Minimizing transfusion requirements for children undergoing craniosynostosis repair: the CHoR protocol

Object Children with craniosynostosis may require cranial vault remodeling to prevent or relieve elevated intracranial pressure and to correct the underlying craniofacial abnormalities. The procedure is typically associated with significant blood loss and high transfusion rates. The risks associated with transfusions are well documented and include transmission of infectious agents, bacterial contamination, acute hemolytic reactions, transfusion-related lung injury, and transfusion-related immune modulation. This study presents the Children's Hospital of Richmond (CHoR) protocol, which was developed to reduce the rate of blood transfusion in infants undergoing primary craniosynostosis repair. Methods A retrospective chart review of pediatric patients treated between January 2003 and Febuary 2012 was performed. The CHoR protocol was instituted in November 2008, with the following 3 components; 1) the use of preoperative erythropoietin and iron therapy, 2) the use of an intraoperative blood recycling device, and 3) acceptance of a lower level of hemoglobin as a trigger for transfusion (< 7 g/dl). Patients who underwent surgery prior to the protocol implementation served as controls. Results A total of 60 children were included in the study, 32 of whom were treated with the CHoR protocol. The control (C) and protocol (P) groups were comparable with respect to patient age (7 vs 8.4 months, p = 0.145). Recombinant erythropoietin effectively raised the mean preoperative hemoglobin level in the P group (12 vs 9.7 g/dl, p < 0.001). Although adoption of more aggressive surgical vault remodeling in 2008 resulted in a higher estimated blood loss (212 vs 114.5 ml, p = 0.004) and length of surgery (4 vs 2.8 hours, p < 0.001), transfusion was performed in significantly fewer cases in the P group (56% vs 96%, p < 0.001). The mean length of stay in the hospital was shorter for the P group (2.6 vs 3.4 days, p < 0.001). Conclusions A protocol that includes preoperative administration of recombinant erythropoietin, intraoperative autologous blood recycling, and accepting a lower transfusion trigger significantly decreased transfusion utilization (p < 0.001). A decreased length of stay (p < 0.001) was seen, although the authors did not investigate whether composite transfusion complication reductions led to better outcomes.

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Adjuvant instant pre-operative renal artery embolization facilitates the radical nephrectomy and thrombectomy in locally advanced renal cancer with venous thrombus: A retrospective study of 54 cases

10.21203/rs.3.rs-28801/v1 ◽

2020 ◽

Author(s):

Guangxin Tang ◽

xiaoxu chen ◽

Jianwei Wang ◽

Wei He ◽

Zhihong Niu

Keyword(s):

Blood Loss ◽

Renal Artery ◽

Locally Advanced ◽

Operation Time ◽

Artery Embolization ◽

Venous Thrombus ◽

Estimated Blood Loss ◽

Transfusion Requirements ◽

Renal Artery Embolization ◽

The Mean

Abstract Background: The role of renal artery embolization (RAE) in the therapeutic armamentarium is always controversial. The present study aimed to assess the safety and the surgical outcomes of the instant renal artery embolization (I-RAE) prior to nephrectomy and thrombectomy in locally advanced renal cell carcinoma patients with venous thrombus.Methods: We performed a retrospective analysis of 54 patients treated with nephrectomy and thrombectomy between Jan 2012 and Jan 2019. Twenty-four patients were treated by I-RAE before surgery. Thirty patients were performed surgery alone (Non-RAE). The patient demographics, operation time, blood loss, transfusion requirements, complications and other surgical parameters were analyzed between the two groups.Results: The mean tumor size in I-RAE group was significantly larger than that in the Non-RAE group (11.1cm versus 7.9cm; p = .001). The mean estimated blood loss was significantly lower in I-RAE group compared to Non-RAE group (596ml versus 827ml; p = .015), and the patients in the Non-RAE group were more likely to receive blood transfusion (RBC units, 4U versus 6U, p = .025; plasma volume, 200ml versus 400ml, p = .01). No differences were found in operative duration, ICU stay, perioperative complications and length of postoperative hospitalization. Conclusions: The adjuvant instant pre-operative renal artery embolization (I-RAE) is a safe technique. It facilitates the nephrectomy and thrombectomy by reduction of blood loss, transfusion requirements and complication of delayed operation, providing the urologists with a reliable option for locally advanced RCC with tumor thrombus.

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Adjuvant instant preoperative renal artery embolization facilitates the radical nephrectomy and thrombectomy in locally advanced renal cancer with venous thrombus: A retrospective study of 54 cases

10.21203/rs.3.rs-28801/v2 ◽

2020 ◽

Author(s):

Guangxin Tang ◽

xiaoxu chen ◽

Jianwei Wang ◽

Wei He ◽

Zhihong Niu

Keyword(s):

Blood Loss ◽

Renal Artery ◽

Locally Advanced ◽

Operation Time ◽

Artery Embolization ◽

Venous Thrombus ◽

Estimated Blood Loss ◽

Transfusion Requirements ◽

Renal Artery Embolization ◽

The Mean

Abstract Background: The role of renal artery embolization (RAE) in the therapeutic armamentarium is always controversial. The present study aimed to assess the safety and the surgical outcomes of the instant renal artery embolization (I-RAE) prior to nephrectomy and thrombectomy in patients with locally advanced renal cell carcinoma (RCC) with venous thrombus.Methods: We performed a retrospective analysis of 54 patients treated with nephrectomy and thrombectomy between January 2012 and January 2019. Twenty-four patients were treated with I-RAE before surgery. Thirty patients received surgery alone (non-RAE group). The patient demographics, operation time, blood loss, transfusion requirements, complications and other surgical parameters were analyzed between the two groups.Results: The mean tumor size in the I-RAE group was significantly larger than that in the non-RAE group (11.1 cm versus 7.9 cm; p = .001). The mean estimated blood loss was significantly lower in the I-RAE group compared to that in the non-RAE group (596 ml versus 827 ml; p = .015), and the patients in the Non-RAE group were more likely to receive blood transfusion (red blood cell, RBC units, 4 U versus 6 U, p = .025; plasma volume, 200 ml versus 400 ml, p = .01). No differences were found in operative duration, ICU stay, perioperative complications and length of postoperative hospitalization. Conclusions: Instant preoperative adjuvant renal artery embolization (I-RAE) is a safe technique. It facilitates nephrectomy and thrombectomy by reducing blood loss, transfusion requirements and complications of delayed operations, providing urologists with a reliable option for treatment of locally advanced RCC with tumor thrombus.

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Autotransfusion by cell saver technique in surgery of lumbar and thoracic spinal fusion with instrumentation

Journal of Neurosurgery Spine ◽

10.3171/spi.2002.96.3.0298 ◽

2002 ◽

Vol 96 (3) ◽

pp. 298-303 ◽

Cited By ~ 7

Author(s):

Amitabha Chanda ◽

Donald R. Smith ◽

Anil Nanda

Keyword(s):

Blood Loss ◽

Spinal Fusion ◽

Autologous Blood ◽

Red Blood Cell Transfusion ◽

Cell Saver ◽

Content Type ◽

Thoracic Spinal ◽

Estimated Blood Loss ◽

The Mean ◽

Fine Print

Object. The authors used a modern cell saver technique to perform autotransfusion in patients undergoing instrument-assisted lumbar and/or thoracic spinal fusion, in whom significant blood loss was anticipated. The safety and benefits of this procedure as well as its cost effectiveness were analyzed. Methods. The authors studied 50 patients who underwent lumbar and/or thoracic spinal fusion in which instrumentation was placed between January 1998 and June 2000 and in whom an estimated blood loss of 500 ml or more was expected. All surgeries were conducted by a single neurosurgeon (D.R.S.). During surgery, the Brat 2 cell saver system was used to salvage the autologous blood. The anesthesiologist and surgeon jointly decided, on the basis of hematocrit and clinical stability, whether transfusion was necessary in each patient. Various parameters (hematocrit, plasma and urine hemoglobin, platelet counts, coagulation profile, and serum bilirubin) were measured pre-, intra-, and postoperatively. Thirty-three patients (66%) required transfusion. The mean blood loss in these patients was 1046 ml. The most important factor affecting blood loss was the number of levels fused (p < 0.0001). Only two patients required postoperative homologous transfusion. The mean decrease in hematocrit was 7.82%. The maximum reduction of platelet count was limited to 80,000/mm3. Major complications such as hemoglobinuria, coagulopathy, cardiopulmonary problems, air embolism, and major sepsis were not observed in this study. Conclusions. Autotransfusion performed using a modern cell saver technique is safe and has many advantages over homologous transfusion. It conserves the homologous blood resources. The costs of the two modes are statistically comparable when greater than 500 ml of red blood cell transfusion is necessary.

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Minimally invasive tethered cord release in adults: a comparison of open and mini-open approaches

Neurosurgical FOCUS ◽

10.3171/2010.3.focus1077 ◽

2010 ◽

Vol 29 (1) ◽

pp. E7 ◽

Cited By ~ 9

Author(s):

Matthew B. Potts ◽

Jau-Ching Wu ◽

Nalin Gupta ◽

Praveen V. Mummaneni

Keyword(s):

Spinal Cord ◽

Length Of Stay ◽

Blood Loss ◽

Minimally Invasive ◽

Tethered Cord ◽

Open Group ◽

Incision Length ◽

Estimated Blood Loss ◽

The Mean ◽

Mini Open

Object Symptomatic tethered cord and associated anomalies such as diastematomyelia rarely present during adulthood but can cause significant pain as well as motor, sensory, and bladder dysfunction. As with children, studies have shown that surgical detethering may provide improvement in pain and neurological deficits. Typical surgical management involves an open laminectomy, sectioning of the filum terminale, and exploration of the split cord malformation. Such open approaches, however, cause significant paraspinous muscle trauma and scarring. Recent advances in minimally invasive techniques allow for access to the spine and thecal sac while minimizing associated muscular trauma. The authors present a comparison of open versus minimally invasive surgery to treat adult tethered cord syndrome. Methods Six adult patients underwent surgical release of a tethered spinal cord (2 of them also had diastematomyelia). The mean age of the patients was 47.78 years (range 31–64 years). All medical records and images were retrospectively reviewed. Three of the patients underwent traditional open laminectomies for detethering (open group) while the other 3 patients underwent minimally invasive (mini-open) spinal cord detethering. The length of the incision, length of stay, estimated blood loss, and complications were compared between the 2 groups. Results All 6 patients had tethered spinal cords, and 1 patient in each group had diastematomyelia. The mean estimated blood loss during surgery (300 ml in the open group vs 167 ml in the mini-open group, p = 0.313) and the mean length of stay (7 days in the open group vs 6.3 days in the mini-open group, p = 0.718) were similar between the 2 groups. The incision length was half as long in the mini-open group versus the open group. However, 1 patient in the mini-open group developed a postoperative pseudomeningocele requiring surgical revision, whereas the open group had no revision surgeries. Conclusions Cases of symptomatic diastematomyelia and tethered cord in adults can be safely and effectively explored through a mini-open approach. In this small case series, the authors did find that the mini-open group had an incision that was 50% smaller than the open group, but they did not find a significant clinical difference between the groups.

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Hepatic Resection Using a Water Jet Dissector

HPB Surgery ◽

10.1155/1993/82362 ◽

1993 ◽

Vol 6 (3) ◽

pp. 189-198 ◽

Cited By ~ 47

Author(s):

H. U. Baer ◽

S. C. Stain ◽

T. Guastella ◽

G. J. Maddern ◽

L. H. Blumgart

Keyword(s):

Blood Loss ◽

Hepatic Resection ◽

Water Jet ◽

Parenchymal Transection ◽

Fracture Group ◽

Mortality And Morbidity ◽

Operative Duration ◽

Estimated Blood Loss ◽

Transfusion Requirements ◽

The Mean

The mortality and morbidity in major hepatic resection is often related to hemorrhage. A high pressure, high velocity water jet has been developed and has been utilized to assist in hepatic parenchymal transection. Sixty-seven major hepatic resections were performed for solid hepatic tumors. The tissue fracture technique was used in 51 patients (76%), and the water jet dissector was used predominantly in 16 patients (24%). The extent of hepatic resection using each technique was similar. The results showed no difference in operative duration (p = .499). The mean estimated blood loss using the water jet was 1386 ml, and tissue fracture technique 2450 ml (p = .217). Transfusion requirements were less in the water jet group (mean 2.0 units) compared to the tissue fracture group (mean 5.2 units); (p = .023). Results obtained with the new water dissector are encouraging. The preliminary results suggest that blood loss may be diminished.

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The Effect of Desmopressin on Reducing Blood Loss in Cardiac Surgery – A Meta-Analysis of Double-Blind, Placebo-Controlled Trials

Thrombosis and Haemostasis ◽

10.1055/s-0038-1649883 ◽

1995 ◽

Vol 74 (04) ◽

pp. 1064-1070 ◽

Cited By ~ 76

Author(s):

Marco Cattaneo ◽

Alan S Harris ◽

Ulf Strömberg ◽

Pier Mannuccio Mannucci

Keyword(s):

Cardiac Surgery ◽

Blood Loss ◽

Meta Analysis ◽

Postoperative Blood Loss ◽

Controlled Trials ◽

Double Blind ◽

Double Blind Placebo ◽

Transfusion Requirements ◽

The Mean ◽

Excessive Blood Loss

SummaryThe effect of desmopressin (DDAVP) on reducing postoperative blood loss after cardiac surgery has been studied in several randomized clinical trials, with conflicting outcomes. Since most trials had insufficient statistical power to detect true differences in blood loss, we performed a meta-analysis of data from relevant studies. Seventeen randomized, double-blind, placebo-controlled trials were analyzed, which included 1171 patients undergoing cardiac surgery for various indications; 579 of them were treated with desmopressin and 592 with placebo. Efficacy parameters were blood loss volumes and transfusion requirements. Desmopressin significantly reduced postoperative blood loss by 9%, but had no statistically significant effect on transfusion requirements. A subanalysis revealed that desmopressin had no protective effects in trials in which the mean blood loss in placebo-treated patients fell in the lower and middle thirds of distribution of blood losses (687-1108 ml/24 h). In contrast, in trials in which the mean blood loss in placebo-treated patients fell in the upper third of distribution (>1109 ml/24 h), desmopressin significantly decreased postoperative blood loss by 34%. Insufficient data were available to perform a sub-analysis on transfusion requirements. Therefore, desmopressin significantly reduces blood loss only in cardiac operations which induce excessive blood loss. Further studies are called to validate the results of this meta-analysis and to identify predictors of excessive blood loss after cardiac surgery.

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Management of intended durotomy in minimally invasive intradural spine surgery

Journal of Neurosurgery Spine ◽

10.3171/2014.3.spine13719 ◽

2014 ◽

Vol 21 (2) ◽

pp. 279-285 ◽

Cited By ~ 14

Author(s):

Lee A. Tan ◽

Ippei Takagi ◽

David Straus ◽

John E. O'Toole

Keyword(s):

Blood Loss ◽

Minimally Invasive ◽

Length Of Hospital Stay ◽

Bed Rest ◽

Tubular Retractor ◽

Specific Patient ◽

Dural Closure ◽

Estimated Blood Loss ◽

The Mean ◽

Operative Notes

Object Minimally invasive surgery (MIS) has been increasingly used for the treatment of various intradural spinal pathologies in recent years. Although MIS techniques allow for successful treatment of intradural pathology, primary dural closure in MIS can be technically challenging due to a limited surgical corridor through the tubular retractor system. The authors describe their experience with 23 consecutive patients from a single institution who underwent MIS for intradural pathologies, along with a review of pertinent literature. Methods A retrospective review of a prospectively collected surgical database was performed to identify patients who underwent MIS for intradural spinal pathologies between November 2006 and July 2013. Patient demographics, preoperative records, operative notes, and postoperative records were reviewed. Primary outcomes include operative duration, estimated blood loss, length of bed rest, length of hospital stay, and postoperative complications, which were recorded prospectively. Results Twenty-three patients who had undergone MIS for intradural spinal pathologies during the study period were identified. Fifteen patients (65.2%) were female and 8 (34.8%) were male. The mean age at surgery was 54.4 years (range 30–74 years). Surgical pathologies included neoplastic (17 patients), congenital (3 patients), vascular (2 patients), and degenerative (1 patient). The most common spinal region treated was lumbar (11 patients), followed by thoracic (9 patients), cervical (2 patients), and sacral (1 patient). The mean operative time was 161.1 minutes, and the mean estimated blood loss was 107.2 ml. All patients were allowed full activity less than 24 hours after surgery. The median length of stay was 78.2 hours. Primary sutured dural closure was achieved using specialized MIS instruments with adjuvant fibrin sealant in all cases. The rate of postoperative headache, nausea, vomiting, and diplopia was 0%. No case of cutaneous CSF fistula or symptomatic pseudomeningocele was identified at follow-up, and no patient required revision surgery. Conclusions Primary dural closure with early mobilization is an effective strategy with excellent clinical outcomes in the use of MIS techniques for intradural spinal pathology. Prolonged bed rest after successful primary dural closure appears unnecessary, and the need for watertight dural closure should not prevent the use of MIS techniques in this specific patient population.

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Endoscopically assisted versus open repair of sagittal craniosynostosis: the St. Louis Children's Hospital experience

Journal of Neurosurgery Pediatrics ◽

10.3171/2011.5.peds1128 ◽

2011 ◽

Vol 8 (2) ◽

pp. 165-170 ◽

Cited By ~ 80

Author(s):

Manish N. Shah ◽

Alex A. Kane ◽

J. Dayne Petersen ◽

Albert S. Woo ◽

Sybill D. Naidoo ◽

...

Keyword(s):

Length Of Stay ◽

Blood Loss ◽

Open Surgery ◽

Operating Time ◽

Endoscopic Procedure ◽

Sagittal Craniosynostosis ◽

Helmet Therapy ◽

Age At Surgery ◽

The Mean ◽

Strip Craniectomy

Object This study investigated the differences in effectiveness and morbidity between endoscopically assisted wide-vertex strip craniectomy with barrel-stave osteotomies and postoperative helmet therapy versus open calvarial vault reconstruction without helmet therapy for sagittal craniosynostosis. Methods Between 2003 and 2010, the authors prospectively observed 89 children less than 12 months old who were surgically treated for a diagnosis of isolated sagittal synostosis. The endoscopic procedure was offered starting in 2006. The data associated with length of stay, blood loss, transfusion rates, operating times, and cephalic indices were reviewed. Results There were 47 endoscopically treated patients with a mean age at surgery of 3.6 months and 42 patients with open-vault reconstruction whose mean age at surgery was 6.8 months. The mean follow-up time was 13 months for endoscopic versus 25 months for open procedures. The mean operating time for the endoscopic procedure was 88 minutes, versus 179 minutes for the open surgery. The mean blood loss was 29 ml for endoscopic versus 218 ml for open procedures. Three endoscopically treated cases (6.4%) underwent transfusion, whereas all patients with open procedures underwent transfusion, with a mean of 1.6 transfusions per patient. The mean length of stay was 1.2 days for endoscopic and 3.9 days for open procedures. Of endoscopically treated patients completing helmet therapy, the mean duration for helmet therapy was 8.7 months. The mean pre- and postoperative cephalic indices for endoscopic procedures were 68% and 76% at 13 months postoperatively, versus 68% and 77% at 25 months postoperatively for open surgery. Conclusions Endoscopically assisted strip craniectomy offers a safe and effective treatment for sagittal craniosynostosis that is comparable in outcome to calvarial vault reconstruction, with no increase in morbidity and a shorter length of stay.

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One hundred consecutive endoscopic repairs of sagittal craniosynostosis: an evolution in care

Journal of Neurosurgery Pediatrics ◽

10.3171/2017.5.peds16674 ◽

2017 ◽

Vol 20 (5) ◽

pp. 410-418 ◽

Cited By ~ 12

Author(s):

Dennis C. Nguyen ◽

Scott J. Farber ◽

Gary B. Skolnick ◽

Sybill D. Naidoo ◽

Matthew D. Smyth ◽

...

Keyword(s):

Blood Loss ◽

Patient Care ◽

Length Of Hospital Stay ◽

Successful Outcome ◽

Emissary Vein ◽

Sagittal Craniosynostosis ◽

Care Protocol ◽

Estimated Blood Loss ◽

Helmet Therapy ◽

The Mean

OBJECTIVEEndoscope-assisted repair of sagittal craniosynostosis was adopted at St. Louis Children’s Hospital in 2006. This study examines the first 100 cases and reviews the outcomes and evolution of patient care protocols at our institution.METHODSThe authors performed a retrospective chart review of the first 100 consecutive endoscopic repairs of sagittal craniosynostosis between 2006 and 2014. The data associated with length of hospital stay, blood loss, transfusion rates, operative times, cephalic indices (CIs), complications, and cranial remolding orthosis were reviewed. Measurements were taken from available preoperative and 1-year postoperative 3D reconstructed CT scans.RESULTSThe patients’ mean age at surgery was 3.3 ± 1.1 months. Of the 100 patients, 30 were female and 70 were male. The following perioperative data were noted. The mean operative time (± SD) was 77.1 ± 22.2 minutes, the mean estimated blood loss was 34.0 ± 34.8 ml, and the mean length of stay was 1.1 ± 0.4 days; 9% of patients required transfusions; and the mean pre- and postoperative CI values were 69.1 ± 3.8 and 77.7 ± 4.2, respectively. Conversion to open technique was required in 1 case due to presence of a large emissary vein that was difficult to control endoscopically. The mean duration of helmet therapy was 8.0 ± 2.9 months. Parietal osteotomies were eventually excluded from the procedure.CONCLUSIONSThe clinical outcomes and improvements in CI seen in our population are similar to those seen at other high-volume centers. Since the inception of endoscope-assisted repair at our institution, the patient care protocol has undergone several significant changes. We have been able to remove less cranium using our “narrow-vertex” suturectomy technique without affecting patient safety or outcome. Patient compliance with helmet therapy and collaborative care with the orthotists remain the most essential aspects of a successful outcome.

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Retrospective comparison of three minimally invasive approaches for adrenal tumors: perioperative outcomes of transperitoneal laparoscopic, retroperitoneal laparoscopic and robot-assisted laparoscopic adrenalectomy

BMC Urology ◽

10.1186/s12894-020-00637-y ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Changwei Ji ◽

Qun Lu ◽

Wei Chen ◽

Feifei Zhang ◽

Hao Ji ◽

...

Keyword(s):

Length Of Stay ◽

Blood Loss ◽

Minimally Invasive ◽

Laparoscopic Adrenalectomy ◽

Perioperative Outcomes ◽

Adrenal Tumors ◽

Transfusion Rate ◽

Robot Assisted ◽

Estimated Blood Loss ◽

Minimally Invasive Adrenalectomy

Abstract Background To compare the perioperative outcomes of transperitoneal laparoscopic (TLA), retroperitoneal laparoscopic (RLA), and robot-assisted transperitoneal laparoscopic (RATLA) adrenalectomy for adrenal tumors in our center. Methods Between April 2012 and February 2018, 241 minimally invasive adrenalectomies were performed. Cases were categorized based on the minimally invasive adrenalectomy technique. Demographic characteristics, perioperative information and pathological data were retrospectively collected and analyzed. Results This study included 37 TLA, 117 RLA, and 87 RATLA procedures. Any two groups had comparable age, ASA score, Charlson Comorbidity Index, and preoperative hemoglobin. The tumor size for RLA patients was 2.7 ± 1.1 cm, which was significantly smaller compared to patients who underwent TLA/RATLA (p = 0.000/0.000). Operative time was similar in any two groups, while estimated blood loss was lower for RATLA group (75.6 ± 95.6 ml) compared with the TLA group (131.1 ± 204.5 ml) (p = 0.041). Conversion to an open procedure occurred in only one (2.7%) patient in the TLA group for significant adhesion and hemorrhage. There were no significant differences between groups in terms of transfusion rate and complication rate. Length of stay was shorter for the RATLA group versus the TLA/RLA group (p = 0.000/0.029). In all groups, adrenocortical adenoma and pheochromocytoma were the most frequent histotypes. Conclusions Minimally invasive adrenalectomy is associated with expected excellent outcomes. In our study, the RATLA approach appears to provide the benefits of decreased estimated blood loss and length of stay. Robotic adrenalectomy appears to be a safe and effective alternative to conventional laparoscopic adrenalectomy.

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