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1.  Topical tranexamic acid reduces blood loss and transfusion rates in total hip and total knee arthroplasty 
The Journal of arthroplasty  2013;28(9):10.1016/j.arth.2013.06.011.
The objective of this study was to determine if tranexamic acid (TXA) applied topically reduced postoperative bleeding and transfusion rates after primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA).
Two hundred and ninety consecutive patients from a single surgeon were enrolled. In TKA, TXA solution was injected into the knee after closure of the arthrotomy. In THA, the joint was bathed in TXA solution at three points during the procedure. In both THA and TKA the TXA solution was at a concentration of 3gm TXA per 100mL saline.
The mean blood loss was significantly higher in the non-TXA patients in both TKA and THA groups. Postoperative transfusions decreased dramatically with TXA, dropping from 10% to 0%, and from 15% to 1%, in the TKA and THA groups, respectively.
Topical application of TXA significantly reduces postoperative blood loss and transfusion risk in TKA and THA.
doi:10.1016/j.arth.2013.06.011
PMCID: PMC3807723  PMID: 23886406
Blood Transfusion; Tranexamic Acid; Antifibrinolytic; Total Knee Arthroplasty; Total Hip Arthroplasty
2.  Blood salvage and cancer surgery: should we do it? 
Transfusion  2009;49(10):2016-2018.
doi:10.1111/j.1537-2995.2009.02379.x
PMCID: PMC4165080  PMID: 19903281
3.  Stored Platelet Functionality is Not Decreased After Warming with a Fluid Warmer 
Anesthesia and analgesia  2013;117(3):575-578.
Background
Warming of IV administered fluids and blood products is routinely performed in the operating room to help maintain normothermia. Current guidelines recommend against the warming of platelets (PLTs), although there is no evidence for this prohibition in the literature. Our goal in this pilot study was to determine if the warming of stored PLTs had any effect on their function.
Methods
Ten units of three-day-old PLT rich plasma-derived whole blood PLTs were acquired from the transfusion service. A 5 mL aliquot was taken from each unit before warming (control samples). The remainder of the unit was then passed into a blood warming device and held there for two minutes. Post-warming (warmed) PLT samples were then collected from the effluent end of the warming device. PLT aggregometry assays with adenosine diphosphate, collagen, and arachidonic acid as agonists were performed on the control and warmed samples. Thromboelastrography (TEG®) tests were also performed on the control and warmed samples from six of the 10 PLT units.
Results
The mean temperature of the control and warmed samples was 22.4 ± 0.5°C and 37.8 ± 2.3°C, respectively. There was no significant difference (all P ≥ 0.13) in any of the PLT aggregometry assays or in the maximum amplitude of the TEG® test between the control and the warmed samples. The observed mean of only one parameter decreased (PLT aggregometry with 5 µM adenosine diphosphate), by 5% (95% CI: −115% to 105%). The maximum change observed was PLT aggregometry with arachidonic acid as agonist, which increased by 116% (95% CI: −91% to 323%).
Conclusion
Although small in size, the results of this study do not support the prohibition against mechanical PLT warming. Studies of PLT activation after warming are also warranted.
doi:10.1213/ANE.0b013e31829cfdfa
PMCID: PMC3784352  PMID: 23921655
4.  Complications following an unnecessary peri-operative plasma transfusion and literature review 
Plasma is used to correct coagulopathies, but not all coagulation abnormalities are clinically significant enough to require correction before an invasive procedure. We report an 82-year-old female who, in response to a mildly prolonged INR of unknown etiology, was unnecessarily transfused with plasma in advance of elective surgery. The patient suffered a moderately severe transfusion reaction, including hives and voice hoarseness, which caused a 4-week delay in her surgery. This delay and adverse reaction could have been avoided had the principles of evidence based plasma therapy, which we herein review, been followed and if the etiology of the mildly elevated INR been investigated before the day of her surgery.
doi:10.4103/0973-6247.137458
PMCID: PMC4140061  PMID: 25161359
Allergic reaction; guidelines; plasma; transfusion
5.  Washing and filtering of cell-salvaged blood – does it make autotransfusion safer? 
doi:10.1111/j.1778-428X.2012.01155.x
PMCID: PMC4064293  PMID: 24955005
Autologous blood; Autotransfusion; Blood salvage; Cell salvage; Red blood cells; Transfusion
6.  The Effect of salvaged blood on Coagulation Function as measured by Thromboelastography 
Transfusion  2012;53(6):1235-1239.
BACKGROUND
There is concern that salvaged blood has the potential to activate the coagulation system, which might place patients at risk of thrombotic complications. The aim of this study was to determine whether transfusion of salvaged blood after total knee arthroplasty (TKA) would lead to procoagulopathic changes as measured by thromboelastography (TEG), and furthermore if washing would reduce this risk.
STUDY DESIGN AND METHODS
Twenty two patients undergoing TKA were enrolled. Control samples were venous blood samples taken before surgery. Test samples were created by mixing the control samples with postoperatively salvaged blood, either washed or unwashed. TEG profiles were measured, noting the time to initiate clotting (R), the time of clot formation (K), the angle of clot formation (α-angle), and the maximum strength of clot (MA).
RESULTS
The changes in the coagulation profile from control samples to test samples were consistent for both the washed and unwashed groups: R time decreased, MA decreased, and K and alpha-angle remained the same. However, the changes were more pronounced in the unwashed group than the washed group, with a 61% decrease in R time as compared with 14%, and a 26% drop in MA as compared with 6%.
CONCLUSION
The addition of salvaged blood to the patient’s preoperative blood resulted in decreased clot strength as well as decreased time to initial clot formation. This suggests that the reinfusion of postoperatively salvaged washed or unwashed blood after TKA favors a change towards a more hypocoagulable state, and washing appears to reduce this effect.
doi:10.1111/j.1537-2995.2012.03884.x
PMCID: PMC3521840  PMID: 22934712
Autotransfusion; Blood transfusion; Coagulation; Salvaged blood; Thromboelastography; Total knee arthroplasty
7.  Changes in hematologic indices in caucasian and non-caucasian pregnant women in the United States 
The Korean Journal of Hematology  2012;47(2):136-141.
Background
The objective of this study was to determine if there are differences in common red blood cell (RBC) indices and platelet concentrations during pregnancy and to establish if any observed differences in these parameters were based on the patient's ethnicity.
Methods
From an electronic perinatal database which stores laboratory and clinical information on a large number of births at a regional hospital specializing in obstetrical care, RBC index and platelet concentration data were retrospectively analyzed at various time points throughout pregnancy. RBC index data was collected from 8,277 pregnant women (5,802 Caucasian pregnant women and 2,475 non-Caucasian pregnant women). Platelet concentration data was available from 8252 pregnant women (5,784 Caucasian pregnant women and 2,468 non-Caucasian pregnant women).
Results
Hemoglobin (HGB) levels were significantly higher amongst Caucasian women compared to non-Caucasian women (P at least <0.01) starting at 27 weeks gestation and proceeding until term. There was no significant difference in the mean PLT counts between Caucasian and non-Caucasian pregnant women at any point during gestation.
Conclusion
There are ethnic differences in HGB levels, but not the platelet concentrations, during pregnancy. Based on this finding it would be reasonable to conduct formal prospective studies to determine the clinical significance of this difference and to establish the threshold for diagnosing gestational anemia, especially in pregnant non-Caucasian women.
doi:10.5045/kjh.2012.47.2.136
PMCID: PMC3389063  PMID: 22783361
Anemia; Complete blood count; Hemoglobin; Pregnancy; Reference Ranges
8.  Intra-operative cell salvage: a fresh look at the indications and contraindications 
Blood Transfusion  2011;9(2):139-147.
doi:10.2450/2011.0081-10
PMCID: PMC3096856  PMID: 21251468
autotransfusion; cell salvage; erythrocytes; allogeneic transfusion; blood conservation
9.  A cost study of post-operative cell salvage in the setting of elective primary hip and knee arthroplasty 
Transfusion  2012;52(8):1750-1760.
Background
The rising costs, limited supply, and clinical risks associated with allogeneic blood transfusion have prompted investigation into autologous blood management strategies, such as post-operative red cell salvage. This study provides a cost comparison of transfusing washed post-operatively salvaged red cells using the OrthoPat device versus unwashed shed blood and banked allogeneic blood.
Study Design and Methods
Cell salvage data was retrospectively reviewed for a sample of 392 patients who underwent primary hip or knee arthroplasty. Average unit costs were calculated for washed salvaged red cells, equivalent units of unwashed shed blood, and therapeutically equivalent volumes of allogeneic packed red cells.
Results
No initial capital investment was required for the establishment of the post-operative cell salvage program. For patients undergoing total knee arthroplasty (TKA), the average unit cost for washed post-operatively salvaged cells, unwashed shed blood, and allogeneic banked blood was $758.80, $474.95, and $765.49, respectively. In patients undergoing total hip arthroplasty (THA), the average unit cost for washed post-operatively salvaged cells, unwashed shed blood, and allogeneic banked blood was $1827.41, $1167.41, and $2609.44, respectively.
Conclusion
This analysis suggests that transfusing washed post-operatively salvaged cells using the OrthoPat device is more costly than using unwashed shed blood in both THA and TKA. When compared to allogeneic transfusion, washed post-operatively salvaged cells carry a comparable cost in TKA, but potentially represent a significant savings in patients undergoing THA. Sensitivity analysis suggests that in the case of TKA, however, cost comparability exists within a narrow range of units collected and infused.
doi:10.1111/j.1537-2995.2011.03531.x
PMCID: PMC3360121  PMID: 22339139
blood salvage; autologous transfusion; allogeneic transfusion; cost study analysis
10.  Blood Utilization After Primary Total Joint Arthroplasty in a Large Hospital Network 
HSS Journal  2013;9(2):123-128.
Background
Since a study in orthopedic hip fracture patients demonstrated that a liberal hemoglobin (Hb) threshold does not improve patient morbidity and mortality relative to a restrictive Hb threshold, the standard of care in total joint arthroplasty (TJA) should be examined to understand the variability of red blood cell (RBC) transfusion following TJA.
Questions/purposes
The study aimed to answer the following questions: (1) What is the blood utilization rate after primary TJA for individual surgeons within a large hospital network? (2) What is the comparison of hospital charges, length of stay (LOS), and discharge locations among TJA patients who were and were not transfused?
Methods
A retrospective study was conducted on 3,750 primary total knee arthroplasties (TKAs) and 2,070 primary total hip arthroplasties (THAs), and data was retrospectively collected over a 15-month period on the number of RBCs transfused per patient, along with demographic and cost details. The number of patients who received at least 1 RBC unit and the number of RBCs transfused per patient was calculated and stratified by surgeon.
Results
In the postoperative period, 19.3% TKA patients and 38.5% THA patients received a RBC transfusion. Transfusion rates following TJA varied widely between surgeons (TKA 4.8–63.8%, THA 4.3–86.8%). Transfused TKA patients received an average of 1.65 ± 0.03 RBCs, and THA patients received an average of 1.97 ± 0.14 RBCs. LOS and hospital charges for blood transfusion patients were higher than nontransfused patients.
Conclusion
Blood utilization after primary TJA varies greatly among surgeons, suggesting that resources may be misallocated. These findings highlight the need to standardize RBC transfusion practice following TJA.
Electronic supplementary material
The online version of this article (doi:10.1007/s11420-013-9327-y) contains supplementary material, which is available to authorized users.
doi:10.1007/s11420-013-9327-y
PMCID: PMC3757482  PMID: 24009534
total joint arthroplasty; blood utilization; transfusion rate; blood management; red blood cell (RBC) transfusion; intervention
11.  Complications following an unnecessary peri-operative plasma transfusion and literature review 
The Korean Journal of Hematology  2012;47(4):298-301.
Plasma is used to correct coagulopathies, but not all coagulation abnormalities are clinically significant enough to require correction before an invasive procedure. We report an 82 year old female who, in response to a mildly prolonged INR of unknown etiology, was unnecessarily transfused with plasma in advance of elective surgery. The patient suffered a moderately severe transfusion reaction, including hives and voice hoarseness, which caused a 4-week delay in her surgery. This delay and adverse reaction could have been avoided had the principles of evidence based plasma therapy, which we herein review, been followed and if the etiology of the mildly elevated INR been investigated before the day of her surgery.
doi:10.5045/kjh.2012.47.4.298
PMCID: PMC3538803  PMID: 23320010
Plasma; FFP; Transfusion; Allergic; Reaction; Complication
12.  Unwashed shed blood: should we transfuse it? 
Blood Transfusion  2011;9(3):241-245.
doi:10.2450/2011.0109-10
PMCID: PMC3136589  PMID: 21627923
13.  Dexmedetomidine for an awake fiber-optic intubation of a parturient with Klippel-Feil syndrome, Type I Arnold Chiari malformation and status post released tethered spinal cord presenting for repeat cesarean section 
Clinics and Practice  2011;1(3):e57.
Patients with Klippel-Feil Syndrome (KFS) have congenital fusion of their cervical vertebrae due to a failure in the normal segmentation of the cervical vertebrae during the early weeks of gestation and also have myriad of other associated anomalies. Because of limited neck mobility, airway management in these patients can be a challenge for the anesthesiologist. We describe a unique case in which a dexmedetomidine infusion was used as sedation for an awake fiber-optic intubation in a parturient with Klippel-Feil Syndrome, who presented for elective cesarean delivery. A 36-year-old female, G2P1A0 with KFS (fusion of cervical vertebrae) who had prior cesarean section for breech presentation with difficult airway management was scheduled for repeat cesarean delivery. After obtaining an informed consent, patient was taken in the operating room and non-invasive monitors were applied. Dexmedetomidine infusion was started and after adequate sedation, an awake fiber-optic intubation was performed. General anesthetic was administered after intubation and dexmedetomidine infusion was continued on maintenance dose until extubation. Klippel-Feil Syndrome (KFS) is a rare congenital disorder for which the true incidence is unknown, which makes it even rare to see a parturient with this disease. Patients with KFS usually have other congenital abnormalities as well, sometimes including the whole thoraco-lumbar spine (Type III) precluding the use of neuraxial anesthesia for these patients. Obstetric patients with KFS can present unique challenges in administering anesthesia and analgesia, primarily as it relates to the airway and dexmedetomidine infusion has shown promising result to manage the airway through awake fiberoptic intubation without any adverse effects on mother and fetus.
doi:10.4081/cp.2011.e57
PMCID: PMC3981373  PMID: 24765318
Klippel-Feil syndrome; dexmedetomidine; awake fiberoptic intubation; cesarean section.
14.  The impact of suctioning RBCs from a simulated operative site on mechanical fragility and hemolysis 
Background
Intraoperative cell salvage exerts shear stress upon RBCs, particularly as they are suctioned from the surgical field. Shear stress can result in overt hemolysis or it can cause sublethal injury to the suctioned RBCs. The mechanical fragility (MF) test uses shear stress to measure the extent of RBC sublethal injury. RBCs that have sustained sublethal injury are more susceptible to shear stress induced hemolysis. In this study we suctioned whole blood samples from an artificial surgical field to determine if pre-menopausal female RBCs would demonstrate greater resistance to hemolysis and less sublethal injury compared to that of males and post-menopausal females.
Methods
Ten CPD-preserved whole blood units from these 3 donor groups were obtained and samples suctioned at -150 mmHg from a simulated surgical field. The MF test was then performed and the % hemolysis calculated. In addition the MF test was serially performed on these whole blood units during the 21 days of storage.
Results
There were no differences in the extent of hemolysis or RBC shear stress resistance after suctioning between the 3 donor groups. During storage the pre-menopausal female RBCs demonstrated higher shear stress tolerance compared to the males or post-menopausal females at all of the time points.
Conclusion
Although during static storage pre-menopausal female RBCs in CPD-preserved whole blood demonstrated higher shear stress tolerance, this enhanced resistance was not observed after suctioning from a simulated surgical field.
doi:10.5045/kjh.2011.46.1.31
PMCID: PMC3065624  PMID: 21461301
Red blood cell; Mechanical fragility; Suctioning; Cell salvage; Hemolysis; Storage lesion; Peri-operative

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