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Development and validation of a nomogram to predict intraoperative blood transfusion for gastric cancer surgery
Huang H, Cao M
Transfusion medicine (Oxford, England). 2021
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Editor's Choice
Abstract
OBJECTIVE To construct and validate a nomogram composed of preoperative variables to predict intraoperative blood transfusion for gastric cancer surgery. BACKGROUND Intraoperative transfusion for gastric cancer surgery is a common medical procedure that is associated with increased postoperative complications. METHODS A total of 999 patients who underwent gastrectomy between January 2010 and June 2019 were randomly allocated into the primary and validation cohorts in a 2:1 ratio. In the primary cohort, logistic analyses were performed to identify independent predictors for transfusion. Using the Akaike information criterion, selected variables were incorporated to construct a nomogram. Validations of the nomogram were performed in the primary and validation cohorts. The discrimination ability of the nomogram was assessed by the concordance index (C-index), and calibration was assessed by calibration curves and the Hosmer-Lemeshow goodness-of-fit test. RESULTS The following risk factors for transfusion were identified and used to construct the nomogram: ASA status (III-IV vs I-II: odds ratio [OR] 1.74), comorbidities (yes vs no: OR 1.57), tumour location (diffuse vs lower: OR 4.05), cTNM stage (III vs I: OR 1.95), and a preoperative haemoglobin level less than 80 g/L (vs over 120 g/L: OR 35.30). The C-index was 0.859 and 0.850 in the primary and validation cohorts, respectively, which both indicated good discrimination of the nomogram. Additionally, both calibration curves and Hosmer-Lemeshow tests (p-value 0.184 and 0.887, respectively) demonstrated high agreement between the predictions and actual outcomes. CONCLUSION A nomogram composed of preoperative variables to predict blood transfusion for gastric cancer surgery was effectively developed and validated. This nomogram could be used to improve the utilisation of red blood cells for gastrectomy.
PICO Summary
Population
Patients undergoing gastric cancer surgery (n= 999).
Intervention
Nomogram of preoperative variables to predict intraoperative blood transfusion (primary cohort, n= 666).
Comparison
Nomogram of preoperative variables to predict intraoperative blood transfusion (validation cohort, n= 333).
Outcome
The following risk factors for transfusion were identified and used to construct the nomogram: ASA (American Society of Anaesthesiologists) physical status, comorbidities, tumour location, Clinical Tumour-Lymph Node-Metastasis stage, and a preoperative haemoglobin level less than 80 g/L. The concordance index was 0.859 and 0.850 in the primary and validation cohorts, respectively, which both indicated good discrimination of the nomogram. Additionally, both calibration curves and Hosmer-Lemeshow tests demonstrated high agreement between the predictions and actual outcomes.
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The Additive Effect of Platelet-Rich Plasma in the Treatment of Actively Bleeding Peptic Ulcer
Seleem WM, Hanafy AS
Clinical endoscopy. 2021
Abstract
BACKGROUND/AIMS: Peptic ulcer bleeding is the most common cause of upper gastrointestinal tract bleeding. Platelet-rich plasma (PRP) enhances tissue repair, and is therefore used in various medical treatments. A combination of mechanical or electrothermal hemostasis has been recommended for upper gastrointestinal tract bleeding treatment. This study evaluated the additive efficacy of PRP in bleeding peptic ulcer hemostasis and recovery. METHODS Eighty patients with peptic ulcer bleeding were initially treated by hemoclipping, and were randomly chosen for either additional PRP (n=40) or additional epinephrine (n=40) injections. Both groups were compared with regard to achieving hemostasis and the frequency of complications. RESULTS Hemostasis was immediately achieved in both groups. Two patients (5%) in the PRP group and 8 (20%) patients in the epinephrine group experienced rebleeding after 15.9±2.8 and 12.3±3.7 days, respectively. They were managed by PRP injection in addition to proton pump inhibitor infusion. Hemoglobin was substantially increased in the PRP-treated group with full recovery occurring in 60.5% compared to 31.3% of patients in the epinephrine group (p=0.001). There was no recurrent bleeding in the PRP group, but 4/32 (12.5%) patients in the epinephrine group exhibited rebleeding. CONCLUSIONS PRP showed additional benefit in reducing peptic ulcer bleeding with no reported significant complications. Clinical trial (NCT03733171).
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Assessment of recurrent anal fistulas treatment with platelet-rich plasma
Cwaliński J, Hermann J, Paszkowski J, Banasiewicz T
Arquivos de gastroenterologia. 2021
Abstract
BACKGROUND Surgical treatment of recurrent anal fistulas can lead to numerous complications, including fecal incontinence. Therefore, sphincter preserving techniques are gaining more popularity. OBJECTIVE The aim of the study was to assess effectiveness of platelet-rich plasma (PRP) therapy in the patients with recurrent cryptoglandular anal fistulas. METHODS A cohort of 18 patients with anal fistulas was enrolled into a preliminary and prospective trial. They were divided into two groups consisting of eight and ten patients respectively. PRP was injected locally in all patients, however in the group II it was applied after 7 days drainage of fistulas with polyurethane foam or negative pressure wound therapy. On average, three doses of PRP were administered, but with the opportunity to double the number of applications if it was clinically justified. The patients were evaluated in an out-patient department after fortnight and then in 1, 6, and 12 months following the last PRP application. RESULTS Anal fistulas were closed in 4 (50%) patients from the group I and in 7 (70%) patients form the group II. Although, the difference between both groups was not statistically significant, PRP therapy should be preceded with fistulous tract drainage in all patients. Summarizing, that successful result was achieved in 11 (60%) patients from the entire group of 18 participants. CONCLUSION The rate of recurrent cryptoglandular anal fistulas closure reaching 60%, after topical treatment with PRP, exceeds the results of other sphincter-saving methods of treatment. Therefore, it might become a novel method of anal fistulas therapy.
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Restrictive versus liberal transfusion strategy in upper gastrointestinal bleeding: A randomized controlled trial
Kola G, Sureshkumar S, Mohsina S, Sreenath GS, Kate V
Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology Association. 2020
Abstract
BACKGROUND The study aimed at comparing restrictive and liberal transfusion strategy in reducing mortality in patients with upper gastrointestinal bleeding (UGIB). METHODS This was a single-center, prospective, open-label, non-inferiority, randomized controlled trial conducted over two years. Patients presenting with UGIB were randomized into restrictive (hemoglobin (Hb) <7 g/dl) or liberal (Hb <8 g/dl) transfusion strategy groups. Transfusion was given till patients achieved target Hb of 9 g/dl in restrictive and 10 g/dl in the liberal arms. Patients with exsanguinating bleeding, transfusion within 90 days, recent history of trauma or surgery were excluded. Primary outcome was mortality rate and the secondary outcomes were morbidity, re-bleeding episodes and the need for intervention. RESULTS A total of 224 patients were randomized to 112 patients in each group. Demographic characteristics were comparable. 45-day mortality was similar between the two groups (restrictive vs. liberal; 10/112 vs. 12/112; P = 0.65). The number of in-hospital bleeding episodes (12 vs. 9; P = 0.25), incidence of re-bleeding during the 45-day follow-up (13 vs. 14; P = 0.84), need for endoscopic banding for varices (37/112 vs. 39/112, P = 0.99), mean hospital stay (days) (3.21 ± 2.78 vs. 2.73 ± 1.29; P = 0.10) were similar between the two groups. CONCLUSION Restrictive transfusion strategy is non-inferior to liberal transfusion strategy in patients with UGIB.
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Comparison of three transfusion protocols prior to central venous catheterization in patients with cirrhosis: A randomized controlled trial
Rocha LL, Neto AS, Pessoa CMS, Almeida MD, Juffermans NP, Crochemore T, Rodrigues RR, Filho RR, Chaves RCF, Cavalheiro AM, et al
Journal of thrombosis and haemostasis : JTH. 2019
Abstract
BACKGROUND Transfusion of blood components prior to invasive procedures in cirrhosis patients is high and associated with adverse events. OBJECTIVES We compared three transfusion strategies prior to central venous catheterization in cirrhosis patients. PATIENTS/METHODS Single center randomized trial that included critically ill cirrhosis patients with indication for central venous line in a tertiary private hospital in Brazil. INTERVENTIONS Restrictive protocol, thromboelastometry-guided protocol, or usual care (based on coagulogram). The primary endpoint was the proportion of patients transfused with any blood component (i.e. fresh frozen plasma, platelets or cryoprecipitate). The secondary endpoints included incidence of bleeding and transfusion-related adverse events. RESULTS A total of 57 patients (19 per group; 64.9% male; mean age, 53.4 +/- 11.3 years) were enrolled. Prior to catheterization, 3/19 (15.8%) in the restrictive arm, 13/19 (68.4%) in the thromboelastometry-guided arm and 14/19 (73.7%) in the coagulogram-guided arm received blood transfusion (OR, 0.07; 95% CI, 0.01 - 0.45; p = 0.002 for restrictive vs. coagulogram-guided arm; OR, 0.09; 95% CI, 0.01 - 0.56; p = 0.006 for restrictive vs. thromboelastometry-guided arm; and OR, 0.77; 95% CI, 0.14 - 4.15; p = 0.931 for thromboelastometry-guided vs. coagulogram-guided arm). The restrictive protocol was cost saving. No difference in bleeding, length of stay, mortality, and transfusion-related adverse events was found. CONCLUSIONS The use of a restrictive strategy is associated with a reduction in transfusion prior to central venous catheterization and costs in critically ill cirrhosis patients. No effect on bleeding was found among the groups.
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Thromboelastography-guided Blood Product Transfusion in Cirrhosis Patients With Variceal Bleeding: A Randomized Controlled Trial
Rout G, Shalimar, Gunjan D, Mahapatra SJ, Kedia S, Garg PK, Nayak B
Journal of clinical gastroenterology. 2019
Abstract
GOALS The aim of this study was to assess the use of thromboelastography (TEG)-directed blood product transfusion in cirrhotic patients with acute variceal bleeding compared with conventional transfusion for correction of coagulopathy. BACKGROUND Coagulopathy is common in patients with cirrhosis. Recommendations for correction of conventional parameters of coagulation-platelets and the international normalized ratio before endoscopy in patients with acute variceal bleeding-need more validation. STUDY In this randomized controlled trial, cirrhotic patients with severe coagulopathy and acute variceal bleeding were randomized to either TEG-guided blood product transfusion or conventional transfusion from March 2017 to December 2017. The primary outcome was the difference in the amount of fresh frozen plasma and platelet units transfused between the groups. Secondary outcomes were rebleeding at 5 days and 42 days, and 6-week mortality. RESULTS Of the 60 recruited patients, 30 each were randomized to the TEG and conventional transfusion groups. There were no differences in baseline characteristic and endoscopic findings between the 2 groups. Four subjects in the TEG group received blood product transfusions versus all in the conventional transfusion group (13.3% vs. 100%; P<0.001). The control of bleeding on initial endoscopy was similar in the 2 groups. Rebleeding in the TEG and conventional transfusion groups at 5 days was similar [1 (3.3%) vs. 4 (13.3%), P=0.167], whereas it was significantly less in the TEG group at 42 days [3 (10%) vs. 11 (36.7%), P=0.012]. Mortality at 6 weeks was seen in 4 (13.3%) in the TEG group and in 8 (26.7%) patients in the conventional transfusion group (P=0.176). CONCLUSIONS TEG-guided strategy was associated with reduced blood product transfusion to correct coagulopathy without compromising hemostasis in cirrhotic patients (Clinical trial ID: CTRI/2017/02/007864).
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Thromboelastography-Guided Blood Component Use in Patients With Cirrhosis With Nonvariceal Bleeding: A Randomized Controlled Trial
Kumar M, Ahmad J, Maiwall R, Choudhury A, Bajpai M, Mitra LG, Saluja V, Mohan Agarwal P, Bihari C, Shasthry SM, et al
Hepatology (Baltimore, Md.). 2019
Abstract
Thromboelastography (TEG) provides a more comprehensive global coagulation assessment than routine tests (international normalized ratio [INR] and platelet [PLT] count), and its use may avoid unnecessary blood component transfusion in patients with advanced cirrhosis and significant coagulopathy who have nonvariceal upper gastrointestinal (GI) bleeding. A total of 96 patients with significant coagulopathy (defined in this study as INR >1.8 and/or PLT count <50 x 10(9) /L) and nonvariceal upper GI bleed (diagnosed after doing upper gastrointestinal endoscopy [UGIE], which showed ongoing bleed from a nonvariceal source) were randomly allocated to TEG-guided transfusion strategy (TEG group; n = 49) or standard-of-care (SOC) group (n = 47). In the TEG group, only 26.5% patients were transfused with all three blood components (fresh frozen plasma [FFP], PLTs, and cryoprecipitate) versus 87.2% in the SOC group (P < 0.001). Whereas 7 (14.3%) patients in the TEG group received no blood component transfusion, there were no such patients in the SOC group (P = 0.012). Also, there was a significantly lower use of blood components (FFP, PLTs, and cryoprecipitate) in the TEG group compared to the SOC group. Failure to control bleed, failure to prevent rebleeds, and mortality between the two groups were similar. CONCLUSION In patients with advanced cirrhosis with coagulopathy and nonvariceal upper GI bleeding, TEG-guided transfusion strategy leads to a significantly lower use of blood components compared to SOC (transfusion guided by INR and PLT count), without an increase in failure to control bleed, failure to prevent rebleed, and mortality.
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The use of a thromboelastometry-based algorithm reduces the need for blood product transfusion during orthotopic liver transplantation: A randomised controlled study
Bonnet A, Gilquin N, Steer N, Gazon M, Quattrone D, Pradat P, Maynard M, Mabrut JY, Aubrun F
European journal of anaesthesiology. 2019;36(11):825-833
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Editor's Choice
Abstract
BACKGROUND Orthotopic liver transplantation is associated with a risk of bleeding. Coagulation in cirrhotic patients is difficult to assess with standard coagulation tests because of rebalanced coagulation. This can be better assessed by thromboelastometry which can detect coagulation impairments more specifically in such patients. OBJECTIVES Our first objective was to compare the number of units of blood products transfused during liver transplantation when using an algorithm based on standard coagulation tests or a thromboelastometry-guided transfusion algorithm. DESIGN Randomised controlled trial. SETTING Single-centre tertiary care hospital in France, from December 2014 to August 2016. PARTICIPANTS A total of 81 adult patients undergoing orthotopic liver transplantation were studied. Patients were excluded if they had congenital coagulopathies. INTERVENTION Transfusion management during liver transplantation was guided either by a standard coagulation test algorithm or by a thromboelastometry-guided algorithm. Transfusion, treatments and postoperative outcomes were compared between groups. MAIN OUTCOME MEASURES Total number of transfused blood product units during the operative period (1 U is one pack of red blood cells (RBCs), fresh frozen plasma (FFP) or platelets). RESULTS Median [interquartile range] intra-operative transfusion requirement was reduced in the thromboelastometry group (3 [2 to 4] vs. 7 [4 to 10] U, P = 0.005). FFP and tranexamic acid were administered less frequently in the thromboelastometry group (respectively 15 vs. 46.3%, P = 0.002 and 27.5 vs. 58.5%, P = 0.005), whereas fibrinogen was more often infused in the thromboelastometry group (72.5 vs. 29.3%, P < 0.001). Median transfusions of FFP (3 [2 to 6] vs. 4 [2 to 7] U, P = 0.448), RBCs (3 [2 to 5] vs. 4 [2 to 6] U, P = 0.330) and platelets (1 [1 to 2] vs. 1 [1 to 2] U, P = 0.910) were not different between groups. In the postoperative period, RBC or platelet transfusion, the need for revision surgery or occurrence of haemorrhage were not different between groups. CONCLUSION A transfusion algorithm based on thromboelastometry assessment of coagulation reduced the total number of blood product units transfused during liver transplantation, particularly FFP administration. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02352181.
PICO Summary
Population
Adult patients undergoing orthotopic liver transplantation (n=81).
Intervention
Transfusion management during liver transplantation was guided by a standard coagulation test algorithm.
Comparison
Transfusion management during liver transplantation was guided by a thromboelastometry-guided algorithm.
Outcome
Median [interquartile range] intra-operative transfusion requirement was reduced in the thromboelastometry group (3 [2 to 4] vs. 7 [4 to 10] U). FFP and tranexamic acid were administered less frequently in the thromboelastometry group (respectively 15 vs. 46.3% and 27.5 vs. 58.5%), whereas fibrinogen was more often infused in the thromboelastometry group (72.5 vs. 29.3%). Median transfusions of FFP (3 [2 to 6] vs. 4 [2 to 7] U, RBCs (3 [2 to 5] vs. 4 [2 to 6] U) and platelets (1 [1 to 2] vs. 1 [1 to 2] U) were not different between groups. In the postoperative period, RBC or platelet transfusion, the need for revision surgery or occurrence of haemorrhage were not different between groups. (1 U is one pack of red blood cells (RBCs), fresh frozen plasma (FFP) or platelets).
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Stroke Volume Variation (SVV) as an Indicator of Intraoperative Transfusion Management during Laparoscopic Colectomy. . Japanese
Suzuki H, Saima S, Arai T, Asa T, Okuda Y
Masui - Japanese Journal of Anesthesiology. 2016;65((8)):790-794.
Abstract
BACKGROUND Intraoperative transfusion manage- ment is difficult during laparoscopic surgery, because peumoperitoneum affects hemodynamics. We studied whether stroke volume variation (SVV) is useful as an indicator of transfusion management Methods : We studied 44 patients undergoing lapa- roscopic colectomy. Patients were randomly allocated to two groups, and the volume of transfusion was decided with the SVV as an indicator in one group (SVV group, n=22) or with conventional indicators, such as blood pressure, heart rate, volume of urine in the other group (control group, n=22) Results : In the SVV group, total transfusion volume and total blood loss during operation were significantly decreased, and the length of hospital stay was signifi- cantly shorter, compared with the control group. CONCLUSIONS We believe that the SVV is a useful indicator of intraoperative transfusi6h management during laparoscopic colectomy.
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The impact of two different transfusion strategies on patient immune response during major abdominal surgery: a preliminary report
Theodoraki K, Markatou M, Rizos D, Fassoulaki A
Journal of Immunological Research. 2014;2014:945829.
Abstract
Blood transfusion is associated with well-known risks. We investigated the difference between a restrictive versus a liberal transfusion strategy on the immune response, as expressed by the production of inflammatory mediators, in patients subjected to major abdominal surgery procedures. Fifty-eight patients undergoing major abdominal surgery were randomized preoperatively to either a restrictive transfusion protocol or a liberal transfusion protocol (with transfusion if hemoglobin dropped below 7.7gdL(-1) or 9.9gdL(-1), respectively). In a subgroup of 20 patients randomly selected from the original allocation groups, blood was sampled for measurement of IL-6, IL-10, and TNFalpha. Postoperative levels of IL-10 were higher in the liberal transfusion group on the first postoperative day (49.82 + 29.07 vs. 15.83 + 13.22pgmL(-1), P < 0.05). Peak postoperative IL-10 levels correlated with the units of blood transfused as well as the mean duration of storage and the storage time of the oldest unit transfused (r(2) = 0.38, P = 0.032, r(2) = 0.52, P = 0.007, and r(2) = 0.68, P<0.001, respectively). IL-10 levels were elevated in patients with a more liberal red blood cell transfusion strategy. The strength of the association between anti-inflammatory IL-10 and transfusion variables indicates that IL-10 may be an important factor in transfusion-associated immunomodulation. This trial is registered under ClinicalTrials.gov Identifier: NCT02020525.