Effect of intraoperative intravenous ferric derisomaltose supplementation on reduction of postoperative anemia and transfusion in chronic kidney disease patients after total knee replacement.

Total knee replacement (TKR) is associated with a large amount of bleeding; therefore, the prevalence of postoperative anemia is high. In particular, patients with chronic kidney disease (CKD) are more vulnerable to postoperative anemia than are healthy individuals. Accordingly, the effect of intraoperative intravenous ferric derisomaltose (FDI) supplementation on postoperative anemia and blood transfusion volume reduction in patients with CKD was studied. Patients who underwent unilateral TKR between January 2019 and December 2020 were retrospectively reviewed. In analyzing the data, the patients fell into the CKD group (n = 85) and the non-CKD group (n = 106). Each group was divided into a group using FDI and a non-FDI group, and classified into 4 groups. The postoperative hemoglobin level for each postoperative day (POD) was determined as the primary outcome. In addition, the patient transfusion rate, volume of transfusion, and length of hospital stay were set as secondary study outcomes during the period from surgery to discharge. There was no statistically significant difference in hemoglobin levels on PODs 0, 1, 2, 7, and 14 in the CKD group. In the CKD group, the transfusion volume of the FDI group was 0.58 ± 0.91 units per person, which was statistically significantly lower than 1.28 ± 1.28 units of the non-FDI group (P = .01). In the CKD group, the transfusion rate of the FDI group was 30.2%, which was statistically significantly lower than that of the non-FDI group, which was 56.3% (P = .02). This study showed that intravenous FDI supplementation after TKR in CKD patients did not reduce postoperative anemia but was an effective and safe treatment to reduce transfusion volume and transfusion rate. There was no statistically significant difference in hemoglobin levels on POD 0, 1, 2, 7, and 14 in the non-CKD group. In the non-CKD group, the transfusion volume of the FDI group was 0.46 ± 0.88 units per person, which was lower than the 0.56 ± 0.91 units of the non-FDI group, but it was not statistically significant (P = .59). In the non-CKD group, the transfusion rate of the FDI group was 23.0%, which was lower than that of the non-FDI group, which was 31.3%, but it was not statistically significant (P = .37).

Intensity Modulated High Dose Rate (HDR) Brachytherapy Using Patient Specific 3D Metal Printed Applicators: Proof of Concept.

Purpose: In high-dose-rate (HDR) brachytherapy, an anisotropic dose distribution may be desirable for achieving a higher therapeutic index, particularly when the anatomy imposes challenges. Several methods to deliver intensity-modulated brachytherapy (IMBT) have been proposed in the literature, however practical implementation is lacking due to issues of increased delivery times and complicated delivery mechanisms. This study presents the novel approach of designing a patient-specific inner shape of an applicator with 3D metal printing for IMBT using an inverse plan optimization model. Methods: The 3D printed patient-specific HDR applicator has an external shape that resembles the conventional brachytherapy applicator. However, at each dwell position of the HDR source, the shielding walls in the interior are divided into six equiangular sections with varying thicknesses. We developed a mathematical model to simultaneously optimize the shielding thicknesses and dwell times according to the patient's anatomical information to achieve the best possible target coverage. The model, which is a bi-convex optimization problem, is solved using alternating minimization. Finally, the applicator design parameters were input into 3D modeling software and saved in a 3D printable file. The applicator has been tested with both a digital phantom and a simulated clinical cervical cancer patient. Results: The proposed approach showed substantial improvements in the target coverage over the conventional method. For the phantom case, 99.18% of the target was covered by the prescribed dose using the proposed method, compared to only 58.32% coverage achieved by the conventional method. For the clinical case, the proposed method increased the coverage of the target from 56.21% to 99.92%. In each case, both methods satisfied the treatment constraints for neighboring OARs. Conclusion: The study simulates the concept of the IMBT with inverse planning using the 3D printed applicator design. The non-isotropic dose map can be produced with optimized shielding patterns and tailored to individual patient's anatomy, to plan a more conformal plan.

Hemodynamic protective effects of epinephrine containing saline irrigation in biportal endoscopic lumbar surgery.

During endoscopic orthopedic surgery, epinephrine mixed with irrigation saline is frequently used to improve visualization. By monitoring hemodynamic parameters throughout the procedure, we intended to discover the hemodynamic effect of epinephrine between the normal saline irrigation fluid without epinephrine group (NS) and normal saline irrigation fluid with epinephrine group (EPI). Patients who underwent 1-level lumbar decompression or discectomy surgery without fusion between August 2019 and July 2020 were reviewed retrospectively. The hemodynamic parameters were compared between the NS group and EPI group. As a second endpoint, the incidence of hypotension and hypertension events, expected blood loss, postoperative nausea and vomiting and postoperative epidural hematoma were compared between the 2 groups. The 2 groups were homogeneous in terms of age, sex, weight, height, body mass index (BMI), ASA physical status (ASA PS), and diagnosis. The incidence of hypotension events (67.2 % in the NS group, 45.7 % in the EPI group, P =.015) and severe hypotension events (51.7 % in the NS group, 28.6 % in the EPI group, P = .015) were less frequent in the EPI group. Only epinephrine had a significant protective effect through a multivariable analysis (P = .027, OR = 2.361) and in severe hypotension events, only epinephrine had a significant protective effect through a multivariable analysis (P = .011, OR = 2.818), and EBL was the risk factor through a multivariable analysis (P = .016, OR = 1.002) We believe that the addition of epinephrine to irrigation saline has hemodynamic protective effects in patients who underwent endoscopic lumbar surgery.

Transient left bundle branch block after posture change to the prone position during general anesthesia: A case report.

RATIONALE: The prone position is commonly used in spinal surgery. There have been many studies on hemodynamic changes in the prone position during general anesthesia. We report a rare case of transient left bundle branch block (LBBB) in a prone position. PATIENT CONCERN: Electrocardiogram (ECG) of a 64-year-old man scheduled for spinal surgery showed normal sinus rhythm change to LBBB after posture change to the prone position. DIAGNOSIS: Twelve lead ECG revealed LBBB. His coronary angio-computed tomography results showed right coronary artery with 30% to 40% stenosis and left circumflex artery with 40% to 50% stenosis. The patient was diagnosed with stable angina and second-degree atrioventricular block of Mobitz type II. INTERVENTION: Nitroglycerin was administered intravenously during surgery. Adequate oxygen was supplied to the patient. After surgery, the patient was prescribed clopidogrel, statins, angiotensin II receptor blocker, and a permanent pacemaker was inserted. OUTCOME: Surgery was completed without complications. After surgery, the transient LBBB changed to a normal sinus rhythm. The patient did not complain of chest pain or dyspnea. LESSON: The prone position causes significant hemodynamic changes. A high risk of cardiovascular disease may cause ischemic heart disease and ECG changes. Therefore, careful management is necessary.