50 Shades of Red: The Predictive Value of Closed Suction Drains for the Detection of Postoperative Bleeding in Breast Surgery

BACKGROUND

While closed suction drains (CSDs) are still frequently employed in clinical practice, the supporting evidence is limited with some studies demonstrating a failure of routine CSD use in preventing hematoma or seroma. Nonetheless, CSD quantity and quality fluid assessment is still appreciated by clinicians to detect postoperative bleeding. This study investigates the value of routine CSD use, in breast surgery, to predict postoperative bleeding.

METHODS

A retrospective, intra-individual analysis, of CSD fluid volumes between the hematoma side and the unaffected contralateral breast, was undertaken in patients (n = 20) with unilateral postoperative bleeding following bilateral breast surgery (2003-2018). Statistical analysis was undertaken to establish a minimum cutoff fluid volume that might assist in the detection of postoperative bleeding. To determine the usefulness of quality assessment of CSD fluid output by visual inspection, surgeons (n = 56) prospectively matched six eligible hemoglobin concentrations corresponding to pre-filled CSDs.

RESULTS

Statistical analysis did not yield a clinically reliable cutoff fluid volume indicating postoperative bleeding. All six eligible hemoglobin concentrations were completely successfully matched to pre-filled CSDs by 30.4% (17/56) of surgeons.

CONCLUSIONS

This study questions the significance of routine CSD use to assist in the decision-making process to return to the theater and address postoperative bleeding. Quantity as well as quality analysis of CSD fluid output failed the reliability and diagnostic validity tests. Hemoglobin measurements in drain fluid specimens via blood gas analysis might contribute to the detection of postoperative bleeding.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparison of Frequency of Late Gastrointestinal Bleeding With Transcatheter Versus Surgical Aortic Valve Replacement

Improvements in technology and operator experience have led to exponential growth of transcatheter aortic valve implantation (TAVI) programs. Late bleeding complications were recently highlighted after TAVI with a high impact on morbidity. The purpose of the present study was to assess the incidence and financial impact of late Gastrointestinal (GI) bleeding after TAVI, and compare with the surgical cohort. Retrospective analysis of the National Readmissions Database was performed from January 2011 to December 2014, and patients who underwent TAVI or surgical aortic valve replacement (SAVR) were identified. Incidence of readmission with a diagnosis of GI bleeding was utilized as the primary end point. Overall, 43,357 patients were identified who underwent TAVI, whereas 310,013 patients underwent SAVR. Compared with SAVR, TAVI patients were older (81 vs 68y, p < 0.001), more women (48% vs 36%, p < 0.001), and had higher Elixhauser Comorbidity Index (6 vs 5, p < 0.001). Hospital stay was shorter with TAVI (5 vs 8 days, p < 0.001), but raw in-hospital mortality rates were similar (4.2% vs 3.8%, p = 0.022). In the TAVI cohort, 3.3% of patients were rehospitalized for GI bleeding compared with 1.5% of the SAVR cohort (p < 0.001). Average time to bleeding readmission was similar between cohorts (92 vs 84 days, p = 0.049). After multivariable adjustment, TAVI remained significantly associated with readmissions for GI bleeding compared with SAVR Adjusted Odds Ratio (AOR 1.54 [1.38 to 1.71], p < 0.001). In this national cohort study, TAVI was associated with more frequent readmissions for late GI bleeding compared with SAVR. In conclusion, strategies to reduce late GI bleeding may serve as important targets for improvement in overall quality of care.

Heparin-protamine balance after neonatal cardiopulmonary bypass surgery

Essentials Heparin-protamine balance (HPB) modulates bleeding after neonatal cardiopulmonary bypass (CPB). HPB was examined in 44 neonates undergoing CPB. Post-operative bleeding occurred in 36% and heparin rebound in 73%. Thrombin-initiated fibrin clot kinetic assay and partial thromboplastin time best assessed HPB.

SUMMARY

Background Neonates undergoing cardiopulmonary bypass (CPB) are at risk of excessive bleeding. Blood is anticoagulated with heparin during CPB. Heparin activity is reversed with protamine at the end of CPB. Paradoxically, protamine also inhibits blood coagulation when it is dosed in excess of heparin. Objectives To evaluate heparin-protamine balance in neonates undergoing CPB by using research and clinical assays, and to determine its association with postoperative bleeding. Patients/Methods Neonates undergoing CPB in the first 30 days of life were studied. Blood samples were obtained during and after surgery. Heparin-protamine balance was assessed with calibrated automated thrombography, thrombin-initiated fibrin clot kinetic assay (TFCK), activated partial thromboplastin time (APTT), anti-FXa activity, and thromboelastometry. Excessive postoperative bleeding was determined by measurement of chest tube output or the development of cardiac tamponade. Results and Conclusions Of 44 neonates enrolled, 16 (36%) had excessive postoperative bleeding. The TFCK value was increased. By heparin in neonatal blood samples, but was only minimally altered by excess protamine. Therefore, it reliably measured heparin in samples containing a wide range of heparin and protamine concentrations. The APTT most closely correlated with TFCK results, whereas anti-FXa and thromboelastometry assays were less correlative. The TFCK and APTT assay also consistently detected postoperative heparin rebound, providing an important continued role for these long-established coagulation tests in the management of postoperative bleeding in neonates requiring cardiac surgical repair. None of the coagulation tests predicted the neonates who experienced postoperative bleeding, reflecting the multifactorial causes of bleeding in this population.

Machine learning for real-time prediction of complications in critical care: a retrospective study

BACKGROUND

The large amount of clinical signals in intensive care units can easily overwhelm health-care personnel and can lead to treatment delays, suboptimal care, or clinical errors. The aim of this study was to apply deep machine learning methods to predict severe complications during critical care in real time after cardiothoracic surgery.

METHODS

We used deep learning methods (recurrent neural networks) to predict several severe complications (mortality, renal failure with a need for renal replacement therapy, and postoperative bleeding leading to operative revision) in post cardiosurgical care in real time. Adult patients who underwent major open heart surgery from Jan 1, 2000, to Dec 31, 2016, in a German tertiary care centre for cardiovascular diseases formed the main derivation dataset. We measured the accuracy and timeliness of the deep learning model's forecasts and compared predictive quality to that of established standard-of-care clinical reference tools (clinical rule for postoperative bleeding, Simplified Acute Physiology Score II for mortality, and the Kidney Disease: Improving Global Outcomes staging criteria for acute renal failure) using positive predictive value (PPV), negative predictive value, sensitivity, specificity, area under the curve (AUC), and the F₁ measure (which computes a harmonic mean of sensitivity and PPV). Results were externally retrospectively validated with 5898 cases from the published MIMIC-III dataset.

FINDINGS

Of 47 559 intensive care admissions (corresponding to 42 007 patients), we included 11 492 (corresponding to 9269 patients). The deep learning models yielded accurate predictions with the following PPV and sensitivity scores: PPV 0·90 and sensitivity 0·85 for mortality, 0·87 and 0·94 for renal failure, and 0·84 and 0·74 for bleeding. The predictions significantly outperformed the standard clinical reference tools, improving the absolute complication prediction AUC by 0·29 (95% CI 0·23-0·35) for bleeding, by 0·24 (0·19-0·29) for mortality, and by 0·24 (0·13-0·35) for renal failure (p<0·0001 for all three analyses). The deep learning methods showed accurate predictions immediately after patient admission to the intensive care unit. We also observed an increase in performance in our validation cohort when the machine learning approach was tested against clinical reference tools, with absolute improvements in AUC of 0·09 (95% CI 0·03-0·15; p=0·0026) for bleeding, of 0·18 (0·07-0·29; p=0·0013) for mortality, and of 0·25 (0·18-0·32; p<0·0001) for renal failure.

INTERPRETATION

The observed improvements in prediction for all three investigated clinical outcomes have the potential to improve critical care. These findings are noteworthy in that they use routinely collected clinical data exclusively, without the need for any manual processing. The deep machine learning method showed AUC scores that significantly surpass those of clinical reference tools, especially soon after admission. Taken together, these properties are encouraging for prospective deployment in critical care settings to direct the staff's attention towards patients who are most at risk.

FUNDING

No specific funding.

Ancillary medications and outcomes in post-tonsillectomy patients

To investigate the impact of medications on outcomes after tonsillectomy, a retrospective review using the MarketScan database was performed. A total of 306,536 privately insured children and adolescents (1 to 17 years old) who underwent tonsillectomy/adenoidectomy were identified from 2008 to 2012. Pharmaceutical claims identified patients who received outpatient prescriptions for ibuprofen, steroids, or topical anesthetics until discharge and for medications for the treatment of attention deficit hyperactivity disorder (ADHD) or montelukast up to 14 days postoperatively. Logistic regression compared prescription claims to outcomes, including postoperative bleeding, dehydration, emergency department visits, and readmissions. Ibuprofen was the only medication associated with increased odds of postoperative bleeding (odds ratio [OR]: 1.45, 95% confidence interval [CI]: 1.07 to 1.95). Patients receiving steroids had lower odds of dehydration (OR: 0.74, 95% CI: 0.65 to 0.84) and emergency department visits (OR: 0.82, 95% CI: 0.76 to 0.88). Odds of dehydration were highest in patients taking ADHD medications (OR: 1.38, 95% CI: 1.15 to 1.66) and topical anesthetics (OR: 1.32, 95% CI: 1.10 to 1.59). Although causality cannot be assumed in observational studies, steroids and ibuprofen should be used judiciously.

Predictors of postoperative bleeding after vitrectomy for vitreous hemorrhage in patients with diabetic retinopathy

AIMS/INTRODUCTION

To clarify the association between perioperative variables and postoperative bleeding in pars plana vitrectomy for vitreous hemorrhage in diabetic retinopathy.

MATERIALS AND METHODS

The present retrospective study enrolled 72 eyes of 64 patients who were admitted to Osaka University Hospital between April 2010 and March 2014, and underwent vitrectomy for vitreous hemorrhage as a result of diabetic retinopathy.

RESULTS

Postoperative bleeding developed in 12 eyes. Using binomial logistic regression analysis, we found that the duration of operation was the only significant variable associated with postoperative bleeding within 12 weeks after vitrectomy. Furthermore, Poisson regression analysis identified fasting blood glucose just before vitrectomy, no treatment with antiplatelet drugs and treatment with antihypertensive drugs, as well as duration of operation, to be significantly associated with the frequency of bleeding within 52 weeks after vitrectomy.

CONCLUSIONS

Long duration of operation can be used to predict bleeding within both 12 and 52 weeks after vitrectomy. In addition, fasting blood glucose just before vitrectomy, no treatment with antiplatelet drugs and treatment with antihypertensive drugs might be risk factors for postoperative bleeding up to 1 year after vitrectomy.

Radial Versus Femoral Approach for Percutaneous Coronary Intervention: MACE Outcomes at Long-Term Follow-up

OBJECTIVE

To compare the main outcomes of radial versus femoral access at long-term follow-up.

BACKGROUND

Little is known about the long-term major cardiovascular events and bleeding complications of patients undergoing percutaneous coronary intervention (PCI) with radial vs femoral approach.

METHODS

A total of 1107 patients from the CENTURY II trial were included. To minimize baseline differences between radial and femoral groups, we applied propensity-score matching for this comparison.

RESULTS

In this multicenter study, the radial approach was used in 73.4% of patients. After propensity-score matching, baseline and procedural characteristics were comparable between both groups. Procedural success was high and similar in radial and femoral approaches (98.2% vs 97.5%; P=.47) while radial access was associated with a shorter hospital stay (1.69 ± 1.92 days vs 2.08 ± 1.98 days; P<.01). The short-term bleeding and vascular complication rates were significantly lower in the radial group (1.7% vs 6.2% [P<.001 in-hospital] and 2.7% vs 9.6% [P<.001 at 1-month follow-up]). At 3-year follow-up, radial access was associated with lower rates of all-cause mortality (3.9 vs 6.9%; P=.04) and cardiovascular death (2.1 vs 4.9%; P=.02). The composite of all-cause mortality, myocardial infarction, and revascularization showed no differences between groups (18.2 vs 21.1%; P=.29).

CONCLUSIONS

Compared to the femoral approach, the radial approach is associated with significantly lower long-term all-cause mortality rate as well as lower in-hospital and short-term bleeding rates. These results suggest additional long-term benefits of radial access for PCI, but should be interpreted within the context of the current study and further verified in future studies.

Emergency bedside evacuation of a subset of large postoperative epidural hematomas after neurosurgical procedures

Postoperative epidural hematoma (POEDH) is a known complication after neurosurgical procedures. Large POEDHs are life-threatening and require emergency evacuation, and open surgery is the mainstay of treatment. Most of POEDHs are hyperdense on computed tomography (CT). We herein report a subset of POEDHs requiring evacuation, which presented with isodense features on CT. The presenting symptoms of patients were severe headache accompanied by nausea and vomiting as well as unilateral limb weakness (n = 1) and consciousness disorder (n = 4). The Glasgow coma score of the patients was 8.4 ± 3.5. All patients underwent emergency bedside burr hole evacuation through a tube, rather than open surgery. The meantime for the bedside procedures is 6.0 ± 1.5 minutes. All 5 POEDHs were proven liquid and evacuated successfully. All patients recovered quickly with good outcomes. We concluded that the isodensity of the POEDHs on CT represent their liquid nature. Bedside burr hole evacuation through a tube may be a recommendable method for this subset of POEDHs requiring evacuation. Thus, an open surgery and general anesthesia may be avoided.

Evaluation of CRUSADE and ACUITY-HORIZONS Scores for Predicting Long-term Out-of-Hospital Bleeding after Percutaneous Coronary Interventions

BACKGROUND

There is scanty evidence concerning the ability of Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) and Acute Catheterization and Urgent Intervention Triage Strategy and Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (ACUITY-HORIZONS) scores to predict out-of-hospital bleeding risk after percutaneous coronary interventions (PCIs) with drug-eluting stents (DES) in patients receiving dual antiplatelet therapy. We aimed to assess and compare the long-term prognostic value of these scores regarding out-of-hospital bleeding risk in such patients.

METHODS

We performed a prospective observational study of 10,724 patients undergoing PCI between January and December 2013 in Fuwai Hospital, China. All patients were followed up for 2 years and evaluated through the Fuwai Hospital Follow-up Center. Major bleeding was defined as Types 2, 3, and 5 according to Bleeding Academic Research Consortium Definition criteria.

RESULTS

During a 2-year follow-up, 245 of 9782 patients (2.5%) had major bleeding (MB). CRUSADE (21.00 [12.00, 29.75] vs. 18.00 [11.00, 26.00], P < 0.001) and ACUITY-HORIZONS (9.00 [3.00, 14.00] vs. 6.00 [3.00, 12.00], P < 0.001) risk scores were both significantly higher in the MB than non-MB groups. Both scores showed a moderate predictive value for MB in the whole study cohort (area under the receiver-operating characteristics curve [AUROC], 0.565; 95% confidence interval [CI], 0.529-0.601, P = 0.001; AUROC, 0.566; 95% CI, 0.529-0.603, P < 0.001, respectively) and in the acute coronary syndrome (ACS) subgroup (AUROC: 0.579, 95% CI: 0.531-0.627, P = 0.001; AUROC, 0.591; 95% CI, 0.544-0.638, P < 0.001, respectively). However, neither score was a significant predictor in the non-ACS subgroup (P > 0.05). The value of CRUSADE and ACUITY-HORIZONS scores did not differ significantly (P > 0.05) in the whole cohort, ACS subgroup, or non-ACS subgroup.

CONCLUSIONS

CRUSADE and ACUITY-HORIZONS scores showed statistically significant but relatively limited long-term prognostic value for out-of-hospital MB after PCI with DES in a cohort of Chinese patients. The value of CRUSADE and ACUITY-HORIZONS scores did not differ significantly (P > 0.05) in the whole cohort, ACS subgroup, or non-ACS subgroup.

Cardioembolic Stroke in Patient With Transcatheter Occluded Left Atrial Appendage

A cerebral ischemic event in a patient managed with left atrial appendage (LAA) transcatheter obliteration is illustrated. Transesophageal echocardiography allowed identification and accurate definition of the LAA device leakage.

Perioperative management of vitamin K antagonists in patients with low thromboembolic risk undergoing elective surgery: A prospective experience

BACKGROUND AND OBJECTIVES

To quantify thromboembolic and bleeding events in patients with low thromboembolic risk, who were chronically receiving vitamin K antagonists and undergoing elective surgery.

MATERIAL AND METHODS

A descriptive, prospective, single-center study was conducted between December 2010 and July 2014. Patients aged over 18 years old, chronically anticoagulated with vitamin K antagonists and admitted for elective surgery were included in the study. We excluded patients with a creatinine clearance<30ml/min, a body weight>120kg, heparin-induced thrombocytopenia, pregnant women, carriers of an epidural catheter for analgesia, patients who underwent unscheduled surgery and high thromboembolic risk-patients. Vitamin K antagonists were discontinued 5 days prior to the procedure without administering anticoagulant enoxaparin. The NIR was measured 24h before the procedure. A single dose of 3mg of vitamin K was administered in cases of a NIR>1.5. Vitamin K antagonists was resumed according to the surgical bleeding risk. Events were registered between 5 days prior to the procedure until 30 days after it.

RESULTS

A total of 75 procedures were included in the study. Fifty-six patients (74.7%) received vitamin K antagonists for atrial fibrillation, 15 suffered from venous thromboembolism (20%) and 4 had mechanical heart valves (5.3%). Twenty-six patients (34.5%) underwent high-bleeding risk surgeries and 49 (65.5%) underwent low risk procedures. No thromboembolic event was recorded. Four bleeding events (5.3%) were reported, 3 of which were considered major bleeding events (2 fatal).

CONCLUSIONS

Suspending vitamin K antagonists with no bridging therapy performed in patients with a low thromboembolic risk does not expose such patients to a significant risk of embolic events.

Arterial Cutaneous Femoral Fistulous Tract Closure Using Surgiflo Hemostatic Matrix: A Novel Adjunct for Post-TAVR Access-Site Management

Several options are available to address hemostasis at the end of a cardiac catheterization or percutaneous transfemoral transcatheter aortic valve replacement (TAVR) when conventional options are ineffective. To date, there have been few studies exploring the use of a topical thrombin preparation, as one of its main contraindications is that it cannot be used intravascularly due to risk of embolization. The following case shows safe utilization of Surgiflo hemostatic gel matrix under fluoroscopic guidance against an inflated balloon in order to achieve closure of a fistulous tract from a femoral artery access site during percutaneous TAVR.

Preoperative thromboelastometry for the prediction of increased chest tube output in cardiac surgery: A retrospective study

Bleeding following cardiac surgery is a serious event with potentially life-threatening consequences. Preoperative recognition of coagulation abnormalities and detection of cardiopulmonary bypass (CPB) related coagulopathy could aid in the start of preventive treatment strategies that minimize perioperative blood loss. Most algorithms that analyze thromboelastometry coagulation tests in elective cardiac surgery do not include test results performed before surgery. We evaluated preoperative rotational thromboelastometry test results for their ability to predict blood loss during and after cardiac surgery.A total of 114 adult patients undergoing cardiac surgery with CPB were included in this retrospective analysis. Each patient had thromboelastometry tests done twice: preoperatively, before the induction of anesthesia and postoperatively, 10 minutes after heparin reversal with protamine after decannulation.Patients were placed into 1 of 2 groups depending on whether preoperative thromboelastometry parameters deviated from reference ranges: Group 1 [N = 29; extrinsically activated test (EXTEM) or INTEM results out of normal range] or Group 2 (N = 85; EXTEM and INTEM results within the normal range). We observed that the total amount of chest tube output was significantly greater in Group 1 than in Group 2 (700 mL vs 570 mL, P = .03). At the same time, the preoperative values of standard coagulation tests such as platelet count, aPTT, and INR did not indicate any abnormalities of coagulation.Preoperative coagulation abnormalities diagnosed with thromboelastometry can predict increased chest tube output in the early postoperative period in elective adult cardiac surgery. Monitoring of the coagulation system with thromboelastometry allows rapid diagnosis of coagulation abnormalities even before the start of the surgery. These abnormalities could not always be detected with routine coagulation tests.

No impact of fish oil supplements on bleeding risk: a systematic review

INTRODUCTION

Fish oil supplementation may inhibit platelet aggregation and can potentially increase the risk of bleeding. The aim of the present systematic review was to evaluate the effect of fish oil supplements on haemostasis and bleeding risk, and to provide recommendations on whether it is necessary to discontinue fish oil supplementation prior to surgery.

METHODS

Studies were identified through PubMed and Embase searches and by reviewing the reference lists of the included papers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Included in the review were publications including a minimum of 20 healthy subjects and studies on patients who were undergoing surgery and who had fish oil exposure.

RESULTS

In total, 52 publications were included; 32 publications on healthy subjects and 20 publications on patients undergoing surgery. The majority of the included studies were randomised controlled trials or included a control group. Overall, fish oil supplements reduced platelet aggregation in healthy subjects. Fish oil exposure in surgical patients did not increase bleeding or blood transfusions either during or after surgery.

CONCLUSION

Fish oil supplements reduced platelet aggregation in healthy subjects. This biochemical effect was not reflected in increased bleeding risk during or after surgery evaluated in randomised controlled trials. Consequently, this systematic review does not support the need for discontinuation of fish oil supplements prior to surgery or other invasive procedures.

Subconjunctival hemorrhage and vision loss after regional ocular anesthesia

PURPOSE

To report two cases of retinal vascular occlusion and associated subconjunctival hemorrhage in needle optic nerve injury during local bulbar anesthesia.

METHODS

Surgical records of these two subjects who presented with acute vision loss after cataract extraction were studied, and systemic workup and ocular imaging were carried out to establish the cause.

RESULTS

Computerized tomography showed evidence of optic nerve injury.

CONCLUSION

Subconjunctival hemorrhage could be an associated clinical finding in hypodermic needle injury-related retinal vascular occlusion during ocular anesthesia.

Hemorrhage after Major Pancreatic Resection: Incidence, Risk Factors, Management, and Outcome

BACKGROUND AND AIMS

Hemorrhage is a rare but dreaded complication after pancreatic surgery. The aim of this study was to examine the incidence, risk factors, management, and outcome of postpancreatectomy hemorrhage in a tertiary care center.

MATERIALS AND METHODS

A retrospective observational study was conducted on 500 consecutive patients undergoing major pancreatic resections at our institution. Postpancreatectomy hemorrhage was defined according to the International Study Group of Pancreatic Surgery criteria.

RESULTS

A total of 68 patients (13.6%) developed postpancreatectomy hemorrhage. Thirty-four patients (6.8%) had a type A, 15 patients (3.0%) had a type B, and the remaining 19 patients (3.8%) had a type C bleed. Postoperative pancreatic fistula Grades B and C and bile leakage were significantly associated with severe postpancreatectomy hemorrhage on multivariable logistic regression. For patients with postpancreatectomy hemorrhage Grade C, the onset of bleeding was in median 13 days after the index operation, ranging from 1 to 85 days. Twelve patients (63.2%) had sentinel bleeds. Surgery lead to definitive hemostatic control in six of eight patients (75.0%). Angiography was able to localize the bleeding source in 8/10 (80.0%) cases. The success rate of angiographic hemostasis was 8/8. (100.0%). The mortality rate among patients with postpancreatectomy hemorrhage Grade C was 2/19 (10.5%), and both fatalities occurred late as a consequence of eroded vessels in association with pancreaticogastrostomy.

CONCLUSION

Delayed hemorrhage is a serious complication after major pancreatic surgery.Sentinel bleed is an early warning sign. Postoperative pancreatic fistula and bile leakage are important risk factors for severe postpancreatectomy hemorrhage.

Kidney injury secondary to endovascular treatment of renal artery stenosis

In this paper, we present a case of kidney injury as a complication of renal artery angioplasty in a 54-year-old female patient that suffered from resistant renovascular hypertension. This case emphasises the unpredictable nature of endovascular procedures, the need for careful post-procedure evaluation and the role of 'old fashioned' surgical techniques in resolving complications of endovascular procedures.

Total Hip Arthroplasty Complicated by a Gluteal Hematoma Resulting in Acute Foot Drop

Total hip arthroplasty is a prevalent orthopedic intervention in the United States. Massive postoperative hematomas are a rare albeit serious complication of the procedure. Sequelae of these hematomas can include lower extremity paralysis from compression of the sciatic nerve. A 66-year-old woman taking aspirin and clopidogrel for coronary stents presented with a complete foot drop, paresthesias, and lower extremity pain 10 days after a total hip arthroplasty. The patient was initially seen by a neurology service at another hospital and thought to have lateral recess stenosis. At the authors' center, magnetic resonance imaging of the lumbar spine failed to show lateral recess stenosis. Urgent pelvic computed tomography showed a large hematoma and raised suspicion of sciatic nerve compression. Hip magnetic resonance imaging showed a right gluteal hematoma compressing the sciatic nerve. The patient was then taken to the operating room for the clot to be evacuated and was later referred for rehabilitation. Massive hematomas after total hip arthroplasty are an important consideration in the differential diagnosis of nontraumatic acute foot drop. Prompt diagnosis may correlate with improved neurological outcome and help reduce overall morbidity.

DIAGNOSTICS AND CORRECTION OF THROMBOHEMORRHAGIC DISORDERS IN PATIENTS WITH GIANT UTERINE MYOMA AT THE PERIOPERATIVE STAGE OF TREATMENT

The aim of the study was to reduce perioperative blood loss in patients with giant uterine myoma. As a result of studies have provided evidence that the use of anti fibrinolytic therapy as intravenous infusion of tranexamic acid for 30 minutes before the surgery in a dose of 20 mg/kg followed by infusion of 5 mg/kg per hour for the first postoperative day, helped to reduce perioperative blood loss by 29%. Hemoglobin level was higher by 10% (p < 0,05), blood loss was lower by 29% (p < 0,05), the length of stay in hospital was reduced by 24% (p < 0,05) in patients of the second group on the second postoperative day.

Hawthorn Herb Increases the Risk of Bleeding after Cardiac Surgery: An Evidence-Based Approach

<strong>Objectives:</strong> Hawthorn extract consumption is becoming more widespread among the Jordanian population with cardiovascular disorders. We conducted this prospective observational longitudinal study to determine the impact of hawthorn extract on bleeding risk in patients who undergo cardiac surgery. <br /><strong>Methods:</strong> A prospective observational study was performed on 116 patients who underwent cardiac surgery in the period between June 2014 and May 2015. Patients were divided into two groups: Group I (patients recently consumed hawthorn extract) and Group II (patients never consumed hawthorn extract). Endpoint measures included the rates of reopening to control bleeding, early mortality, duration of intensive care unit stay, total in-hospital stay period, and duration and amount of chest tube drainage. <br /><strong>Results:</strong> Hawthorn patients had a significantly higher rate of postoperative bleeding necessitating take back to the operating room compared to the control group (10% versus 1%; <br />P = .03) respectively. The overall mortality rate for group I and II was 4% and 0% respectively; P = .17. Chest tubes were kept in for longer times in group I compared to group II <br />(54 ± 14.6 versus 49 ± 14.7 hours respectively; P = .01). Group I stayed longer in the intensive care unit compared to group II (24 versus 22 hours respectively; P = .01). The total in-hospital stay period was comparable between the two groups. <br /><strong>Conclusion:</strong> Hawthorn extract consumption does increase the potential for bleeding and the amount of chest tube output after cardiac surgery.

Subcapsular hematoma after ureteroscopy and laser lithotripsy

Subcapsular hematoma is an uncommon complication after ureteroscopy and laser lithotripsy. We report on a 38-year-old male with an 8 mm lower pole stone who underwent a left ureteroscopy and laser lithotripsy. The stone was successfully fragmented. Several hours after being discharged home, the patient returned complaining of back pain and hematuria. He was hemodynamically stable. Laboratory exams were normal. A CT study showed a crescent renal subcapsular hematoma surrounding the left kidney. The patient was admitted to the ward for conservative treatment. No additional intervention was necessary. Most subcapsular hematomas tend to resolve spontaneously.

Superficial siderosis complicated by hydrocephalus: bleeding from the dura mater in the cerebrospinal fluid cavity after brain tumor surgery

BACKGROUND

In most patients with superficial siderosis of the central nervous system, the exact source of bleeding remains unknown and a treatment has not yet been established.

METHODS

We herein presented a case of superficial siderosis complicated by hydrocephalus 19 years after supratentorial brain tumor resection.

RESULTS

The bleeding source was identified as the dura mater in the intracranial cerebrospinal fluid cavity, and not a recurrent tumor.

CONCLUSION

Chronic intracranial bleeding from the dura mater was successfully arrested by replacement of the dura mater with the autologous fascia of the thigh, and hydrocephalus was treated with endoscopic surgery.

Using Cone and Plate(let) Analyzer to Predict Bleeding in Cardiac Surgery

The cone and plate(let) analyzer is an established method for assessing platelet function. It evaluates adherence of platelets on an extracellular matrix, expressed as a percentage of surface coverage and the average size of the aggregates. The purpose of this study was to determine the applicability of the cone and plate(let) analyzer in monitoring platelet function and predicting postoperative bleeding. The relationship between postoperative bleeding, perioperative platelet function, and other parameters was studied. A significant decrease in surface coverage was detected upon establishment of cardiopulmonary bypass (from 6.9% ± 3.9% to 4.7% ± 1.7%) with a return to preoperative values at the end of surgery. Preoperative average size and surface coverage were the only parameters that significantly and linearly correlated with postoperative bleeding. Patients with an aggregate average size < 20 μm2 had a significantly higher incidence of severe bleeding (> 965 mL) than those with a size > 20 μm2 (44% vs. 0%), and a higher mean blood loss (908 ± 322 mL vs. 337 ± 78 mL). Similar results were obtained for surface coverage < 5%, indicating the predictive value of these parameters. Preoperative platelet function as evaluated by the cone and plate(let) analyzer is an independent risk factor determining postoperative bleeding.