Blood on the drapes: A multispecialty comparison of blood spill estimates.

INTRODUCTION: Estimated blood loss (EBL) is an important part of the perioperative process. This project aims to determine the accuracy of perioperative team members to estimate blood volume on drapes and the operating room floor. METHODS: Aliquots of unused human blood were used to create surgical scenarios, and standardized pictures and videos were taken. Physicians, residents, nurses, medical students, and surgical technicians were surveyed and asked to estimate the blood volume for each series. Accuracy and consistency of responses was analyzed. RESULTS: One hundred and forty five responses were recorded: 57 attending physicians, 36 residents, 27 registered nurses, 17 medical students, and seven circulating surgical techs. Median percent error (PE) for all cases was 211.11%, demonstrating a global overestimation of blood volume. PE for the 150 mL images was statistically significantly lower than that of the 50 and 100 mL images. Circulating Surgical Technicians were the most accurate group, with a median PE of 125%, followed closely by Medical Students (PE = 158.33%). The most accurate specialty was Orthopedics (PE = 168.06%). The least accurate groups were Attending Physicians (PE = 286.11%) and General surgery (GSGY) (PE = 327.78%). The most accurate orthopedic surgery and GSGY subspecialties were Hand (PE = 237.64%) and Vascular (PE = 108.33%), respectively. Statistical analyses showed no significant differences by clinical role, surgical specialty, or subspecialty. CONCLUSION: This study demonstrates a global overestimation of blood volume when using the visual method, with improved accuracy at higher volumes. Our findings highlight the limitations of visual estimation methods for EBL.

Blood loss quantification during major abdominal surgery: prospective observational cohort study.

BACKGROUND: Blood loss during major abdominal surgery is an essential parameter in the evaluation of strategies aimed at reducing perioperative bleeding. However, blood loss quantification remains unreliable and inaccurate. The aim of this study was to compare several methods of blood loss quantification-visual estimation by surgeon and anesthesiologist, the gravimetric method, the calculation method with spectrophotometric measurement. The spectrophotometric measurement is considered as the most accurate method. METHODS: The study was designed as a prospective observational cohort single-center study. We analyzed 61 patients who underwent elective liver or pancreatic resection. The anesthesiologists' and surgeons' estimate of blood loss was based on a visual assessment. The gravimetric method was based on weighing the suction canister and surgical drapes before and after use. The basis of calculation method was anthropometric and hematological parameters, we used López-Picado's formula. The spectrophotometric method was based on the spectrophotometric determination of hemoglobin mass in the lost blood. We compared the methods using paired t-test, non-parametric Wilcoxon test and Bland-Altman analysis. RESULTS: Visual estimation by surgeons and anesthesiologists, gravimetric measurement, and calculation method were significantly different from spectrophotometric measurement at the significance level α = 0.05. All methods overestimated blood loss which was measured by spectrophotometric method. The estimate by surgeons was the closest to the spectrophotometric measurement, difference 68.7 ml (95% confidence interval [CI]: -129.3--8.2). CONCLUSIONS: We conclude that the estimate of blood loss by surgeons and anesthesiologists, as well as gravimetric method and calculation method are all significantly inaccurate in real surgical setting. We did not confirm the commonly accepted assumption that surgeons underestimate the blood loss. TRIAL REGISTRATION: The study was registered under the title " Blood Loss Quantification During Major Abdominal Surgery" at ClinicalTrials.gov with the registration number NCT05316649. Date of the first registration was 20/3/2022.

Maternal body weight and estimated circulating blood volume: a review and practical nonlinear approach.

Postpartum haemorrhage continues to be a leading cause of morbidity and mortality in the obstetric population worldwide, especially in patients at extremes of body weight. Quantification of blood loss has been considered extensively in the literature. However, these volumes must be contextualised to appreciate the consequences of blood loss for individual parturients. Knowledge of a patient's peripartum circulating blood volume is essential to allow accurate interpretation of the significance of haemorrhage and appropriate resuscitation. Greater body weight in obesity can lead to overestimation of blood volume, resulting in inappropriately high thresholds for blood product transfusion and delays in treatment. The most recent Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) surveillance report demonstrated the risk to this population, with more than half of all maternal mortality recorded in parturients who were either overweight or obese. Current linear calculations used to estimate circulating blood volumes based on patients' weights could be contributing to this phenomenon, as blood volume increases at a disproportional rate to body composition. In this review, we summarise the relevant physiology and explore the existing literature on the estimation of circulating blood volume, both during pregnancy and in obesity. Building on key works and principal findings, we present a practical, nonlinear approach to the adjustment of estimated blood volume with increasing body mass. This clinical tool aims to reduce the clinical bias influencing the management of obstetric haemorrhage in a population already at increased risk of morbidity and mortality. Discussion of the limitations of this approach and the call for further research within this field completes this review.

Effect of tourniquet application on postoperative outcomes in sinus tarsi approach for intra-articular calcaneus fractures.

INTRODUCTION: Tourniquets are commonly used during foot and ankle surgery to provide a bloodless operative field and increase surgical comfort, despite the potential risks associated with it. This study compared postoperative outcomes of tourniquet-assisted and non-tourniquet-assisted operative fixation of calcaneal fractures via the sinus tarsi approach. MATERIALS AND METHODS: A retrospective study from March 2015 to December 2018 revealed 131 patients with closed calcaneal fractures who underwent minimally invasive surgery at our hospital. Visualization, operating time, blood loss, and postoperative pain were collected. Patients in the tourniquet group (n = 62) were compared with patients in the non-tourniquet group (n = 69). RESULTS: The visibility of the surgical field was fair/poor in 2 cases in the tourniquet group and fair/poor in 19 cases in the non-tourniquet group (P < 0.05). The mean operative time was 64.7 ± 3.5 min in the tourniquet group and 76.0 ± 6.1 min in the non-tourniquet group (P < 0.05). The estimated intraoperative and postoperative blood loss was 56.6 ± 33.3 and 100.0 ± 25.3 mL, respectively, in the tourniquet group and 205.0 ± 31.6 and 38.3 ± 19.8 mL, respectively, in the non-tourniquet group (P < 0.05). The VAS pain scores 24 h, 48 h, and 72 h postoperatively were 4.3 ± 1.8, 3.1 ± 1.2, and 2.0 ± 0.5 points, respectively, in the tourniquet group and 2.1 ± 1.1, 1.6 ± 1.0, and 1.0 ± 0.3 points, respectively, in the non-tourniquet group (P < 0.05). CONCLUSION: Tourniquet application during the sinus tarsi approach for calcaneal fractures can significantly improve surgical visualization and reduce intraoperative blood loss. However, adverse events associated with the use of tourniquets include increased postoperative pain and bleeding. Due to increased postoperative bleeding and pain, more attention should be given to the postoperative phase in patients treated with tourniquets.

Optimal Release Timing of Drain Clamping to Reduce Postoperative Bleeding after Total Knee Arthroplasty with Intraarticular Injection of Tranexamic Acid.

Background and Objectives: Intraarticular injection of tranexamic acid (IA-TXA) plus drain-clamping is a preferred method of reducing bleeding after total knee arthroplasty (TKA). However, no consensus has been reached regarding the timing of the clamping. The purpose of this study was to determine the optimum duration of drain-clamping after TKA with IA-TXA. Materials and Methods: We retrospectively reviewed 151 patients that underwent unilateral TKA with IA-TXA plus drain-clamping for 30 min, 2 h, or 3 h. The total drained volume was reviewed as the primary outcome, and hematocrit (Hct) reductions, estimated blood loss (EBL), transfusion rates, and wound complications were reviewed as secondary outcomes. Results: The mean total drained volume, Hct reduction, and EBL were significantly less in the 3 h group than in the 30 min group. Between the 2 h and 3 h groups, there was no statistical difference in the mean total drained volume, Hct reduction, or EBL. The proportion of patients who drained lesser than 300 mL was high in the 3 h group. No significant intergroup difference was observed for transfusion volume, transfusion rate, and wound related complications. Conclusions: In comparison of the IA-TXA plus drain-clamping after TKA, there was no difference in EBL between the 2 h group and the 3 h group, but the amount of drainage volume was small in the 3 h group.

Does simulation improve clinical performance in management of postpartum hemorrhage?

BACKGROUND: Although simulation is now widely used to improve teamwork and communication, data demonstrating improvement in clinical outcomes are limited. OBJECTIVE: This study aimed to examine the clinical performance and outcomes associated with postpartum hemorrhage because of uterine atony following the implementation of a multidisciplinary simulation program. STUDY DESIGN: This was a prospective observational study of response to postpartum hemorrhage because of uterine atony in an academic medical center before (epoch 1: July 2017-June 2018) and after (epoch 2: July 2019-June 2020) implementing a multidisciplinary simulation program. A total of 22 postpartum hemorrhage simulations were performed from July 2018 to June 2019 involving more than 300 nursing, obstetrical, and anesthesia providers. The simulation program focused on managing postpartum hemorrhage events and improving teamwork and communication of the multidisciplinary teams. To evaluate the clinical effectiveness of the simulation program, the primary outcome was response to postpartum hemorrhage defined as the time from the administration of uterotonic medications to transfusion of the first unit of blood in the first 12 hours following delivery, comparing epoch 2 to epoch 1 following the implementation of a simulation program. Statistical analysis included the use of the Pearson chi-square test, Wilcoxon rank-sum test, Hodges-Lehmann statistic for differences, and bootstrap methods with a P value of <.05 considered significant. RESULTS: Between July 1, 2017, and June 30, 2018, there were 12,305 patients who delivered, of which 495 patients (4%) required transfusion. Between July 1, 2019, and June 30, 2020, there were 12,414 patients who delivered, of which 480 patients (4%) required transfusion. When isolating cases of postpartum hemorrhage because of uterine atony in both transfused groups, there were 157 women in the presimulation group (epoch 1) and 165 women in the postsimulation group (epoch 2), respectively. There was no difference in age, race, parity, or perinatal outcomes between the 2 epochs. Women in epoch 2 began receiving blood products significantly earlier in the first 12 hours following delivery compared with women in epoch 1 (51 [range, 28-125] minutes vs 102 [range, 32-320] minutes; P=.005). In addition, there was a significantly decreased variation in the time from the administration of uterotonic medications to transfusion of blood in epoch 2 (P=.035). Furthermore, women in epoch 2 had significantly lower estimated blood loss than women in epoch 1 (1250 [range, 1000-1750] mL vs 1500 [range, 1000-2000] mL; P=.032). CONCLUSION: The implementation of a multidisciplinary simulation program at a large academic center focusing on the management of postpartum hemorrhage was associated with an improved clinical response. Specifically, there were significantly faster times from the administration of uterotonic medications to transfusion of blood, decreased variance in the time from the administration of uterotonic medications to transfusion of blood, and lower estimated blood loss following the implementation of a simulation program. Because delay in treatment is a major cause of preventable maternal death in obstetrical hemorrhage, the results in our study provided clinical evidence that a simulation program may improve patient outcomes in such emergencies.

Single-unit vs multiple-unit transfusion in hemodynamically stable postpartum anemia: a pragmatic randomized controlled trial.

BACKGROUND: The American Academy of Blood Banks recommends single-unit red cell transfusion protocols across medicine to reduce transfusion complications and the use of a scarce resource. There are minimal data regarding single-unit protocols in obstetrics. OBJECTIVE: We aimed to compare single-unit vs multiple-unit transfusion protocols for treatment of hemodynamically stable postpartum anemia. STUDY DESIGN: We performed a randomized trial comparing initial transfusion with 1 unit of packed red blood cells (single-unit protocol) to 2 units of packed red blood cells (multiple-unit protocol) from March 2018 to July 2019. Women who required transfusion >6 hours postpartum were approached for consent. Unstable vital signs, hemoglobin level <5 g/dL, hemoglobinopathy, and cardiomyopathy were exclusion criteria for enrollment. Hemoglobin assessment and standardized clinical evaluation were performed 4 to 6 hours posttransfusion; additional packed red blood cells were given if indicated. The primary outcome was total units transfused. Secondary outcomes included length of stay, endometritis, wound separation or infection, venous thromboembolism, and intensive care unit admission within 30 days postpartum. Breastfeeding, depression, maternal attachment, and fatigue scores were assessed at 4 to 9 weeks postpartum. A total of 66 women were required to detect a 20% reduction in units transfused with a single-unit protocol (power=80%; α=0.05). RESULTS: A total of 66 women were randomized (33 per arm). There were no differences between groups in demographic or clinical characteristics, including delivery mode, blood loss, and randomization hemoglobin levels. The mean number of units transfused was lower in the single-unit protocol than in the multiple-unit protocol (1.2 U vs 2.1 U; P<.001). Only 18.2% of women in the single-unit arm required additional packed red blood cells. At posttransfusion assessment, women in the single-unit arm had lower hemoglobin levels (7.8 g/dL vs 8.7 g/dL; P<.001), but there were no differences in vital signs or symptoms between groups. There were also no differences in length of stay, 30-day complications, or 4 to 9 week postpartum outcomes. CONCLUSION: In women with hemodynamically stable postpartum anemia, a single-unit protocol avoided a second unit of packed red blood cells in >80% of women without significant impact on morbidity. Our work supports the use of single-unit initial transfusion in this population.

Older fusion-surgery age in congenital scoliosis patients is a risk factor for extended length of stay, more estimated blood loss, longer fused segments and higher medical costs: a retrospective study.

BACKGROUND: Contradictory opinions about whether early correction and fusion surgeries should be performed for congenital scoliosis (CS) patients at a young age exist. The objectives of this study were to analyze the association between patient characteristics and fusion-surgery outcomes in CS patients treated with spinal correction and fusion surgeries and to report risk factors for extended length of stay (LOS), more estimated blood loss (EBL), longer fused segments and higher medical costs. METHODS: We analyzed data of 1,207 CS inpatients treated with fusion surgeries in our institute from January 2010 - December 2019. All patients underwent spinal X-ray, CT, MRI, echocardiogram and urogenital ultrasound. We analyzed demographic and clinical information and outcome measures, including LOS, EBL, fused segments and medical costs. RESULTS: Age at fusion (OR = 1.053; p < 0.001), musculoskeletal defects (OR = 1.670; p = 0.004) and thoracic deformity (OR = 1.519; p = 0.03) were risk factors for extended LOS. Age at fusion (OR = 1.117; p < 0.001), male sex (OR = 1.813; p < 0.001), mixed defects (OR = 1.662; p = 0.027) and failure of formation (OR = 1.718; p = 0.021) were risk factors for more EBL. Age at fusion (OR = 1.213; p < 0.001) was a risk factor for longer fused segments. Age at fusion (OR = 1.091; p < 0.001) and thoracic deformity (OR = 1.853; p = 0.004) were risk factors for higher medical costs. CONCLUSIONS: We found that older age at fusion in CS patients is a risk factor for extended LOS, more EBL, longer fused segments and higher medical costs with the risk increasing by 5-21 % for each year of age. Other identified risk factors include thoracic deformity for extended LOS; longer fused segments, higher medical costs, and musculoskeletal defects for extended LOS; and CS type (FF and MD) and sex (male) for more EBL.

Minimally invasive surgical treatment of intracranial meningiomas in elderly patients (≥ 65 years): outcomes, readmissions, and tumor control.

OBJECTIVE: Increased lifespan has led to more elderly patients being diagnosed with meningiomas. In this study, the authors sought to analyze and compare patients ≥ 65 years old with those < 65 years old who underwent minimally invasive surgery for meningioma. To address surgical selection criteria, the authors also assessed a cohort of patients managed without surgery. METHODS: In a retrospective analysis, consecutive patients with meningiomas who underwent minimally invasive (endonasal, supraorbital, minipterional, transfalcine, or retromastoid) and conventional surgical treatment approaches during the period from 2008 to 2019 were dichotomized into those ≥ 65 and those < 65 years old to compare resection rates, endoscopy use, complications, and length of hospital stay (LOS). A comparator meningioma cohort of patients ≥ 65 years old who were observed without surgery during the period from 2015 to 2019 was also analyzed. RESULTS: Of 291 patients (median age 60 years, 71.5% females, mean follow-up 36 months) undergoing meningioma resection, 118 (40.5%) were aged ≥ 65 years and underwent 126 surgeries, including 20% redo operations, as follows: age 65-69 years, 46 operations; 70-74 years, 40 operations; 75-79 years, 17 operations; and ≥ 80 years, 23 operations. During 2015-2019, of 98 patients referred for meningioma, 67 (68%) had surgery, 1 (1%) had radiosurgery, and 31 (32%) were observed. In the 11-year surgical cohort, comparing 173 patients < 65 years versus 118 patients ≥ 65 years old, there were no significant differences in tumor location, size, or outcomes. Of 126 cases of surgery in 118 elderly patients, the approach was a minimally invasive approach to skull base meningioma (SBM) in 64 cases (51%) as follows: endonasal 18, supraorbital 28, minipterional 6, and retrosigmoid 12. Endoscope-assisted surgery was performed in 59.5% of patients. A conventional approach to SBM was performed in 15 cases (12%) (endoscope-assisted 13.3%), and convexity craniotomy for non-skull base meningioma (NSBM) in 47 cases (37%) (endoscope-assisted 17%). In these three cohorts (minimally invasive SBM, conventional SBM, and NSBM), the gross-total/near-total resection rates were 59.5%, 60%, and 91.5%, respectively, and an improved or stable Karnofsky Performance Status score occurred in 88.6%, 86.7%, and 87.2% of cases, respectively. For these 118 elderly patients, the median LOS was 3 days, and major complications occurred in 10 patients (8%) as follows: stroke 4%, vision decline 3%, systemic complications 0.7%, and wound infection or death 0. Eighty-three percent of patients were discharged home, and readmissions occurred in 5 patients (4%). Meningioma recurrence occurred in 4 patients (3%) and progression in 11 (9%). Multivariate regression analysis showed no significance of American Society of Anesthesiologists physical status score, comorbidities, or age subgroups on outcomes; patients aged ≥ 80 years showed a trend of longer hospitalization. CONCLUSIONS: This analysis suggests that elderly patients with meningiomas, when carefully selected, generally have excellent surgical outcomes and tumor control. When applied appropriately, use of minimally invasive approaches and endoscopy may be helpful in achieving maximal safe resection, reducing complications, and promoting short hospitalizations. Notably, one-third of our elderly meningioma patients referred for possible surgery from 2015 to 2019 were managed nonoperatively.

The effect of anterior lumbar interbody fusion staging order on perioperative complications in circumferential lumbar fusions performed within the same hospital admission.

OBJECTIVE: Anterior lumbar interbody fusion (ALIF) is a powerful technique that provides wide access to the disc space and allows for large lordotic grafts. When used with posterior spinal fusion (PSF), the procedures are often staged within the same hospital admission. There are limited data on the perioperative risk profile of ALIF-first versus PSF-first circumferential fusions performed within the same hospital admission. In an effort to understand whether these procedures are associated with different perioperative complication profiles, the authors performed a retrospective review of their institutional experience in adult patients who had undergone circumferential lumbar fusions. METHODS: The electronic medicals records of patients who had undergone ALIF and PSF on separate days within the same hospital admission at a single academic center were retrospectively analyzed. Patients carrying a diagnosis of tumor, infection, or traumatic fracture were excluded. Demographics, surgical characteristics, and perioperative complications were collected and assessed. RESULTS: A total of 373 patients, 217 of them women (58.2%), met the inclusion criteria. The mean age of the study cohort was 60 years. Surgical indications were as follows: degenerative disease or spondylolisthesis, 171 (45.8%); adult deformity, 168 (45.0%); and pseudarthrosis, 34 (9.1%). The majority of patients underwent ALIF first (321 [86.1%]) with a mean time of 2.5 days between stages. The mean number of levels fused was 2.1 for ALIF and 6.8 for PSF. In a comparison of ALIF-first to PSF-first cases, there were no major differences in demographics or surgical characteristics. Rates of intraoperative complications including venous injury were not significantly different between the two groups. The rates of postoperative ileus (11.8% vs 5.8%, p = 0.194) and ALIF-related wound complications (9.0% vs 3.8%, p = 0.283) were slightly higher in the ALIF-first group, although the differences did not reach statistical significance. Rates of other perioperative complications were no different. CONCLUSIONS: In patients undergoing staged circumferential fusion with ALIF and PSF, there was no statistically significant difference in the rate of perioperative complications when comparing ALIF-first to PSF-first surgeries.

Rate of failure of indirect decompression in lateral single-position surgery: clinical results.

OBJECTIVE: Lateral single-position surgery (LSPS) of the lumbar spine generally involves anterior lumbar interbody fusion (ALIF) performed in the lateral position (LALIF) at L5-S1 with or without lateral lumbar interbody fusion (LLIF) at L4-5 and above, followed by bilateral pedicle screw fixation (PSF) without repositioning the patient. One obstacle to more widespread adoption of LSPS is the perceived need for direct decompression of the neural elements, which typically requires flipping the patient to the prone position. The purpose of this study was to examine the rate of failure of indirect decompression in a cohort of patients undergoing LSPS from L4 to S1. METHODS: A multicenter, post hoc analysis was undertaken from prospectively collected data of patients at 3 institutions who underwent LALIF at L5-S1 with or without LLIF at L4-5 with bilateral PSF in the lateral decubitus position between March 2018 and March 2020. Inclusion criteria were symptoms of radiculopathy or neurogenic claudication, central or foraminal stenosis (regardless of degree or etiology), and indication for interbody fusion at L5-S1 or L4-S1. Patients with back pain only; those who were younger than 18 years; those with tumor, trauma, or suspicion of infection; those needing revision surgery; and patients who required greater than 2 levels of fusion were excluded. Baseline patient demographic information and surgical data were collected and analyzed. The number of patients in whom indirect decompression failed was recorded and each individual case of failure was analyzed. RESULTS: A total of 178 consecutive patients underwent LSPS during the time period (105 patients underwent LALIF at L5-S1 and 73 patients underwent LALIF at L5-S1 with LLIF at L4-5). The mean follow-up duration was 10.9 ± 6.5 months. Bilateral PSF was placed with the patient in the lateral decubitus position in 149 patients, and there were 29 stand-alone cases. The mean case time was 101.9 ± 41.5 minutes: 79.3 minutes for single-level cases and 134.5 minutes for 2-level cases. Three patients (1.7%) required reoperation for failure of indirect decompression. CONCLUSIONS: The rate of failure of indirect decompression in LSPS from L4 to S1 is exceedingly low. This low risk of failure should be weighed against the risks associated with direct decompression as well as the risks of the extra operative time needed to perform this decompression.

Minimally invasive lateral corpectomy for thoracolumbar traumatic burst fractures.

OBJECTIVE: The need for anterior column reconstruction after thoracolumbar burst fractures remains controversial. Here, the authors present their experience with minimally invasive lateral thoracolumbar corpectomies for traumatic fractures. METHODS: Between 2012 and 2019, 59 patients with 65 thoracolumbar fractures underwent 65 minimally invasive lateral corpectomies (MIS group). This group was compared to 16 patients with single-level thoracolumbar fractures who had undergone open lateral corpectomies with the assistance of general surgery between 2007 and 2011 (open control group). Comparisons of the two groups were made with regard to operative time, estimated blood loss, time to ambulation, and fusion rates at 1 year postoperatively. The authors further analyzed the MIS group with regard to injury mechanism, fracture characteristics, neurological outcome, and complications. RESULTS: Patients in the MIS group had a significantly shorter mean operative time (228.3 ± 27.9 vs 255.6 ± 34.1 minutes, p = 0.001) and significantly shorter mean time to ambulation after surgery (1.8 ± 1.1 vs 5.0 ± 0.8 days, p < 0.001) than the open corpectomy group. Mean estimated blood loss did not differ significantly between the two groups, though the MIS group did trend toward a lower mean blood loss. There was no significant difference in fusion status at 1 year between the MIS and open groups; however, this comparison was limited by poor follow-up, with only 32 of 59 patients (54.2%) in the MIS group and 8 of 16 (50%) in the open group having available imaging at 1 year. Complications in the MIS group included 1 screw misplacement requiring revision, 2 postoperative femoral neuropathies (one of which improved), 1 return to surgery for inadequate posterior decompression, 4 pneumothoraces requiring chest tube placement, and 1 posterior wound infection. The rate of revision surgery for the failure of fusion in the MIS group was 1.7% (1 of 59 patients). CONCLUSIONS: The minimally invasive lateral thoracolumbar corpectomy approach for traumatic fractures appears to be relatively safe and may result in shorter operative times and quicker mobilization as compared to those with open techniques. This should be considered as a treatment option for thoracolumbar spine fractures.

Clinical characteristics and outcomes in elderly patients undergoing transsphenoidal surgery for nonfunctioning pituitary adenoma.

OBJECTIVE: Life expectancy has increased over the past century, causing a shift in the demographic distribution toward older age groups. Elderly patients comprise up to 14% of all patients with pituitary tumors, with most lesions being nonfunctioning pituitary adenomas (NFPAs). Here, the authors evaluated demographics, outcomes, and postoperative complications between nonelderly adult and elderly NFPA patients. METHODS: A retrospective review of 908 patients undergoing transsphenoidal surgery (TSS) for NFPA at a single institution from 2007 to 2019 was conducted. Clinical and surgical outcomes and postoperative complications were compared between nonelderly adult (age ≥ 18 and ≤ 65 years) and elderly patients (age > 65 years). RESULTS: There were 614 and 294 patients in the nonelderly and elderly groups, respectively. Both groups were similar in sex (57.3% vs 60.5% males; p = 0.4), tumor size (2.56 vs 2.46 cm; p = 0.2), and cavernous sinus invasion (35.8% vs 33.7%; p = 0.6). Regarding postoperative outcomes, length of stay (1 vs 2 days; p = 0.5), extent of resection (59.8% vs 64.8% gross-total resection; p = 0.2), CSF leak requiring surgical revision (4.3% vs 1.4%; p = 0.06), 30-day readmission (8.1% vs 7.3%; p = 0.7), infection (3.1% vs 2.0%; p = 0.5), and new hypopituitarism (13.9% vs 12.0%; p = 0.3) were similar between both groups. Elderly patients were less likely to receive adjuvant radiation (8.7% vs 16.3%; p = 0.009), undergo future reoperation (3.8% vs 9.5%; p = 0.003), and experience postoperative diabetes insipidus (DI) (3.7% vs 9.4%; p = 0.002), and more likely to have postoperative hyponatremia (26.7% vs 16.4%; p < 0.001) and new cranial nerve deficit (1.9% vs 0.0%; p = 0.01). Subanalysis of elderly patients showed that patients with higher Charlson Comorbidity Index scores had comparable outcomes other than higher DI rates (8.1% vs 0.0%; p = 0.006). Elderly patients' postoperative sodium peaked and troughed on postoperative day 3 (POD3) (mean 138.7 mEq/L) and POD9 (mean 130.8 mEq/L), respectively, compared with nonelderly patients (peak POD2: mean 139.9 mEq/L; trough POD8: mean 131.3 mEq/L). CONCLUSIONS: The authors' analysis revealed that TSS for NFPA in elderly patients is safe with low complication rates. In this cohort, more elderly patients experienced postoperative hyponatremia, while more nonelderly patients experienced postoperative DI. These findings, combined with the observation of higher DI in patients with more comorbidities and elderly patients experiencing later peaks and troughs in serum sodium, suggest age-related differences in sodium regulation after NFPA resection. The authors hope that their results will help guide discussions with elderly patients regarding risks and outcomes of TSS.

Lateral lumbar interbody fusion in revision surgery for restenosis after posterior decompression.

OBJECTIVE: The purpose of this study was to compare the clinical results of revision interbody fusion surgery between lateral lumbar interbody fusion (LLIF) and posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF) with propensity score (PS) adjustments and to investigate the efficacy of indirect decompression with LLIF in previously decompressed segments on the basis of radiological assessment. METHODS: A retrospective study of patients who underwent revision surgery for recurrence of neurological symptoms after posterior decompression surgery was performed. Postoperative complications and operative factors were evaluated and compared between LLIF and PLIF/TLIF. Moreover, postoperative improvement in cross-sectional areas (CSAs) in the spinal canal and intervertebral foramen was evaluated in LLIF cases. RESULTS: A total of 56 patients (21 and 35 cases of LLIF and PLIF/TLIF, respectively) were included. In the univariate analysis, the LLIF group had significantly more endplate injuries (p = 0.03) and neurological deficits (p = 0.042), whereas the PLIF/TLIF group demonstrated significantly more dural tears (p < 0.001), surgical site infections (SSIs) (p = 0.02), and estimated blood loss (EBL) (p < 0.001). After PS adjustments, the LLIF group still showed significantly more endplate injuries (p = 0.03), and the PLIF/TLIF group demonstrated significantly more dural tears (p < 0.001), EBL (p < 0.001), and operating time (p = 0.04). The PLIF/TLIF group showed a trend toward a higher incidence of SSI (p = 0.10). There was no statistically significant difference regarding improvement in the Japanese Orthopaedic Association scores between the 2 surgical procedures (p = 0.77). The CSAs in the spinal canal and foramen were both significantly improved (p < 0.001). CONCLUSIONS: LLIF is a safe, effective, and less invasive procedure with acceptable complication rates for revision surgery for previously decompressed segments. Therefore, LLIF can be an alternative to PLIF/TLIF for restenosis after posterior decompression surgery.

The effect of an oxytocin washout period on blood loss at cesarean delivery.

Objectives Prolonged oxytocin exposure may result in increased blood loss during delivery. Our objective was to determine whether an oxytocin rest period before cesarean delivery had an impact on blood loss. Methods We performed a retrospective cohort study of women who underwent primary cesarean delivery after oxytocin augmentation. The primary outcome was change between pre- and postoperative hematocrit (Hct) in women with less than 60-min oxytocin rest period (<60 min) and greater than 60-min rest period (>60 min). Results There was no difference in demographic characteristics (age, BMI, or gestational age at delivery) between the two groups. Women in the >60 min group had a higher cumulative dose and longer duration of oxytocin administration. There was no significant difference in change in Hct between the two groups when controlling for these factors. Conclusions We did not find a significant correlation between the duration of the oxytocin rest period and blood loss. Oxytocin washout periods of greater than 60 min may not result in decreased blood loss at cesarean delivery, and thus, women may not benefit from such oxytocin washout periods.

Estimated versus actual; The accuracy of accounting for blood loss during endoscopic sinus surgery.

PURPOSE: Endoscopic sinus surgery (ESS) is the mainstay for chronic inflammatory and neoplastic sinonasal process and as a result many modalities have been studied to minimize blood loss and patient morbidity and to maximize intraoperative visualization. However, often conclusions of actual blood loss are based on surgeons' estimations without ever actually assessing the accuracy of these estimations. The objective of this study was to determine the accuracy of intraoperative blood loss estimates by attending otolaryngology surgeons among patients undergoing ESS. MATERIALS AND METHODS: After obtaining institutional review board approval, data were collected on six surgeons performing ESS at a military academic medical center for 21 surgical cases. Specifically, both hourly and end-of-case total "estimated" (EBL) and "calculated actual" (ABL) blood loss values were recorded and compared statistically. Surgeons were blinded to the results until after all data were collected. RESULTS: The difference between mean EBL and ABL was 62.5 ml and was statistically significant (p = .007, Power 86.2%). EBL lagged ABL for both hourly intervals during a surgical case and the total end-of-surgery values. CONCLUSION: The surgeons studied had EBL that were statistically significantly less than ABL both at hourly intervals during the surgery and at the conclusion of the case. As a result there exists potential for adverse consequences in clinical care and in efforts in medical research/advancement.

Validation of a new method to assess estimated blood loss in the obstetric population undergoing cesarean delivery.

BACKGROUND: Postpartum hemorrhage is the leading cause of maternal mortality in developing countries and the primary cause of one-quarter of all maternal deaths globally. Inaccuracy in estimating blood loss obscures the diagnosis of postpartum hemorrhage and its management. OBJECTIVE: Our objective was to compare assessment of blood loss using the quantitative Triton system (Gauss Surgical, Inc, Los Altos, CA) with other measures of blood loss in women undergoing cesarean delivery. STUDY DESIGN: Women scheduled for cesarean deliveries at our facility were included. Intraoperative blood loss was measured using the Triton, which was masked to the clinical team, as well as estimated by the surgeon (subjective estimated blood loss). The relation between the 2 methods (Triton and subjective estimated blood loss) and postoperative hemoglobin as well as delta hemoglobin (postoperative minus preoperative hemoglobin) was determined using the Spearman correlation. Triton measurement and subjective estimated blood loss were compared between women with delta hemoglobin in the upper quartile (cases) vs all other quartiles (control). Prediction of delta hemoglobin in the upper quartile also was evaluated for each method, and the area under the receiver operating characteristic curves was compared. RESULTS: The trial enrolled 242 patients. The mean blood loss estimated by the Triton device was significantly lower than that estimated by clinical judgment (415.3±260.6 vs 799.6±215.6 mL, P<.01). The Triton estimate correlated best with delta hemoglobin. Seventy patients had delta hemoglobin in the upper quartile (delta hemoglobin ≥2). There was a significant difference in the Triton blood loss measurement between cases and controls but no difference with subjective estimated blood loss. Triton, but not subjective estimated blood loss, was predictive of delta hemoglobin ≥2 g/dL (Triton: area under the receiver operating characteristic curve, 0.66; 95% confidence interval, 0.58-0.74; P<.01 vs subjective estimated blood loss: area under the receiver operating characteristic curve, 0.53; 95% confidence interval, 0.45-0.61; P=.45). CONCLUSIONS: The Triton system provides a better estimate of blood loss than the visual estimate. Clinical trials to evaluate its benefit are warranted.

Prediction of perioperative outcome after hepatic resection for pediatric patients.

BACKGROUND: Hepatic resection is associated with significant risk of morbidity and mortality. Optimising the surgical techniques and perioperative management may improve in operative morbidity and mortality. However, perioperative variables involved in the improvement for postoperative outcomes in pediatric hepatectomy have not been defined. METHODS: We retrospectively reviewed 156 consecutive pediatric patients who underwent hepatectomy at our center (an academic tertiary care hospital) between 2006 and 2016. Baseline demographic variables, intraoperative variables, complications, and hospital stay were explored. The patients were further investigated using univariate and multivariate analysis for the factors involved in the postoperative outcomes. RESULTS: Of the conditions requiring resections, malignant and benign liver diseases accounted for 47.4% (74/156) and 52.6% (82/156), respectively. The overall hospital mortality was 1.9% (3/156) and the overall postoperative complication rate was 44.2% (69/156). Anatomical resections were performed in 128 patients (82.1%), including 14(9.0%) extended hepatectomies. Eighty percent of patients had three or more segments resected. The median operative time was 167.7 (65-600) minutes and median estimated blood loss was 320.1(10-1600) mL. On multivariate analysis, the estimated blood loss (EBL) (mL) (OR, 2.19; 95CI, 1.18-3.13; p = 0.016), extent of hepatectomy (OR, 1.81; 95CI, 1.06-2.69; p = 0.001) and pringle maneuver (OR, 1.38; 95CI, 1.02-1.88; p = 0.038) were the independent predictors of postoperative complications. CONCLUSIONS: Extent of hepatectomy and estimated blood loss are largely responsible for the perioperative complications. With the surgical devices and management amelioration, like pringle maneuver, the treatment planning may be optimize in pediatric liver resection.

Preoperative anatomical road mapping reduces variability of operating time, estimated blood loss, and lymph node yield in right colectomy with extended D3 mesenterectomy for cancer.

OBJECTIVE: To assess the impact of individual patient anatomy on operating time, estimated blood loss (EBL), and lymph node yield in right colectomy with extended D3 mesenterectomy, where surgeons have access to a preoperative 3-D reconstruction of the vascular anatomy of patients before surgery. Data on the impact of individual patient vascular anatomy when surgeons have an anatomical road map as a guide at surgery is still missing in the literature. METHOD: Consecutive patients enrolled in an ongoing trial were classified into 4 groups and 2 subgroups using a 3-D vascular anatomy reconstruction derived from the staging CT. Outcome measures are operating time, EBL, vascular events, and D3 volume lymph node yield. SPSS was used for statistical analysis. RESULTS: One hundred seventy-six (77 men) patients included. Mean operating time was 200 ± 50 min. Type 4b required significantly longer operating time (mean, 219 ± 59) compared to type 3 (mean, 188 ± 43) (p = 0.004). Vascular events occurred most often in anatomy type 4b (20.0%) and 3 (19.2%). No difference in EBL and lymph node yield was found (p = 0.102 and p = 0.803, respectively). CONCLUSION: The use of a roadmap at surgery seems to even differences in operating time, EBL, and lymph node yield, independent of the complexity of the individual patient's central mesenteric vascular anatomy. The incidents of vascular events requiring hemostasis do not cause differences in EBL between the anatomy groups, suggesting that preoperative awareness of the anatomy is beneficial at surgery.

Intraoperative blood loss and transfusion during primary pediatric liver transplantation: A single-center experience.

Children undergoing liver transplantation are at a significant risk for intraoperative hemorrhage and thrombotic complications, we aim to identify novel risk factors for massive intraoperative blood loss and transfusion in PLT recipients and describe its impact on graft survival and hospital LOS. We reviewed all primary PLTs performed at our institution between September 2007 and September 2016. Data are presented as n (%) or median (interquartile range). EBL was standardized by weight. Massive EBL and MT were defined as greater than the 85th percentile of the cohort. 250 transplantations were performed during the study period. 38 (15%) recipients had massive EBL, and LOS was 31.5 (15-58) days compared to 11 (7-21) days among those without massive EBL (P < 0.001). MT median LOS was 34 (14-59) days compared to 11 (7-21) days among those without MT (P = 0.001). Upon backward stepwise regression, technical variant graft, operative time, and transfusion of FFP, platelet, and/or cryoprecipitate were significant independent risk factors for massive EBL and MT, while admission from home was a protective factor. Recipient weight was a significant independent risk factor for MT alone. Massive EBL and MT were not statistically significant for overall graft survival. MT was, however, a significant risk factor for 30-day graft loss. PLT recipients with massive EBL or MT had significantly longer LOS and increased 30-day graft loss in patients who required MT. We identified longer operative time and technical variant graft were significant independent risk factors for massive EBL and MT, while being admitted from home was a protective factor.