Effect of induced hypotensive anaesthesia vs isovolaemic haemodilution on blood loss and transfusion requirements in orthognathic surgery: a prospective, single-blinded, randomized, controlled clinical study

Induced hypotensive anaesthesia and isovolaemic haemodilution are well-established blood-sparing techniques in major surgery. This prospective study compared them for blood loss, transfusion requirements, and surgical field quality during standardized orthognathic operations. In a surgeon-blinded trial, 60 healthy patients requiring either Le Fort I osteotomy or bimaxillary surgery were randomly allocated to receive normotensive anaesthesia, induced hypotensive anaesthesia, or induced hypotensive anaesthesia combined with isovolaemic haemodilution. Blood loss and haemoglobin level were measured intraoperatively and calculated on postoperative day 3. The surgeons rated surgical field quality. Mean blood loss was 1021.63, 392.38 (p<0.05) and 1191.65ml in the normotensive, hypotensive and haemodilution groups, respectively. Mean haemoglobin level immediately after surgery was 9.3, 10.3, and 7.4g/dl (p<0.05), respectively. No hypotensive group patients received transfusions; four normotensive group patients required allogenic transfusions; seven haemodilution group patients needed autogenous retransfusions (p<0.05). Surgical field quality was significantly better in the hypotensive than in the normotensive (p<0.05) or haemodilution (p<0.05) groups. In orthognathic surgery, hypotensive anaesthesia significantly reduces blood loss and transfusion requirements and minimizes allogenic transfusions risks. Induced hypotensive anaesthesia combined with isovolaemic haemodilution has no additional blood-sparing effects but impairs surgical field quality.     

Evaluation of hemorrhage depressors on blood loss during orthognathic surgery: a retrospective study.

PURPOSE: Correction of dentofacial deformities by orthognathic surgery may cause significant bleeding and therefore hypotensive anesthesia is often used to reduce the blood loss. The main objective of the present clinical study was to determine whether the addition of hemorrhage depressors to other medication during orthognathic surgery would further reduce the blood loss. PATIENTS AND METHODS: Thirty patients, consecutively operated on with standardized Le Fort I osteotomies in 1998 (n = 15, control group) and 1999 (n = 15, treatment group), were included in the study. Both groups received hypotension anesthesia during surgery and the treatment group received additional hemorrhage depressors; tranexamic acid and desmopressin. RESULTS: The mean blood loss was 740 +/- 410 mL (11.3 mL/kg) in the control group and 400 +/- 210 mL (5.7 mL/kg) in the treatment group. The results showed a statistically significant reduction of blood loss in the treatment group (P <.01). CONCLUSIONS: This study shows that blood loss during orthognathic surgery under hypotensive anesthesia can be significantly reduced when a combination of tranexamic acid and desmopressin is added.     

Comprehensive assessment of tranexamic acid during orthognathic surgery: A systematic review and meta-analysis of randomized,controlled trials

The objective of this study was to comprehensively assess the use of tranexamic acid (TXA) during orthognathic surgery. A systematic review and meta-analysis of randomized controlled trials addressing these issues were carried out. Three electronic databases, included PubMed, Web of Science, and Cochrane Library, were searched until April 30, 2018. Eligible studies were restricted to randomized, controlled trials (RCTs). Weighted mean differences (WMD) for blood loss, operation time, haematocrit, quality of surgical field, and odds ratio (OR) for transfusion rates were pooled for the included studies. Eight randomized, controlled trials were included for analysis. Compared with the control group, the TXA group showed a reduction in intraoperative blood loss of 165.03 ml (p < 0.00001; 95% CI, ?200.93 to ?129.13 ml), a reduction in the drop of haematocrit of 2.32 g/dl (p < 0.00001; 95% CI, ?3.38 to ?1.26 g/dl), and an improved quality of surgical field (p < 0.00001; MD, ?1.01; 95% CI, ?1.23 to ?0.80). Tranexamic acid has a limited effect on reducing operative time (p < 0.00001; MD, ?16.18 min; 95% CI, ?19.60 to ?12.75 min) and on decreasing the transfusion rates (p = 0.02; OR = 0.33; 95% CI, 0.13 to 0.83).     

Are postoperative intravenous antibiotics necessary after bimaxillary orthognathic surgery? A prospective, randomized, double-blind, placebo-controlled clinical trial

Postoperative antibiotic prophylaxis is often administered intravenously, despite an increased morbidity rate compared with oral application. This study investigates whether a postoperative oral antibiotic regimen is as effective as incorporation of intravenous antibiotics after bimaxillary orthognathic surgery. 42 patients who underwent bimaxillary orthognathic surgery between December 2008 and May 2010 were randomly allocated to 2 placebo-controlled postoperative antibiotic prophylaxis groups. Group 1 received oral amoxicillin 500 mg three times daily; group 2 received intravenous ampicillin 1 g four times daily, during the first two postoperative days. Both groups subsequently took oral amoxicillin for three more days. Clinically, the infection rate was assessed in both study groups for a period of 6 weeks after the surgery. 9 patients (21.4%) developed infection. No adverse drug event was detected. No significant difference (p = 0.45) was detected in the infection rate between group 1 (3/21) and group 2 (6/21). Age, type of surgical procedures, duration of the operative procedure, surgical procedure-related events, blood loss, and blood transfusion were all found not related to infection (p > 0.05). Administration of more cost-effective oral antibiotic prophylaxis, which causes less comorbidity, can be considered to be safe in bimaxillary orthognathic surgery with segmentalizations.     

The effect of different dosage regimens of tranexamic acid on blood loss in bimaxillary osteotomy: a randomized,double-blind,placebo-controlled study

The purpose of this study was to compare the effects of three dosage regimens of intravenous tranexamic acid and normal saline placebo on blood loss and the requirement for transfusion during bimaxillary osteotomy. A prospective, randomized, double-blind, placebo-controlled study was performed. Eighty patients scheduled for elective bimaxillary osteotomy were divided into four groups: a placebo group and three groups receiving a single dose of tranexamic acid 10, 15, or 20 mg/kg body weight after the induction of anaesthesia. Demographic data, the anaesthetic time, the operative time, and the experience of the surgical team were similar in the four groups. Patients receiving placebo had increased blood loss compared to those receiving tranexamic acid. No significant difference in blood loss was found among those who received 10, 15, or 20 mg/kg body weight of tranexamic acid. There was no significant difference in transfusion requirement, amount of 24-h postoperative vacuum drainage, length of hospital stay, or complications among the four groups. Prophylactic tranexamic acid decreased bleeding during bimaxillary osteotomy. Of the three dosages of tranexamic acid studied, the most efficacious and cost-effective dose to reduce bleeding was 10 mg/kg body weight.     

Effectiveness of tranexamic acid on intraoperative blood loss in isolated Le Fort I osteotomies – A prospective,triple blinded randomized clinical trial

The aim of this triple blinded randomized clinical trial was to evaluate the efficacy of tranexamic acid when used in conjunction with hypotensive anaesthesia exclusively for Le Fort I osteotomies. 49 patients undergoing Le Fort I osteotomy for correction of dentofacial deformity were divided into two groups; Group 1 received a placebo of saline 5 ml and Group 2 received 10 mg/kg body weight of tranexamic acid. The operating surgeon, anaesthetist and investigator were blinded. The variables of interest recorded in this study included the change in Hb%, PCV, total blood loss, total operating time and quality of the surgical field using Fromme's Ordinal Scale. Statistically significant differences between the two groups were found between the following variables: post-operative Hb%, drop in Hb%, post-operative PCV, drop in PCV, total surgical blood loss, total operating time and quality of surgical field (P < 0.05). Group 2 patients exhibited a smaller drop in Hb% and PCV, with a lower Fromme's Ordinal Scale value and decreased total blood loss and operating time. In conclusion single preoperative administration of tranexamic acid in the dose of 10 mg/kg, when combined with hypotensive anaesthesia is effective in controlling blood loss with regards to single piece Le Fort I surgery.     

Operative time,blood loss,hemoglobin drop,blood transfusion,and hospital stay in orthognathic surgery

Purpose

This study was conducted to evaluate the operative time, blood loss, hemoglobin drop, blood transfusion, and length of hospital stay in orthognathic surgery.

Methods

A 10-year retrospective analysis was performed on patients who underwent bilateral sagittal split osteotomy (with or without genioplasty), Le Fort I osteotomy (with or without genioplasty), or any combination of these procedures. A total of 271 patients were included.

Results

The age range was 17 to 49 years, with a mean age of 24.13 ± 4.51 years. Approximately 62% of patients underwent double-jaw surgery. The most common procedure was bilateral sagittal split with Le Fort I (37%). The average operative time was 3.96 ± 1.25 h. The mean estimated blood loss was 345.2 ± 149.74 mL. Approximately 9% of patients received intraoperative blood transfusion. The mean hemoglobin drop in the non-transfusion cases was 2.38 ± 0.89 g/dL. The mean postoperative hospital stay was 1.85 ± 0.83 days. Only one patient was admitted to the ICU for one night.

Conclusions

In orthognathic surgery, blood loss is relatively minor, blood transfusion is frequent, and ICU admission is unlikely. Operative time, blood loss, blood transfusion, and the complexity of the surgical procedure can significantly increase the length of hospital stay. Males may bleed more than females in orthognathic surgery. Hemoglobin drop can be overestimated due to hemodilution in orthognathic surgery, which may influence the decision to use blood transfusion.

     

Intraoperative blood loss and blood transfusion requirements in patients undergoing orthognathic surgery

Procedures for the surgical correction of dentofacial deformities may produce important complications, whether due to the potential for vascular injury or to prolonged surgery, both of which may lead to severe blood loss. Fluid replacement with crystalloid, colloid, or even blood products may be required. The aim of this study was to assess blood loss and transfusion requirements in 45 patients (18 males and 27 females; mean age 29.29 years, range 16–52 years) undergoing orthognathic surgery, assigned to one of two groups according to procedure type—rapid maxillary expansion or double-jaw orthognathic surgery. Preoperative hemoglobin and hematocrit levels and intraoperative blood loss were measured. There was a substantial individual variation in pre- and postoperative hemoglobin values (10.3–17 and 8.8–15.4 g/dL, respectively; p?相似文献   

Blood transfusions in bimaxillary orthognathic surgery: are they necessary?

Excessive blood loss is one of the major complications of orthognathic surgery. Numerous strategies, including hypotensive anesthetic techniques and blood transfusion, have been developed to deal with the blood loss. Blood for transfusions can be obtained from banked blood or from autologous donation. In this study, the authors looked at 2 groups of patients who had bimaxillary orthognathic surgery. One group included patients who had autodonated blood (group 1) and who were operated on between 1991 and 1993, and the other patients did not autodonate and were operated on between 1998 and 2000 (group 2). It was found that fewer than 50% of patients in group 1 were transfused, and none of the group 2 patients were. A protocol to lessen blood loss that should obviate the need for blood transfusion is proposed. It is concluded that blood transfusion should no longer be a consideration during routine bimaxillary orthognathic surgery.     

乌拉地尔用于正颌手术控制性降压的效果评价

目的：观察乌拉地尔在正颌手术控制性降压中的应用效果。方法：选取正颌手术患者40例,ASAⅠ～Ⅱ级。随机分为2组,U组（乌拉地尔复合异丙酚组20例）和P组（异丙酚组20例）。麻醉诱导,2组都给予咪达唑仑0．05mg／kg、芬太尼2μg／kg、异丙酚2mg／kg、罗库溴铵0．8mg／kg行麻醉诱导插管。2组均由2％七氟烷和异丙酚维持麻醉。U组在异丙酚的基础上复合乌拉地尔行控制性降压。P组仅用异丙酚行控制性降压。2组都以平均动脉压（MAP）维持在60～65mmHg为目标。记录2组在诱导前后及降压前后各个时间段的心率（HR）、收缩压（SBP）、舒张压（DBP）及MAP的值,并进行比较,同时根据Fromme术野评分表评定手术视野质量。采用SPSS11．0软件包进行统计学分析。结果：控制性降压期间,2组MAP都低于术前（P〈0．01）。U组在5、10、20min的MAP显著低于P组（P〈0．01）。U组的术野评分也优于P组（P〈0．01）。但两组心率都有增高,差异不显著（P〉0．01）。结论：乌拉地尔用于正颌手术控制性降压安全有效,起效迅速,可使术野质量更加清晰。     

Preoperative autologous blood donation for oral and maxillofacial surgery: an analysis of 913 patients.

PURPOSE: Autologous transfusions are frequently used with elective surgical procedures and are a mandated choice under California law. Because unused units cannot be transfused to other patients, it is important to assess utilization and minimize waste. METHODS: The transfusion needs of 913 consecutive patients scheduled for major oral and maxillofacial surgery at the University of California San Francisco were evaluated in 3 categories: oncologic and reconstructive surgery (563), orthognathic surgery (260), and temporomandibular joint surgery (90). RESULTS: 24.9% of patients chose to undergo preoperative autologous blood donation. 24.2%, 20.6%, and 11.4% of oncologic and reconstructive surgery, orthognathic surgery, and temporomandibular joint surgery patients, respectively, who made an autologous donation preoperatively, subsequently received a transfusion postoperatively. CONCLUSION: Transfusion needs for most oral surgery procedures are clearly overestimated; the relatively low risk of blood loss associated with these procedures today should be taken into account when asking patients to participate in preoperative autologous blood donation.     

The assessment of blood loss in orthognathic surgery for prognathia.

PURPOSE: It is difficult to predict the need for blood transfusion during orthognathic surgery. The purpose of this study was to evaluate differences between patients who underwent different orthognathic procedures, and to assess the need for transfusion in orthognathic surgery. SUBJECTS AND METHODS: We examined 62 prognathic patients who underwent orthognathic surgery in our hospital. The subjects were divided into 4 groups according to procedure. Pre- and postoperative values of blood parameters were evaluated statistically. RESULTS: A greater amount of blood was lost in the double-jaw surgeries than in the single-jaw surgeries. There was a significant difference between sagittal split ramus osteotomy (SSRO) combined with Le Fort I osteotomy and intraoral vertical ramus osteotomy (IVRO) ( P < .05). However, none of the patients required transfusion intraoperatively. In all groups except the IVRO group, there were significant differences in red blood cell count, hemoglobin, and hematocrit between preoperative values and 1 week postoperative values ( P < .05). Although the values of red blood cell, hemoglobin, and hematocrit tended to decrease until 2 weeks postoperative, no complications occurred. Simple regression analysis showed significant positive correlation between duration of operation and blood loss ( P < .05). CONCLUSION: The present results indicate that there is little risk of marked bleeding in routine procedures, and that IVRO causes minimal bleeding. Transfusion was not necessary in IVRO or SSRO with or without Le Fort I osteotomy.     

Tranexamic acid as a mouthwash in anticoagulant-treated patients undergoing oral surgery: An alternative method to discontinuing anticoagulant therapy

A double-blind randomized study was carried out to evaluate the clinical hemostatic effect of tranexamic acid mouthwash after dental extraction in 30 patients who received anticoagulant agents. Surgery was performed with a reduction in the level of anticoagulant therapy in the control group and with no change in the level of anticoagulant therapy in the group who received the tranexamic acid. After the extraction the surgical field was irrigated with a 5% solution of tranexamic acid in the group of 15 patients whose anticoagulant treatment had not been discontinued and with a placebo solution in the group of 15 patients for whom the anticoagulant therapy was reduced. Patients were instructed to rinse their mouths with 10 ml of the assigned solution for 2 minutes four times a day for 7 days. There was no significant difference between the two treatment groups in the bleeding incidence after oral surgery. We conclude that the anticoagulant treatment does not need to be withdrawn before oral surgery provided that local antifibrinolytic therapy is instituted.     

The efficacy of tranexamic acid for orthognathic surgery: a meta-analysis of randomized controlled trials

The efficacy of tranexamic acid in orthognathic surgery remains controversial. We conducted a systematic review and meta-analysis to explore the influence of tranexamic acid on blood loss for orthognathic surgery.We performed a search of PubMed, Embase, Web of science, EBSCO, and Cochrane library databases through October 2017 for randomized controlled trials (RCTs) assessing the effects of tranexamic acid versus placebo on orthognathic surgery. Meta-analysis was performed using the random-effects model.Six RCTs were included in the meta-analysis. Overall, compared with placebo in orthognathic surgery, tranexamic acid administration results in significantly decreased blood loss [mean difference (MD) = −159.73; 95% confidence interval (CI) = −236.42 to −83.03; P < 0.0001], and higher postoperative haemoglobin (MD = 0.71; 95% CI = 0.11 to 1.31; P = 0.02), but has no remarkable impact on postoperative haematocrit (MD = 1.23; 95% CI = −1.22 to 3.69; P = 0.33) and operation time (MD = −2.35; 95% CI = −18.05 to 13.36; P = 0.77). In addition, patients with orthognathic surgery need decreased amounts of irrigant fluid (MD = −229.23; 95% CI = −399.63 to −58.83; P = 0.008) after using tranexamic acid.We concluded that tranexamic acid promotes the bleeding control in orthognathic surgery.     

Risk of surgical glove perforation in oral and maxillofacial surgery

Oral and maxillofacial surgery, which involves several sharp instruments and fixation materials, is consistently at a high risk for cross-contamination due to perforated gloves, but it is unclear how often such perforations occur. This study aimed to address this issue. The frequency of the perforation of surgical gloves (n=1436) in 150 oral and maxillofacial surgeries including orthognathic surgery (n=45) was assessed by the hydroinsufflation technique. Orthognathic surgery had the highest perforation rate in at least 1 glove in 1 operation (91.1%), followed by cleft lip and palate surgery (55.0%), excision of oral soft tumour (54.5%) and dental implantation (50.0%). The perforation rate in scrub nurses was 63.4%, followed by 44.4% in surgeons and first assistants, and 16.3% in second assistants. The odds ratio for the perforation rate in orthognathic surgery versus other surgeries was 16.0 (95% confidence interval: 5.3-48.0). The protection rate offered by double gloving in orthognathic surgery was 95.2%. These results suggest that, regardless of the surgical duration and blood loss in all fields of surgery, orthognathic surgery must be categorized in the highest risk group for glove perforation, following gynaecological and open lung surgery, due to the involvement of sharp objects.     

Nitrous oxide does not aggravate postoperative emesis after orthognathic surgery in female and nonsmoking patients.

PURPOSE: The purpose of this study was to evaluate the effect of supplemental nitrous oxide on postoperative nausea and vomiting (PONV) after propofol anesthesia for orthognathic surgery in female and nonsmoking patients. PATIENTS AND METHODS: We compared PONV in 28 ASA-I female nonsmoking patients undergoing orthognathic surgery. Anesthesia was induced with propofol combined with fentanyl, and tracheal intubation was facilitated with vecuronium. Anesthesia was maintained with propofol with or without nitrous oxide. No patient received neostigmine. PONV was assessed as score 0 (no PONV), score 1 (nausea), and score 2 (vomiting) during the 24-hour recovery period. RESULTS: There were no differences in the patients' characteristics, operation, anesthesia and emergence time, fluid transfusion, blood loss, urine output, and total propofol and fentanyl doses between the 2 groups. There was also no difference in PONV score in 2 groups. Only 1 patient in each group vomited. CONCLUSIONS: It is suggested that supplemental nitrous oxide does not aggravate PONV after propofol anesthesia for orthognathic surgery in female nonsmoking patients.     

Hemoglobin value reduction and necessity of transfusion in bimaxillary orthognathic surgery.

PURPOSE: It has been the aim of the present clinical study to assess the reduction of the hemoglobin value and the frequency of blood transfusions during bimaxillary orthognathic surgery and to discuss the clinical consequences. PATIENTS AND METHODS: Fifty-six patients (31 female, 25 male; mean age, 28.6 +/- 13.0 years; range, 14 to 66 years) were operated on. Twenty-nine patients predeposited blood before surgery. As a threshold for intraoperative or postoperative transfusion, a hemoglobin value of 7.5 g/100 mL was chosen. RESULTS: Perioperatively, the hemoglobin values of the patients who predeposited blood decreased significantly after blood donation. The hemoglobin value reduced postoperatively by 2.6 +/- 1.4 g/100 mL in the non-donors and by 2.6 +/- 1.1 g/mL in the donors. None of the patients who did not predeposit blood received homologous blood transfusions intraoperatively or postoperatively. In the group of patients who predeposited blood, 3 were transfused intraoperatively. They received 1 or 2 units of autologous blood. CONCLUSION: The individual statistics of the department show that there was only a limited reduction of the intraoperative and postoperative hemoglobin values as a consequence of bimaxillary orthognathic surgery. The increased safety of homologous blood and the minimal transfusion rates support abandonment of routine predepositing of autologous blood and the acceptance of homologous blood in the rare case of transfusion in bimaxillary surgery.     

头高脚低位对正颌外科术中出血量影响的研究

目的:比较头高脚低10°体位和平卧位对正颌外科手术术中出血量的影响。方法::将需行Le Fort I型截骨术、双侧下颌矢状劈开截骨术(bilateral sagittal ramus osteotomy,BSSRO)及水平截骨颏成形术(horizontal genioplasty)的牙颌面畸形患者63例根据投币随机分为A组(32例)和B组(31例),分别在头高脚低10°体位和平卧位下接受双颌正颌外科手术,比较两组术中出血量差异。结果:63例患者中,出血总量平均值:A组(147.1±62.6) mL,B组(243.9±86.8) mL,两组出血总量比较,差异具有统计学意义(P<0.001)。每分钟出血量平均值:A组(0.78±0.25) ml/min ,B组(1.20±0.39) ml/min,两组每分钟出血量比较,差异具有统计学意义(P<0.001)。不同术者对出血总量影响也具有显著性差异(P<0.001),不同术者对每分出血量影响无显著性差异(P=0.78)。结论:头高脚低10°体位相比平卧位显著减少正颌外科术中出血;若术者经验无明显差异,手术时间越短,术中出血量越少。     

Changes in hemoglobin and hematocrit levels following orthognathic surgery of the mandible

Red blood cell mass has been shown to recover rapidly with great decreases, as occurs in orthognathic surgery. However, blood loss during bilateral sagittal split osteotomy is considered minimal. The purpose of this study was to verify changes in hemoglobin (Hb) and hematocrit (Ht) levels following orthognathic surgery of the mandible. Data from 12 patients with a mean age of 27.5 years, from both genders, that were submitted to bilateral sagittal split osteotomy in the prognathism reduction were evaluated. No patient received blood transfusion during the procedure nor postoperatively. Procedures were performed by the same surgeon, with the use of reciprocating and sagittal saws. Levels of Hb and Ht were obtained in preoperative, one day postsurgery, and one, three and six weeks postoperatively. Statistical analyses were used to verify the difference in each group, and between periods. Patients lost a mean decrease in Hb of 2.0 g/dl, and in Ht of 5.2%. There was significant difference as to the levels of Hb (p=0.002) and Ht (p=0.010). These levels presented significant changes from immediate postoperative to six weeks for Hb, and to three weeks for Ht. It was concluded that a slow recovery of hemoglobin and hematocrit levels occurred following orthognathic surgery of the mandible.     

尼卡地平用于正颌手术控制性降压的系统评价和Meta分析

目的:评价尼卡地平用于正颌手术控制性降压的效果.方法:计算机检索英文及中文数据库收集所有相关随机对照试验,2名研究者评价纳入研究质量并提取相关数据,应用Rev Man 5.3.3软件进行数据统计分析.结果:纳入5项RCT,248例患者,Meta分析及定性分析结果显示:尼卡地平组术中出血量显著多于瑞芬太尼组[WMD=43.85,95％ CI (20.52,67.18)],与右美托咪定及硝酸甘油相比无显著差异;输血量各组均无显著差异;尼卡地平控制性降压期间患者心率较降压前显著增快,Q-T间期延长(P＜0.001);使用尼卡地平行控制性降压不影响患者脑氧饱和度及术后神经生理功能;与瑞芬太尼相比,尼卡地平组患者术后尿N-乙酰-β-D-葡萄糖苷酶显著降低(P＜0.05).结论:尼卡地平可有效地达到正颌手术控制性降压要求,可能具有潜在的肾脏保护作用.在减少术中出血方面效果不及瑞芬太尼,可增快患者心率,延长Q-T间期.