Matthew A. Warner

Changing transfusion practices in hip and knee arthroplasty

BACKGROUND: This study was designed to examine changes in perioperative transfusion practices after the introduction of autologous blood conservation strategies into routine clinical practice.

Sacral tumor resection: the effect of surgical staging on patient outcomes, resource management, and hospital cost.

Study Design. Single-institution retrospective study. Objective. To assess the effect surgical staging (i.e., sequencing) has on clinical and economic outcomes for patients undergoing sacropelvic tumor resection requiring lumbopelvic stabilization. Summary of Background Data. Sacral corpectomy with lumbopelvic stabilization is an extensive surgical procedure that can be performed in either a single episode or multiple episodes of care on different days. The impact of varied sequencing of surgical episodes of care on patient, resource, and financial outcomes is unknown. Methods. This single-center retrospective case series identified all cases of sacropelvic tumor resection requiring lumbopelvic stabilization over an 8-year period. We assessed and compared clinical and economic outcomes for patients whose anterior exposure and posterior resection were separated into two distinct surgical episodes of care (staged) versus patients whose anterior exposure and posterior resection occurred in a single encounter (nonstaged procedures). Primary endpoints included procedural outcomes (operative and after-hours surgical time), resuscitative requirements, adverse perioperative events, mortality, and direct medical costs (hospital and physician) associated with the surgical episodes of interest. Results. From January 1, 2000, to July 15, 2008, a total of 25 patients were identified. Eight patients had their procedure staged. Surgical staging was associated with a significant increase in intensive care unit free days (P = 0.03), ventilator free days (P < 0.01), and reduced morbidity (P < 0.01). Surgical staging significantly reduced postoperative red blood cell (P = 0.03), and after-hours red blood cell (P < 0.01) and component requirements (P = 0.04). Mean total inpatient costs were

Preoperative platelet transfusions and perioperative red blood cell requirements in patients with thrombocytopenia undergoing noncardiac surgery

89,132 lower for patients undergoing the staged procedure (95% confidence interval of mean cost difference = −

Preprocedural platelet transfusion for patients with thrombocytopenia undergoing interventional radiology procedures is not associated with reduced bleeding complications

178,899 to −

Red urinary discolouration following hydroxocobalamin treatment for vasoplegic syndrome

4661). Conclusion. Separating the anterior exposure and posterior resection phases of complex sacral tumor resection into two separate surgical episodes of care is associated with improved clinical outcomes and reduced inpatient cost.

Bleeding Complications in Patients Undergoing Celiac Plexus Block.

Perioperative hemorrhage impacts patient outcomes and health care resource utilization, yet the risks of transfusion therapies are significant. In patients with preoperative thrombocytopenia, the effects of prophylactic preoperative platelet (PLT) transfusion on perioperative bleeding complications remain uncertain.

Prophylactic Plasma Transfusion Is Not Associated With Decreased Red Blood Cell Requirements in Critically Ill Patients

Platelet (PLT) transfusion before interventional radiology procedures is commonly performed in patients with thrombocytopenia. However, it is unclear if PLT transfusion is associated with reduced bleeding complications.

Pain Management in Four‐Limb Amputation: A Case Report

Vasoplegic syndrome is a state of profoundly low systemic vascular resistance secondary to aberrant nitric oxide production, release, and signaling. Hydroxocobalamin (Cyanokit , Meridian Medical Technologies, Columbia, MD, USA), a form of vitamin B12 conventionally used to treat cyanide poisoning, has recently been described as an off-label treatment for vasoplegic syndrome because it inhibits nitric oxide synthase and binds nitric oxide directly. An 82-yr-old man underwent open explantation of an abdominal aortic stent graft with replacement. Intraoperatively, he developed refractory vasoplegia despite high-dose norepinephrine, epinephrine, vasopressin, and phenylephrine therapy. He received a single 5 g iv dose of hydroxocobalamin, resulting in substantial improvement in hemodynamics and decreased vasopressor requirement. Within several hours, his urine turned bright red, discolouration that persisted for two weeks. Urinalysis revealed no red blood cells or other abnormalities. Red or purple chromaturia is a side effect of hydroxocobalamin, typically resolving over several weeks. Additional causes of red urine include blood (e.g., traumatic catheterization, malignancy, infection), dietary ingestion (e.g., beets), and medications (e.g., rifampin, phenothiazines). Although benign and not warranting further evaluation by itself, hydroxocobalamin-induced discolouration of body fluids may interfere with colorimetric sensors. For example, intermittent hemodialysis may be impeded for several weeks owing to pigment distribution across the dialysate membrane with subsequent triggering of a colorimetric alarm designed to detect blood leaks. Continuous renal replacement therapy, however, is unaffected. Although our experience suggests that hydroxocobalamin does not cause clinically significant interference with non-invasive pulse oximetry, there is evidence to suggest that co-oximetric blood gas analysis with several unique analyzers may be altered in the presence of hydroxocobalamin, specifically with false elevations of carboxyhemoglobin and methemoglobin concentrations and underestimation of true oxygen saturation values. There is no available evidence regarding the accuracy of other commonly utilized oximetric monitoring modalities (e.g., cerebral oximetry) following hydroxocobalamin administration. This image displays the anticipated urinary colour change following administration of hydroxocobalamin, which is benign and self-limited but may make intermittent hemodialysis difficult. Further testing beyond simple urinalysis to exclude the presence of heme is typically unnecessary. M. A. Warner, MD (&) Division of Critical Care Medicine, Mayo Clinic, Rochester, MN, USA e-mail: warner.matthew@mayo.edu

Severe acute postoperative airway compromise secondary to submandibular sialadenitis

Background and Objectives Celiac plexus blockade has known risks including bleeding and neurologic injury because of the close proximity of vascular and neuraxial structures. The aim of this study was to determine the incidence of bleeding complications in patients undergoing celiac plexus block (CPB), with an emphasis on preprocedural antiplatelet medication use and coagulation status. Methods This is a retrospective study from 2005 to 2014 of adult patients undergoing CPB by the pain medicine division at a tertiary care center. The primary outcome was red blood cell (RBC) transfusion within 72 hours of needle placement, with a secondary outcome of bleeding complications requiring emergency medicine, neurology, or neurosurgical evaluation within 31 days. Results A total of 402 procedures were performed on 298 unique patients, with 58 patients (14.4%) receiving aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) preoperatively. Five patients (1.2%) received RBC transfusion within 72 hours, of which one had received preprocedure NSAIDs. A platelet count measured within 30 days was available for 268 patients, with 7 patients (2.6%) having platelet counts of 100 × 109/L or less at the time of needle placement. A total of 187 patients had a valid preoperative international normalized ratio (INR), with 9 (4.8%) having an INR of 1.5 or higher (range, 1.5–2.6). One patient (11.1%) required RBC transfusion compared with an RBC transfusion rate of 2.3% (4 of 178) in those with normal INR (P = 0.221). We identified no bleeding complications requiring emergency medicine, neurology, or neurosurgical evaluation. Conclusions This study suggests that CPBs may be safely performed in patients receiving aspirin and/or NSAID therapy.

Bleeding and Neurologic Complications in 58,000 Interventional Pain Procedures

BACKGROUND: Critically ill patients frequently receive plasma transfusion under the assumptions that abnormal coagulation test results confer increased risk of bleeding and that plasma transfusion will decrease this risk. However, the effect of prophylactic plasma transfusion remains poorly understood. The objective of this study was to determine the relationship between prophylactic plasma transfusion and bleeding complications in critically ill patients. METHODS: This is a retrospective cohort study of adults admitted to the intensive care unit (ICU) at a single academic institution between January 1, 2009 and December 31, 2013. Inclusion criteria included age ≥18 years and an international normalized ratio measured during ICU admission. Multivariable propensity-matched analyses were used to evaluate associations between prophylactic plasma transfusion and outcomes of interest with a primary outcome of red blood cell transfusion in the ensuing 24 hours and secondary outcomes of hospital- and ICU-free days and mortality within 30 days of ICU discharge. RESULTS: A total of 27,561 patients were included in the investigation with 2472 (9.0%) receiving plasma therapy and 1105 (44.7%) for which plasma transfusion was prophylactic in nature. In multivariable propensity-matched analyses, patients receiving plasma had higher rates of red blood cell transfusion (odds ratio: 4.3 [95% confidence interval: 3.3–5.7], P < .001) and fewer hospital-free days (estimated % increase: −11.0% [95% confidence interval: −11.4, −10.6%], P < .001). There were no significant differences in ICU-free days or mortality. These findings appeared robust, persisting in multiple predefined sensitivity analyses. CONCLUSIONS: Prophylactic administration of plasma in the critically ill was not associated with improved clinical outcomes. Further investigation examining the utility of plasma transfusion in this population is warranted.