Uso tópico de ácido tranexámico en el reemplazo total de rodilla primario / Topical administration of tranexamic acid in primary total knee replacement

Introducción: El reemplazo total de rodilla es un procedimiento que puede generar una gran perdida de sangre durante el periodo posoperatorio. El acido tranexamico es un agente sintetico antifbrinolitico que, en los ultimos anos, se ha administrado por via intravenosa, con buenos resultados, al reducir el sangrado asociado al reemplazo total de rodilla. Sin embargo, existe escasa experiencia con su uso topico. Materiales y Métodos: Se llevo a cabo un estudio comparativo retrospectivo de 117 reemplazos totales de rodilla primarios, para comparar los resultados obtenidos en 63 cirugias con el uso topico de acido tranexamico y en 54 reemplazos sin acido tranexamico. Se compararon la tasa de transfusion, las concentraciones de hemoglobina y hematocrito a las 24 y 48 h, las curaciones requeridas, las comorbilidades y las complicaciones. Resultados: En el grupo con acido tranexamico topico, se redujo un 43,9% la tasa de transfusiones cuando se lo comparo con el otro grupo. Ademas, se registro una disminucion de 0,2-1,3 g/dl en la caida de la hemoglobina a las 24 h de la cirugia. No se detectaron complicaciones. Conclusiones: El uso topico de acido tranexamico en reemplazos totales primarios de rodilla disminuye los requerimientos de transfusiones, sin incrementar el riesgo de complicaciones. Nivel de Evidencia: III

Introduction: Total knee replacement is associated with extensive postoperative blood loss. Tranexamic acid is a synthetic antifibrinolytic agent that, in the last few years, has been successfully used intravenously to reduce bleeding after total knee replacement. However, topical application of tranexamic acid in total knee replacement remains largely unexplored. Methods: A retrospective study of 117 primary total knee replacements was conducted: 63 surgeries with topical tranexamic acid and 54 replacements without tranexamic acid. A comparison analysis was made, capturing results of blood transfusion rates, postoperative hemoglobin levels (24 and 48 hours), number of changed bandages, comorbidities and complications. Results: Tranexamic acid reduced blood transfusion rate by 43.9% when compared with the group without tranexamic acid. A lower decline in postoperative hemoglobin levels (24 hours) by 0.2-1.3 g/dL was also observed in this same group. There were no complications in both groups. Conclusions: Topically applied tranexamic acid was effective in reducing the need for blood transfusion following total knee replacement, without additional adverse effects. Level of Evidence: III

El recuperador celular y necesidad transfusional en pacientes intervenidos de cirugía cardíaca / The cell saver and the transfusional need in patients undergoing cardiac surgery

Resumen Objetivo Los pacientes intervenidos de cirugía cardíaca presentan riesgo elevado de ser transfundidos con sangre durante el postoperatorio, debido al descenso de sus cifras de hemoglobina y hematocrito. Una de las alternativas a la transfusión sanguínea es el uso del recuperador celular intraquirúrgico. El objetivo de este estudio fue identificar si el uso del recuperador celular intraquirúgico disminuye la tasa transfusional durante el postoperatorio inmediato. También se ven las complicaciones postquirúrgicas inmediatas en ambos grupos. Material y Métodos Estudio analítico, prospectivo con dos cohortes de pacientes distribuidos en grupo control (162) y grupo intervención (162). Se analizarón variables sociodemográficas, de sus diagnósticos y tratamientos quirúrgicos, tiempos de isquemia cardíaca, hemoglobina, hematocrito, transfusión sanguínea y hemorragias, así como variables propias del recuperador celular. Las complicaciones estudiadas fueron; hemoglobinuria, fiebre, náuseas y vómitos. Se obtuvo el consentimiento informado de todos los pacientes y se sometió los datos al paquete estadístico SPSS versión 22.0. Resultados Las cifras de hemoglobina y hematocrito de los pacientes después de ser intervenido quirúrgicamente, fueron diferentes entre los grupos respectivamente (GC, 8,3 g/dL, 22,8%. GI,10,4 g/dL, 31,1%). Coincidiendo que los mayores transfundidos fueron los del grupo control (18,2%) frente al grupo intervención (3,9%). El grupo que presentó mayor complicación fue el grupo intervención (13,6%) que eran los que utilizaron el recuperador celular. Siendo la hemoglobinuria (82%) la mayor complicación. Conclusiones Los pacientes que utilizaron el recuperador celular disminuyeron la necesidad transfusional, sin embargo, fueron los que mayor incidencia de hemoglobinuria padecieron.

Objetive Patients undergoing cardiac surgery are at high risk of being transfused with blood during the postoperative period, due to the decrease in haemoglobin and haematocrit levels. One of the alternatives to blood transfusion is the use of the intraoperative cell saver. The objective of this study was to identify whether the use of the intra-uremic cell saver decreases the transfusional rate during the immediate postoperative period. The immediate postoperative complications were also demonstrated in both groups. Material and Methods Analytical, prospective study with two cohorts of patients distributed in control group (162) and intervention group (162). Sociodemographic variables, their diagnoses and surgical treatments, time of cardiac ischemia, haemoglobin, haematocrit, blood transfusion and haemorrhages, as well as variables specific to the cell saver were analyzed. The complications studied were; haemoglobinuria, fever, nausea and vomiting. The informed consent of all the patients was obtained and the data was submitted to the statistical package SPSS version 22.0. Results The haemoglobin and haematocrit values of patients after surgery were different between groups (GC, 8.3 g/dl, 22.8%, GI, 10.4 g/dl, 31.1 g %). Coinciding that the major transfused were those of the control group (18.2%) versus the intervention group (3.9%). The group that presented the greatest complication was the intervention group (13.6%) who were those who used the cell saver. Hemoglobinuria (82%) being the major complication. Conclusions Patients who used the cell saver decreased the need for transfusion, but were the ones with the highest incidence of hemoglobinuria.

Preoperative treatment with 5α-reductase inhibitors and the risk of hemorrhagic events in patients undergoing transurethral resection of the prostate - A population-based cohort study

OBJECTIVES: To assess the associations between preoperative treatment with 5-alpha reductase inhibitors and the risks of blood transfusion during transurethral resection of the prostate and blood clot evacuation or emergency department visits for hematuria within 1 month after surgery. METHODS: We used data from the Taiwan National Health Insurance Research Database in this population-based cohort study. A total of 3,126 patients who underwent first-time transurethral resection of the prostate from 2004 to 2013 were identified. Adjusted odds ratios estimated by multiple logistic regression models were used to assess the independent effects of the preoperative use of 5-alpha reductase inhibitors on the risks of perioperative hemorrhagic events after adjustment for potential confounders. RESULTS: Two hundred and ninety-seven (9.4%) patients were treated with 5-alpha reductase inhibitors for <3 months, and 65 (2.1%) patients were treated for ≥3 months prior to undergoing transurethral resection of the prostate. The blood transfusion rates for patients who were not treated with 5-alpha reductase inhibitors (controls), patients who were treated with 5-alpha reductase inhibitors for <3 months, and patients who were treated with 5-alpha reductase inhibitors ≥3 months were 9.5%, 8.8%, and 3.1%, respectively. 5-alpha reductase inhibitors tended to decrease the risk of blood transfusion; however, this association was not statistically significant (adjusted odds ratio=0.14, 95% confidence interval: 0.02-1.01). Age ≥80 years, coagulopathy, and a resected prostate tissue weight >50 g were associated with significantly higher risks of blood transfusion than other parameters. CONCLUSIONS: This nationwide study did not show that significant associations exist between 5-alpha reductase inhibitor use before transurethral resection of the prostate and the risks of blood transfusion and blood clot evacuation or emergency visits for hematuria.

Use of preoperative embolization prior to transplant nephrectomy

ABSTRACT Introduction After a failed transplant, management of a non-functional graft with pain or recurrent infections can be challenging. Transplant nephrectomy (TN) can be a morbid procedure with the potential for significant blood loss. Embolization of the renal artery alone has been proposed as a method of reducing complications from an in vivo failed kidney transplant. While this does yield less morbidity, it may not address an infected graft or refractory hematuria or rejection. We elected to begin preoperative embolization to assess if this would help decrease the blood loss and transfusion rate associated with TN. Materials and Methods We performed a retrospective analysis of all patients who underwent non-emergent TN at our institution. Patients who had functioning grafts that later failed were included in analysis. TN was performed for recurrent infections, pain or hematuria. We evaluated for blood loss (EBL) during TN, transfusion rate and length of hospital stay. Results A total of 16 patients were identified. Nine had preoperative embolization or no blood flow to the graft prior to TN. The remaining 7 did not have preoperative embolization. The shortest time from transplant to TN was 8 months and the longest 18 years with an average of 6.3 years. Average EBL for the embolized patients (ETN) was 143.9cc compared to 621.4cc in the non-embolized (NETN) group (p=0.041). Average number of units of blood transfused was 0.44 in the ETN with only 3/9 patients requiring transfusion. The NETN patients had average of 1.29 units transfused with 5/7 requiring transfusion. The length of stay was longer for the ETN (5.4 days) compared to 3.9 in the NETN. No intraoperative complications were seen in either group and only one patient had a postoperative ileus in the NETN. Conclusion Embolization prior to TN significantly decreases the EBL but does not significantly decrease transfusion rate. However, patients do require a significantly longer hospitalization with embolization due to the time needed for embolization. Larger studies are needed to determine if embolization before transplant nephrectomy reduces the transfusion rates and overall complications.

Preventing bleeding and thromboembolic complications in atrial fibrillation patients undergoing surgery / Prevenindo complicações hemorrágicas e tromboembólicas de cirurgias em pacientes anticoagulados por fibrilação atrial

Neurologists feel uneasy when asked about temporary anticoagulant interruption for surgery in patients with atrial fibrillation (AF). Rational decisions can be made based on current scientific evidence. Method Critical review of international guidelines and selected references pertaining to bleeding and thromboembolism during periods of oral anticoagulant interruption. Results Withholding oral anticoagulants leads to an increased risk of perioperative thromboembolism, depending on factors such as age, renal and liver function, previous ischemic events, heart failure etc. Surgeries are associated with a variable risk of bleeding - from minimal to very high. Individualized decisions about preoperative drug suspension, bridging therapy with heparin and time to restart oral anticoagulants after hemostasis can significantly reduce these opposing risks. Conclusion Rational decisions can be made after discussion with all Health care team professionals involved and consideration of patient fears and expectations. Formal written protocols should help managing antithrombotic treatment during this delicate period. .

Preocupação com sangramentos em pacientes anticoagulados por fibrilação atrial (FA) expõe os mesmos a riscos tromboembólicos que aumentam ainda mais quando anticoagulantes são suspensos para operações ou outras intervenções invasivas. Método Revisão de Diretrizes internacionais e outras publicações sobre riscos relacionados a cirurgias. Resultados A suspensão dos anticoagulantes aumenta o risco de complicações tromboembólicas na FA, em razão de idade, função renal e hepática, eventos isquêmicos prévios, cardiopatias etc. O risco hemorrágico das intervenções varia de mínimo a extremamente elevado. Decisões individualizadas sobre suspensão das drogas, recurso a anticoagulantes parenterais no preparo dos pacientes para cirurgia, tempo para retomada do anticoagulante oral após hemostasia reduzem significativamente estes riscos. Conclusão Decisões racionais podem ser tomadas após discussão com os profissionais envolvidos – dentistas, anestesistas, cirurgiões; levando em conta inclusive temores e expectativas dos pacientes. Protocolos institucionais favorecem o manejo perioperatório seguro e devem ser discutidos com os pacientes e seus cuidadores. .