Effect of continuous infusion of dexmedetomidine on blood loss in orthognathic surgery: a retrospective study

Background Patients with maxillofacial deformities require orthognathic surgeries to correct occlusion. The surgical procedure may lead to massive bleeding, which is associated with haematoma, respiratory obstruction, and asphyxia. Dexmedetomidine has been used in controlled hypotension and may reduce blood loss in orthognathic surgery. We conducted a retrospective cohort study to evaluate the effect of dexmedetomidine on blood loss in orthognathic surgeries. Methods The primary outcome examined was blood loss, and secondary outcomes were postoperative haemoglobin level; intraoperative heart rate and blood pressure (T1: at incision; T2: 30 min after incision; T3: 60 min after incision; T4: 120 min after incision); dosage of fentanyl, remifentanil, urapidil, and esmolol; operation time; and incidence of allogeneic blood transfusion. Results A total of 1247 patients were included in this study, and 540 patient pairs were matched via propensity score matching. There were significant decreases in mean blood loss, heart rate at T1–T4, blood pressure at T1, and remifentanil and esmolol dosage in the dexmedetomidine group compared with those in the control group. There was also a significant increase in the postoperative haemoglobin level of the dexmedetomidine group. Conclusions Continuous infusion of dexmedetomidine can decrease blood loss in orthognathic surgery. Trial registration: ChiCTR1800018794 (retrospectively registered) Name of registry: Chinese Clinical Trial Registry Date of registration: 2018/10/09 URL: www.chictr.org.cn/showproj.aspx?proj=30612

Efficacy and safety of tranexamic acid in hip fracture surgery: A comparative study of 613 patients

Background Blood loss is a major concern in the frail elderly patient undergoing hip fracture surgery. The objective of this study was to investigate the efficacy of tranexamic acid in reducing blood loss and allogenic blood transfusions. The study also investigated the safety profile by comparing rates of thromboembolic events, Methods A total of 613 patients with hip fractures were included in the study. Patients received 1g of tranexamic acid on induction of anaesthesia. Postoperative haemoglobin was measured on day one. Blood loss was calculated, and blood transfusion was recorded. Results Tranexamic acid use resulted in a higher mean postoperative haemoglobin (110.3 ± 15.9 vs 106.8 ± 16.2; p = 0.023) and reduced mean estimated blood loss (571.3 ± 150.4 vs 678.3 ± 201.2; p = 0.001). There was also a significantly reduced number of transfusions in tranexamic acid group (13% vs 28%; p = 0.002). There was no difference in rates of deep vein thrombosis (4 vs 3; p = 0.98) or pulmonary embolism (2 vs 2; p = 1). Conclusion The use of tranexamic acid is effective in reduction of blood loss and rates of blood transfusion, without an apparent increase in adverse thromboembolic events.

Can an outpatient risk assessment tool predict who needs postoperative haemoglobin monitoring?

Aims Recent improvements in surgical technique and perioperative blood management after total joint replacement (TJR) have decreased rates of transfusion. However, as many surgeons transition to outpatient TJR, obtaining routine postoperative blood tests becomes more challenging. Therefore, we sought to determine if a preoperative outpatient assessment tool that stratifies patients based on numerous medical comorbidities could predict who required postoperative haemoglobin (Hb) measurement. Methods We performed a prospective study of consecutive unilateral primary total knee arthroplasties (TKAs) and total hip arthroplasties (THAs) performed at a single institution. Prospectively collected data included preoperative and postoperative Hb levels, need for blood transfusion, length of hospital stay, and Outpatient Arthroplasty Risk Assessment (OARA) score. Results A total of 504 patients met inclusion criteria. Mean age at time of arthroplasty was 65.3 years (SD 10.2). Of the patients, 216 (42.9%) were THAs and 288 (57.1%) were TKAs. Six patients required a blood transfusion postoperatively (1.19%). Transfusion after surgery was associated with lower postoperative day 1 Hb (median of 8.5 (interquartile range (IQR) 7.9 to 8.6) vs 11.3 (IQR 10.4 to 12.2); p < 0.001), longer length of stay (1 day (IQR 1 to 1) vs 2 days (IQR 2 to 3); p < 0.001), higher OARA score (median of 60.0 (IQR 40 to 75) vs 5.0 (IQR 0-35); p = 0.001), and total hip arthroplasty (p < 0.001). All patients who received a transfusion had an OARA score > 34; however, this did not reach statistical significance as a screening threshold. Conclusion Risk of blood transfusion after primary TJR was uncommon in our series, with an incidence of 1.19%. Transfusion was associated with OARA scores > 60. The OARA score, not American Society of Anesthesiologists grade, reliably identified patients at risk for postoperative blood transfusion. Selective Hb monitoring may result in substantial cost savings in the era of cost containment. Cite this article: Bone Joint J 2021;103-B(1):65–70.

Effect of Continuous Infusion of Dexmedetomidine on Blood Loss in Orthognathic Surgery: A Retrospective Study

Background: Patients with maxillofacial deformities require orthognathic surgeries to correct occlusion. The surgical procedure may lead to massive bleeding, which is associated with hematoma, respiratory obstruction, and asphyxia. Dexmedetomidine has been used in controlled hypotension, and may decrease blood loss in orthognathic surgery. We conducted a retrospective cohort study to evaluate the effect of dexmedetomidine on blood loss in orthognathic surgeries.Methods: The primary outcome examined was blood loss, and secondary outcomes were postoperative haemoglobin level, intraoperative heart rate, and blood pressure (T0: preoperative; T1: at incision; T2: 30 minutes after incision; T3: 60 minutes after incision; T4: 120 minutes after incision); dose of fentanyl, remifentanil, urapidil, and esmolol; operation time; incidence of allogeneic blood transfusion; crystalloid fluids volume; and colloidal fluid volume. Results: A total of 1,247 patients were included in the study, and 557 patient pairs were matched via propensity score matching. There were significant decreases in mean blood loss, heart rate at T1–T4, blood pressure at T1, remifentanil and esmolol dosage, and crystalloid fluid volume in the dexmedetomidine group compared with those in the control group. There was also a significant increase in the postoperative haemoglobin level of the dexmedetomidine group. Conclusions: Continuous infusion of dexmedetomidine can decrease blood loss in orthognathic surgery.Trial registration number: ChiCTR1800018794 (retrospectively registered)Name of registry: Chinese Clinical Trial RegistryDate of registration: 2018/10/09URL: www.chictr.org.cn/showproj.aspx?proj=30612

A randomised trial evaluating the effect of intraoperative iron administration

Perioperative anaemia increases postoperative morbidity and mortality, and iron deficiency is anaemia’s most common cause in surgical patients. Preoperative intravenous iron increases postoperative haemoglobin; however, data regarding intraoperative intravenous iron’s effectiveness are inadequate. This study examined intraoperative intravenous iron’s effects on postoperative haemoglobin levels in adults. Fifty-seven healthy subjects (aged 19–40 years) scheduled for bimaxillary orthognathic surgery were assigned randomly to the iron (n = 28) or control (n = 29) groups. The iron group received intravenous ferric derisomaltose (1,000 mg) after anaesthetic induction. The control group received an identical volume of intravenous normal saline. The primary outcome was postoperative haemoglobin level. Secondary outcomes included other postoperative haematologic and iron parameters. Laboratory data were obtained preoperatively and at 1 day, 2 weeks, and 4 weeks postoperatively. Haemoglobin was higher in the iron group 2 weeks postoperatively (12.9 g/dL vs. 12.2 g/dL), but the between-group difference was not significant after adjustment for multiple testing. However, the reticulocyte production index was significantly higher in the iron group 2 weeks postoperatively. Intraoperative intravenous iron maintains postoperative haemoglobin values in patients undergoing bimaxillary orthognathic surgery by increasing haematopoietic function and iron bioavailability and therefore appears to be a useful strategy for blood management.

Balloon versus Amplatz for tract dilation in fluoroscopically guided percutaneous nephrolithotomy: a systematic review and meta-analysis

ObjectiveTo compare the safety and efficacy of balloon and Amplatz for tract dilation in fluoroscopically guided percutaneous nephrolithotomy (PCNL).MethodEMBASE, PUBMED, MEDLINE and the Cochrane Central Register of Controlled Trials were searched for pertinent studies up until 30 October 2019. Pooled effects were calculated as ORs with 95% CIs or mean differences (MD) with 95% CIs. Endpoints included postoperative decrease in haemoglobin, transfusion rate, complication rate, successful dilation rate, stone-free rate, fluoroscopy time, access time, total operation time and length of postoperative hospitalisation (LPH). Bonferroni’s correction was intercalated to reduce the likelihood of making a meta-analytical false positive.ResultsOne randomised controlled trial and five controlled clinical trials were included, which involved 1317 patients in total. We found a lower drop in postoperative haemoglobin for patients receiving balloon dilation compared with those in the Amplatz group (MD=−0.21, 95% CI −0.33 to 0.09, p=0.0005; Bonferroni correction a=0.005). Access time in the balloon group was also, on average, 2.61 min shorter than the Amplatz group (MD=−2.61, 95% CI −4.20 to 1.01, p=0.001; Bonferroni correction a=0.005). No significant differences were identified between the two dilation methods in terms of transfusion rate, complication rate, successful dilation rate, stone-free rate, fluoroscopy time, total operation time and LPH.ConclusionBalloon dilation is a safe and effective tract dilation technique for access creation during fluoroscopically guided PCNL. Both of methods have similar success rates although balloon dilation is associated with significantly less postoperative haemoglobin decline and shorter access time. Therefore, balloon dilation appears to be the superior tract dilation technique, but further confirmatory research is required to confirm these findings.