Activated coagulation time vs. intrinsically activated modified rotational thromboelastometry in assessment of hemostatic disturbances and blood loss after protamine administration in elective cardiac surgery: analysis from the clinical trial (NCT01281397)

BACKGROUND

Excessive bleeding after cardiopulmonary bypass (CPB) is risk factor for adverse outcomes after elective cardiac surgery (ECS). Although many different point-of-care devices to diagnose hemostatic disturbances after CPB are available, the best test is still unclear. The study aim was to compare the accuracy of hemostatic disorder detection between two point-of-care devices.

METHODS

We enrolled 148 patients (105 male and 43 female) undergoing ECS in a prospective observational study. Rotational thromboelastometry (TEM, with InTEM test), and Activated coagulation time (ACT) measurement were performed 15 min after protamine administration. The cohort group was divided into two subgroups according to occurrence of excessive postoperative bleeding. Endpoints were defined in two ways: as total amount of chest tube output (CTO) and blood product transfusion requirements.

RESULTS

Total amount of CTO value of 1507,50 mL presented 75th percentile of distribution, thus cut-off value for bleeder category. InTEM parameters, but not ACT, correlated significantly with CTO. InTEM parameters with the strongest correlation to CTO were tested for accuracy in predicting excessive postoperative bleeding using ROC analysis. InTEM A 10 value of 38 mm, InTEM A 20 value of 49 mm and InTEM A 30 value of 51 mm delineated bleeding tendency. Patients with total amount of CTO exceeding 75th percentile were more frequently transfused with fresh frozen plasma (51.4% vs. 9.9%, p < 0.001), fibrinogen concentrate (21.6% vs. 2.7%, p = 0.001) and platelet concentrate (13.5% vs. 0.9%, p = 0.004).

CONCLUSION

Our study showed that InTEM test, but not ACT is useful in prediction of bleeding tendency after protamine administration following weaning from CPB. InTEM test could be used as a first line test in screening of possible hemostatic disorder following protamine administration.

[Evaluation of non-invasive hemoglobin measurements using the Masimo Rainbow Radical-7® device in a patient with extracorporeal membrane oxygenation]

Circulatory assist devices such as extracorporeal membrane oxygenation are indicated in cases of cardiogenic shock refractory to optimal conventional treatment. Bleeding is a serious complication of such systems, mainly due to coagulation disorders caused by continuous administration of heparin, as well as platelet dysfunction. Serial coagulation and hemoglobin (Hb) measurements are essential. Hb measurements can be performed through repeated arterial blood gasometry, and more recently with a new spectrophotometric sensor, Masimo Rainbow Radical-7® device, which gives Hb values continuously and non-invasively. We report a case of a patient undergoing cardiac surgery who required extracorporeal membrane oxygenation for severe cardiogenic shock immediately after surgery. We compare the correlation and the level of agreement with Hb levels measured by 2 existing systems in clinical practice. Our results indicate that the Masimo® spectrophotometric monitor showed statistically comparable Hb values, in the correlation (r=.85; P<.01) and in agreement with those obtained by serial blood gas analyzer, ABL800 FLEX® (wavelength). In view of these results we consider the Masimo® device as a valid alternative for the continuous follow-up of the Hb and control of bleeding in these patients.

Embolization of post-biliary sphincterotomy bleeding refractory to medical and endoscopic therapy: technical results, clinical efficacy and predictors of outcome

PURPOSE

To retrospectively analyse the technical and clinical outcomes of embolotherapy for post-biliary sphincterotomy bleeding refractory to medical and endoscopic therapy, and in addition, to analyse factors potentially influencing 30-day mortality.

MATERIALS AND METHODS

From November 1998 to November 2012, 34 patients underwent percutaneous embolotherapy for post-biliary sphincterotomy bleeding refractory to medical and endoscopic treatment. Demographic, laboratory, angiographic, and clinical follow-up data were collected.

RESULTS

Indication for initial endoscopic sphincterotomy was benign (n = 28) or malignant (n = 6) disease. A precut sphincterotomy followed by sphincterotomy was performed in 13 patients (38 %), whereas the remaining 21 patients (62 %), underwent only sphincterotomy. Seven patients (20.6 %) were still on antithrombotic medication at the time of sphincterotomy. Angiographic evaluation revealed contrast extravasation (n = 31), pseudoaneurysm (n = 2), or a combination of both (n = 1). Embolization was successful in 33 of 34 patients (97 %). Recurrent bleeding occurred in three patients (9 %), and 30-day mortality was 20.6 % (n = 7). Factors significantly influencing 30-day mortality were INR (P = 0.008) and aPTT (P = 0.012).

CONCLUSION

Angiographic embolization is very effective in stopping post-biliary sphincterotomy bleeding refractory to medical and endoscopic therapy. The rate of rebleeding is acceptably low, but 30-day mortality remains significant. Haemostatic disorders appear to significantly influence 30-day survival.

KEY POINTS

• Transcatheter embolization is very effective in stopping major post-biliary sphincterotomy bleeding • The rate of rebleeding is acceptably low • Haemostatic disorders appear to significantly influence 30-day survival.

Femoral vein injury managed by in situ saphenous vein bypass : a case report

Injured veins of the lower limbs may cause massive haemorrhage requiring early control. Operative management of injured veins remains a controversial topic and reconstruction or ligation depends on venous and adjacent tissue damage. Nevertheless, venous reconstruction seems to reduce the complications of venous ligation. The case of a 33 year old women with a venous wound to the right groin is presented. Surgical management consisted of controlling the bleeding and venous revascularisation with an in situ saphenous vein bypass to substitute the injured femoral vein. The patient had an uneventful postoperative period without any complications. The case demonstrates this method of vascular venous repair is the preferable one.

Short-term clinical outcomes of postoperative intrapelvic bleeding after extended pelvic surgery: a single institute experience

BACKGROUND/AIM

Intrapelvic bleeding after extended pelvic surgery is fatal, but few reports have addressed this serious situation. The objective of the present study was to evaluate the short-term clinical outcome of this complication.

PATIENTS AND METHODS

This study was a retrospective medical chart review of 130 patients who underwent extended pelvic surgery between 2000 and 2012 at our Institute. Based on the classification of the bleeding pelvic artery, how initial hemostasis and control of secondary pelvic abscess were mainly evaluated.

RESULTS

In 6 patients, bleeding involved a peripheral artery (peripheral group) and 4 a main artery (central group). For initial hemostasis, interventional radiology was efficacious. Compared to the peripheral group, even if initial hemostasis succeeded, unsatisfactory abscess drainage easily became fatal in the central group.

CONCLUSION

Aggressive surgical abscess drainage should be considered at an appropriate time for optimal survival in patients with involvement of a main artery with insufficient tube drainage.

Post-tonsillectomy complications in children less than three years of age: a case-control study

OBJECTIVES

To assess the need for post-tonsillectomy admission in children under the age of three years.

DESIGN

A retrospective case-control study.

METHOD

Medical records of 127 children under the age of three years who underwent tonsillectomy with or without adenoidectomy were reviewed for complications and compared to 127 gender-matched controls between three to four years of age.

RESULTS

Overall complication rate in the study group was 9.4% (12 of 127). Early complications (3.1%) were respiratory related, while late complications (6.3%) were due to dehydration and hemorrhage. Comparable complication rate was observed in the control group (8.7%, P>0.05); early complication rate of 3.1% and late complication rate of 5.5% was ascertained. Similar types of complications occurred in the control group.

CONCLUSIONS

Post-tonsillectomy complication rates were low and no significant difference was observed between the study and control groups. This suggests that postoperative admission for children younger than three years of age may not be necessary in all cases.

Thromboelastography can Identify Postoperative Active Bleeding and Evaluate Blood Product Requirements in Abdominal Surgery

BACKGROUND/AIMS

Hemorrhage after abdominal surgery remains a frequent clinical complication, and associated with prolonged length of stay, increased complications and mortality. Indication of blood product requirements accurately and promptly is very important for recovery of patients. Thrombelastography (TEG) as a tool for evaluation of bleeding and effects of blood components and blood products is increasing. We investigated that whether TEG can identify postoperative active bleeding and evaluate blood product requirements in abdominal surgery.

METHODOLOGY

Between June to December in 2012, there were 55 patients who had bleeding after operation in SICU of Jinling Hospital. Recorded data included vital signs (MAP, heart rate, respiratory rate, blood oxygen saturation), urine volume per hour, blood routine (Hb, Hct, Plt), the coagulation tests (Fib, PT, aPTT, INR), TEG parameters (R, K, Angle, MA, Cl) and blood product requirements within 24h. Patients were divided into active bleeding group and non-active bleeding group based on the findings of reoperation or digital subtraction angiography (DSA). To compare vital signs, laboratory values, TEG values and blood product requirements in two groups.

RESULTS

Vital signs (MAP, heart rate, respiratory rate, blood oxygen saturation), urine volume per hour and the coagulation tests (Fib, PT, INR) showed no significant correlations with subsequent blood product requirements, but aPTT (R = 0.546, P = 0.000) and MA (R = 0.665, P = 0.000) correlated with the blood products use. MA values of patients had more blood loss was significantly lower and had a descending tendency which did not showed in aPTT values. 25 patients had postoperative active bleeding confirmed by reoperation or DSA. They had significantly increased use of blood products, and significantly lower MA, Hb, Hct, and Fib values, whereas aPTT exhibited no significant differences.

CONCLUSION

MA can not only identify postoperative active bleeding together with hemoglobin, hematocrit, and fibrinogen, but also evaluate blood product requirements in abdominal surgery.

Postoperative gastrointestinal bleeding after an orthotopic liver transplant: a single-center experience

OBJECTIVES

The overall incidence, causes, and treatment of posttransplant gastrointestinal bleeding, have been previously described. In this study, we examined the causes and treatment of postoperative gastrointestinal bleeding after orthotopic liver transplant.

MATERIALS AND METHODS

Clinical data of 335 patients who underwent an orthotopic liver transplant at our institution between September 2001 and December 2012 were analyzed retrospectively. The diagnosis and treatment of postoperative gastrointestinal bleeding after an orthotopic liver transplant were reviewed.

RESULTS

Gastrointestinal bleeding occurred in 13 patients (3.8%) after an orthotopic liver transplant. Five patients (38.4%) were adult and 8 patients (61.6%) were pediatric. The sites of the bleeding were Roux-en-Y anastomosis bleeding in 5 cases, peptic ulcer in 3 cases, erosive gastritis in 3 cases, gastric and esophageal varices in 1 case, and hemobilia in 1 case. These 13 patients with gastrointestinal bleeding were managed with conservative treatment, endoscopic treatment, radiologic interventional embolism, or exploratory laparotomy. No patients died because of gastro--intestinal bleeding. During follow-up, 4 patients died because of sepsis and 1 patient died of recurrence of hepatocellular carcinoma.

CONCLUSIONS

Gastrointestinal bleeding after liver transplant and its incidence, causes, and treatment are not well-described in the literature. Diagnosis and management of gastrointestinal bleeding requires a multidisciplinary approach involving surgeons, hepatologists, advanced and experienced endoscopists, and interventional radiologists.

[Severe postoperative bleeding after Total Prolift procedure for vaginal vault prolapse - case study]

OBJECTIVE

To describe a case of a severe postoperative bleeding after Total Prolift procedure for vaginal vault prolapse.

DESIGN

Case study.

SETTINGS

Department of Obstetrics and Gynecology, Medical Faculty in Pilsen, Charles University in Prague.

CASE

A 55-year-old woman underwent a surgery with a Prolift procedure for vaginal prolapse after hysterectomy. The surgery was carried out without any complications. In the first 24 hours after Prolift surgery we diagnosed massive bleeding and hypovolemic shock. The condition required repeated re-exploration and ligation of hypogastric artery and pelvic packing to stop the bleeding.

CONCLUSION

Bleeding is a major complication in gynecological surgery. Severe hemorrhage is a rare condition after surgical treatment of vaginal prolapse after hysterectomy using a Prolift procedure.

[Richter's sacrospinous ligament fixation and its place in current gynecology]

In 1968 K. Richter treated post-hysterectomy prolapse of the vaginal stump by fixating the vaginal stump to the sacrospinous ligament via transvaginal route. Nowadays most authors perceive this technique as an inseparable component of vaginal hysterectomy, for the purpose of preventing vaginal stump prolapse. The authors present the results of Richter's operation among 53 patients, 33 of whom operated on in the Department of General and Oncological Gynaecology at the Military Medical Academy (Sofia), 12 operated on in the Department of Gynaecology at the Military Medical Academy (Varna), 4 in the Municipal Maternity Hospital "St Sofia" (Sofia) and 4 in the Department of Obstetrics and Gynaecology at the Multi-profile Hospital for Active Medical Treatment (Samokov) during the period 2009-2013. In 26 of the cases (49%) the operative indication was a severe vaginal descensus, in 23 (44%)--total uterine prolapse, in 4 (7%)--prolapse of the vaginal stump following hysterectomy. Twenty-six of those women (56%) didn't have any symptoms of urinary incontinence, as 20 (38%) had symptoms of urinary stress incontinence. The median age of operated women is 64 (age range: 43-78 y.o.). All of them experienced at least once a vaginal birth (average parity: 2). The average duration of subjective complaints caused by their condition was 41 months (range: 2-120 months.) The average duration of the operation was 122 minutes (range: 60-210 min). The average amount of blood lost during the operation was 218 ml (range: 60-400 ml). No intraoperative complications were registered. Early postoperative complications consisted in 3 cases of considerable bleeding through the stitches which faded without any special measures, blood transfusion included. One patient developed a haematoma in the ischiorectal fossa which was incised and evacuated. The long-term results, recorded at post-op visits 1 and 6 months after the operation, were satisfactory: regardless their age and their preoperative genital status, surgery in 93% of the cases has led to stable correction of the pelvic statics and disappearance of urinary incontinence in case the latter did exist. Recurrent prolapse was noted in 4 cases (7%), in two of which the condition was diagnosed as a partial recurrence. The authors regard those recurrences as resulting from technical errors, rather than as a shortcoming of the surgical procedure.

Predictors of 24-hour drain volume after coronary artery bypass graft

BACKGROUND

Excessive postoperative hemorrhage in cardiac surgery is a serious complication associated with adverse postoperative events. Also, its associated risk of re-exploration, places a high demand on hospital resources in terms of transfusion needs, ventilatory support requirements, intensive care support, and manpower requirements.

OBJECTIVE

To determine predictors of 24-hour drain volume (pleural and mediastinal) after coronary artery bypass graft (CABG), in order to focus on preventive measures for patients with identified risk factors.

PATIENTS AND METHODS

Fifty-four consecutive adult patients who had CABG at the Madras Medical Mission, Chennai, India in July 2008 were retrospectively studied. In order to determine risk factors for excessive post-operative bleeding, 11 pre-operative, and 13 operative and 2 post-operative variables were analyzed using univariate analysis and multiple linear regression.

RESULTS

Cardiopulmonary bypass was used for all the patients and anti-fibrinolytic in 13 (22.8%). No mortality was recorded. Mean 24-hour post-operative drain volume was 458 ± 270 ml (range 90-1230). Re-exploration for bleeding was required in 2 (3.5%) patients. Predictors of 24-hour drain volume were heparin therapy before commencement of CPB (p=0.024), intra-operative transfusion of fresh frozen plasma (p=0.010), and pre-operative serum ALT value (p=0.047). The strongest predictor was intra-operative transfusion of platelets (p=0.005).

CONCLUSION

To guard against excessive post-operative haemorrhage after CABG, pre-operative stabilisation and correction of coagulation should be achieved. Also the administration of heparin intra-operatively should be individualized and not only based on dose per body weight.

[Diagnostics and surgical treatment of lung cancer in conditions of special thoracal department for patients with purulent lung diseases]

The authors investigated features of diagnostics and surgical treatment of lung cancer which was complicated by purulent destructive process. The possibilities of radical operative intervention were considered after preliminary adequate treatment of purulent complications in 226 patients. It was noted, that the diagnostic thoracotomy should be used in doubtful cases in order to estimate the resectability of lung cancer.

Use of Flavonoids for the treatment of symptoms after hemorrhoidectomy with radiofrequency scalpel

OBJECTIVES

Control of postoperative symptoms is of paramount importance in proctologic surgery. Phlebotropic activity, protective effect on the capillaries and anti-inflammatory properties of the flavonoids have been reported in several studies. They have been used to treat a variety of conditions including chronic venous insufficiency, lymphedema and hemorrhoids. Numerous trials, assessing the effect of phlebotonics in treating the symptoms and signs of haemorrhoidal disease, suggest that there is a potential benefit. Our trial was conducted to evaluate whether the flavonoids reduce postoperative bleeding, pain and other symptoms after hemorrhoidectomy.

PATIENTS AND METHODS

We compared the results obtained in 24 patients undergoing open hemorrhoidectomy with radiofrequency scalpel. Our study cohort was randomized in two groups: the Group A received flavonoids in the postoperative period, the Group B has constituted the control group, without administration of study drug. Follow-up outpatient visits were performed on 7, 15 and 30 postoperative day (POD). During the visits the patients expressed trough a list of specific questions, based on a scoring system (1 to 10), their opi-nion about the extent of postoperative symptoms as pain, bleeding, tenesmus, pruritus and perianal weight.

RESULTS

We observed that the results obtained after 7 days of surgery are similar in both study groups. Even after 15 and 30 days no significant changes were observed between the two groups about pain and bleeding. Instead, we observed significant differences regarding tenesmus (group A: 8.0±1.1 vs Group B: 5.4 ± 1.5 at 15 POD, p < 0.05; group A: 9.1±0.8 vs Group B: 5.7 ± 0.9 at 30 POD, p < 0.05), pruritus (group A: 7.1 ± 1.4 vs Group B: 4.8 ± 1 at 15 POD, p < 0.05; group A: 9.5 ± 0.5 vs Group B: 6.6 ± 0.8 at 30 POD, p < 0.05) and perianal weight (group A: 7.2 ± 0.9 vs Group B: 6.2 ± 0.8 at 15 POD, p < 0.05; group A: 9.75 ± 0.4 vs Group B: 7.3 ± 0.9 at 30 POD, p < 0.05).

CONCLUSIONS

Our results confirm the usefulness of this drug to reduce the prevalence and the importance of post-hemorrhoidectomy symptoms and make more comfortable the postoperative period.

[Peculiarities of blood supply of palatal tonsils and the potential risk of hemorrhage during tonsillectomy: the literature review and case report]

The present review encompasses the publications concerning peculiarities of blood supply of palatal tonsils, the frequency and variants of the anomalous structure of internal carotid artery. Analysis of the literature data has shown that the anomalous vascular structure is one of the important risk factors of the development of intra- and postoperative hemorrhage, besides redundant blood supply of the oropharynx, inflammatory changes in the tissue of tonsils and peritonsillar region. Special attention is given to the peculiarities of diagnostics of such conditions. The emphasis is laid on the importance of timely diagnostics of the anomalous structural changes in the main vessels of the neck prior to the surgical intervention on the pharynx. The analysis of the anomalous structure of internal carotid artery is presented.

[Experience of percutaneous transhepatic rheolytic thrombectomy using in treatment of postresection portal vein thrombosis]

Vessels resection in case of pancreatic head cancer may be associated with portal vein thrombosis. System AngioJet 9000 (Possis Medical Inc.) for rheolytic thrombectomy is one of endovascular device for treatment of patients with venous thrombosis. Descriptions of 3 cases with rheolytic thrombectomy using are presented in the article. Percutaneous transhepatic approach under ultrasound control was used for visualization of portal vein branches. Stent-grafts were implanted in 2 of 3 cases after thrombectomy in zone of portal vein thrombosis. Bleeding from liver puncture site was observed in 1 case in early postoperative period. There was not recurrent thrombosis in long-term postoperative period (31 months after surgery maximally). The authors consider that use of several endovascular techniques such as rheolytic thrombectomy with stenting or without it provides satisfactory clinical results in treatment of patients with postoperative portal vein thrombosis.

Endovascular pseudoaneurysm repair after distal pancreatectomy with celiac axis resection

Erosive hemorrhage due to pseudoaneurysm is one of the most life-threatening complications after pancreatectomy. Here, we report an extremely rare case of rupture of a pseudoaneurysm of the common hepatic artery (CHA) stump that developed after distal pancreatectomy with en block celiac axis resection (DP-CAR), and was successfully treated through covered stent placement. The patient is a 66-year-old woman who underwent DP-CAR after adjuvant chemoradiotherapy for locally advanced pancreatic body cancer. She developed an intra-abdominal abscess around the remnant pancreas head 31 d after the surgery, and computed tomography (CT) showed an occluded portal vein due to the spreading inflammation around the abscess. Her general condition improved after CT-guided drainage of the abscess. However, 19 d later, she presented with melena, and CT showed a pseudoaneurysm arising from the CHA stump. Because the CHA had been resected during the DP-CAR, this artery could not be used as the access route for endovascular treatment, and instead, we placed a covered stent via the inferior pancreaticoduodenal artery originating from the superior mesenteric artery. After stent placement, cessation of bleeding and anterograde hepatic artery flow were confirmed, and the patient recovered well without any further complications. CT angiography at the 6-mo follow-up indicated the patency of the covered stent with sustained hepatic artery flow. To our knowledge, this is the first reported case of endovascular repair of a pseudoaneurysm that developed after DP-CAR.

Ileal conduit stomal variceal bleeding managed by endovascular embolization

Ileal conduit stomal varices are rare, and may result in bleeding. The standard treatment modality for management of this type of hemorrhage has not been established. We present the case of a 70-year-old woman with progressive ileal conduit stomal variceal bleeding which was successfully managed by endovascular embolization via the transjugular transhepatic approach. In conclusion, transjugular transhepatic endovascular embolization is a good choice in patients with ileal conduit stomal variceal bleeding who have failed conservative therapy.

Facial and neck hematoma after carotid artery stenting: an uncommon misadventure in endovascular carotid revascularization

The complication rates of carotid artery stenting (CAS) vary from 3.0% to 4.4%, and most commonly include ischemic stroke, intracranial hemorrhage, or groin complications. We present the rare complication of a patient who underwent CAS for a symptomatic 90% left internal carotid artery stenosis and developed an expanding cervical hematoma after the procedure with imminent respiratory compromise. After intubation, an arteriogram revealed perforation of the external carotid artery trunk, proximal to the origin of the internal maxillary artery. The artery was subsequently embolized and the hematoma resolved without further intervention. We present a potential catastrophic complication and suggest potential causes and treatment options available.

Red cell distribution width as a bleeding predictor after percutaneous coronary intervention

BACKGROUND

Red cell distribution width (RDW), a measure of variability in the size of circulating erythrocytes, is an independent predictor of mortality in cardiovascular disease and in patients undergoing percutaneous coronary intervention (PCI). We set out to determine if RDW is a prognostic marker of major bleeding post-PCI.

METHODS

The study population included 6,689 patients who were subjected to PCI. The RDW was derived from a complete blood count drawn before PCI. Major inhospital bleeding was defined as a hematocrit decrease ≥12%, hemoglobin drop of ≥4, transfusion of ≥2 units of packed red blood cells, retroperitoneal, or gastrointestinal or intracranial bleeding. Multivariable logistic analysis of major inhospital bleeding was performed using a logistic regression model that comprised the National Cardiovascular Data Registry (NCDR) risk score model as a single variable.

RESULTS

Major bleeding (P < .001), vascular complications (P = .005), and transfusions (P < .001) were significantly higher in patients with higher baseline RDW values. After adjustment for known bleeding correlates, RDW was a significant predictor for major bleeding (odds ratio 1.12, 95% CI 1.06-1.19, P < .001). Although the c statistic of the NCDR risk prediction model changed from 0.730 to 0.737 (P = .032), the net reclassification improvement increased significantly after the addition of RDW as a continuous variable (17.3% CI 6.7%-28%, P = .002).

CONCLUSIONS

Red cell distribution width, an easily obtainable marker, has an independent, linear relationship with major bleeding post-PCI and incrementally improves the well-validated NCDR risk prediction model. These data suggest that further investigation is necessary to determine the relationship of RDW and post-PCI bleeding.