Perioperative Blood Transfusion in Head and Neck Cancer Revisited.

OBJECTIVE: To reevaluate the frequency of perioperative blood transfusion, transfusion triggers, and survival impact in patients with incident, surgically treated head and neck cancer (HNC) in restrictive transfusion regimens. METHODS: Retrospective analysis of surgically treated patients with incident HNC with and without perioperative blood transfusion between 2008 and 2019 at the Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, according to the department's clinical Head and Neck Tumor Registry. RESULTS: Of the 590 patients included, perioperative transfusions were administered in 6.3% (n = 37, transfusion group). Following multivariable logistic regression, likelihood of blood transfusions was increased in patients with poorer general health conditions (ASA score III/IV; OR 3.7; 95% CI 1.9-8.6; p = 0.002), hemoglobin <12.5 g/dL (OR 2.7; 95% CI 1.1-6.4; p = 0.03), longer duration of surgery (OR 1.006 per minute of surgery time; 95% CI 1.003-1.008; p < 0.001), and negative p16 status (OR 5.3; 95% CI = 1.1-25; p = 0.03). Based on 14 matching variables related to survival and perioperative blood transfusion, a control group of 37 matching patients without perioperative transfusion was identified. Using univariate analysis, overall survival in transfusion and control groups did not differ significantly (p = 0.25). After adjusting for four parameters with limited matching accuracy (Chi square p < 0.2) in Cox regression analysis, a transfusion related hazard ratio close to 1 (HR 0.92; 95% CI 0.34-2.51; p = 0.87) was observed. CONCLUSION: Considering current restrictive transfusion regimens and general transfusion risks, the administration of blood products in HNC patients during the perioperative period is not associated with additional oncologic hazard. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1638-1644, 2023.

[The Status of Spiroergometry in Preoperative Risk Assessment]. / Spiroergometrie ­ Stellenwert in der präoperativen Risikobeurteilung.

Physical performance is considered as a prognostic factor for perioperative mortality and morbidity. Thus, in recent years, spiroergometry has gained increasing significance in preoperative assessment. Beside the measurement of functional capacity, spiroergometric results may yield indications for cardiocirculatory or pulmonary disorders. A significant increased risk profile is reflected in the values VO2max < 15 ml/kg/min, VO2 at the first ventilatory threshold (VT1) < 11 ml/kg/min, and VE/VCO2 at VT1 > 34. Prior to the examination, contraindications should be taken into account and standardized conduction must be adhered to. Many studies substantiate the positive effect of prehabilitation on morbidity, quality of life, and length of hospitalization, in particular in abdominal, thoracic and hepatobiliary surgery. Using the data acquired in the performance diagnostic, an optimized individual training plan can be drawn up. Besides, the risk evaluation contributes to planning surgical and anaesthetic procedures. Regular training and interdisciplinary teamwork are of utmost importance for the correct interpretation and application of the partly rather complex results.

Reversal of trauma-induced coagulopathy using first-line coagulation factor concentrates or fresh frozen plasma (RETIC): a single-centre, parallel-group, open-label, randomised trial.

BACKGROUND: Effective treatment of trauma-induced coagulopathy is important; however, the optimal therapy is still not known. We aimed to compare the efficacy of first-line therapy using fresh frozen plasma (FFP) or coagulation factor concentrates (CFC) for the reversal of trauma-induced coagulopathy, the arising transfusion requirements, and consequently the development of multiple organ failure. METHODS: This single-centre, parallel-group, open-label, randomised trial was done at the Level 1 Trauma Center in Innsbruck Medical University Hospital (Innsbruck, Austria). Patients with trauma aged 18-80 years, with an Injury Severity Score (ISS) greater than 15, bleeding signs, and plasmatic coagulopathy identified by abnormal fibrin polymerisation or prolonged coagulation time using rotational thromboelastometry (ROTEM) were eligible. Patients with injuries that were judged incompatible with survival, cardiopulmonary resuscitation on the scene, isolated brain injury, burn injury, avalanche injury, or prehospital coagulation therapy other than tranexamic acid were excluded. We used a computer-generated randomisation list, stratification for brain injury and ISS, and closed opaque envelopes to randomly allocate patients to treatment with FFP (15 mL/kg of bodyweight) or CFC (primarily fibrinogen concentrate [50 mg/kg of bodyweight]). Bleeding management began immediately after randomisation and continued until 24 h after admission to the intensive care unit. The primary clinical endpoint was multiple organ failure in the modified intention-to-treat population (excluding patients who discontinued treatment). Reversal of coagulopathy and need for massive transfusions were important secondary efficacy endpoints that were the reason for deciding the continuation or termination of the trial. This trial is registered with ClinicalTrials.gov, number NCT01545635. FINDINGS: Between March 3, 2012, and Feb 20, 2016, 100 out of 292 screened patients were included and randomly allocated to FFP (n=48) and CFC (n=52). Six patients (four in the FFP group and two in the CFC group) discontinued treatment because of overlooked exclusion criteria or a major protocol deviation with loss of follow-up. 44 patients in the FFP group and 50 patients in the CFC group were included in the final interim analysis. The study was terminated early for futility and safety reasons because of the high proportion of patients in the FFP group who required rescue therapy compared with those in the CFC group (23 [52%] in the FFP group vs two [4%] in the CFC group; odds ratio [OR] 25·34 [95% CI 5·47-240·03], p<0·0001) and increased needed for massive transfusion (13 [30%] in the FFP group vs six [12%] in the CFC group; OR 3·04 [0·95-10·87], p=0·042) in the FFP group. Multiple organ failure occurred in 29 (66%) patients in the FFP group and in 25 (50%) patients in the CFC group (OR 1·92 [95% CI 0·78-4·86], p=0·15). INTERPRETATION: Our results underline the importance of early and effective fibrinogen supplementation for severe clotting failure in multiple trauma. The available sample size in our study appears sufficient to make some conclusions that first-line CFC is superior to FFP. FUNDING: None.

Damage control surgery with abdominal vacuum and delayed bowel reconstruction in patients with perforated diverticulitis Hinchey III/IV.

OBJECTIVE: With the use of abdominal vacuum therapy, we have developed a damage control concept for patients with perforated diverticulitis and generalized peritonitis. The primary aim of this concept was to enhance recovery and allow bowel reconstruction in a second-look operation. METHODS: A total of 51 patients (28 female, 55%) with a median (range) age of 69 (28-87) years, with perforated diverticulitis Hinchey III (n = 40, 78%) or Hinchey IV (n = 11, 22%) and a median (range) Mannheim peritonitis index of 26 (12-39), admitted between October 2006 and September 2011, were prospectively enrolled in the study. At initial operation, limited resection of the diseased segment, lavage, and application of abdominal vacuum-assisted closure dressing was performed. After patient resuscitation, a second look was performed in an elective setting. RESULTS: Hospital mortality rate was 9.8%; 35 (76%) of patients were discharged with reconstructed colon, and 93% of patients live without a stoma at follow-up. Risk factors for mortality were American Society of Anesthesiologist score (p = 0.01), organ failure at initial presentation (p = 0.03), cardiac comorbidity (p = 0.05), and a Hartmann procedure at second look (p = 0.00). CONCLUSION: With this abdominal vacuum-based damage control concept, an acceptable hospital mortality rate and a high rate of bowel reconstruction at second look were achieved in patients with perforated diverticulitis and generalized peritonitis.

Role of arginine vasopressin in the setting of cardiopulmonary resuscitation.

Arginine vasopressin (AVP) constitutes an integral part of the neuroendocrine stress response during cardiac arrest. A strong correlation between endogenous AVP secretion and outcome from cardiac arrest has led to a number of experimental studies indicating a survival benefit of AVP compared to epinephrine. In the clinical setting, however, things are less clear. Although current data suggest that both epinephrine and AVP are equally effective to restore spontaneous circulation in out-of-hospital cardiac arrest, benefits of AVP in specific patient groups, e.g. those with asystolic cardiac arrest, have been shown. The latest international guidelines recommend AVP as an alternative vasopressor drug which may replace the first or second dosage of epinephrine in the treatment of pulseless arrest If the combined use of AVP and epinephrine is superior to epinephrine alone in terms of improved hospital admission and discharge rates this needs to be re-confirmed by the results of an ongoing multicenter trial.

Arginine vasopressin: a promising rescue drug in the treatment of uncontrolled haemorrhagic shock.

Haemorrhagic shock is one of the most frequent types of shock. If haemorrhage cannot be controlled and fluid resuscitation as well as catecholamines are insufficient to stabilize cardiovascular function, uncontrolled haemorrhagic shock occurs. Several approaches have been suggested as promising alternatives to volume resuscitation. The rationale for the use of arginine vasopressin (AVP) is the pharmacologic amplification of the neuroendocrine stress response. AVP-mediated vasoconstriction is the first physiologic step to haemostasis and shifts blood away from the bleeding site towards the heart, lungs and brain. Particularly, when uncontrolled haemorrhage is accompanied by traumatic brain injury this may help to reduce secondary neurological damage. Since AVP can prevent acute death only transiently, it must comprehensively be combined with rapid hospital admission, immediate control of haemorrhage followed by aggressive fluid resuscitation and blood transfusion. This review article summarizes current experimental and clinical evidence on the use of AVP in uncontrolled haemorrhagic shock.

Preventing cardiac arrest during hemorrhagic shock with vasopressin.

The optimal strategy of stabilizing hemodynamic function in uncontrolled traumatic hemorrhagic shock states is unclear. Although fluid replacement is established in controlled hemorrhagic shock, its use in uncontrolled hemorrhagic shock is controversial, because it may worsen bleeding. In the refractory phase of severe hemorrhagic shock, arginine vasopressin has been shown to be beneficial in selected cases due to an increase in arterial blood pressure, shift of blood away from a subdiaphragmatic bleeding site toward the heart and brain, and decrease in fluid-resuscitation requirements. Especially in patients with severe traumatic brain injury, rapid stabilization of cardiocirculatory function is essential to ensure adequate brain perfusion, thus, to prevent neurologic damage and to improve outcome. In addition, despite wide distribution of highly developed and professional emergency medical systems in western industrialized countries, survival chances of patients with uncontrolled traumatic hemorrhagic shock in the preclinical setting are still poor.

Arginine vasopressin during sinus rhythm: effects on haemodynamic variables, left anterior descending coronary artery cross sectional area and cardiac index, before and after inhibition of NO-synthase, in pigs.

UNLABELLED: We have shown previously that arginine vasopressin (AVP) given during sinus rhythm increases mean arterial blood pressure (MAP) and left anterior descending (LAD) coronary artery cross sectional area. AVP was assumed to result in vasodilatation via activation of the endothelial nitric oxide system. The purpose of the present study was to assess the effects of AVP before and after NO-inhibition. Nine domestic pigs were instrumented for measurement of haemodynamic variables using micromanometer-tipped catheters, and measurement of LAD coronary artery cross sectional area employing intravascular ultrasound (IVUS). Haemodynamic variables, LAD coronary artery cross sectional area and cardiac output were measured at baseline, 90 s and 5, 15, and 30 min after AVP (0.4 U kg (-1) IV) before and after blockade of nitric oxide synthase with N(G)-nitro L-arginine methyl ester (L-NAME). Compared with baseline, AVP significantly increased MAP after 90 s (89+/-4 versus 160+/-5 mm Hg), increased LAD coronary artery cross sectional area (11.3+/-1 versus 11.8+/-1 mm(2)) and decreased cardiac index (138+/-6 versus 53+/-6 mL/min kg(-1)). After blockade of nitric oxide synthase, AVP significantly increased MAP after 90 s (135+/-4 versus 151+/-3 mm Hg), increased LAD coronary artery cross sectional area (8.7+/-1 versus 8.9+/-1 mm(2)), and significantly decreased cardiac index (95+/-6 versus 29+/-4 mL/min kg (-1)). IMPLICATIONS: During sinus rhythm, AVP increased MAP and LAD coronary artery cross sectional area, but decreased cardiac index.