative adhesion is one of the most common complications that occur during and after surgery; thus, materials that can prevent adhesion are often applied. Starch powders with a high water absorption capacity are preferred, and many studies have focused on increasing the water absorption of modified starches, as native starch powders display poor water-holding capacities. The effects of salts on the physical properties of acetylated distarch phosphate potato starch powders were investigated here. Changes in functional groups, the crystal structures of modified starch, particle morphologies, water absorption, viscosity, and in vivo adhesion were investigated. The results showed that salts greatly improved the water absorption and viscosity of acetylated distarch phosphate potato starch powders. Among the three different salt-modified starch powders, NaCl-modified starch powders displayed higher water absorption and viscosity and demonstrated better in vivo anti-adhesion performance. The results of this study propose a potential biomaterial that may function as an anti-adhesive, potentially leading to reduced surgical risks and a better quality of life for patients.

Outcomes following perioperative red blood cell transfusion in patients undergoing elective major abdominal surgery: a systematic review and meta-analysis

BACKGROUND

Perioperative red blood cell transfusion is a double-edged sword for surgical patients. While transfusion of red cells can increase oxygen delivery by increasing haemoglobin levels, its impact on short- and long-term postoperative outcomes, particularly in patients undergoing elective major abdominal surgery, is unclear.

METHODS

We conducted a systematic review and meta-analysis on the effect of perioperative blood transfusions on postoperative outcomes in elective major abdominal surgery. PubMed, Cochrane, and Scopus databases were searched for studies with data collected between January 1, 2000 and June 6, 2020. The primary outcome was short-term mortality, including all-cause 30-day or in-hospital mortality. Secondary outcomes included long-term all-cause mortality, any morbidity, infectious complications, overall survival, and recurrence-free survival. No randomised controlled trials were found. Thirty-nine observational studies were identified, of which 37 were included in the meta-analysis.

RESULTS

Perioperative blood transfusion was associated with short-term all-cause mortality (odds ratio [OR] 2.72, 95% confidence interval [CI] 1.89-3.91, P<0.001), long-term all-cause mortality (hazard ratio 1.35, 95% CI 1.09-1.67, P=0.007), any morbidity (OR 2.18, 95% CI 1.81-2.64, P<0.001), and infectious complications (OR 1.90, 95% CI 1.60-2.26, P<0.001). Perioperative blood transfusion remained associated with short-term mortality in the sensitivity analysis after excluding studies that did not control for preoperative anaemia (OR 2.27, 95% CI 1.59-3.24, P<0.001).

CONCLUSIONS

Perioperative blood transfusion in patients undergoing elective major abdominal surgery is associated with poorer short- and long-term postoperative outcomes. This highlights the need to implement patient blood management strategies to manage and preserve the patient's own blood and reduce the need for red blood cell transfusion.

TRIAL REGISTRATION

PROSPERO (CRD42021254360).

Comparison of Postoperative Hemorrhage Risk After Partial Liver Transplantation Versus Whole Liver Transplantation: A Single-Center Experience

BACKGROUND

We aimed to identify risk factors associated with reoperation for postoperative intraperitoneal hemorrhage (PIH) after orthotopic liver transplantation and investigate if partial liver transplantation (PLT) increases the risk of PIH.

METHODS

We retrospectively analyzed the medical records of 304 consecutive recipients who underwent orthotopic liver transplantation at the Affiliated Lihuili Hospital, Ningbo University, from January 2016 to July 2022. Data were compared between recipients who experienced PIH requiring reoperation and those who did not. Subgroup propensity score matching analysis was performed to assess the impact of PLT on PIH risk. Neither prisoners nor participants who were coerced or paid were used in the study.

RESULTS

Among the 304 recipients, 22 (7.2%) underwent reoperation for PIH. Multivariate analysis revealed that the recipient Model for End-Stage Liver Disease (MELD) score (odds ratio = 1.066, 95% CI [1.025-1.109], P = .001) and volume of intraoperative packed red blood cell transfusion (odds ratio = 1.089, 95% CI [1.032-1.481], P = .002) were independent risk factors for PIH. No significant differences were observed in the risk of PIH between PLT and whole liver transplantation.

CONCLUSION

Preoperative MELD score and intraoperative packed red blood cell transfusion should be carefully considered to manage the risk of PIH in liver transplantation recipients. Partial liver transplantation, a crucial approach for addressing donor shortages, does not increase the risk of reoperation for PIH in recipients.

Comparison of a gelatin thrombin versus a modified absorbable polymer as a unique treatment for severe hepatic hemorrhage in swine

There are many surgical techniques (packing, Pringle maneuver, etc.) and hemostatic agents to manage hepatic bleeding in trauma surgery. This study compares the effectiveness of two different types of hemostatic agents, one is an active flowable hemostat and the other is a passive hemostat made of modified absorbable polymers [MAP]. Both surgical technique and hemostatic agents can be used together as a means of controlling bleeding. We have hypothesized that a single hemostatic agent might be as effective as a unique hemostatic surgical technique. Twenty swine were prospectively randomized to receive either active Flowable (Floseal) or passive MAP powder (PerClot) hemostatic agents. We used a novel severe liver injury model that caused exsanguinating hemorrhage. The main outcome measure was total blood loss volume. The total volume of blood loss, from hepatic injury to minute 120, was significantly lower in the Flowable group (407.5 cm3; IqR: 195.0-805.0 cm3) compared to MAP group (1107.5 cm3; IqR: 822.5 to 1544.5 cm3) (Hodges-Lehmann median difference: - 645.0 cm3; 95% CI: - 1144.0 to - 280.0 cm3; p = 0.0087). The rate of blood loss was significantly lower in the flowable group compared with the MAP group as measured from time of injury to minutes 3, 9, 12, and 120 (except for 6 min). The mean arterial pressure gradually recovered in the flowable group by 24 h, whereas in the MAP group, the mean arterial pressure was consistently stayed below baseline values. Kaplan-Meier survival analysis indicated similar rates of death between study groups (Logrank test p = 0.3395). Both the flowable and the MAP hemostatic agents were able to effectively control surgical bleeding in a novel severe liver injury model, however, the flowable gelatin-thrombin agent provided quicker and better bleed control.

Red Blood Cell Transfusion Guided by Hemoglobin Only or Integrating Perfusion Markers in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis With Trial Sequential Analysis

OBJECTIVE

Strategies for red blood cell (RBC) transfusion in patients undergoing cardiac surgery have been traditionally anchored to hemoglobin (Hb) targets. A more physiologic approach would consider markers of organ hypoperfusion.

DESIGN

The authors conducted a systematic review and meta-analysis with trial sequential analysis of randomized controlled trials (RCTs).

SETTING

Cardiac surgery.

PARTICIPANTS

Adult patients.

INTERVENTION

RBC transfusion targeting only Hb levels compared with strategies combining Hb values with markers of organ hypoperfusion.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were the number of RBC units transfused, the number of patients transfused at least once, and the average number of transfusions. Secondary outcomes were postoperative complications, intensive care (ICU) and hospital lengths of stay, and mortality. Only 2 RCTs were included (n = 257 patients), and both used central venous oxygen saturation (ScvO2) as a marker of organ hypoperfusion (cut-off: <70% or ≤65%). A transfusion protocol combining Hb and ScvO2 reduced the overall number of RBC units transfused (risk ratio [RR]: 1.57 [1.33-1.85]; p < 0.0001, I2 = 0%), and the number of patients transfused at least once (RR: 1.33 [1.16-1.53]; p < 0.0001, I2 = 41%), but not the average number of transfusions (mean difference [MD]: 0.18 [-0.11 to 0.47]; p = 0.24, I2 = 66%), with moderate certainty of evidence. Mortality (RR: 1.29, [0.29-5.77]; p = 0.73, I2 = 0%), ICU length-of-stay (MD: -0.06 [-0.58 to 0.46]; p = 0.81, I2 = 0%), hospital length-of-stay (MD: -0.05 [-1.49 to 1.39];p = 0.95, I2 = 0%), and all postoperative complications were not affected.

CONCLUSIONS

In adult patients undergoing cardiac surgery, a restrictive protocol integrating Hb values with a marker of organ hypoperfusion (ScvO2) reduces the number of RBC units transfused and the number of patients transfused at least once without apparent signals of harm. These findings were preliminary and warrant further multicentric research.

Comparative study of carbazochrome sodium sulfonate and tranexamic acid in reducing blood loss and inflammatory response following direct anterior total hip arthroplasty: a prospective randomized controlled trial

PURPOSE

Carbazochrome sodium sulfonate (CSS) is a haemostatic agent. However, its hemostatic and anti-inflammatory effects in patients undergoing total hip arthroplasty (THA) via a direct anterior approach (DAA) are unknown. We investigated the efficacy and safety of CSS combined with tranexamic acid (TXA) in THA using DAA.

METHODS

This study enrolled 100 patients who underwent primary, unilateral THA through a direct anterior approach. Patients were randomly divided into two groups: Group A used a combination of TXA and CSS, while Group B used TXA only. The primary outcome was total perioperative blood loss. The secondary outcomes were hidden blood loss, postoperative blood transfusion rate, inflammatory reactant levels, hip function, pain score, venous thromboembolism (VTE), and incidence of associated adverse reactions.

RESULTS

The total blood loss (TBL) in group A was significantly lower than in group B. The levels of inflammatory reactants and the rate of blood transfusion were also significantly lower. However, the two groups had no significant differences in intraoperative blood loss, postoperative pain score, or joint function. There were no significant differences in VTE or postoperative complications between the groups.

CONCLUSION

As a haemostatic agent, CSS combined with TXA can reduce postoperative blood loss in patients undergoing THA via DAA and seems to have an anti-inflammatory effect. Moreover, it did not increase the incidence of VTE or its related complications.

Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects

One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.

Hemoadhican, a Tissue Adhesion Hemostatic Material Independent of Blood Coagulation

Uncontrolled hemorrhage is a leading cause of death, emphasizing the need for novel hemostatic agents. Here, a novel hemostatic polysaccharide hemoadhican (HD) is screened out by analyzing the rheological properties of screened material mixed blood sludges, which is prepared by mixing polysaccharide granules and whole blood to mimic the coagulation in vitro. HD is produced by a bacterial isolate Paenibacillus sp.1229, and the repeating units of HD are →)-α-L-Rhap-(1→3)-β-D-Glcp-(1→4)[4,6-ethylidene-α-D-Galp-(1→4)-α-D-Glcp-(1→3)]-α-D-Manp-(1→. Compared to chitosan and celox, HD achieves more effective hemostasis in animal models with mouse and rat femoral arteries, rat carotid arteries, and rabbit femoral arteries. Especially, HD maintains an excellent hemostatic capability in animals with heparin-induced hemorrhage diathesis. In vitro experiments show HD granules can quickly absorb a small amount of blood component to create a hemophobic blood sludge resistant to high pressure. The blood sludge firmly adheres to damaged tissue and efficiently repels blood. In vitro experiments show that HD does not actively trigger blood coagulation cascade and is independent of blood conditions including heparin treatment. In addition, HD moisturizes wounds and accelerates wound healing, exhibiting excellent biodegradability, and hemocompatibility. The results indicate that HD is a promising hemostatic material for treating traumatic hemorrhages and uncontrollable surgical bleeding.

Prospective Study of Flap Surgery-Related Complications in Cutaneous Tumors: A Tertiary Care Institutional Experience of 6 Years

Introduction

Flap surgeries are the standard choice for reconstruction of defects post excision of cutaneous tumours. Complications following these surgeries predominantly result as a consequence of bleeding, tension, ischemia, infection.

Study Design

A Prospective study of patients treated for tumor excision and flap reconstruction between the period of 2014 and 2020 were followed up and complications encountered were analysed.

Results

A total of 70 patients with cutaneous malignancies underwent flap surgeries. Complications encountered were bleeding, hematoma, infection, necrosis, pincushioning, keloid, hypertrophic scars.

Conclusion

Successful outcome depends on pre operative evaluation, appropriate technique selection based on site of tumor, intraoperative care, post operative care and timely management of complications if any.

Pathophysiological Changes in the Hemostatic System and Antithrombotic Management in Kidney Transplant Recipients

Nowadays, the main cause for early graft loss is renal graft thrombosis because kidney transplant outcomes have improved drastically owing to advances in immunological techniques and immunosuppression. However, data regarding the efficacy of antithrombotic therapy in the prevention of renal graft thrombosis are scarce. Adequate antithrombotic management requires a good understanding of the pathophysiological changes in the hemostatic system in patients with end-stage kidney disease (ESKD). Specifically, ESKD and dialysis disrupt the fine balance between pro- and anticoagulation in the body, and further changes in the hemostatic system occur during kidney transplantation. Consequently, kidney transplant recipients paradoxically are at risk for both thrombosis and bleeding. This overview focuses on the pathophysiological changes in hemostasis in ESKD and kidney transplantation and provides a comprehensive summary of the current evidence for antithrombotic management in (adult) kidney transplant recipients.

An autologous blood-derived patch as a hemostatic agent: evidence from thromboelastography experiments and a porcine liver punch biopsy model

Perioperative bleeding is a common complication in surgeries that increases morbidity, risk of mortality, and leads to increased socioeconomic costs. In this study we investigated a blood-derived autologous combined leukocyte, platelet, and fibrin patch as a new means of activating coagulation and maintaining hemostasis in a surgical setting. We evaluated the effects of an extract derived from the patch on the clotting of human blood in vitro, using thromboelastography (TEG). The autologous blood-derived patch activated hemostasis, seen as a reduced mean activation time compared to both non-activated controls, kaolin-activated samples, and fibrinogen/thrombin-patch-activated samples. The accelerated clotting was reproducible and did not compromise the quality or stability of the resulting blood clot. We also evaluated the patch in vivo in a porcine liver punch biopsy model. In this surgical model we saw 100% effective hemostasis and a significant reduction of the time-to-hemostasis, when compared to controls. These results were comparable to the hemostatic properties of a commercially available, xenogeneic fibrinogen/thrombin patch. Our findings suggest clinical potential for the autologous blood-derived patch as a hemostatic agent.

Patient Blood Management in Transurethral Resection Surgery: Overview and Strategy Analysis from a French Tertiary Hospital

INTRODUCTION

Since Patient blood management (PBM) suggests a bundle of measures aiming to reduce perioperative blood transfusion because preoperative anemia and blood transfusion are associated with poor postoperative outcomes. There is a lack of data on the effect of PBM in patients undergoing transurethral resection of prostate (TURP) or bladder tumor (TURBT). We aimed to assess the bleeding risk in TURP and TURBT procedures and the effect of preoperative anemia on postoperative morbimortality.

METHODS

A single-center retrospective observational cohort study was conducted in a tertiary hospital in Marseille, France. All patients undergoing TURP or TURBT were included in 2020 and divided into two groups: preoperative anemia (n = 19) and no preoperative anemia (n = 59). We recorded demographic characteristics, preoperative hemoglobin concentration, iron deficiency markers, preoperative initiation of a treatment for anemia, perioperative bleeding, and postoperative outcomes up to 30 days including blood transfusion, hospital readmission, reintervention, infection, and mortality.

RESULTS

Baseline characteristics were comparable between groups. No patient had iron deficiency markers and no prescription of iron was initiated before surgery. No major bleeding was reported during surgery. Postoperative anemia was found in 21 patients, including 16 (76%) in the preoperative anemia group and 5 (24%) in the non-preoperative anemia group. One patient of each group received a blood transfusion after surgery. No significant differences in 30-day outcomes were reported.

CONCLUSION

Our study suggests that TURP and TURBT are not associated with a high-risk of postoperative bleeding. In such procedures, adherence PBM strategies do not seem beneficial. Since recent guidelines recommend restricting preoperative testing, our results may help to improve preoperative risk stratification.

Validation of the IMPROVE bleeding risk assessment model in surgical patients: Results from the DissolVE-2 Study

INTRODUCTION

IMPROVE Bleeding Risk Score (BRS) is known to be validated and widely accepted in medical patients. However, its relevance in surgical patients has so far not been explored. External validation of the IMPROVE BRS on bleeding in surgical patients can hopefully improve clinical practice (for surgical patients).

METHODS

Data from 6986 surgical patients were collected from the DissolVE-2 cohort. The Kaplan-Meier method was used to assess the incidences of major bleeding and any bleeding among surgical patients within 14 days of admission. A cut-off value of BRS ≥7 indicated a higher risk of bleeding. Risk factors associated with major and any bleeding were analysed by the Cox regression method. Model discrimination was evaluated by area under the receiver operator characteristic curves (AUC). Calibration curves and Hosmer-Lemeshow χ² statistics were used to measure the difference between predicted and observed bleeding risks.

RESULTS

A total of 6399 surgical patients were included in the final validation cohort. The cumulative incidence rate of any bleeding was 3.9 % (95 % confidence interval [CI], 3.4-4.5), of which the incidence rate of major bleeding was 1.2 % (95 % CI, 0.9-1.6). Among patients with a BRS of ≥7, 16.3 % reported any bleeding, and 26.3 % reported major bleeding. The IMPROVE BRS had a better discriminative power (AUC = 0.69) and excellent goodness of fit (Hosmer-Lemeshow test, P = 0.208) for the prediction of major bleeding events as compared with any bleeding (AUC = 0.55; Hosmer-Lemeshow test, P = 0.004). The calibration plot suggested a more accurate prediction for major bleeding events. Moreover, the IMPROVE BRS had a higher AUC value of 0.83 and better goodness of fit (P = 0.2616) for major bleeding in patients undergoing abdominal surgery than other surgery types.

CONCLUSION

The IMPROVE BRS is a simple and practical technique that can help in predicting the risk of major bleeding in surgical patients, improving functional and safety outcomes of hospitalized patients with surgery.

Pathological Background and Clinical Procedures in Oral Surgery Haemostasis Disorders: A Narrative Review

Haemostasis disorders are serious pathologies that could put dental and surgical procedures at risk as they are associated with postoperative bleeding, which in some circumstances could be prolonged and dangerous for the patient. In-depth knowledge of the problems associated with coagulation pathologies and the suitable specific procedures should be implemented in dental practice. A good awareness of the clinical protocols to be used in these circumstances may help reduce operator stress and increase patient compliance. Collaboration with the haematologist is always recommended to establish an adequate treatment plan, both regarding the administration of therapies that promote haemostasis and for assessing the operative risk. Hereby, we summarize the congenital and hereditary pathologies that lead to haemostasis disorders, which can be found in patients undergoing dental procedures. The purpose of this narrative review is to frame the diseases from a clinical, anamnestic, and etiopathological standpoint, as well as to evaluate an operative approach to the pathology under consideration, with particular attention to anaesthesia manoeuvres and post-surgical haemostasis, to avoid hematoma formation and uncontrolled bleeding which can lead procedure failure up and even death. Of note, it is likewise important to educate the patient about prevention, to keep the oral cavity healthy and avoid invasive procedures, limiting the number of operative sessions.

Intraoperative blood product transfusion in pediatric cardiac surgery patients: A retrospective review of adverse outcomes

BACKGROUND

Resuscitation with blood products is often required for pediatric cardiac surgery patients following cardiopulmonary bypass. However, data suggest that blood product transfusion is an independent predictor of adverse outcomes. Most studies have specifically found detrimental effects of overall transfusion of red blood cells in particular, but few have analyzed outcomes by the other specific blood product components.

AIMS

The objective of this study is to analyze adverse outcomes associated with intraoperative transfusion of specific blood product components.

METHODS

A retrospective review was performed on 643 pediatric patients who underwent cardiac surgery requiring cardiopulmonary bypass to evaluate the risk of selected adverse outcomes associated with intraoperative blood product transfusion. Adverse outcomes included thrombotic complications, stroke, acute kidney injury, prolonged mechanical ventilation, and death. Univariate logistic and linear regression analyses were performed to explore the association between various blood products and the occurrence of postoperative complications. Multiple logistic and linear regression analyses were performed adjusting for age, cyanotic status, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Score (STAT score), and cardiopulmonary bypass time.

RESULTS

Unadjusted analysis using univariate logistic and linear regressions showed statistically significant associations of almost all blood components (per 10 mL/kg dose increments) with multiple postoperative complications, including mortality, thrombotic complications, stroke, and days of mechanical ventilation. After adjusting for patient age, cyanotic status, STAT score, and cardiopulmonary bypass time, multivariable logistic and linear regression analyses revealed no association between transfusion of blood products with acute kidney injury and stroke. Administration of red blood cells was the only category significantly correlated with increased days of mechanical ventilation (0.5 days increase in mechanical ventilation per 10 mL/kg transfusion of red blood cells). The only blood product to show complete lack of a statistically significant association with any of the studied outcomes was cryoprecipitate.

CONCLUSIONS

Transfusion of blood products following cardiopulmonary bypass is associated with postoperative adverse outcomes. Future studies aimed at strategies to reduce intraoperative bleeding and decrease the amount of blood products administered are warranted.

Effect of spinal fusion on degenerative scoliosis in elderly patients and analysis of influencing factors

OBJECTIVE

To analyze the factors influencing efficacy of spinal fusion for the improvement of degenerative scoliosis in elderly patients.

METHODS

Retrospective analysis of clinical data was conducted on 194 elderly patients with degenerative scoliosis treated with minimally invasive lumbar lateral fusion at Affiliated Hospital of Hebei University on February 2018 to February 2021. The patients were divided into a recovered group (n = 138) and an uncured group (n = 56) according to their recovery. The basic information of patients, preoperative complications, preoperative and postoperative imaging results, clinical function scores, postoperative complications, and other relevant information were collected. Logistic regression analysis was used to analyze the factors affecting outcome. Receiver operating characteristic curves were used to determine the predictive value of factors influencing prognosis.

RESULTS

Univariate analysis showed that, compared to the uncured group, the recovered group showed younger age, shorter duration of symptoms and length of hospital stay, less history of hypertension or diabetes, and lower Oswestry disability index (ODI), and Japanese Orthopedic Association scores (P<0.05). Multivariate retrospective analysis revealed that age, duration of symptoms, length of hospital stay, history of hypertension and pretreatment ODI score were independent risk factors affecting treatment efficacy (P<0.05). The area under the curve of the risk model for predicting efficacy was 0.951.

CONCLUSION

Age, duration of symptoms, length of hospital stay, history of hypertension, and pretreatment ODI score are risk factors affecting the treatment outcome of elderly patients with degenerative scoliosis, so these preoperative indications may be indicators to predict efficacy.

Myocardial infarction after craniotomy for asymptomatic meningioma

A man in his 40s with a history of coronary artery disease previously treated with a drug-eluting stent presented for elective craniotomy and resection of an asymptomatic but enlarging meningioma. During his craniotomy, he received desmopressin and tranexamic acid for surgical bleeding. Postoperatively, the patient developed chest pain and was found to have an ST-elevation myocardial infarction (MI). Because of the patient's recent neurosurgery, standard post-MI care was contraindicated and he was instead managed symptomatically in the intensive care unit. Echocardiogram on postoperative day 1 demonstrated no regional wall motion abnormalities and an ejection fraction of 60%. His presentation was consistent with thrombosis of his diagonal stent. He was transferred out of the intensive care unit on postoperative day 1 and discharged home on postoperative day 3.

Effects and Safety of Traditional Chinese Medicine for Hidden Blood Loss after Total Hip Arthroplasty—A Systematic Review and Meta-Analysis

Background

Hidden blood loss (HBL) after total hip arthroplasty (THA) would lead to many undesirable consequences. Traditional Chinese medicine (TCM) is now increasingly used for hidden blood loss. We performed this systematic review and meta-analysis to summarize the effect and safety of TCM treatment of HBL after THA.

Methods

We searched PubMed, Embase, Cochrane Library, CNKI, VIP, WanFang, and CBM for the updated articles published from the inception of each database to May, 2022, among which results such as abstracts, comments, letters, reviews, and case reports were excluded. The efficacy and safety of TCM treatment of HBL after THA were synthesized and discussed by the outcomes of total blood loss (TBL), hidden blood loss (HBL), hemoglobin (Hb), and hematocrit (HCT), and the incidence of adverse reactions.

Results

A total of 12 articles and 881 patients were included. There were 441 cases in the intervention group and 440 cases in the control group. Compared with the control group, the intervention group had more advantages in TBL (MD = −251.68, 95% CI = [−378.36, −125]; Z = 3.89, P < 0.00001), HBL (MD = −159.64, 95% CI = [−252.56, −66.71]; Z = 3.37, P=0.0008), Hb (MD = 11.39, 95% CI = [7.35, 15.43]; Z = 5.53, P < 0.00001), and HCT (MD = 2.87, 95% CI = [0.97, 4.78]; Z = 2.95, P=0.003), and had less incidence of adverse reactions (OR = −0.20, 95% CI = [−0.35, −0.05]; Z = 2.64, P=0.008).

Conclusion

TCM has advantages in the efficacy and safety of treating hidden blood loss after THA. The strength of the evidence of the research results is limited by the quality of the included literature, and more high-quality RCTs are needed to confirm.

Applicability and reproducibility of the validated intraoperative bleeding severity scale (VIBe scale) in liver surgery: A multicenter study

BACKGROUND

Bleeding is an intraoperative and postoperative complication of liver surgery of concern, and yet evidence to support utility and reproducibility of bleeding scales for liver surgery is limited. We determined the reproducibility of the clinician-reported validated intraoperative bleeding severity scale and its clinical value of implementation in liver surgery.

METHODS

In this descriptive and observational multicenter study, we assessed the performance of liver surgeons instructed on the clinician-reported intraoperative bleeding severity scale using training videos that covered all 5 grades of bleeding severity. Surgeons were stratified according to years of surgical experience and number of surgeries performed per year based on a median split in low and high values. Intraobserver and interobserver agreement was assessed using Kendall's coefficient of concordance (Kendall's W).

RESULTS

Forty-seven surgeons from 10 hospitals in Spain participated in the study. The overall intraobserver concordance was 0.985, and the overall interobserver concordance was 0.929. For "high experience" surgeons, the intraobserver and interobserver agreement values were 0.990 and 0.941, respectively. For "low experience" surgeons, the intraobserver and interobserver agreement was 0.981 and 0.922, respectively. Regarding the annual number of surgeries, intraobserver and interobserver agreement values were 0.995 and 0.940, respectively, for surgeons performing >35 surgeries per year, with 0.979 and 0.923, respectively, for surgeons who perform ≤35 surgeries year.

CONCLUSION

The clinician-reported intraoperative bleeding severity scale shows high interobserver and intraobserver concordance, suggesting it is a useful tool for assessing severity of bleeding during liver surgery; years of surgical experience and number of annual procedures performed did not affect the applicability of the clinician-reported intraoperative bleeding severity scale.

Exploring Adverse Events and Utilization of Topical Hemostatic Agents in Surgery

Background and Objectives:

This retrospective study provides preliminary qualitative assessment of the adverse events (AEs), focusing on pelvic and abdominal AEs and patient outcomes reported for three hemostatic agents used in gynecologic surgery.

Methods:

Utilization rates for oxidized regenerated cellulose powder (ORC), polysaccharide powder (PSP), and fibrin sealant solution (FSS) were obtained from hospitals via the Premier Healthcare databases for all surgical procedures from January 1, 2018 to September 30, 2020. All reported cases were extracted from the Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database for ORC and PSP and from the FDA Adverse Event Reporting System (FAERS) database for FSS. Distributions of AEs by anatomical site (MAUDE/FAERS) and surgical procedures by specialty (Premier) were evaluated for each product. Number of cases and number and types of AEs were compared to the total utilization for each product.

Results:

PSP was the most used product during the period analyzed (n = 126,509 uses), followed by FSS (n = 80,628 uses), and ORC (n = 41,583 uses). Distribution of surgical procedures by anatomical site varied significantly between hemostatic agents (p < 0.001). ORC was associated with more patient cases with AEs and numbers of reported AEs compared with PSP and FSS (p < 0.001). ORC was associated with higher number of infections than PSP (p < 0.001) and FSS (p < 0.001).

Conclusion:

These findings suggest that ORC use in abdominal and pelvic surgery may result in more postoperative complications compared with non-ORC hemostatic agents. Further prospective randomized studies are needed to compare efficacy and safety of these products.

Applications of Chitosan in Surgical and Post-Surgical Materials

The continuous advances in surgical procedures require continuous research regarding materials with surgical applications. Biopolymers are widely studied since they usually provide a biocompatible, biodegradable, and non-toxic material. Among them, chitosan is a promising material for the development of formulations and devices with surgical applications due to its intrinsic bacteriostatic, fungistatic, hemostatic, and analgesic properties. A wide range of products has been manufactured with this polymer, including scaffolds, sponges, hydrogels, meshes, membranes, sutures, fibers, and nanoparticles. The growing interest of researchers in the use of chitosan-based materials for tissue regeneration is obvious due to extensive research in the application of chitosan for the regeneration of bone, nervous tissue, cartilage, and soft tissues. Chitosan can serve as a substance for the administration of cell-growth promoters, as well as a support for cellular growth. Another interesting application of chitosan is hemostasis control, with remarkable results in studies comparing the use of chitosan-based dressings with traditional cotton gauzes. In addition, chitosan-based or chitosan-coated surgical materials provide the formulation with antimicrobial activity that has been highly appreciated not only in dressings but also for surgical sutures or meshes.

Local Mucosal CO2 but Not O2 Insufflation Improves Gastric and Oral Microcirculatory Oxygenation in a Canine Model of Mild Hemorrhagic Shock

Introduction

Acute hemorrhage results in perfusion deficit and regional hypoxia. Since failure of intestinal integrity seem to be the linking element between hemorrhage, delayed multi organ failure, and mortality, it is crucial to maintain intestinal microcirculation in acute hemorrhage. During critical bleeding physicians increase FiO₂ to raise total blood oxygen content. Likewise, a systemic hypercapnia was reported to maintain microvascular oxygenation (μHbO₂). Both, O₂ and CO₂, may have adverse effects when applied systemically that might be prevented by local application. Therefore, we investigated the effects of local hyperoxia and hypercapnia on the gastric and oral microcirculation.

Methods

Six female foxhounds were anaesthetized, randomized into eight groups and tested in a cross-over design. The dogs received a local CO₂-, O₂-, or N₂-administration to their oral and gastric mucosa. Hemorrhagic shock was induced through a withdrawal of 20% of estimated blood volume followed by retransfusion 60 min later. In control groups no shock was induced. Reflectance spectrophotometry and laser Doppler were performed at the gastric and oral surface. Oral microcirculation was visualized by incident dark field imaging. Systemic hemodynamic parameters were recorded continuously. Statistics were performed using a two-way-ANOVA for repeated measurements and post hoc analysis was conducted by Bonferroni testing (p < 0.05).

Results

The gastric μHbO₂ decreased from 76 ± 3% to 38 ± 4% during hemorrhage in normocapnic animals. Local hypercapnia ameliorated the decrease of μHbO₂ from 78 ± 4% to 51 ± 8%. Similarly, the oral μHbO₂ decreased from 81 ± 1% to 36 ± 4% under hemorrhagic conditions and was diminished by local hypercapnia (54 ± 4%). The oral microvascular flow quality but not the total microvascular blood flow was significantly improved by local hypercapnia. Local O₂-application failed to change microvascular oxygenation, perfusion or flow quality. Neither CO₂ nor O₂ changed microcirculatory parameters and macrocirculatory hemodynamics under physiological conditions.

Discussion

Local hypercapnia improved microvascular oxygenation and was associated with a continuous blood flow in hypercapnic individuals undergoing hemorrhagic shock. Local O₂ application did not change microvascular oxygenation, perfusion and blood flow profiles in hemorrhage. Local gas application and change of microcirculation has no side effects on macrocirculatory parameters.

Therapeutic Perspectives for the Perioperative Period in Oral Squamous Cell Carcinoma (OSCC)

The perioperative period is the relatively short window of time, usually measured in days or weeks, around the surgical procedure. Despite its short duration, this time period is of great importance for cancer patients. From a biological point of view, the perioperative period is complex. Synchronous with primary tumor removal, surgery has local and distant consequences, including systemic and local inflammation, coagulation and sympathetic activation. Furthermore, the patients often present comorbidities and receive several medical prescriptions (hypnotics, pain killers, anti-emetics, hemostatics, inotropes, antibiotics). Because of the complex nature of the perioperative period, it is often difficult to predict the oncological outcome of tumor resection. Here, we review the biological consequences of surgery of Oral Squamous Cell Carcinoma (OSCC), the most frequent form of primary head and neck tumors. We briefly address the specificities and the challenges of the surgical care of these tumors and highlight the biological and clinical studies that offer insight into the perioperative period. The recent trials examining neoadjuvant immunotherapy for OSCC illustrate the therapeutic opportunities offered by the perioperative period.

Nomogram Models to Predict Postoperative Hyperlactatemia in Patients Undergoing Elective Cardiac Surgery

Objectives: Postoperative hyperlactatemia (POHL) is common in patients undergoing cardiac surgery and is associated with poor outcomes. The purpose of this study was to develop and validate two predictive models for POHL in patients undergoing elective cardiac surgery (ECS).

Methods: We conducted a multicenter retrospective study enrolling 13,454 adult patients who underwent ECS. All patients involved in the analysis were randomly assigned to a training set and a validation set. Univariate and multivariate analyses were performed to identify risk factors for POHL in the training cohort. Based on these independent predictors, the nomograms were constructed to predict the probability of POHL and were validated in the validation cohort.

Results: A total of 1,430 patients (10.6%) developed POHL after ECS. Age, preoperative left ventricular ejection fraction, renal insufficiency, cardiac surgery history, intraoperative red blood cell transfusion, and cardiopulmonary bypass time were independent predictors and were used to construct a full nomogram. The second nomogram was constructed comprising only the preoperative factors. Both models showed good predictive ability, calibration, and clinical utility. According to the predicted probabilities, four risk groups were defined as very low risk (<0.05), low risk (0.05–0.1), medium risk (0.1–0.3), and high risk groups (>0.3), corresponding to scores of ≤ 180 points, 181–202 points, 203–239 points, and >239 points on the full nomogram, respectively.

Conclusions: We developed and validated two nomogram models to predict POHL in patients undergoing ECS. The nomograms may have clinical utility in risk estimation, risk stratification, and targeted interventions.

Platelet function assessed by ROTEM® platelet in patients receiving antiplatelet therapy during cardiac and vascular surgery

Patients undergoing coronary artery bypass graft (CABG) surgery or carotid endarterectomy (CEA) continue antiplatelet therapy perioperatively, which may increase bleeding risk. We aimed to investigate whether Rotational thromboelastometry (ROTEM^®) platelet, a newly marketed platelet function analysis, would detect antiplatelet therapy in CABG and CEA patients; whether detection of reduced platelet function was associated with increased bleeding; and whether ex vivo desmopressin increased platelet function. We included 20 CABG patients continuing aspirin and 20 CEA patients continuing clopidogrel (n = 1) or clopidogrel and aspirin (n = 19). Platelet function was analyzed with ROTEM^® platelet and light transmission aggregometry (LTA). According to the lower reference limit, ROTEM^® platelet managed to detect aspirin, but clopidogrel detection was inadequate compared to LTA. Using a previously published cut-off for bleeding risk, 6 (30%) patients receiving aspirin and 4 (21%) patients receiving both clopidogrel and aspirin demonstrated platelet function below this cut-off. One of the four CEA patients below the cut-off died from intracerebral hemorrhage postoperatively. CABG patients below (n = 6) and above (n = 14) the cut-off did not differ in chest tube output (median [range]: 373 ml [250-900] vs. 368 ml [195-820]). Ex vivo addition of desmopressin did not increase platelet function. In conclusion, ROTEM^® platelet does reveal aspirin treatment whereas clopidogrel treatment is most often overlooked. Due to low bleeding in the study population, it was not possible to conclude on the association with bleeding risk.

Safety and efficacy of sFilm-FS, a novel biodegradable fibrin sealant, in Göttingen minipigs

Bleeding during surgical procedures is a common complication. Therefore, hemostatic agents have been developed to control bleeding, and fibrin sealants have several benefits. sFilm-FS is a novel fibrin sealant that comprises a biodegradable co-polymeric film embedded with human fibrinogen and thrombin. Herein, the safety and efficacy of sFilm-FS were compared using a liver and spleen puncture model of Göttingen minipigs with those of the standard hemostatic techniques (control animals) and EVARREST^®, a reference fibrin sealant. Hemostasis and reduced blood loss were more effectively achieved with sFilm-FS than with the standard techniques in the control animals and comparable to those achieved with EVARREST^®. No treatment-related adverse effects were observed in any of the groups. Histopathological evaluation indicated that sFilm-FS was slightly and moderately reactive at the liver puncture site and spleen, respectively, compared with the standard techniques in the control animals. These changes are expected degradation reactions of the co-polymeric film and are not considered as adverse events. No treatment-related abnormalities were noted in the other evaluated organs. Additionally, no evidence of local or systemic thromboses was noted. These results support the use of sFilm-FS for hemostasis in humans.

The clinical impact of cirrhosis on the postoperative outcomes of patients undergoing bariatric surgery: propensity score-matched analysis of 2011-2017 US hospitals

Objectives: Since there is increasing number of patients with cirrhosis who require the bariatric procedure due to obesity and obesity-related nonalcoholic steatohepatitis fibrosis, we evaluate the effect of cirrhosis on post-bariatric surgery outcomes.Methods: 2011-2017 National Inpatient Sample was used to isolate bariatric cases, which were stratified by cirrhosis; controls were propensity-score matched to cases and compared to endpoints: mortality, length of stay (LOS), costs, and postoperative complications.Results: From 190,753 patients undergoing bariatric surgery, there were 957 with cirrhosis and 957 matched controls. There was no difference in mortality (0.94 vs 0.52% p = 0.42, OR 1.81 95%CI 0.60-5.41); however, cirrhosis patients had higher LOS (3.36 vs 2.89d p = 0.002), costs ($68,671 vs $61,301 p < 0.001), and bleeding (2.09 vs 0.72% p < 0.001, OR 2.95 95%CI 1.89-4.61). In multivariate, there was no difference in mortality (p = 0.330, aOR 1.73 95%CI 0.58-5.19). In subgroup comparison of cirrhosis patients, those with decompensated cirrhosis had higher mortality (7.69 vs 0.94% p < 0.001, OR 8.78 95%CI 3.41-22.59).Conclusion: The results of this study show compensated cirrhosis does not pose an increased risk toward post-bariatric surgery mortality; however, hepatic decompensation increases the postsurgical risks.

Effect of Intra- and Post-Operative Fluid and Blood Volume on Postoperative Pulmonary Edema in Patients with Intraoperative Massive Bleeding

In patients with intraoperative massive bleeding, the effects of fluid and blood volume on postoperative pulmonary edema are uncertain. Patients with intraoperative massive bleeding who had undergone a non-cardiac surgery in five hospitals were enrolled in this study. We evaluated the association of postoperative pulmonary edema risk and intra- and post-operatively administered fluid and blood volumes in patients with intraoperative massive bleeding. In total, 2090 patients were included in the postoperative pulmonary edema analysis, and 300 patients developed pulmonary edema within 72 h of the surgery. The postoperative pulmonary edema with hypoxemia analysis included 1660 patients, and the condition occurred in 161 patients. An increase in the amount of red blood cells transfused per hour after surgery increased the risk of pulmonary edema (hazard ratio: 1.03; 95% confidence interval: 1.01–1.05; p = 0.013) and the risk of pulmonary edema with hypoxemia (hazard ratio: 1.04; 95% confidence interval: 1.01–1.07; p = 0.024). An increase in the red blood cells transfused per hour after surgery increased the risk of developing pulmonary edema. This increase can be considered as a risk factor for pulmonary edema.

Comparative study of suction drainage placement in cementless hip replacement among patients undergoing extended thromboprophylaxis: a prospective randomized study

Background

The use of drains reportedly does not improve surgical outcomes after hip replacement. There is still a lack of strict recommendations for drain placement after primary hip replacement. This study aimed to assess the safety of not using suction drainage after primary hip replacement in a population of patients undergoing extended thromboprophylaxis.

Methods

In this prospective randomized study, all patients were qualified for primary hip replacement and were divided into two groups: with and without drainage. The inclusion criterion was idiopathic hip osteoarthritis. The exclusion criteria were secondary coxarthrosis, autoimmune disease, coagulopathy, venous/arterial thrombosis, hepatic/renal insufficiency, cement, or hybrid endoprostheses. We performed an intention-to-treat analysis. Clinical, laboratory, and radiographic parameters were measured for the first three days after surgery. Hematoma collection, due to extended thromboprophylaxis, in the joint and soft tissues was evaluated precisely. The patients underwent follow-up for 30 days.

Results

The final analysis included a total of 100 patients. We did not find any significant statistical differences between groups in terms of hip fluid collection (9.76 vs. 10.33 mm, with and without drainage, respectively; mean difference, 0.6 mm; 95 % confidence interval [CI] -2.8 to 3.9; p = 0.653), estimated blood loss (1126 vs. 1224 ml; mean difference, 97.1 ml; 95 % CI -84.1 to 278.2; p = 0.59), and hemoglobin levels on postoperative day 3 (11.05 vs. 10.85 g/dl; mean difference, 0.2; 95 % CI -2.1 to 2.5; p = 0.53). In addition, the other parameters did not show significant differences between groups. Notably, two cases of early infections were observed in the no-drainage group, whereas there were no such complications in the drainage group.

Conclusions

We conclude that the use of closed suction drainage after primary hip replacement is a safe procedure in patients undergoing extended thromboprophylaxis. Further research is warranted to validate these findings.

Trial registration

The study was successfully registered retrospectively at Clinicaltrial.gov with the identification number NCT04333264 03 April 2020.

Blood product transfusion and lung transplant outcomes: A systematic review

The perioperative transfusion of blood products has long been linked to development of acute lung injury and associated with mortality across both medical and surgical patient populations.^1,2 The need for blood product transfusion during and after lung transplantation is common and, in many instances, unavoidable. However, this practice may potentially be modifiable.³ In this systematic review, we explore and summarize what is known regarding the impact of blood product transfusion on outcomes following lung transplantation, highlighting the most recent work in this area. Overall, the majority of the literature consists of single center retrospective analyses or the work of multicenter working groups referencing the same database. In the end, there are a number of remaining questions regarding blood product transfusion and their downstream effects on graft function and survival.

Re-exploration for bleeding after cardiac surgery: revaluation of urgency and factors promoting low rate

BACKGROUND

Re-exploration of bleeding after cardiac surgery is associated with significant morbidity and mortality. Perioperative blood loss and rate of re-exploration are variable among centers and surgeons.

OBJECTIVE

To present our experience of low rate of re-exploration based on adopting checklist for hemostasis and algorithm for management.

METHODS

Retrospective analysis of medical records was conducted for 565 adult patients who underwent surgical treatment of congenital and acquired heart disease and were complicated by postoperative bleeding from Feb 2006 to May 2019. Demographics of patients, operative characteristics, perioperative risk factors, blood loss, requirements of blood transfusion, morbidity and mortality were recorded. Logistic regression was used to identify predictors of re-exploration and determinants of adverse outcome.

RESULTS

Thirteen patients (1.14%) were reexplored for bleeding. An identifiable source of bleeding was found in 11 (84.6%) patients. Risk factors for re-exploration were high body mass index, high Euro SCORE, operative priority (urgent/emergent), elevated serum creatinine and low platelets count. Re-exploration was significantly associated with increased requirements of blood transfusion, adverse effects on cardiorespiratory state (low ejection fraction, increased s. lactate, and prolonged period of mechanical ventilation), longer intensive care unit stay, hospital stay, increased incidence of SWI, and higher mortality (15.4% versus 2.53% for non-reexplored patients). We managed 285 patients with severe or massive bleeding conservatively by hemostatic agents according to our protocol with no added risk of morbidity or mortality.

CONCLUSION

Low rate of re-exploration for bleeding can be achieved by strict preoperative preparation, intraoperative checklist for hemostasis implemented by senior surgeons and adopting an algorithm for management.

The Association between Prognostic Nutritional Index (PNI) and Intraoperative Transfusion in Patients Undergoing Hepatectomy for Hepatocellular Carcinoma: A Retrospective Cohort Study

BACKGROUND

PNI is significantly associated with surgical outcomes; however, the association between PNI and intraoperative transfusions is unknown.

METHODS

This study retrospectively analyzed 1065 patients who underwent hepatectomy. We divided patients into two groups according to the PNI (<44 and >44) and compared their transfusion rates and surgical outcomes. We performed multivariate logistic and Cox regression analysis to determine risk factors for transfusion and the 5-year survival. Additionally, we found the net reclassification index (NRI) to validate the discriminatory power of PNI.

RESULTS

The PNI <44 group had higher transfusion rates (adjusted odds ratio [OR]: 2.20, 95%CI: 1.06-4.60, p = 0.035) and poor surgical outcomes, such as post hepatectomy liver failure (adjusted [OR]: 3.02, 95%CI: 1.87-4.87, p < 0.001), and low 5-year survival (adjusted OR: 1.68, 95%CI: 1.17-2.24, p < 0.001). On multivariate analysis, PNI <44, age, hemoglobin, operation time, synthetic colloid use, and laparoscopic surgery were risk factors for intraoperative transfusion. On Cox regression analysis, PNI <44, MELD score, TNM staging, synthetic colloid use, and transfusion were associated with poorer 5-year survival. NRI analysis showed significant improvement in the predictive power of PNI for transfusion (p = 0.002) and 5-year survival (p = 0.004).

CONCLUSIONS

Preoperative PNI <44 was significantly associated with higher transfusion rates and surgical outcomes.

Extended intensive care correlates with worsening of surgical outcome after elective abdominal aortic reconstruction

BACKGROUND

The aim of this study was to evaluate the impact of extended postoperative intensive care on short- and long-term patient outcome after elective abdominal aortic surgery and to assess the risk factors for patient survival after extended intensive care unit (ICU) treatment.

METHODS

The data of 231 patients that underwent open or endovascular abdominal aortic surgery were retrospectively analysed with regard to extended postoperative intensive care, defined as ICU treatment for more than 24 consecutive hours. Pre- and intraoperative factors were evaluated. The endpoints of the study were postoperative complications, mortality, and long-term follow-up. Univariate and multivariate Cox proportional regression analyses were performed to identify risk factors of worse overall survival.

RESULTS

Extended postoperative intensive care was needed in 84 patients (63 after open and 21 after endovascular surgery). The period of ICU treatment was similar in both groups. Only the wound complications (31.8% vs. 9.5%, p=.0498; OR 4.42 (0.94-20.84)) and the rate of acute kidney injury (82.5% vs. 57.1%, p=.0352; OR 3.55 (1.20-0.46)) were more frequent after open surgery, whereas brief reactive psychosis (38.1% vs. 14.3%, p=.0281; OR 0.27 (0.09- 0.84)) was more frequent after endovascular surgery. ICU stay of ≥8 days correlated with significantly lower survival rates compared to a shorter ICU stay (p=.0034), independent of open or endovascular techniques. Other multivariate risk factors for worse survival were the absence of preoperative aspirin medication, a body mass index (BMI) of <25, chronic renal insufficiency (CRI), and coronary artery disease (CAD). Endovascular therapy was a positive predictive factor of short ICU stay of ≤3 days.

CONCLUSIONS

The outcome after extended intensive care following elective aortic surgery is strongly dependent on the length of ICU stay.

[Results of implementation of a perioperative Patient Blood Management program in cardiovascular surgery]

BACKGROUND AND OBJECTIVE

Cardiovascular surgery (CCV) patients have a high incidence of perioperative anemia and bleeding that determines a high rate of allogeneic blood transfusion (AST). This is associated with an increase in morbidity, mortality and prolongs length of stay in hospital. Unnecessary transfusion is one of the measures to avoid and Patient Blood Management (PBM) programs have proven their effectiveness. Our objective was to reduce the transfusion of patients in cardiac surgery, without inferior results in morbidity and mortality, length of stay in hospital and being cost-effective, through the implementation of a PBM program.

MATERIAL AND METHODS

A mixed cohort study of 226 patients divided into 2 groups: retrospective pre-PBM (GP), from 2016, and intervention group (IG), prospective from 2018, with the results of the implementation of the guide.

RESULTS

The clinical results obtained allowed reducing the TSA from 92.59% to 79.69% (P<.001), saving 2.59 units of CH and 2.5 of PFC per patient (P<.001). A decrease was found in patients with fever (12.35% vs 1.56% with P=.006) and the need to escalate antibiotics (64.8% vs 42.19%, P=.002). The rest of postoperative complications and mortality at 3months did not present statistically significant differences. The length of stay was reduced by an average 3.6days in the IG, (95%CI: -8.10 to 0.9, P=.18). The cost decreased by 163.29€ per patient, taking into account exclusively the saving of blood components.

CONCLUSION

The PBM program is effective in reducing TSA in cardiac surgery in a tertiary hospital with high complexity patients and high transfusion rate. There are signs suggestive of a decrease in infections and a tendency to decrease the length of stay and mortality. In the economic approximation carried out, the cost of the intervention was lower than the savings implied by the decrease in transfusion.

To drain or not to drain following carotid endarterectomy: a systematic review and meta-analysis

INTRODUCTION

A postoperative neck hematoma can be a life-threatening complication after carotid endarterectomy necessitating urgent surgical decompression to avoid airway compromise. The practice of routine incisional drain placement is variable with few published studies evaluating the "to drain versus not to drain" approach. We conducted a systematic review and meta-analysis of the safety and efficacy of neck drain placement for prevention of neck hematoma requiring re-exploration for decompression.

EVIDENCE ACQUISITION

This study is a systematic review and meta-analysis performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Pooled odds ratios with 95% confidence intervals were calculated for the outcome of surgical re-exploration for neck decompression among patients receiving or not receiving wound drainage.

EVIDENCE SYNTHESIS

We identified 5 studies for inclusion, comprising 48,297 patients with 19,832 (41.1%) patients receiving a drain after carotid endarterectomy. Patients in the drain group had a significantly higher re-exploration rate after carotid endarterectomy compared to those who did not receive a drainage (OR=1.24, 95% CI: 1.03-1.49; P=0.02) with no heterogeneity (I²=0%).

CONCLUSIONS

Routine drain placement does not offer complete protection against neck hematoma development and may give the surgeon a false sense of security in wound drainage. Thus, we conclude that drain placement following carotid endarterectomy should be selective, not routine.

Comparison of 4-Factor Prothrombin Complex Concentrate With Frozen Plasma for Management of Hemorrhage During and After Cardiac Surgery: A Randomized Pilot Trial

IMPORTANCE

Approximately 15% of patients undergoing cardiac surgery receive frozen plasma (FP) for bleeding. Four-factor prothrombin complex concentrates (PCCs) have logistical and safety advantages over FP and may be a suitable alternative.

OBJECTIVES

To determine the proportion of patients who received PCC and then required FP, explore hemostatic effects and safety, and assess the feasibility of study procedures.

DESIGN, SETTING, AND PARTICIPANTS

Parallel-group randomized pilot study conducted at 2 Canadian hospitals. Adult patients requiring coagulation factor replacement for bleeding during cardiac surgery (from September 23, 2019, to June 19, 2020; final 28-day follow-up visit, July 17, 2020). Data analysis was initiated on September 15, 2020.

INTERVENTIONS

Prothrombin complex concentrate (1500 IU for patients weighing ≤60 kg and 2000 IU for patients weighing >60 kg) or FP (3 U for patients weighing ≤60 kg and 4 U for patients weighing >60 kg), repeated once as needed within 24 hours (FP used for any subsequent doses in both groups). Patients and outcome assessors were blinded to treatment allocation.

MAIN OUTCOMES AND MEASURES

Hemostatic effectiveness (whether patients received any hemostatic therapies from 60 minutes to 4 and 24 hours after initiation of the intervention, amount of allogeneic blood components administered within 24 hours after start of surgery, and avoidance of red cell transfusions within 24 hours after start of surgery), protocol adherence, and adverse events. The analysis set comprised all randomized patients who had undergone cardiac surgery, received at least 1 dose of either treatment, and provided informed consent after surgery.

RESULTS

Of 169 screened patients, 131 were randomized, and 101 were treated (54 with PCC and 47 with FP), provided consent, and were included in the analysis (median age, 64 years; interquartile range [IQR], 54-73 years; 28 [28%] were female; 82 [81%] underwent complex operations). The PCC group received a median 24.9 IU/kg (IQR, 21.8-27.0 IU/kg) of PCC (2 patients [3.7%; 95% CI, 0.4%-12.7%] required FP). The FP group received a median 12.5 mL/kg (IQR, 10.0-15.0 mL/kg) of FP (4 patients [8.5%; 95% CI, 2.4%-20.4%] required >2 doses of FP). Hemostatic therapy was not required at the 4-hour time point for 43 patients (80%) in the PCC group and for 32 patients (68%) in the FP group (P = .25) nor at the 24-hour time point for 41 patients (76%) in the PCC group and for 31 patients (66%) patients in the FP group (P = .28). The median numbers of units for 24-hour cumulative allogeneic transfusions (red blood cells, platelets, and FP) were 6.0 U (IQR, 4.0-11.0 U) in the PCC group and 14.0 U (IQR, 8.0-20.0 U) in the FP group (ratio, 0.58; 95% CI, 0.45-0.77; P < .001). After exclusion of FP administered as part of the investigational medicinal product, the median numbers of units were 6.0 U (IQR, 4.0-11.0 U) in the PCC group and 10.0 U (IQR, 6.0-16.0 U) in the FP group (ratio, 0.80; 95% CI, 0.59-1.08; P = .15). For red blood cells alone, the median numbers were 1.5 U (IQR, 0.0-4.0 U) in the PCC group and 3.0 U (IQR, 1.0-5.0 U) in the FP group (ratio, 0.69; 95% CI, 0.47-0.99; P = .05). During the first 24 hours after start of surgery, 15 patients in the PCC group (28%) and 8 patients in the FP group (17%) received no red blood cells (P = .24). Adverse event profiles were similar.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that the study protocols were feasible. Adequately powered randomized clinical trials are warranted to determine whether PCC is a suitable substitute for FP for mitigation of bleeding in cardiac surgery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04114643.