scholarly journals The Effect of Systemic Tranexamic Acid on Hypercoagulable Complications and Perioperative Outcomes Following Three-Column Osteotomy for Adult Spinal Deformity

2020 ◽  
pp. 219256822095381
Author(s):  
Alexander F. Haddad ◽  
Christopher P. Ames ◽  
Michael Safaee ◽  
Vedat Deviren ◽  
Darryl Lau
Keyword(s):  
Blood Loss ◽  
Tranexamic Acid ◽  
Spinal Deformity ◽  
Operative Time ◽  
Adult Spinal Deformity ◽  
High Volume ◽  
Perioperative Outcomes ◽  
Surgeon Experience ◽  
Volume Blood ◽  
High Doses

Study Design: Retrospective cohort study. Objective: Thoracolumbar 3-column osteotomy (3CO) is a powerful technique for correction of rigid adult spinal deformity (ASD). However, it can be associated with high-volume blood loss. This study seeks to investigate the efficacy and safety of tranexamic acid (TXA) in 3CO ASD patients. Methods: ASD patients who underwent 3CO from 2006 to 2019 were retrospectively reviewed. Outcomes were compared between TXA and non-TXA patients, and TXA doses. Results: A total of 365 ASD patients were included: 181 TXA and 184 non-TXA. The mean age was 64.6 years and 60.5% were female. Operative time was shorter in the TXA group (295.6 vs 320.2 minutes, P < .001). However, TXA was not associated with shorter operative time (β = −6.5 minutes, 95% CI −29.0 to 15.9, P = .567) after accounting for surgeon experience. There was no difference in blood loss (2020.2 vs 1914.1 mL, P = .437) between groups. Overall complications (37.0% vs 33.2%, P = .439), including hypercoagulable (2.2% vs 3.8%, P = .373) and cardiac (13.3% vs 7.1%, P = .050) complications were similar between groups. TXA was not independently associated with blood loss or TXA-related complications. Both groups had comparable intensive care unit (2.5 vs 2.0 days, P = .060) and hospital (8.9 vs 8.2 days, P = .190) stays. There were no differences in outcomes between TXA dosing subgroups. Conclusions: Systemic TXA use during 3CO for ASD surgery was not associated with decreased blood loss. TXA patients had shorter operative times, but this was driven mainly by surgeon experience on multivariate analysis. Routine use of TXA is safe and does not increase the incidence of hypercoagulable complications even at high doses.

The impact of surgeon experience on perioperative complications and operative measures following thoracolumbar 3-column osteotomy for adult spinal deformity: overcoming the learning curve

2020 ◽  
Vol 32 (2) ◽  
pp. 207-220 ◽  
Author(s):  
Darryl Lau ◽  
Vedat Deviren ◽  
Christopher P. Ames
Keyword(s):  
Blood Loss ◽  
Operative Time ◽  
Surgical Complication ◽  
Perioperative Complications ◽  
Adult Spinal Deformity ◽  
Neurological Deficits ◽  
Complication Rates ◽  
Years Of Experience ◽  
Surgeon Experience ◽  
Operative Measures

OBJECTIVEPosterior-based thoracolumbar 3-column osteotomy (3CO) is a formidable surgical procedure. Surgeon experience and case volume are known factors that influence surgical complication rates, but these factors have not been studied well in cases of adult spinal deformity (ASD). This study examines how surgeon experience affects perioperative complications and operative measures following thoracolumbar 3CO in ASD.METHODSA retrospective study was performed of a consecutive cohort of thoracolumbar ASD patients who underwent 3CO performed by the senior authors from 2006 to 2018. Multivariate analysis was used to assess whether experience (years of experience and/or number of procedures) is associated with perioperative complications, operative duration, and blood loss.RESULTSA total of 362 patients underwent 66 vertebral column resections (VCRs) and 296 pedicle subtraction osteotomies (PSOs). The overall complication rate was 29.4%, and the surgical complication rate was 8.0%. The rate of postoperative neurological deficits was 6.2%. There was a trend toward lower overall complication rates with greater operative years of experience (from 44.4% to 28.0%) (p = 0.115). Years of operative experience was associated with a significantly lower rate of neurological deficits (p = 0.027); the incidence dropped from 22.2% to 4.0%. The mean operative time was 310.7 minutes overall. Both increased years of experience and higher case numbers were significantly associated with shorter operative times (p < 0.001 and p = 0.001, respectively). Only operative years of experience was independently associated with operative times (p < 0.001): 358.3 minutes from 2006 to 2008 to 275.5 minutes in 2018 (82.8 minutes shorter). Over time, there was less deviation and more consistency in operative times, despite the implementation of various interventions to promote fusion and prevent construct failure: utilization of multiple-rod constructs (standard, satellite, and nested rods), bone morphogenetic protein, vertebroplasty, and ligament augmentation. Of note, the use of tranexamic acid did not significantly lower blood loss.CONCLUSIONSSurgeon years of experience, rather than number of 3COs performed, was a significant factor in mitigating neurological complications and improving quality measures following thoracolumbar 3CO for ASD. The 3- to 5-year experience mark was when the senior surgeon overcame a learning curve and was able to minimize neurological complication rates. There was a continuous decrease in operative time as the surgeon’s experience increased; this was in concurrence with the implementation of additional preventative surgical interventions. Ongoing practice changes should be implemented and can be done safely, but it is imperative to self-assess the risks and benefits of those practice changes.

Effect of Tranexamic Acid on Blood Loss, D-Dimer, and Fibrinogen Kinetics in Adult Spinal Deformity Surgery

2018 ◽  
Vol 100 (9) ◽  
pp. 758-764 ◽  
Author(s):  
Ryan P. Pong ◽  
Jean-Christophe A. Leveque ◽  
Alicia Edwards ◽  
Vijay Yanamadala ◽  
Anna K. Wright ◽  
...  
Keyword(s):  
Blood Loss ◽  
Tranexamic Acid ◽  
Spinal Deformity ◽  
Adult Spinal Deformity ◽  
Spinal Deformity Surgery ◽  
D Dimer

scholarly journals Different Dose Regimens of Intravenous Tranexamic Acid in Adolescent Spinal Deformity Surgery: A Systematic Review and Meta-Analysis

2020 ◽  
Vol 2020 ◽  
pp. 1-16
Author(s):  
Zhencheng Xiong ◽  
Kexin Wu ◽  
Jiayu Zhang ◽  
Delong Leng ◽  
Ziyi Yu ◽  
...  
Keyword(s):  
Blood Transfusion ◽  
Blood Loss ◽  
Tranexamic Acid ◽  
Spinal Deformity ◽  
Dose Group ◽  
Low Dose ◽  
Operative Time ◽  
Meta Analysis ◽  
High Dose ◽  
Spinal Deformity Surgery

Objective. To evaluate the efficacy and safety of different dose regimens of intravenous (IV) tranexamic acid (TXA) in adolescent spinal deformity surgery. Methods. Two researchers independently searched multiple databases, including PubMed, Embase, Cochrane Library, and Web of Science to find studies that met the inclusion criteria. A meta-analysis was performed based on the guidelines of the Cochrane Reviewer’s Handbook. Results. Six randomized controlled trials (RCTs) and eleven non-RCTs were identified, including 1148 patients. According to different dose regimens of IV TXA, the included studies were divided into the high-dose group and the low-dose group. Compared with placebo, both groups had less total blood loss (TBL) (high dose: WMD = − 1737.55 , 95% CI: (-2247.16, -1227.94), P < 0.001 , I 2 = 0 % ; low dose: WMD = − 528.67 , 95% CI: (-666.06, -391.28), P < 0.001 , I 2 = 0 % ), intraoperative blood loss (IBL) (high dose: WMD = − 301.48 , 95% CI: (-524.3, -78.66), P = 0.008 , I 2 = 60.3 % ; low dose: WMD = − 751.14 , 95% CI: (-967.21, -535.08), P < 0.001 , I 2 = 0 % ), and blood transfusion rates (high dose: RR = 0.19 , 95% CI: (0.1, 0.37), P < 0.001 , I 2 = 0 % ; low dose: RR = 0.4 , 95% CI: (0.18, 0.91), P = 0.029 , I 2 = 57 % ). High-dose IV TXA use was associated with more vertebral fusion segments ( WMD = 0.53 , 95% CI: (0.23, 0.82), P < 0.001 , I 2 = 31.2 % ). Low-dose IV TXA use was associated with shorter operative time ( WMD = − 18.43 , 95% CI: (-26.68, -10.17), P < 0.001 , I 2 = 0 % ). Conclusion. High-dose and low-dose IV TXA were effective in reducing TBL, IBL, and blood transfusion rates without increasing complications in adolescent patients undergoing spinal deformity surgery. Low-dose IV TXA was effective in reducing the operative time. Both the high-dose and low-dose groups had similar preoperative and postoperative Hb levels compared to the control group.

Impact of Surgical Mentorship on Retroperitoneoscopic Adrenalectomy with Comparison to Transperitoneal Laparoscopic Adrenalectomy

2013 ◽  
Vol 79 (2) ◽  
pp. 162-166
Author(s):  
James T. Broome ◽  
Carmen C. Solorzano
Keyword(s):  
Blood Loss ◽  
Laparoscopic Adrenalectomy ◽  
Operative Time ◽  
Length Of Hospital Stay ◽  
High Volume ◽  
Perioperative Outcomes ◽  
Adrenal Tumors ◽  
Retroperitoneoscopic Adrenalectomy ◽  
The Mean ◽  
The Impact

Retroperitoneoscopic adrenalectomy (RA) provides a direct approach to the adrenal gland. RA represents a complex approach with unique orientation that is less intuitive. The authors objectively evaluated the impact of mentorship on the performance of RA and also compared it with laparoscopic adrenalectomy (LA). After implementing the use of RA, a retrospective review of the operative experience of two high-volume endocrine surgeons was performed. Both surgeons participated in a hands-on RA mentorship. Clinical presentation and perioperative outcomes were compared. Subgroup analysis was used to compare RA pre- and postmentorship and with LA. Sixty-one LAs and 31 RAs were included in the analysis. The mean operative time was 115 for LA versus 90 minutes for RA ( P = 0.002). Blood loss was greater for LA versus RA (56 vs 22 mL; P = 0.001). Length of stay (LOS) for LA was 2.2 versus 1.5 days for RA ( P = 0.029). Ten patients were treated by RA in the prementorship era versus 21 in the postmentorship era. The mean operative time for the prementorship group was 118 minutes, which decreased to 77 minutes postmentorship ( P < 0.0001). LOS also decreased from 2.0 to 1.2 days ( P = 0.04) in the postmentorship era. RA demonstrates a shorter operative time, less blood loss, and decrease length of hospital stay as compared with standard LA. After proper mentorship and patient selection, RA may represent a superior option for removal of small, benign adrenal tumors.

Utility of topical tranexamic acid for adult patients with spinal deformity and contraindications to systemic tranexamic acid: initial experience and report of 2 cases

2019 ◽  
Vol 30 (4) ◽  
pp. 500-505 ◽  
Author(s):  
Bhargav D. Desai ◽  
Davis G. Taylor ◽  
Ching-Jen Chen ◽  
Thomas J. Buell ◽  
Jeffrey P. Mullin ◽  
...  
Keyword(s):  
High Risk ◽  
Blood Loss ◽  
Tranexamic Acid ◽  
Spine Surgery ◽  
Spinal Deformity ◽  
Adult Spinal Deformity ◽  
Primary Objective ◽  
Postoperative Blood Loss ◽  
Initial Experience ◽  
Meta Analyses

Tranexamic acid (TXA) is an antifibrinolytic agent with demonstrated efficacy in reducing blood loss when administered systemically. However, in patients with contraindications to systemic or intravenous TXA, topical TXA (tTXA) has been shown to reduce perioperative blood loss, with some studies suggesting equivalence compared to systemic TXA. However, these studies have been conducted in healthy cohorts without contraindications to systemic TXA. In the surgical management of adult spinal deformity (ASD), comorbid disease is commonly encountered and may preclude use of systemic TXA. In this subset of patients with ASD who have contraindications for systemic TXA, use of tTXA has not been reported.The primary objective of this study was to conduct a systematic review on the use of tTXA in spine surgery and to present the authors’ initial experience with tTXA as a novel hemostatic technique for 2 patients with medically complex ASD. Both patients had contraindications to systemic TXA use and underwent high-risk, long-segment fusion operations for correction of ASD. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to obtain studies related to spine surgery and tTXA from the National Institutes of Health PubMed (www.pubmed.gov) database. Criteria for final selection included a demonstration of quantitative data regarding operative or postoperative blood loss with the use of tTXA, and selection criteria were met by 6 articles.Topical TXA may offer a potential therapeutic role in reducing intra- and postoperative blood loss following long-segment spinal fusion surgeries, particularly for medically complex patients with contraindications to systemic TXA. It is reasonable to consider the use of tTXA as a salvage technique in complex high-risk patients with contraindications to systemic TXA, although further research is needed to delineate safety, magnitude of benefit, and optimization of dosing.

Perioperative outcomes associated with thoracolumbar 3-column osteotomies for adult spinal deformity patients with rheumatoid arthritis

2019 ◽  
Vol 30 (6) ◽  
pp. 822-832
Author(s):  
Cecilia L. Dalle Ore ◽  
Christopher P. Ames ◽  
Vedat Deviren ◽  
Darryl Lau
Keyword(s):  
Rheumatoid Arthritis ◽  
Spinal Deformity ◽  
Perioperative Complications ◽  
Adult Spinal Deformity ◽  
Vena Cava ◽  
Deformity Correction ◽  
Perioperative Outcomes ◽  
Medical Complications ◽  
Filter Placement ◽  
Estimated Blood Loss

OBJECTIVESpinal deformity causing spinal imbalance is directly correlated to pain and disability. Prior studies suggest adult spinal deformity (ASD) patients with rheumatoid arthritis (RA) have more complex deformities and are at higher risk for complications. In this study the authors compared outcomes of ASD patients with RA following thoracolumbar 3-column osteotomies to outcomes of a matched control cohort.METHODSAll patients with RA who underwent 3-column osteotomy for thoracolumbar deformity correction performed by the senior author from 2006 to 2016 were identified retrospectively. A cohort of patients without RA who underwent 3-column osteotomies for deformity correction was matched based on multiple clinical factors. Data regarding demographics and surgical approach, along with endpoints including perioperative outcomes, reoperations, and incidence of proximal junctional kyphosis (PJK) were reviewed. Univariate analyses were used to compare patients with RA to matched controls.RESULTSEighteen ASD patients with RA were identified, and a matched cohort of 217 patients was generated. With regard to patients with RA, 11.1% were male and the mean age was 68.1 years. Vertebral column resection (VCR) was performed in 22.2% and pedicle subtraction osteotomy (PSO) in 77.8% of patients. Mean case length was 324.4 minutes and estimated blood loss (EBL) was 2053.6 ml. Complications were observed in 38.9% of patients with RA and 29.0% of patients without RA (p = 0.380), with a trend toward increased medical complications (38.9% vs 21.2%, p = 0.084). Patients with RA had a significantly higher incidence of deep vein thrombosis (DVT)/pulmonary embolism (PE) (11.1% vs 1.8%, p = 0.017) and wound infections (16.7% vs 5.1%, p = 0.046). PJK occurred in 16.7% of patients with RA, and 33.3% of RA patients underwent reoperation. Incidence rates of PJK and reoperation in matched controls were 12.9% and 25.3%, respectively (p = 0.373, p = 0.458). At follow-up, mean sagittal vertical axis (SVA) was 6.1 cm in patients with RA and 4.5 cm in matched controls (p = 0.206).CONCLUSIONSFindings from this study suggest that RA patients experience a higher incidence of medical complications, specifically DVT/PE. Preoperative lower-extremity ultrasounds, inferior vena cava (IVC) filter placement, and/or early initiation of DVT prophylaxis in RA patients may be indicated. Perioperative complications, morbidity, and long-term outcomes are otherwise similar to non-RA patients.

Double-blind, randomized controlled trial of tranexamic acid in minor lumbar spine surgery: no effect on operative time, intraoperative blood loss, or complications

2019 ◽  
Vol 31 (2) ◽  
pp. 194-200 ◽  
Author(s):  
Signe Elmose ◽  
Mikkel Ø. Andersen ◽  
Else Bay Andresen ◽  
Leah Yacat Carreon
Keyword(s):  
Placebo Group ◽  
Lumbar Spine ◽  
Blood Loss ◽  
Tranexamic Acid ◽  
Spine Surgery ◽  
Operative Time ◽  
Decompressive Surgery ◽  
Lumbar Spine Surgery ◽  
Intraoperative Blood Loss ◽  
Double Blind

OBJECTIVEThe purpose of this study was to investigate the effect of tranexamic acid (TXA) compared to placebo in low-risk adult patients undergoing elective minor lumbar spine surgery—specifically with respect to operative time, estimated blood loss, and complications. Studies have shown that TXA reduces blood loss during major spine surgery. There have been no previous studies on the effect of TXA in minor lumbar spine surgery in which these variables have been evaluated.METHODSThe authors enrolled patients with ASA grades 1 to 2 scheduled to undergo lumbar decompressive surgery at Middelfart Hospital into a double-blind, randomized, placebo-controlled, parallel-group study. Patients with thromboembolic disease, coagulopathy, hypersensitivity to TXA, or a history of convulsion were excluded. Patients were randomly assigned, in blocks of 10, to one of 2 groups, TXA or placebo. Anticoagulation therapy was discontinued 2–7 days preoperatively. Prior to the incision, patients received either a bolus of TXA (10 mg/kg) or an equivalent volume of saline solution (placebo). Independent t-tests were used to compare differences between the 2 groups, with statistical significance set at p < 0.05.RESULTSOf the 250 patients enrolled, 17 patients were excluded, leaving 233 cases for analysis (117 in the TXA group and 116 in the placebo group). The demographics of the 2 groups were similar, except for a higher proportion of women in the TXA group (TXA 50% vs placebo 32%, p = 0.017). There was no significant between-groups difference in operative time (49.53 ± 18.26 vs 54.74 ± 24.49 minutes for TXA and placebo, respectively; p = 0.108) or intraoperative blood loss (55.87 ± 48.48 vs 69.14 ± 83.47 ml for TXA and placebo, respectively; p = 0.702). Postoperative blood loss measured from drain output was 62% significantly lower in the TXA group (13.03 ± 21.82 ml) than in the placebo group (34.61 ± 44.38 ml) (p < 0.001). There was no significant difference in number of dural lesions or postoperative spinal epidural hematomas, and there were no thromboembolic events.CONCLUSIONSTranexamic acid did not have a statistically significant effect on operative time, intraoperative blood loss, or complications. This study gives no evidence to support the routine use of TXA during minor lumbar decompressive surgery.Clinical trial registration no.: NCT03714360 (clinicaltrials.gov)

Influence of Fluid Infusion Associated with High-volume Blood Loss on Plasma Propofol Concentrations

2004 ◽  
Vol 100 (4) ◽  
pp. 871-878 ◽  
Author(s):  
Tadayoshi Kurita ◽  
Tomiei Kazama ◽  
Koji Morita ◽  
Shunsuke Fujii ◽  
Masahiro Uraoka ◽  
...  
Keyword(s):  
Steady State ◽  
Blood Loss ◽  
Hydroxyethyl Starch ◽  
High Volume ◽  
Fluid Infusion ◽  
Ringer’S Solution ◽  
Group A ◽  
Volume Blood ◽  
Lactated Ringer's Solution ◽  
Common Clinical Practice

Background It is common clinical practice to use fluid infusion to manage high-volume blood loss until a blood transfusion is performed. The authors investigated the influence of fluid infusion associated with blood loss on the pseudo-steady state propofol concentration. Methods Twenty-seven swine were assigned to a lactated Ringer's solution group, a hydroxyethyl starch group, or a threefold lactated Ringer's solution group (n = 9 in each group). After 180 min of steady state infusion of propofol at a rate of 2 mg.kg(-1).h(-1), hemorrhage and infusion were induced by stepwise bleeding followed by fluid infusion every 30 min. In each of the first two steps, 400 ml blood was collected; thereafter, 200 ml was collected at each step. Just after each bleeding step, fluid infusion was rapidly performed using a volume of lactated Ringer's solution or hydroxyethyl starch equivalent to the blood withdrawn, or a threefold volume of lactated Ringer's solution. Hemodynamic parameters and the plasma propofol concentration were recorded at each step. Results Although the plasma propofol concentration in the lactated Ringer's solution group increased with hemorrhage and infusion, it decreased in both the hydroxyethyl starch and the threefold lactated Ringer's solution groups. The propofol concentration in the hydroxyethyl starch group could be expressed by the following equation: Plasma Propofol Concentration Decrease (%) = 0.80 x Hematocrit Decrease (%) (r2 = 0.83, P &lt; 0.0001). Conclusions When high-volume blood loss is managed by isovolemic hemodilution, the plasma propofol concentration during continuous propofol infusion decreases linearly with the hematocrit decrease.

Multilevel Arthrodesis for Adult Spinal Deformity: When Should We Anticipate Major Blood Loss?

2019 ◽  
Vol 7 (1) ◽  
pp. 141-145 ◽  
Author(s):  
Micheal Raad ◽  
Raj Amin ◽  
Amit Jain ◽  
Steven M. Frank ◽  
Khaled M. Kebaish
Keyword(s):  
Blood Loss ◽  
Spinal Deformity ◽  
Adult Spinal Deformity

scholarly journals Evolution and trends in the adoption of laparoscopic liver resection in Singapore: Analysis of 300 cases

2021 ◽  
Vol 50 (10) ◽  
pp. 742-750
Author(s):  
Brian K Goh ◽  
Zhongkai Wang ◽  
Ye-Xin Koh ◽  
Kai-Inn Lim
Keyword(s):  
Liver Resection ◽  
Blood Loss ◽  
Abdominal Surgery ◽  
Laparoscopic Liver Resection ◽  
Conversion Rate ◽  
Perioperative Outcomes ◽  
Transfusion Rate ◽  
Open Conversion ◽  
Previous Abdominal Surgery ◽  
Surgeon Experience

ABSTRACT Introduction: The introduction of laparoscopic surgery has changed abdominal surgery. We evaluated the evolution and changing trends associated with adoption of laparoscopic liver resection (LLR) and the experience of a surgeon without prior LLR experience. Methods: A retrospective review of 310 patients who underwent LLR performed by a single surgeon from 2011 to 2020 was conducted. Exclusion criteria were patients who underwent laparoscopic liver surgeries such as excision biopsy, local ablation, drainage of abscesses and deroofing of liver cysts. There were 300 cases and the cohort was divided into 5 groups of 60 patients. Results: There were 288 patients who underwent a totally minimally invasive approach, including 28 robotic-assisted procedures. Open conversion occurred for 13 (4.3%) patients; the conversion rate decreased significantly from 10% in the initial period to 3.3% subsequently. There were 83 (27.7%) major resections and 131 (43.7%) resections were performed for tumours in the difficult posterosuperior location. There were 152 (50.7%) patients with previous abdominal surgery, including 52 (17.3%) repeat liver resections for recurrent tumours, and 60 patients had other concomitant operations. According to the Iwate criteria, 135 (44.7%) were graded as high/expert difficulty. Major morbidity (>grade 3a) occurred in 12 (4.0%) patients and there was no 30-day mortality. Comparison across the 5 patient groups demonstrated a significant trend towards older patients, higher American Society of Anesthesiologists (ASA) score, increasing frequency of LLR with previous abdominal surgery, increasing frequency of portal hypertension and huge tumours, decreasing blood loss and decreasing transfusion rate across the study period. Surgeon experience (≤60 cases) and Institut Mutualiste Montsouris (IMM) high grade resections were independent predictors of open conversion. Open conversion was associated with worse perioperative outcomes such as increased blood loss, transfusion rate, morbidity and length of stay. Conclusion: LLR can be safely adopted for resections of all difficulty grades, including major resections and for tumours located in the difficult posterosuperior segments, with a low open conversion rate. Keywords: Laparoscopic hepatectomy, laparoscopic liver resection, robotic hepatectomy, robotic liver resection, Singapore

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