Development of the functional recovery index for ambulatory surgery and anesthesia.

BACKGROUND: It is increasingly important to evaluate patients' recovery after ambulatory surgery. The authors developed the Functional Recovery Index (FRI) to assess postdischarge functional recovery for ambulatory surgical patients. METHODS: The scale development involved four phases: item generation, item selection, reliability, and validity testing. A draft questionnaire was tested and revised. Items were selected through testing endorsement frequency, factor analysis, and testing internal consistency. The interrater reliability was calculated. Construct validity was tested by multiple hypotheses on convergent validity, extreme groups, and discriminant validity. Responsiveness was assessed by measuring the FRI postoperatively and comparing minor versus more extensive surgery. The rate of response and the time for completion of the questionnaire were recorded. RESULTS: The final questionnaire had 14 items grouped under 3 factors. Each item was scored from 0 to 10, with 0 = no difficulty and 10 = extreme difficulty with the activity. The 3 factors were summated for a total score. Internal consistency for the 3 factors (pain and social activity, lower limb activity, and general physical activity) was as follows: Cronbach alpha = 0.90, 0.89, and 0.86, respectively. Interrater reliability was 0.99. Convergent validity for FRI versus verbal rating scale pain score was 0.76. Discriminant validity testing showed that the type of surgery was significant and that intermediate (beta = 0.138) and major surgery (beta = 0.337) were associated with higher FRI scores than minor surgery. The time to complete the questionnaires ranged between 4 min 10 s and 4 min 35 s. CONCLUSIONS: The FRI had excellent reliability, good validity, responsiveness, and acceptability, indicating that this questionnaire will be a good instrument for assessing functional recovery of ambulatory surgical patients.

Tranexamic Acid reduces perioperative blood loss in adult patients having spinal fusion surgery.

BACKGROUND: Spinal reconstructive surgery in adults can be associated with significant blood loss, often requiring allogeneic blood transfusion. The objective of this randomized, prospective, double-blind, multicenter study was to evaluate the efficacy of tranexamic acid (TXA) in reducing perioperative blood loss and transfusion in adult patients having elective posterior thoracic/lumbar instrumented spinal fusion surgery. METHODS: One hundred fifty-one adult patients were randomized to receive either a bolus of 10 mg/kg IV of TXA after induction followed by a maintenance infusion of 1 mg/kg/hr of TXA, or an equivalent volume of placebo (normal saline). The primary outcome was the total perioperative estimated and calculated blood loss intraoperatively and 24 h postoperatively. Secondary outcomes were incidence of allogeneic blood exposure, and duration of hospital stay. RESULTS: Four patients were withdrawn for identifiable surgical bleeding, therefore 147 patients were included in the analysis. The total estimated and calculated perioperative blood loss was approximately 25% and 30% lower in patients given TXA versus placebo (1592 +/- 1315 mL vs 2138 +/- 1607 mL, P = 0.026; 3079 +/- 2558 vs 4363 +/- 3030, P = 0.017), respectively. There was no difference in the amounts of blood products transfused, and length of stay between the two groups. TXA, surgical duration, and number of vertebrae fused were independent factors related to perioperative blood loss. Predictors for the need for allogeneic red blood cell transfusion were ASA classification, surgical duration and number of levels fused. CONCLUSIONS: TXA significantly reduced the estimated and calculated total amount of perioperative blood loss in adult patients having elective posterior thoracic/lumbar instrumented spinal fusion surgery.

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

BACKGROUND: Topical application of tranexamic acid to bleeding wound surfaces reduces blood loss in patients undergoing some major surgeries, without systemic complications. The objective of the present trial was to assess the efficacy and safety of the topical application of tranexamic acid on postoperative blood loss in patients undergoing primary unilateral total knee arthroplasty with cement. METHODS: In a prospective, double-blind, placebo-controlled trial, 124 patients were randomized to receive 1.5 or 3.0 g of tranexamic acid in 100 mL of normal saline solution or an equivalent volume of placebo (normal saline solution) applied into the joint for five minutes at the end of surgery. The primary outcome was blood loss calculated from the difference between the preoperative hemoglobin level and the corresponding lowest postoperative value or hemoglobin level prior to transfusion. The safety outcomes included Doppler ultrasound in all patients and measurement of plasma levels of tranexamic acid one hour after release of the tourniquet. RESULTS: Twenty-five patients were withdrawn for various reasons; therefore, ninety-nine patients were included in the intention-to-treat analysis. The postoperative blood loss was reduced in the 1.5 and 3-g tranexamic acid groups (1295 mL [95% confidence interval, 1167 to 1422 mL] and 1208 mL [95% confidence interval, 1078 to 1339 mL], respectively) in comparison with the placebo group (1610 mL [95% confidence interval, 1480 to 1738 mL]) (p < 0.017). The postoperative hemoglobin levels were higher in the 1.5 and 3.0-g tranexamic acid groups (10.0 g/dL [95% confidence interval, 9.5 to 10.4 g/dL] and 10.1 g/dL [95% confidence interval, 9.8 to 10.5 g/dL], respectively) in comparison with the placebo group (8.6 g/dL [95% confidence interval, 8.2 to 9 g/dL]) (p < 0.017). With the numbers studied, there was no difference in the rates of deep-vein thrombosis or pulmonary embolism between the three groups. Minimal systemic absorption of tranexamic acid was observed. CONCLUSIONS: At the conclusion of a total knee arthroplasty with cement, topical application of tranexamic acid directly into the surgical wound reduced postoperative bleeding by 20% to 25%, or 300 to 400 mL, resulting in 16% to 17% higher postoperative hemoglobin levels compared with placebo, with no clinically important increase in complications being identified in the treatment groups.