The effect of tranexamic acid on blood loss in non-urgent trauma patients undergoing major orthopaedic surgery: A retrospective cohort study

Objectives: This study aims to clarify the role of prophylactic TXA on blood loss and transfusion requirements in a subgroup of trauma patients undergoing major orthopaedic surgery on a non-urgent basis. Study design: This is a retrospective cohort study Setting: Tertiary University Hospital of Crete (2017-2018) Patients/participants: Polytrauma patients who underwent delayed major orthopaedic surgery Main outcome measurement: Significant haemorrhage occurrence in relation to TXA administration. In a subgroup of patients Rotational Thromboelastometry (ROTEM) was used to reveal their haemostatic profile prior to TXA administration. Methods: Data from anaesthetic and ICU records were analyzed regarding age, sex, body mass index, ASA physical status, Injury Severity Score, Caprini Score, intraoperative blood loss, number of packed red blood cells units transfused, volume of crystalloids administered, operation duration, preoperative and postoperative haemoglobin values, and days from hospital admission to surgery. ROTEM analysis in a subgroup of patients revealed their haemostatic profile prior to TXA administration. Results: Twenty five out of 46 patients received prophylactic TXA treatment. After adjustment for confounding factors, the odds ratio for the composite endpoint for prophylactic TXA (n=25) vs no TXA (n=21) was 1.27 (95% confidence interval, CI 0.39-4.16). Propensity matched analysis confirmed the absence of a difference between patients with and without TXA. In all patients analyzed with ROTEM normal or hypercoagulable status was revealed. Conclusions: In trauma patients undergoing major orthopaedic surgery more than 12 hours after the initial injury, TXA has no effect on blood loss and transfusion requirements. Keywords: tranexamic acid; blood loss; transfusion; orthopaedic trauma surgery; spine surgery; pelvis surgery; significant bleeding in orthopaedic surgery

An audit of unnecessary preoperative urea and electrolyte panel tests in patients undergoing major orthopaedic surgery at a quaternary South African hospital

Background: Preoperative urea and electrolyte (U&E) panels are frequently requested for major surgery patients at risk for postoperative acute kidney injury (AKI). There is only one published study that has audited unnecessary preoperative U&E test panel utilisation in major surgery patients at a South African (SA) public sector hospital. This has significant implications for laboratory workloads, healthcare expenditure, and patient-friendly practice in the resource-limited SA public healthcare sector. Objective: To audit preoperative U&E panel requests in a sample of SA patients undergoing major orthopaedic surgery. Methods: We conducted a retrospective audit of adult primary hip arthroplasty patients who attended a quaternary SA hospital. Data on demographics, medical history, preoperative anaesthetic evaluations, operation details, and U&E panel requests were collected from each patient’s medical chart. The National Institute for Health and Care Excellence (NICE) guidelines, based on American Society of Anesthesiologists (ASA) grading and the presence of AKI risk factors, was used to distinguish between necessary and unnecessary preoperative U&E requests. We used descriptive statistics to analyse our study data. Results: Of the 175 patients comprising our study sample, 23 (13.1%) had preoperative U&E panels requested unnecessarily. All 23 patients were otherwise healthy and did not have any AKI risk factors. Conclusion: A small proportion of preoperative U&E test panels in our study sample of major orthopaedic surgery patients were deemed unnecessary. With that being said, there is still room for improvement in practices around preoperative U&E panel requests, which could be achieved through educational, computerised, and audit feedback interventions.

165 A Review of The Current Literature on LMWH Administered at Different Times in Relation to MOS (Major Orthopaedic Surgery): Assessment of The Safety and Efficacy of The Different Proposed Strategies

Nowadays venous VTE represents an important perioperative and postoperative complication in patients undergoing elective Major Orthopedic Surgery (MOS). There are significant discrepancies between clinical practice, international recommendations, and published guidelines. Although thromboembolic events may be less common these days than in the past, they can still lead to serious medical complications. Therefore, most patients undergoing MOS procedures are provided with one of the thromboprophylactic treatments. The optimum timing of LMWH administrations remains debated. Customized structured electronic searches in PubMed and Cochrane database. Meta-Analysis, Randomized Controlled Trials, Systematic Reviews on different strategies of the use of LMWH for MOS. Studies on prophylactic regimens showed that subcutaneous LMWH plays a key role in the management of thromboprophylaxis in MOS. However, some controversies still stand. Among those most relevant, it remains unclear whether to start thromboprophylaxis before or after MOS to better balance the risks of clotting and bleeding. With regards to different times of LMWH administration, there is no convincing evidence that starting prophylaxis 12 hours preoperatively is associated with lower risks of VTE compared to prophylaxis started 12 to 24 hours postoperatively. Furthermore, it seems that the most safe and efficient LMWH regimen is the one called “Just-in-time” (LMWH started 6 hours post-op).

Comparison of low-molecular-weight heparins in thromboprophylaxis of major orthopaedic surgery – randomized, prospective pilot study

AimTo compare the clinical effectiveness of the two most commonly used LMWHs, dalteparin (DALT) and enoxaparin (ENOX), in thromboprophylaxis of elective total hip replacement (THR) or total knee replacement (TKR).Material and methodsTo the prospective, randomized study were included 66 adult patients qualified to undergo THR or TKR (age 63 ± 12 years, 44 women). The patients were randomized to daily in-hospital subcutaneous prophylaxis with 5,000 I.U. of DALT or 40 mg of enoxaparin. Clinical and laboratory data were collected before surgery, and on 1st and 5th days after surgery.ResultsThirty-four patients were randomized to prophylaxis with ENOX and 32 with DALT. The groups did not differ significantly in age, sex, creatinine and most of the laboratory parameters. The compared groups had similar surgical parameters, but more patients in the ENOX group received red blood cell infusion (17(50%) vs 8(25%); p < 0.05). The Lee–White coagulation time mildly decreased in ENOX and DALT following the surgery (p = ns). There was a shortening of Duke’s bleeding time in DALT after the surgery and it became significantly quicker than that in ENOX on Day 5 (p = 0.03).ConclusionThe observed difference in Duke’s bleeding time and exceeding blood loss during the surgery on the enoxaparin demands confirmation, as it can be important information for clinical management.

Feasibility and Efficacy of Lung Ultrasound to Investigate Pulmonary Complications in Patients Who Developed Postoperative Hypoxaemia-A Prospective Study

Background: Postoperative pulmonary complications (PPCs) and hypoxaemia is associated with morbidity and mortality. We aim to evaluate the feasibility and efficacy of lung ultrasound (LUS) to diagnose PPCs in patients suffering from hypoxemia after general anesthesia and compare the results to those of thoracic computed tomography (CT). Methods: Adult patients who received general anesthesia and suffered from hypoxaemia in the postanaesthesia care unit (PACU) were analyzed. Hypoxaemia was defined as an oxygen saturation measured by pulse oximetry (SPO 2 ) less than 92% for more than 30 seconds under ambient air conditions. LUS was performed by two trained anaesthesiologists once hypoxaemia occurred. After LUS examination, each patient was transported to the radiology department for thoracic CT scan within 1 hour before returning to the ward. Results: From January 2019 to May 2019, 113 patients (61 men) undergoing abdominal surgery (45 patients, 39.8%), video-assisted thoracic surgery (31 patients, 27.4%), major orthopaedic surgery (17 patients, 15.0%), neurosurgery (10 patients, 8.8%) or other surgery (10 patients, 8.8%) were included. CT diagnosed 327 of 1356 lung zones as atelectasis, while LUS revealed atelectasis in 311 of the CT-confirmed zones. Pneumothorax was detected by CT scan in 75 quadrants, 72 of which were detected by LUS. Pleural effusion was diagnosed in 144 zones on CT scan, and LUS detected 131 of these zones. LUS was reliable in diagnosing atelectasis (sensitivity 98.0%, specificity 96.7% and diagnostic accuracy 97.2%), pneumothorax (sensitivity 90.0%, specificity 98.9% and diagnostic accuracy 96.7%) and pleural effusion (sensitivity 92.9%, specificity 96.0% and diagnostic accuracy 95.1%). Conclusions: Lung ultrasound is feasible, efficient and accurate in diagnosing different aetiologies of postoperative hypoxia in healthy-weight patients in the PACU.

COMPARATIVE STUDY OF SEQUENTIAL COMBINED SPINAL EPIDURAL ANAESTHESIA VERSUS SPINAL ANAESTHESIA IN HIGH RISK GERIATRIC PATIENTS FOR MAJOR ORTHOPAEDIC SURGERY

Sequential combined spinal epidural anaesthesia (Sequential CSEA) is probably the greatest advance in central neuraxial block in this decade for high risk geriatric patients because here the advantages of both spinal and epidural anaesthesia are summated avoiding the side effects. This study is designed to compare the clinical effects of sequential combined spinal epidural anaesthesia versus spinal anaesthesia in high risk geriatric patients undergoing major orthopaedic procedure. Sixty patients aged 65 to 80 years, ASA III were randomly allocated into two equal groups. Group A (n=30) received sequential combined spinal epidural anaesthesia with 1 ml (5 mg) of 0.5% hyperbaric bupivacaine with 20 mg fentanyl through spinal route, and the expected incompleteness of spinal block was managed with small incremental dose of 0.5% isobaric bupivacaine through epidural catheter, 1.5 to 2 ml for every unblocked segment to achieve T10 sensory level. Group B (n=30) received spinal anaesthesia with 2 ml (10 mg) of 0.5% hyperbaric bupivacaine and 20 mg of fentanyl. Both the groups showed rapid onset, excellent analgesia and good quality motor block. Group A showed a significantly less incidence of hypotension (p< 0.01) along with the provision of prolonging analgesia as compared to group B. So sequential combined spinal epidural anaesthesia is a safe, effective, reliable technique with stable haemodynamic along with provision of prolonging analgesia compared to spinal anaesthesia for high risk geriatric patients undergoing major orthopaedic surgery. Keywords: Sequential combined spinal epidural anaesthesia, Spinal anaesthesia, Fentanyl, Geriatric

Feasibility and Efficacy of Lung Ultrasound to Investigate Pulmonary Complications in Patients Who Developed Postoperative Hypoxaemia-A Prospective Study

Background: Postoperative pulmonary complications (PPCs) and hypoxaemia are associated with morbidity and mortality. We aimed to evaluate the feasibility and efficacy of lung ultrasound (LUS) to diagnose PPCs in patients suffering from hypoxaemia after general anaesthesia and compare the results to those of thoracic computed tomography (CT). Methods: Adult patients who received general anaesthesia and suffered from hypoxaemia in the postanaesthesia care unit (PACU) were analysed. Hypoxaemia was defined as an oxygen saturation measured by pulse oximetry (SPO2) less than 92% for more than 30 seconds under ambient air conditions. LUS was performed by two trained anaesthesiologists once hypoxaemia occurred. After LUS examination, each patient was transported to the radiology department for thoracic CT scan within 1 hour before returning to the ward. Results: From January 2019 to May 2019, 113 patients (61 men) undergoing abdominal surgery (45 patients, 39.8%), video-assisted thoracic surgery (31 patients, 27.4%), major orthopaedic surgery (17 patients, 15.0%), neurosurgery (10 patients, 8.8%) or other surgery (10 patients, 8.8%) were included. CT diagnosed 327 of 1356 lung zones as atelectasis, while LUS revealed atelectasis in 311 of the CT-confirmed zones. Pneumothorax was detected by CT scan in 75 quadrants, 72 of which were detected by LUS. Pleural effusion was diagnosed in 144 zones on CT scan, and LUS detected 131 of these zones. LUS was reliable in diagnosing atelectasis (sensitivity 98.0%, specificity 96.7% and diagnostic accuracy 97.2%), pneumothorax (sensitivity 90.0%, specificity 98.9% and diagnostic accuracy 96.7%) and pleural effusion (sensitivity 92.9%, specificity 96.0% and diagnostic accuracy 95.1%). Conclusions: Lung ultrasound is feasible, efficient and accurate in diagnosing different aetiologies of postoperative hypoxia in healthy-weight patients in the PACU.