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Purpose: We evaluated efficacy and safety profile of patients with anticoagulation therapy (AT) undergoing holmium laser enucleation of the prostate (HoLEP).
Methods: Within our prospective institutional database (11/2017 to 11/2019), we analyzed functional outcomes and 30-day complication rates of HoLEP patients according to Clavien–Dindo classification (CLD), stratified according to specific AT vs. no AT. Further analyses consisted of uni- and multivariate logistic regression models (LRM) predicting complications.
Results: Of 268 patients undergoing HoLEP, 104 (38.8%) received AT: 25.7% were treated with platelet aggregation inhibitors (PAI), 8.2% with new oral anticoagulants (NOAC) and 4.9% with AT-combinations or coumarins bridged with low molecular weight heparins (LMWH/combination). Patients receiving AT were significantly more comorbid (p < 0.01). Pre- and postoperative maximal flow rates, residual void urine and IPSS at 3 months after surgery were invariably improved after HoLEP for patients with/ without AT. Overall complication rate was 19.5% in patients with no AT vs. 26.1% vs. 27.3 vs. 46.2%, respectively, in patients with PAI, NOAC and LMWH/combination (p < 0.01). Major complications (CLD ≥ 3b) occurred in 6.1% of no AT patients vs. 4.3% vs. 4.5 vs. 0% in patients with PAI, NOAC and LMWH/combination, respectively (p < 0.01). In multivariate LRM, AT was not significantly associated with higher complication rates, whereas high ASA status (OR 2.2, p = 0.04), age (OR 1.04, p = 0.02) and bioptical or incidental prostate cancer (OR 2.5, p = 0.01) represented independent risk factors.
Conclusion: Despite higher overall complication rates in AT patients, major complications were not more frequent in AT patients. HoLEP is safe and effective in anticoagulated patients.
Background: The most common technique used worldwide to quantify blood loss during an operation is the visual assessment by the attending intervention team. In every operating room you will find scaled suction canisters that collect fluids from the surgical field. This scaling is commonly used by clinicians for visual assessment of intraoperative blood loss. While many studies have been conducted to quantify and improve the inaccuracy of the visual estimation method, research has focused on the estimation of blood volume in surgical drapes. The question whether and how scaling of canisters correlates with actual blood loss and how accurately clinicians estimate blood loss in scaled canisters has not been the focus of research to date.
Methods: A simulation study with four “bleeding” scenarios was conducted using expired whole blood donations. After diluting the blood donations with full electrolyte solution, the sample blood loss volume (SBL) was transferred into suction canisters. The study participants then had to estimate the blood loss in all four scenarios. The difference to the reference blood loss (RBL) per scenario was analyzed.
Results: Fifty-three anesthetists participated in the study. The median estimated blood loss was 500 ml (IQR 300/1150) compared to the RBL median of 281.5 ml (IQR 210.0/1022.0). Overestimations up to 1233 ml were detected. Underestimations were also observed in the range of 138 ml. The visual estimate for canisters correlated moderately with RBL (Spearman’s rho: 0.818; p < 0.001). Results from univariate nonparametric confirmation statistics regarding visual estimation of canisters show that the deviation of the visual estimate of blood loss is significant (z = − 10.95, p < 0.001, n = 220). Participants’ experience level had no significant influence on VEBL (p = 0.402).
Conclusion: The discrepancies between the visual estimate of canisters and the actual blood loss are enormous despite the given scales. Therefore, we do not recommend estimating the blood loss visually in scaled suction canisters. Colorimetric blood loss estimation could be a more accurate option.
Background: Patient Blood Management (PBM) is a systematic quality improving clinical model to reduce anemia and avoid transfusions in all kinds of clinical settings. Here, we investigated the potential of PBM in oncologic surgery and hypothesized that PBM improves 2-year overall survival (OS).
Methods: Retrospective analysis of patients 2 years before and after PBM implementation. The primary endpoint was OS at 2 years after surgery. We identified a sample size of 824 to detect a 10% improvement in survival in the PBM group.
Results: The analysis comprised of 836 patients that underwent oncologic surgery, 389 before and 447 after PBM, was implemented. Patients in the PBM+ presented significantly more frequent with normal hemoglobin values before surgery than PBM− (56.6 vs. 35.7%; p < 0.001). The number of transfusions was significantly reduced from 5.5 ± 11.1 to 3.0 ± 6.9 units/patient (p < 0.001); moreover, the percentage of patients being transfused during the clinic stay was significantly reduced from 62.4 to 40.9% (p < 0.001). Two-year OS was significantly better in the PBM+ and increased from 67.0 to 80.1% (p = 0.001). A normal hemoglobin value (> 12 g/dl in female and > 13 g/dl in male) before surgery (HR 0.43, 95% CI 0.29–0.65, p < 0.001) was the only independent predictive factor positively affecting survival.
Conclusions: PBM is a quality improvement tool that is associated with better mid-term surgical oncologic outcome. The root cause for improvement is the increase of patients entering surgery with normal hemoglobin values.
Background: Cell salvage is commonly used as part of a blood conservation strategy. However concerns among clinicians exist about the efficacy of transfusion of washed cell salvage.
Methods: We performed a meta-analysis of randomized controlled trials in which patients, scheduled for all types of surgery, were randomized to washed cell salvage or to a control group with no cell salvage. Data were independently extracted, risk ratio (RR), and weighted mean differences (WMD) with 95% confidence intervals (CIs) were calculated. Data were pooled using a random effects model. The primary endpoint was the number of patients exposed to allogeneic red blood cell (RBC) transfusion.
Results: Out of 1140 search results, a total of 47 trials were included. Overall, the use of washed cell salvage reduced the rate of exposure to allogeneic RBC transfusion by a relative 39% (RR = 0.61; 95% CI 0.57 to 0.65; P < 0.001), resulting in an average saving of 0.20 units of allogeneic RBC per patient (weighted mean differences [WMD] = -0.20; 95% CI -0.22 to -0.18; P < 0.001), reduced risk of infection by 28% (RR = 0.72; 95% CI 0.54 to 0.97; P = 0.03), reduced length of hospital stay by 2.31 days (WMD = -2.31; 95% CI -2.50 to -2.11; P < 0.001), but did not significantly affect risk of mortality (RR = 0.92; 95% CI 0.63 to 1.34; P = 0.66). No statistical difference could be observed in the number of patients exposed to re-operation, plasma, platelets, or rate of myocardial infarction and stroke.
Conclusions: Washed cell salvage is efficacious in reducing the need for allogeneic RBC transfusion and risk of infection in surgery.
Introduction: In recent years, resource-saving handling of allogeneic blood products and a reduction of transfusion rates in adults has been observed. However, comparable published national data for transfusion practices in pediatric patients are currently not available. In this study, the transfusion rates for children and adolescents were analyzed based on data from the Federal Statistical Office of Germany during the past 2 decades. Methods: Data were queried via the database of the Federal Statistical Office (Destasis). The period covered was from 2005 to 2018, and those in the sample group were children and adolescents aged 0–17 years receiving inpatient care. Operation and procedure codes (OPS) for transfusions, procedures, or interventions with increased transfusion risk were queried and evaluated in detail. Results: In Germany, 0.9% of the children and adolescents treated in hospital received a transfusion in 2018. A reduction in transfusion rates from 1.02% (2005) to 0.9% (2018) was observed for the total collective of children and adolescents receiving inpatient care. Increases in transfusion rates were recorded for 1- to 4- (1.41–1.45%) and 5- to 10-year-olds (1.24–1.33%). Children under 1 year of age were most frequently transfused (in 2018, 40.2% of the children were cared for in hospital). Transfusion-associated procedures such as chemotherapy or machine ventilation and respiratory support for newborns and infants are on the rise. Conclusion: Transfusion rates are declining in children and adolescents, but the reasons for increases in transfusion rates in other groups are unclear. Prospective studies to evaluate transfusion rates and triggers in children are urgently needed.
Purpose: Anaemia is one of the leading causes of death among severely injured patients. It is also known to increase the risk of death and prolong the length of hospital stay in various surgical groups. The main objective of this study is to analyse the anaemia rate on admission to the emergency department and the impact of anaemia on in-hospital mortality.
Methods: Data from the TraumaRegister DGU® (TR-DGU) between 2015 and 2019 were analysed. Inclusion criteria were age ≥ 16 years and most severe Abbreviated Injury Scale (AIS) score ≥ 3. Patients were divided into three anaemia subgroups: no or mild anaemia (NA), moderate anaemia (MA) and severe anaemia (SA). Pre-hospital data, patient characteristics, treatment in the emergency room (ER), outcomes, and differences between trauma centres were analysed.
Results: Of 67,595 patients analysed, 94.9% (n = 64,153) exhibited no or mild anaemia (Hb ≥ 9 g/dl), 3.7% (n = 2478) displayed moderate anaemia (Hb 7–8 g/dl) and 1.4% (n = 964) presented with severe anaemia (Hb < 7 g/dl). Haemoglobin (Hb) values ranged from 3 to 18 g/dl with a mean Hb value of 12.7 g/dl. In surviving patients, anaemia was associated with prolonged length of stay (LOS). Multivariate logistic regression analyses revealed moderate (p < 0.001 OR 1.88 (1.66–2.13)) and severe anaemia (p < 0.001 OR 4.21 (3.46–5.12)) to be an independent predictor for mortality. Further significant predictors are ISS score per point (OR 1.0), age 70–79 (OR 4.8), age > 80 (OR 12.0), severe pre-existing conditions (ASA 3/4) (OR 2.26), severe head injury (AIS 5/6) (OR 4.8), penetrating trauma (OR 1.8), unconsciousness (OR 4.8), shock (OR 2.2) and pre-hospital intubation (OR 1.6).
Conclusion: The majority of severely injured patients are admitted without anaemia to the ER. Injury-associated moderate and severe anaemia is an independent predictor of mortality in severely injured patients.
In Deutschland werden jährlich gut drei Millionen Erythrozytenkonzentrate (EKs) transfundiert. Moderne Herstellungsmethoden und molekulare Diagnoseverfahren konnten die Sicherheit von Blutprodukten im Laufe der Jahre weiter verbessern. Wie bei jedem Medikament kann es nichtsdestotrotz bei der Therapie mit EKs zu Nebenwirkungen kommen. Dazu gehören unter anderem allergische Reaktionen, hämolytische und nicht hämolytische Transfusionsreaktionen, Übertragungen von Infektionskrankheiten und Eisenüberladung. Es werden weitere Nebenwirkungen postuliert, deren Zusammenhang mit Hämotherapie allerdings hinsichtlich einer möglichen Kausalität noch nicht abschließend untersucht wurde. Im Hinblick auf Malignompatienten zeigen retrospektive Untersuchungen eine deutliche Assoziation von Transfusionen und ungünstigem Behandlungsausgang. Diese Beobachtung könnte kausal oder durch Störfaktoren wie den medizinischen Umständen einer Transfusion oder patienteneigener Risikofaktoren erklärt werden. Während randomisierte Studien zur Überprüfung einer Kausalität sich aus ethischen Gründen verbieten, wurden mögliche Mechanismen aufgedeckt, die diese Assoziation erklären könnten. Dazu gehört unter anderem die transfusion-related immunomodulation (TRIM), an der auch erythrozytäre Mikropartikel (red blood cell-derived microparticles, RMPs) beteiligt sein könnten.
RMPs sind extrazelluläre Vesikel (EVs), die von Erythrozyten bei der Apoptose und bei Einwirken verschiedener Stressoren gebildet werden. Bei der Prozessierung und Lagerung von EKs akkumulieren RMPs in unphysiologischer Menge, und möglicherweise sind diese RMPs anders als jene, die in vivo gebildet werden. Ob RMPs direkte Effekte auf Malignomzellen haben, wurde noch nicht untersucht.
Das Forschungsgebiet rund um EVs ist relativ jung, weshalb noch keine echten Goldstandards bei Isolierung und Quantifizierung vorliegen. Während bei den RMPs hierfür am häufigsten Ultrazentrifugation (UZ) und Durchflusszytometrie verwendet werden, haben beide Methoden gewisse Einschränkungen. Mit der Größenausschlusschromatographie (size exclusion chromatography, SEC) liegt ein Verfahren vor, das sich bei anderen EVs als effektive Alternative zur UZ gezeigt hat und das zudem die Eigenschaften und biologischen Aktivitäten der empfindlichen EVs möglicherweise besser erhält.
Ziel dieser Arbeit war es, im Zellkulturmodell zu untersuchen, ob RMPs aus EKs möglicherweise einen Einfluss auf Viabilität, Migration und Invasion maligner Zellen haben. Hierzu wurde die Kolonkarzinomzelllinie HCT-116 genutzt. Zudem sollte mit der SEC eine alternative Isolierungsmethode für RMPs etabliert werden und ein möglicher Einfluss der Isolierungsmethode auf die biologische Aktivität der RMPs untersucht werden.
Insgesamt zeigte sich in den in vitro-Untersuchungen ein geringer Effekt von RMPs auf die Viabilität, Migration und Invasion von HCT-116-Zellen und dies auch nur in sehr hohen Konzentrationen, die in der Hämotherapie eines Patienten vermutlich nie erreicht werden. Es gilt, diese Beobachtungen in weiterführenden in vivo-Studien (zum Beispiel in Tiermodellen) zu verifizieren.
Die SEC zeigte sich als gut geeignet zur Isolierung von RMPs im Hinblick auf die RMP-Ausbeute und die Auftrennung der RMPs von Proteinen. Die RMPs, die via SEC isoliert wurden, hatten im Gegensatz zu RMPs, die via UZ isoliert wurden, keinen Einfluss auf die Viabilität von HCT-116-Zellen.
Die primäre Quantifizierungsmethode für RMPs war die Durchflusszytometrie, welche bei der Untersuchung kleiner EVs einige Einschränkungen hat, da die Auflösungsgrenze im Bereich der EV-Größe liegt. Ein Vergleich mit einer für EVs ausgelegten Technik, der Nanopartikel-Tracking-Analyse (NTA), zeigte, dass der Großteil der in den RMP-Isolaten enthaltenen Partikel in der Durchflusszytometrie nicht erkannt wird. Dieses Ergebnis könnte durch eine mangelhafte Sensitivität der Durchflusszytometrie, aber auch durch die Unspezifität der NTA erklärt werden. Es wurde in der NTA keine Färbung verwendet, daher konnten auch andere EVs und Partikel wie Lipoproteine mitgezählt werden.