Resumo em Inglês:

Abstract Background Major Orthopedic Surgery (MOS) is frequently associated with significant blood loss, potentially resulting in perioperative anemia and the need for allogeneic blood transfusion, which carries inherent risks. This study aimed to identify independent preoperative predictors of early Packed Red Blood Cell (PRBC) transfusion in patients undergoing MOS. Methods We analyzed, retrospectively, data from 7072 patients who underwent MOS. The variables assessed included age, sex, weight, height, Body Mass Index (BMI), ASA (American Society of Anesthesiologists) physical status classification, surgical category (hip, knee, spine), type of procedure (primary or revision total hip/knee arthroplasty, spinal arthrodesis, scoliosis surgery), preoperative hemoglobin levels and levels at 8:00 AM on postoperative day 1, hemoglobin thresholds (> 13, < 13, < 12, < 11, and < 10 g.dL-1), administration of tranexamic acid, and the requirement for PRBC transfusion. Results The overall transfusion rate was 4.8 % (3.6 % for hip, 2.7 % for knee, and 15.0 % for spine surgery). Independent predictors of PRBC transfusion included: preoperative hemoglobin < 13 g.dL-1 (Relative Risk [RR] 6.55), high-risk surgical procedures (RR = 7.40), ASA physical status III‒IV (RR = 2.00), absence of tranexamic acid use (RR = 2.52), and, to a lesser extent, age > 75 years (RR = 1.50). The combination of all identified risk factors was associated with a markedly increased transfusion risk (RR = 14.55; p < 0.0001). Conclusion These findings have informed modifications to our clinical practice, aimed at enhancing quality standards through the implementation of more effective Patient Blood Management (PBM) strategies.

Resumo em Inglês:

Abstract Background Intraoperative coagulopathies are common in complex surgeries, and timely coagulation monitoring is crucial. We assessed the accuracy of the point-of-care CoaguChek XS test against standard laboratory measurements in patients undergoing cardiac surgery with Cardiopulmonary Bypass (CPB). Methods We conducted a single-center, diagnostic accuracy study to assess the coagulation profile of 50 participants before and after CPB. The index test was the CoaguChek XS device and the reference test was the standard laboratory assay. The primary outcome was the accuracy of the CoaguChek device in measuring the International Normalized Ratio (INR). We pre-specified a tolerance range of ± 0.5 INR units. Secondary outcomes included accuracy in measuring prothrombin time and prothrombin activity. Results We included 50 patients undergoing cardiac surgery with CPB between October 2023 and January 2024. The mean (standard deviation) age was 59.2 (12.3) years, and 32 participants (64%) were male. For INR values, Lin’s coefficient was 0.72 (95% CI: 0.60‒0.82) pre-CPB and 0.66 (95% CI: 0.50‒0.77) post-CPB, both indicating good agreement. In the pre-CPB period, on average, the index test readings exceeded reference readings by 0.045 INR units (95% CI: 0.030‒0.059, p < 0.001), while in post-CPB period, index readings were, on average, 0.064 INR units lower (95% CI: -0.09 to -0.04, p < 0.001). Although statistically significant differences were observed, they fell within predefined tolerance range and were considered clinically irrelevant. Analyses of secondary outcomes were consistent with the primary outcome findings. Conclusion In patients undergoing cardiac surgery with cardiopulmonary bypass, CoaguChek XS provided results comparable to standard laboratory coagulation monitoring, both pre-and post-cardiopulmonary bypass. Research Board Approval Plataforma Brasil CAAE 70266023.8.0000.5553. Clinical Trials Registration (https://clinicaltrials.gov/study/NCT06037720) NCT06037720, 14/09/2023.

Resumo em Inglês:

ABSTRACT Background Anemia is a common and critical condition in the perioperative management of patients undergoing major elective surgeries, posing significant risks to postoperative recovery. This study aimed to evaluate the prevalence of preoperative and postoperative anemia in surgical patients from a university hospital in northeastern Brazil. Methods This retrospective study included 508 patients aged 18 years or older who underwent major elective surgeries between October 2021 and October 2022. Anemia was defined according to World Health Organization criteria (hemoglobin < 13 g.dL-1 for men and < 12 g.dL-1 for women). Data were extracted from medical records and included preoperative and postoperative hemoglobin levels, surgical types, and transfusion requirements. Results Preoperative anemia was observed in 59.6% of 508 patients analyzed, with a mean Hb level of 11.66 (± 2.75) g.dL-1 and 11.13 (± 2.08) g.dL-1 for women and men, respectively. In the postoperative period, the anemia rate increased to 94.6%, with a mean Hb level of 9.36 (± 1.55) g.dL-1 and 9.49 (± 1.36) g.dL-1 for women and men, respectively. The transfusion rate was 27% in the total sample. Patients with preoperative anemia were 4.6 times more likely to require intraoperative transfusion compared to non-anemic patients (OR = 4.58; 95% CI: 2.78-7.52; p < 0.001). Higher preoperative hemoglobin levels were identified as protective against transfusion (OR = 0.65; 95% CI: 0.59-0.72; p < 0.001). Conclusions Preoperative anemia is a highly prevalent and modifiable risk factor associated with increased transfusion requirements and adverse perioperative outcomes. The study highlights the importance of implementing patient blood management protocols in surgical practice.

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Abstract Background Despite advances in surgical and blood management techniques, it continues to carry risks of excessive blood loss and transfusion. Tranexamic Acid (TXA), an antifibrinolytic agent, has shown efficacy in reducing these risks across various surgeries. This retrospective cohort study evaluated factors influencing intraoperative blood loss in Adolescent Idiopathic Scoliosis (AIS) surgery, focusing on low-dose TXA administration. Methods This retrospective cohort study included 187 AIS patients undergoing posterior spinal fusion with or without intraoperative TXA. Patients were grouped into non-TXA (116 patients) and TXA (71 patients) cohorts. The TXA group received a 10 mg.kg-1 intravenous loading dose over 15 minutes, followed by a continuous infusion of 1 mg.kg-1.h-1 until skin closure. Outcomes included estimated blood loss, transfusion needs, length of stay, and thromboembolic or neurologic complications. Multivariate regression adjusted intraoperative blood volume loss for potential covariates. Results Baseline demographic characteristics were similar between groups. However, differences in surgical complexity cannot be excluded and are acknowledged. TXA use was associated with a 39% reduction in estimated intraoperative blood volume loss compared with the non-TXA group. Blood loss correlated significantly with TXA use, sex, ASA status, number of fused levels, curve type, and surgery duration. Conclusion Low-dose TXA significantly reduced intraoperative blood loss and transfusion requirements during AIS surgery. Greater blood loss was linked to longer procedures and more fused levels, whereas lumbar curve type appeared protective. This study provides insights into AIS outcomes and their associations with predictive factors and TXA use. Level of evidence Level III - retrospective cohort study.

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Abstract Background Preoperative anemia is common and associated with adverse postoperative outcomes. Objective To evaluate the association between preoperative anemia severity and clinical outcomes in patients undergoing elective noncardiac surgery. Methods This retrospective cohort included 23,579 adults assessed preoperatively between January 2015 and August 2025, all with documented hemoglobin (Hb) and hospitalized for noncardiac surgery. Patients were stratified as no anemia (≥ 13 g.dL−1), mild (11.1‒12.9 g.dL−1), moderate (8.1‒11.0 g.dL−1), or severe anemia (≤ 8.0 g.dL−1). Outcomes were in-hospital mortality, Intensive Care Unit (ICU) admission, and Length of Stay (LOS). Analyses used Poisson regression with robust variance adjusted for confounders. Results Among the participants, 15,909 (67.5%) had no anemia, 6,396 (27.1%) mild, 1,174 (5.0%) moderate, and 100 (0.4%) severe anemia. Overall, 62.6% were female, and the mean age was 60.7 years (SD ±15.4). Compared with no anemia, all anemia categories were independently associated with higher in-hospital mortality, increased ICU admission, and longer LOS. Severe anemia was the strongest predictor of in-hospital mortality (adjusted RR = 24.7; 95% CI 13.3‒46.0; p < 0.001). Intermediate or major surgeries (RR = 4.7; 95% CI 3.4‒6.6), age > 54 years (RR = 4.4; 95% CI 2.6‒7.6), and male sex (RR = 2.1; 95% CI 1.6‒2.9) were also independent predictors of in-hospital mortality. Conclusions Preoperative anemia, even when mild, was independently associated with higher in-hospital mortality, greater ICU admission, and prolonged hospitalization. These results support systematic screening and targeted management, including Patient Blood Management (PBM) strategies, to improve perioperative outcomes.

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Abstract Introduction Burn injuries often require surgery, posing challenges due to significant intraoperative blood loss and transfusion risks. Tranexamic Acid (TXA), an antifibrinolytic agent, stabilizes clots and reduces fibrinolysis, with proven efficacy in various surgical settings. However, the benefits in burn patients are yet to be established. Methods We performed a systematic review and meta-analysis. PubMed, Embase, and Cochrane databases were searched for Randomized Clinical Trials (RCTs) comparing TXA versus control in burned patients. Risk Ratios (RR) and Mean Differences (MD) with 95% CIs were computed for binary and continuous outcomes, respectively. The primary endpoint of interest was blood loss. Statistical analyses were performed using RStudio software (version 4.2.2). The certainty of the evidence was evaluated using the GRADE approach. Results Four RCTs comprising 204 patients were included, with 102 (50%) assigned to the TXA group. The mean patient age across studies ranged from 32.15 to 39.70 years. TXA significantly reduced total blood loss (MD = -183.93 mL; 95% CI: -278.44 to -89.42; p < 0.01), need for packed red blood cell transfusions (RR = 0.42, 95% CI 0.26 to 0.66; p < 0.01), while also improving hematocrit (MD = 3.49%; 95% CI: 1.58 to 5.41; p < 0.01) and hemoglobin levels (MD = 0.87 g.dL-1; 95% CI: 0.35 to 1.39; p < 0.01). Conclusion In patients with burns, TXA was associated with reduced blood loss and packed cell transfusions. However, certainty is limited by the small number and heterogeneity of available trials. Registration PROSPERO ID: CRD420251000356. Registered on 07 March 2025.

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Abstract Background Coronary Artery Bypass Grafting (CABG) is the most widely used cardiac intervention and can be accomplished without an extracorporeal circulation off-pump. The benefits of antifibrinolytics in off-pump CABG have yet to be demonstrated. Methods Randomized Controlled Trials (RCTs) and observational studies comparing the use of antifibrinolytic agents (tranexamic acid, aprotinin, and epsilon-aminocaproic) versus controls in patients undergoing off-pump CABG were searched in the PubMed, Embase, and Cochrane databases. Outcomes included thromboembolic events, in-hospital mortality, overall mortality, bleeding, Intensive Care Unit (ICU) length of stay, and blood product transfusions. Meta-analyses were conducted using the Inverse Variance method under a random-effects model, with p < 0.05 considered statistically significant. Results Of the 23,149 patients in 20 RCTs and seven observational studies, 51% received antifibrinolytic agents (tranexamic acid or aprotinin). Observational and randomized designs were analyzed separately in primary subgroup analyses. Significant reduction was found for overall mortality (RR = 0.72; [95% CI 0.54-0.95]) in the RCT subgroup. Red-blood-cell transfusion requirements were reduced (RR = 0.65; [95% CI 0.53, 0.78]) as well as Platelets (RR = 0.59; [95% CI 0.41, 0.84]) and fresh-frozen-plasma (RR = 0.39; [95% CI 0.36, 0.42]) transfusion requirement. The RCT subgroup showed a reduction in thromboembolic events (RR = 0.55; [95% CI 0.39, 0.79]). Conclusions In off-pump CABG, antifibrinolytics reduced the need for blood transfusion while reducing thromboembolic events and overall mortality in RCT subgroups, while pooled analyses combining RCTs and observational studies did not demonstrate significant reductions. Prospero Link https://www.crd.york.ac.uk/PROSPERO/view/CRD42024545640