Pheochromocytoma, Fulminant Heart Failure, and a Phenylephrine Challenge. The Perioperative Management of Adrenalectomy in a Jehovah’s Witness Patient: A Case Report

Perioperative management of pheochromocytoma in the setting of catecholamine-induced heart failure requires careful consideration of hemodynamic optimization and possible mechanical circulatory support. A Jehovah’s Witness patient with catecholamine-induced acutely decompensated heart failure required dependable afterload reduction for a cardio-protective strategy. This was emphasized due to the relative contraindication to perioperative anticoagulation required for mechanical circulatory support. A phenylephrine challenge clearly demonstrated adequate alpha blockade after only 24 hours of phenoxybenzamine treatment. This resulted in advancement of the surgery date. This case also highlights management of beta blockade, volume and salt loading, autologous blood transfusion, and profound post-operative vasoplegia in the setting of cardiogenic shock. Careful attention to hemodynamic optimization and cardio-protective strategies ultimately resulted in positive outcome for this challenging clinical scenario.

Erythropoietin and miRNA profiles during the menstrual cycle in relation to hematological and lipid biomarkers

Background: Circulatory micro RNAs (miRNA) have been discussed as complementary diagnostic markers in cardiovascular diseases, and in anti-doping testing. MiR-144 and miR-486 have been associated with cholesterol homeostasis and hematopoiesis, respectively. In addition, they have been suggested as putative biomarkers for autologous blood transfusion and erythropoietin (EPO) doping. The aim of the present study was to assess the variability of miR-144-3p/5p, miR-486-5p/3p and EPO during the menstrual cycle. Secondary aim was to study the correlations between miRNAs, EPO and hematological parameters and lipids. Methods: 13 healthy women with regular menses were followed with weekly blood sampling during two whole menstrual cycles. MiRNAs were analyzed using TaqMan and PCR followed by calculation of the relative expression for each miRNA using ddCT approach. Results: There was no menstrual cycle variability in miRNAs and EPO. MiRNA-144-3p was associated with HDL-C (rs=-0.34, p=0.036) and miRNA-486-5p with Hb (rs=0.32, p=0.046). EPO concentrations correlated to lymphocytes (rs=-0.062, p=0.0002)), Hb (rs= -0.42, p=0.0091), HDL-C (rs=0.36, p=0.030) and triglycerides (rs=-0.54, p=0.0006). Conclusions: The results of this study may increase the understanding of how miR486-5p and miR144-3p as well as EPO correlate to hematopoietic and lipid biomarkers.

The importance of autologous blood transfusion in lung transplantation and cardiovascular surgeries

Background: In this study, we aimed to investigate the effect of using autologous blood recovery systems on transfusion-related complications in patients undergoing lung transplantation and cardiovascular surgeries. Methods: Between May 2016 and May 2019, a total of 104 patients (90 males, 14 females; mean age: 59.3±16.4 years; range, 12 to 89 years) in whom cell-saver and autologous blood recovery systems were used during lung transplantation or cardiovascular surgeries were retrospectively analyzed. The patients were divided into two groups as Group 1 (n=61) consisting of patients who received autologous blood transfusion and as Group 2 (n=43) consisting of patients who did not. Data including demographic and clinical characteristics of the patients, operation data, and postoperative complications were recorded. Results: The total amount of transfused blood/blood product was found to be significantly higher in Group 1 (p=0.018). However, transfusionrelated complications were found to be higher in Group 2 (p=0.0261). There was no significant difference in the length of hospital stay between the groups. Conclusion: Autologous blood transfusion may prevent the development of transfusion-related complications by reducing the amount of allogenic transfusion in major surgical procedures. In our study, the autologous blood transfusion was used in critical patients with major bleeding and, therefore, the total amount of transfused blood/blood product was higher in these patients. Nevertheless, lower complication rates in this patient group emphasize the importance of autologous blood transfusion.

Clinical and radiological outcomes of total hip arthroplasty in patients affected by Paget’s disease: a combined registry and single-institution retrospective observational study

Background Total hip arthroplasty (THA) in patients with Paget’s disease can be associated with technical difficulties related to deformities and altered mechanical bone properties, and hypervascularity leads to significative intra-operative bleeding. The purpose of this registry and single-institution study was to investigate overall survival and causes of failure of THA in pagetic patients, together with an analysis of the clinical and radiological complications. Material and methods Registry-based survival and complication analysis, type of fixation, intra- and post-operative complications, clinical (pharmacological history, blood transfusions, Harris hip score [HHS]) and radiographic (cup orientation, stem axial alignment, osteolysis around the cup and the stem and heterotopic ossification [HO]) data were reviewed. Results In total, 66 patients (27 males and 39 females, mean age at surgery 71.1 years for males and 74.8 years for female) from the registry study presented a 10-year survival of 89.5%. In the institutional study, involving 26 patients (14 males and 12 females, 69 years average) and 29 THAs, hip function improved significantly. Average cup orientation was 40.5°, while varus stem alignment was 13.8%. In total, 52% of hips had heterotopic ossifications. Peri-acetabular osteolysis was in 13.8% of implants and in 45% of hips was found around the stem. Allogenic and autologous blood transfusion rate were 68.2% and 31.8%, respectively, with an average transfusion of 2 units of blood (range 1–6 units). HHS improved by an average of 34 points, with excellent result in 64.3% of patients. Two implants failed, one due to traumatic ceramic head fracture 64 months after surgery, and one due to mobilization of the cup on the second post-operative day. Conclusion THA surgery in Paget’s patients is a safe procedure, and implant survival is only partly affected by bone remodelling and choice of fixation. The post-operative functional outcome is largely similar to that of other patients. Bleeding-related complications are the main complications; a careful pharmacological strategy should be recommended to decrease the risk of transfusions and of HO development. Level of evidence Level III

Impact of Intraoperative Salvaged Blood Autotransfusion During Obstetric Hemorrhage on the Coagulation Function: A Retrospective Cohort Analysis

Objective This study aimed to explore the effect of intraoperative blood salvage (autotransfusion) on coagulation function in the rescue of an obstetric hemorrhage. Methods A total of 65 pregnant women who were diagnosed with placenta previa in our Hospital and gave birth in the hospital were enrolled in the study. All the patients underwent thromboelastography, routine blood tests, and blood coagulation series + D-dimer before and within 30 min of the autologous blood transfusion. The differences in various indicators were evaluated. Results (1) After the autotransfusion, the hemoglobin and neutrophil counts were significantly higher than beforehand, and the platelet count was significantly reduced; the differences were statistically significant (p < .05). (2) There were no significant differences in prothrombin time (PT), fibrinogen, and D-dimer levels before and after the autotransfusion ( p > .05). The activated partial thromboplastin time after autotransfusion was shorter than that beforehand, and the difference was statistically significant ( p < .05). (3) There were no significant differences in the R value, K value, α value, and MA value of the thromboelastogram before and after the autotransfusion ( p > .05). Conclusion After the recovery autotransfusion, the hemoglobin of patients with a massive obstetric hemorrhage increased significantly, while the platelet count decreased, but the coagulation function and thromboelastogram did not change significantly, indicating the autotransfusion did not affect the coagulation function of the obstetric hemorrhage rescue. Thus, it would appear that intraoperative blood salvage can be safely used in the clinical rescue of massive hemorrhaging during cesarean section.