Does salvage and tranexamic acid reduce the need for blood transfusion in revision hip surgery?

We carried out a retrospective case-control study in 80 patients who underwent a revision total hip replacement. Group A (40 patients) received tranexamic acid and intra-operative cell salvage. Group B (40 patients) was a matched control group and did not receive this management. Each group was divided into four subgroups: revision of both components, revision of both components with bone grafting, revision of the acetabular component with or without bone graft, and revision of the femoral component with or without bone graft. In group A the total number of units transfused was 52, compared with 139 in group B, representing a reduction in blood usage of 62.5%. The mean amount of blood transfused from cell salvage in each group was 858 ml (113 to 2100), 477 ml (0 to 2680), 228 ml (75 to 315) and 464 ml (120 to 1125), respectively. There was a significant difference in the amount of blood returned between the groups (p < 0.0001). In group A, 22 patients needed transfusion and in group B, 37 (p < 0.0001). A cost analysis calculation showed a total revenue saving of pounds sterling 70 000 and a potential saving throughout our facility of pounds sterling 318 288 per year. Our results show that a significant reduction in blood transfusion can be made using combined cell salvage and tranexamic acid in revision surgery of the hip.     

Is perioperative blood transfusion a risk factor for mortality or infection after hip fracture?

OBJECTIVES: To assess whether allogeneic blood transfusion in the perioperative period is associated with changes in mortality or complication rates in patients undergoing surgical treatment for hip fracture (proximal femoral fracture). DESIGN: Retrospective case-control series, all patients followed up for 1 year or until death. SETTING: District General Hospital in Peterborough, UK. PATIENTS PARTICIPANTS: Three thousand six hundred twenty-five consecutive patients admitted and operated for hip fracture (proximal femoral fracture) during July 1989 to January 2002 (151 months); 1068 (29.9%) received a perioperative allogeneic blood transfusion. MAIN OUTCOME MEASURES: Thirty- 120-, and 365-day mortality, deep and superficial wound infection rates. RESULTS: Overall mortality for all patients at 1 year post fracture was 28.2% (1007 patients). Transfusion was associated with a statistically significant increase in mortality from 120 days onward after hip fracture. However, when this was adjusted with a statistical regression model for baseline characteristics and confounding variables, this difference became statistically insignificant (P = 0.17). Infection rates in the transfusion group were 2.0% for superficial infection and 0.9% for deep infection compared with 1.9% and 0.6%, respectively, in the nontransfusion group. These figures were not statistically significantly different. Other complications of deep venous thrombosis, chest infection, and congestive cardiac failure showed no statistically significant increase in those patients who received transfusion. CONCLUSIONS: Our data suggest that transfusion is not associated with a change in mortality or infection rates in the hip-fracture patient.     

Is homologous blood transfusion a risk factor for infection after hip replacement?

OBJECTIVES: To assess the risk of postoperative infection associated with blood transfusion in patients who undergo primary total hip arthroplasty. DESIGN: A retrospective cohort study. SETTING: Victoria General Hospital, Halifax, (a tertiary-care centre). PATIENTS: All patients who underwent primary total hip replacement between 1990 and 1995 (N = 1206). INTERVENTIONS: Hip replacement with or without perioperative blood transfusion. OUTCOME MEASURES: The rate of postoperative infection, the number of blood transfusions, patient age and sex, duration of surgery and the surgeon who performed the procedure. Victoria General Hospital medical records, the transfusion services record and the Dalhousie University Hip Study databases were integrated and analyzed using a standard statistical package. RESULTS: The incidence of infection postoperative was 9.9% overall, 8.4% in patients receiving no transfusion, and 14% in those receiving homologous transfusion (p = 0.035). There were no infections in the 11 patients who received an autologous blood transfusion. Significant predictors of postoperative infection were sex, age and duration surgery; these were not confounding variables multivariate analysis). Neither the operating surgeon nor the blood product transfused affected the infection rate. CONCLUSIONS: These findings suggest an increased risk of postoperative infection in patients who undergo primary hip replacement and receive homologous blood transfusions perioperatively.     

Can early surgery reduce the need to packed red blood cell transfusion in elderly patients with intertrochanteric femur fractures?

IntroductionThis study was designed to compare and analyse the amount of packed red blood cell transfusions (PRBCTs) in relation to surgical timing in elderly patients undergoing cephalomedullary nailing due to intertrochanteric fractures.Materials and methodsA total of 110 patients (24 men, 86 women) who had received cephalomedullary nailing for intertrochanteric fractures were retrospectively investigated. A restrictive transfusion strategy was followed during the peri-operative period. Patient characteristics and fracture classifications, methods of anaesthesia, time interval from admission to surgery (TI) and operative duration (OD) were investigated. The amount of PRBCTs was measured and categorised as pre-operative, post-operative and entire peri-operative values. The patients were divided into early surgery (ES) and delayed surgery (DS) groups based on surgical treatment within or after 48 h of admission. In addition, multiple regression analysis including TI and other factors likely to affect blood loss and PRBCT was conducted to objectively evaluate the impact of TI on the amount of the entire peri-operative PRBCT.ResultsThe patients had a mean age of 82.6 years (range, 68–98), mean TI of 41.1 h (range, 5–110) and mean OD of 37 min (range, 15–90). Although the amount of pre-operative PRBCT was significantly different between the ES and DS groups (36.2 ml vs. 168.3 ml, p < 0.001), they displayed no remarkable difference regarding post-operative and the entire peri-operative amount of PRBCTs (279.7 ml vs. 189.8 ml, p = 0.064 and 315.9 ml vs. 358.0 ml, p = 0.992, respectively). The results from multiple regression analysis demonstrated that TI did not significantly affect the amount of the entire peri-operative PRBCT.ConclusionsIf an appropriate transfusion strategy is adopted, TI does not seem to affect the amount of peri-operative PRBCT in elderly patients with intertrochanteric fractures. Nevertheless, careful transfusion management with a view to compensating for any drop in pre-operative haemoglobin is necessary when surgery is delayed.     

Should we reconsider triggers for red blood cell transfusion?

Very few randomized controlled trials on the benefits of red blood cell (RBC) transfusions in humans have been published. Consequently, most clinical practice guidelines remain based on expert opinion, animal studies and the limited human trials available. In the absence of definitive outcome studies, numerous theoretical arguments have been put forward either to support or to condone the classic transfusion threshold of 10 g/dL. However, the limited data available from randomized controlled trials suggest that a restrictive transfusion strategy (transfusion threshold between 7 and 8 g/dL) is associated with decreased transfusion requirements, that overall morbidity (including cardiac morbidity) and mortality, hemodynamic, pulmonary and oxygen transport variables are not different between restrictive and liberal transfusion strategies and, finally, that a restrictive transfusion strategy is not associated with increased adverse outcomes. In fact, a restrictive strategy may be associated with decreased adverse outcomes in younger and less sick critical care patients. The majority of existing guidelines conclude that transfusion is rarely indicated when the hemoglobin concentration is greater than 10 g/dL and is almost always indicated when it falls below a threshold of 6 g/dL in healthy, stable patients or more in older, sicker patients. In anesthetized patients, this threshold should be modulated by factors related to the dynamic nature of surgery, such as uncontrolled hemorrhage, coagulopathy, etc. Since transfusions are administered to correct inadequate oxygen delivery, whether global or regional, reliable monitors of tissue oxygenation will be required to study the benefits (or lack thereof) of RBC transfusions. The quest for a universal transfusion trigger, the holy grail of transfusion medicine, must be abandoned. All RBC transfusions must be tailored to the patient's needs, at the moment the need arises. In conclusion most published recommendations are appropriate but their conclusions are limited, as they are commensurate with existing knowledge. Reliable monitors to guide transfusion therapy and well conducted trials to determine optimal transfusion strategies are required.     

Can laparoscopy for colon resection reduce the need for discharge to skilled care facility?

Background

A significant proportion of patients, especially the elderly undergoing colon resections, are likely to be discharged to a skilled care facility. This study aims to examine whether the technique of colectomy, open versus laparoscopic, contributed to their discharge to a skilled care facility.

Methods

This was a retrospective analysis using discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Adult patients who underwent colectomy in 2009 were evaluated. SAS and SUDAAN software were used to provide weighted estimates and to account for the complex sampling design of the NIS. We compared routine discharge to nonroutine discharge, defined as transfer to short-term hospital, skilled nursing facility, intermediate care, home health, or another type of facility.

Results

A weighted total of 221,294 adult patients underwent colectomy in 2009 and had the primary outcome of discharge available. Of these colon resections, 70,361 (32 %) were performed laparoscopically and 150,933 (68 %) by open technique. A total of 139,047 (62.8 %) patients had routine discharge and 73,572 (33.3 %) nonroutine. A total of 8,445 (3.8 %) patients died while in the hospital, and 229 (0.1 %) left against medical advice and were excluded from further analysis. On univariate analysis, age ≥65 years, female gender, Black/Hispanic race, open technique (compared to laparoscopic), Medicare/Medicaid insurance status, comorbidity index of ≥1, and malignant primary diagnosis predicted nonroutine discharge. A multivariate logistic model was then used to predict nonroutine discharge in these patients using variables significant in the univariate analysis at the α = 0.05 significance level. In the multivariate analysis, open compared to laparoscopic technique was independently associated with increased likelihood of discharge to skilled care facilities (odds ratio 2.85, 95 % confidence interval 2.59–3.14).

Conclusions

In addition to the expected factors like advancing age, female gender, and increasing comorbidity index, open compared to laparoscopic technique for colectomy is associated with an increased likelihood of discharge to skilled care facilities. When feasible, the laparoscopic technique should be considered as an option, especially in the elderly patients who require colon resection, because it may reduce their likelihood of discharge to a skilled care facility.     

Complications after hip fracture surgery: are they preventable?

European Journal of Trauma and Emergency Surgery - Surgery for hip fractures is frequently followed by complications that hinder the rehabilitation of patients. The aim of this study was to...     

Can the salvaged autologous blood transfusion be safe during TIVA?

BACKGROUND: This study aimed to determine whether the salvaged blood can be safely used after surgery and to examine the blood concentration of anesthetics in salvaged blood processed by autologous transfusion device (Cell Saver 5, Haemonetics Corp.) during propofol anesthesia. METHODS: Ten consenting patients (aged 48-79 yr, classified ASA physical status I or II) scheduled for total hip arthroplasty were randomly divided into two groups: in the first group, slowing pattern of electroencephalographic activity (moderate-dose group: M) was obtained and in the second group, a burst-suppression (high-dose group: H) was obtained. Employing the electroencephalogram (EEG) and spectral edge frequency, propofol was titrated to maintain the EEG pattern. All patients received propofol anesthesia combined with lumbar epidural anesthesia. RESULTS: The infusion rates of propofol at the end of surgery were 9.6 +/- 1.1 (H) and 7.0 +/- 1.4 mg.kg-1.h-1(M), respectively. The blood concentration of propofol in the H group was significantly greater than that in the M group. But no significant difference was observed in the salvaged blood concentration of propofol between the two groups (H: 0.391 +/- 0.158 microgram.ml-1, M: 0.401 +/- 0.236 microgram.ml-1). CONCLUSION: The concentrations of propofol in salvaged blood were low, irrespective of the different infusion rates. These results demonstrate that salvaged autologous blood would not contribute to sedative or anesthetic effect.     

What works? Interventions to reduce readmission after hip fracture: A rapid review of systematic reviews

BackgroundHip fracture is a common serious injury in older people and reducing readmission after hip fracture is a priority in many healthcare systems. Interventions which significantly reduce readmission after hip fracture have been identified and the aim of this review is to collate and summarise the efficacy of these interventions in one place.MethodsIn a rapid review of systematic reviews one reviewer (ELS) searched the Ovid SP version of Medline and the Cochrane Database of Systematic Reviews. Titles and abstracts of 915 articles were reviewed. Nineteen systematic reviews were included. (ELS) used a data extraction sheet to capture data on interventions and their effect on readmission. A second reviewer (RK) verified data extraction in a random sample of four systematic reviews. Results were not meta-analysed. Odds and risk ratios are presented where available.ResultsThree interventions significantly reduce readmission in elderly populations after hip fracture: personalised discharge planning, self-care and regional anaesthesia. Three interventions are not conclusively supported by evidence: Oral Nutritional Supplementation, integration of care, and case management. Two interventions do not affect readmission after hip fracture: Enhanced Recovery pathways and comprehensive geriatric assessment.ConclusionsThree interventions are most effective at reducing readmissions in older people: discharge planning, self-care, and regional anaesthesia. Further work is needed to optimise interventions and ensure the most at-risk populations benefit from them, and complete development work on interventions (e.g. interventions to reduce loneliness) and intervention components (e.g. adapting self-care interventions for dementia patients) which have not been fully tested yet.     

The use of the autologous blood transfusion to the respiratory surgery: autologous blood transfusion or no-blood transfusion surgery?

We could report the effect of the autologous blood transfusion to the lobectomy, by comparison with no-blood transfusion group and MAP-red cell concentrate transfused group (MAP group). Autologous blood which was stored three days before an operation and preserved at 4 degrees C kept 89.9 +/- 11.7% of the number of erythrocyte and 59.6 +/- 23.4% of platelet. Autologous blood transfusion group and MAP group showed significantly more than no-blood transfusion group on the number of erythrocyte at the time of discharge. These facts suggest that the autologous blood has an ability of coagulation. We concluded that on lobectomy autologous blood transfusion was better than MAP-red cell concentrate transfusion in point of protection from disease transmission and better than no-blood transfusion in point of post-operative recovery.     

Do we need intraoperative radiographs for positioning the femoral component in total hip arthroplasty?

Introduction

Poor long-term results of total hip arthroplasty (THA) can result from femoral component misalignment. There are few reports that discuss the effectiveness of intraoperative radiographs for placing femoral components. This study is a retrospective review to find out the usefulness of intraoperative radiographs in detecting and improving the femoral component misalignment in posterior-approached primary THA.

Materials and methods

The study group included 150 primary THAs performed between September 2009 and April 2012. After the trial component insertion in lateral decubitus position, intraoperative radiography was performed. The surgeon assessed the femoral component position in three aspects: alignment, leg length, and offset. If it is not following the preoperative template, the surgeon makes the intraoperative adjustments to change the femoral component position. After the operation, postoperative radiograph was taken; the same parameters were measured and were compared to intraoperative findings. The changes in each parameter were classified into three categories: satisfactory, no change, and unsatisfactory. Among the three parameters, if one is satisfactory and the others are not unsatisfactory, we defined it as accurate positioning of the femoral component.

Results

Intraoperative adjustments were made in 122 cases (81.3 %). The adjustments included changes in the component size (35.3 %), component alignment (38.6 %), femoral offset (14.0 %), and additional femoral neck cuts (56.0 %). As a result, accurate positioning was successfully achieved in 112 cases (91.8 %) by taking intraoperative radiographs.

Conclusion

Our data suggest that intraoperative radiography is a useful method for detecting the errors of placing the femoral components, and the success of a surgeon to correct those errors after detecting them intraoperatively.     

Can FDG-PET reduce the need for mediastinoscopy in potentially resectable nonsmall cell lung cancer?

BACKGROUND: Few fluoro-deoxy-glucose (FDG)-positron emission tomography (PET) nonsmall cell lung cancer (NSCLC) trials have had sufficient patients to adequately evaluate PET for mediastinal staging. We question whether once PET is performed, is mediastinoscopy necessary? METHODS: We performed a 5-year retrospective analysis of operable patients with known or suspicious NSCLC. Standard PET techniques were used. Inclusion criteria were (1) surgical mediastinal nodal sampling by mediastinoscopy within 31 days of the PET and (2) definitive diagnosis. RESULTS: There were 237 patients who met the evaluation criteria; ninety-nine patients with NSCLC and 138 with suspicious lesions (137 men and 100 women; aged 20 to 88 years). The PETs were performed from 0 to 29 days before mediastinoscopy (median, 7 days). The standardized uptake value for the primary lesion was 0 to 24.6 (7.9+/-5.0). Nine primary lesions had no FDG uptake (1 benign, 8 NSCLCs). Seventy-one patients (31%) had mediastinal PET positive disease, and 44 patients (19%) had histologic positive mediastinal disease; N2 41 patients (17%) and N3 9 patients (4%). In 6 patients (3%), the initial frozen sections were negative, but PET positivity encouraged further biopsies that were positive for cancer. The PET sensitivity was 82%, specificity 82%, accuracy 82%, negative predictive value 95%, and positive predictive value was 51%. All primary lesions with a standardized uptake value less than 2.5 and a negative mediastinal PET were negative histologically (n = 29). Logistic regression analysis resulted in 100% specificity for PET in this group. CONCLUSIONS: In NSCLC PET may reduce the necessity for mediastinoscopy when the primary lesion standardized uptake value is less than 2.5 and the mediastinum is PET negative. Accepting this approach in our patient population, the need for mediastinoscopy would have been reduced by 12%.