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Çakil Güzin A, Oymak Y, Oral A, Vergin C. Diagnostic Value of the Pediatric Bleeding Questionnaire in Prediction of Bleeding in Minor Surgery. J Pediatr Hematol Oncol 2024; 46:e300-e304. [PMID: 38691048 DOI: 10.1097/mph.0000000000002874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 04/04/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE Preoperative coagulation tests have not been shown to be effective in predicting bleeding complications. The Pediatric Bleeding Questionnaire (PBQ) is a proven and sensitive tool for diagnosing children with a predisposition to bleeding. The aim of this study was to evaluate the usefulness of PBQ as a preoperative screening tool for the prediction of bleeding after minor surgical interventions. METHODS Preoperative coagulation tests and PBQ were performed in all patients who underwent minor surgery. The postoperative bleeding status was evaluated and then compared with the coagulation tests and PBQ of the patients. RESULTS Evaluation was made of a total of 706 patients, comprising 91.2% males and 8.8% females, with a mean age of 4.8 years (median: 4 y, QR: 1 to 7 y). Prolongation in coagulation tests was observed in 131 (18.5%) patients. Repeated tests in 116 patients were within the normal range, and 5 patients received treatment. Postoperative bleeding occurred in 4 (0.5%) patients. The relationship between coagulation tests and postoperative bleeding was not significant. PBQ was found to be ≥2 in 14 patients, but none of these patients had postoperative bleeding. No significant relationship was found between postoperative bleeding status and PBQ ( p :0.77). The sensitivity, specificity, positive predictive, and negative predictive values of PBQ were 0%, 98%, 0%, and 97.4%, respectively. CONCLUSIONS The results of this study demonstrated that neither coagulation tests nor PBQ will be sufficient to predict bleeding after minor surgery, that prolongation in coagulation tests does not always indicate a bleeding tendency, and that bleeding history should also be recorded in detail.
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Affiliation(s)
- Ayşe Çakil Güzin
- Department of Pediatric Infectious Disease, Faculty of Medicine, Dokuz Eylül University
| | - Yeşim Oymak
- Department of Pediatric Hematology, University of Health Sciences Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital
| | - Akgün Oral
- Department of Pediatric Surgery, University of Health Sciences Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir, Turkey
| | - Canan Vergin
- Department of Pediatric Hematology, University of Health Sciences Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital
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2
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Epure V, Gheorghe DC. Is it possible to predict post-adenotonsillectomy hemorrhage in children with preoperative blood tests? Single-center retrospective study. Sci Prog 2023; 106:368504231215591. [PMID: 38055322 DOI: 10.1177/00368504231215591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
Introduction: Post-adenotonsillectomy (PAT) bleeding, a life-threatening surgical complication, remains unpredictable despite preoperative blood tests. Every surgeon would like predictive markers for this complication of one of the most common procedures performed in pediatric ear, nose, and throat (ENT). Objective: The purpose of the study is to see whether the results of the blood tests we perform routinely preoperatively in children undergoing adenotonsillectomy (AT) (lymphocyte count and percentage, C reactive protein, fibrinogen, or coagulation variables International Normalized Ratio and activated partial thromboplastin time) can potentially predict early post-AT bleeding. Focus has been placed on the presence of relative lymphocytosis (a value of lymphocyte percentage above 55%) in the blood cell count of the patients and its possible connection to postoperative hemorrhage. Method: We conducted an observational retrospective study on 801 children undergoing adenoidectomy, tonsillectomy, or AT over a period of 6 months in our ENT department. Statistical analysis was performed to compare the data. Results: we did not find a statistically significant correlation between preoperative blood markers (coagulation or inflammatory) and early post-AT bleeding. An important blood marker in relation to PAT bleeding appears to be relative lymphocytosis. Relative lymphocytosis has a weak predictive value of early postoperative bleeding in children with AT (sensitivity of only 31.58%, but acceptable specificity of above 80%). In other words, 80% of patients without relative lymphocytosis will not bleed in the first 24 h postoperatively. Children with relative lymphocytosis may need tighter surveillance in the first 24 h after AT. Conclusions: Relative lymphocytosis has a weak predictive value of early postoperative bleeding in children with AT children.
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Affiliation(s)
- Veronica Epure
- ENT Department, MS Curie Hospital, Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- ENT Department, "MS Curie" Hospital, Bucharest, Romania
| | - Dan Cristian Gheorghe
- ENT Department, MS Curie Hospital, Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- ENT Department, "MS Curie" Hospital, Bucharest, Romania
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3
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Marsee MK, Shariff FS, Wiarda G, Watson PJ, Sualeh AH, Brenner TJ, McCoy ML, Al-Fadhl HD, Jones AJ, Davis PK, Zimmer D, Folsom C. Use of Thromboelastography and Rotational Thromboelastometry in Otolaryngology: A Narrative Review. J Clin Med 2022; 11:jcm11041119. [PMID: 35207392 PMCID: PMC8876674 DOI: 10.3390/jcm11041119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/09/2022] [Accepted: 02/18/2022] [Indexed: 01/27/2023] Open
Abstract
In the field of otolaryngology—head and neck surgery (ENT), coagulopathies present unique diagnostic and therapeutic challenges. In both hyper- and hypocoagulable patients, management of coagulopathies requires intricate attention to the nature of hemostatic competence. Common coagulation tests (CCTs) offer only a snapshot of hemostatic competence and do not provide a clear insight into the patient’s real-time hemostatic condition. Viscoelastic tests (VETs) offer a holistic and concurrent picture of the coagulation process. Although VETs have found prominent utilization in hepatic transplants, obstetrics, and emergent surgical settings, they have not been fully adopted in the realm of otolaryngology. The objective of this manuscript is to provide an overview of the literature evaluating the current utilization and possible future uses of VETs in the field of otolaryngology. The authors performed a comprehensive literature search of the utilization of VETs in otolaryngology and identified applicable studies that included descriptions of viscoelastic testing. Twenty-five studies were identified in this search, spanning topics from head and neck oncology, microvascular free flap reconstruction, obstructive sleep apnea, adenotonsillectomy, facial trauma, and epistaxis. The applicability of VETs has been demonstrated in head and neck oncology and microvascular free flap management, although their pervasiveness in practice is limited. Underutilization of VETs in the field of otolaryngology may be due to a lack of familiarity of the tests amongst practitioners. Instead, most otolaryngologists continue to rely on CCTs, including PT, PTT, INR, CBC, fibrinogen levels, and thrombin time. Learning to perform, interpret, and skillfully employ VETs in clinical and operative practice can greatly improve the management of coagulopathic patients who are at increased risk of bleeding or thrombosis.
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Affiliation(s)
- Mathew K. Marsee
- Department of Graduate Medical Education, Navy Medicine Readiness and Training Command, Portsmouth, VA 23708, USA
- Correspondence:
| | - Faisal S. Shariff
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (F.S.S.); (P.J.W.)
| | - Grant Wiarda
- Department of Biological Sciences, Vanderbilt University, Nashville, TN 37235, USA;
| | - Patrick J. Watson
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (F.S.S.); (P.J.W.)
| | - Ali H. Sualeh
- Department of Biochemistry, Indiana University Bloomington, Bloomington, IN 47405, USA; (A.H.S.); (M.L.M.); (H.D.A.-F.)
| | - Toby J. Brenner
- Department of Biochemistry, Indiana Wesleyan University, Marion, IN 46953, USA;
| | - Max L. McCoy
- Department of Biochemistry, Indiana University Bloomington, Bloomington, IN 47405, USA; (A.H.S.); (M.L.M.); (H.D.A.-F.)
| | - Hamid D. Al-Fadhl
- Department of Biochemistry, Indiana University Bloomington, Bloomington, IN 47405, USA; (A.H.S.); (M.L.M.); (H.D.A.-F.)
| | - Alexander J. Jones
- Department of Otolaryngology, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (A.J.J.); (P.K.D.)
| | - Patrick K. Davis
- Department of Otolaryngology, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (A.J.J.); (P.K.D.)
| | - David Zimmer
- Cleveland Clinic Foundation, Cleveland, OH 44195, USA;
| | - Craig Folsom
- Department of Otolaryngology, Navy Medicine Readiness and Training Command, Portsmouth, VA 23708, USA;
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4
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The ASH-ASPHO Choosing Wisely Campaign: 5 hematologic tests and treatments to question. Blood Adv 2022; 6:679-685. [PMID: 35072726 PMCID: PMC8791561 DOI: 10.1182/bloodadvances.2020003635] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/24/2020] [Indexed: 11/20/2022] Open
Abstract
Choosing Wisely is a medical stewardship and quality-improvement initiative led by the American Board of Internal Medicine Foundation in collaboration with leading medical societies in the United States. The American Society of Hematology (ASH) has been an active participant in the Choosing Wisely project. In 2019, ASH and the American Society of Pediatric Hematology/Oncology (ASPHO) formed a joint task force to solicit, evaluate, and select items for a pediatric-focused Choosing Wisely list. By using an iterative process and an evidence-based method, the ASH-ASPHO Task Force identified 5 hematologic tests and treatments that health care providers and patients should question because they are not supported by evidence, and/or they involve risks of medical and financial costs with low likelihood of benefit. The ASH-ASPHO Choosing Wisely recommendations are as follows: (1) avoid routine preoperative hemostatic testing in an otherwise healthy child with no previous personal or family history of bleeding, (2) avoid platelet transfusion in asymptomatic children with a platelet count >10 × 103/μL unless an invasive procedure is planned, (3) avoid thrombophilia testing in children with venous access-associated thrombosis and no positive family history, (4) avoid packed red blood cells transfusion for asymptomatic children with iron deficiency anemia and no active bleeding, and (5) avoid routine administration of granulocyte colony-stimulating factor for prophylaxis of children with asymptomatic autoimmune neutropenia and no history of recurrent or severe infections. We recommend that health care providers carefully consider the anticipated risks and benefits of these identified tests and treatments before performing them.
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5
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Levy E, Kuperman A, Sela E, Kashkoush A, Miari AD, Hana RY, Freilich I, Bader A, Gruber M. Utility of the Pediatric Bleeding Questionnaire in Predicting Posttonsillectomy Bleeding. Otolaryngol Head Neck Surg 2021; 167:576-582. [PMID: 34813387 DOI: 10.1177/01945998211061474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Posttonsillectomy bleeding is a dreadful complication that may be life-threatening. Preoperative coagulation tests have not been shown to be effective in predicting this complication. The Pediatric Bleeding Questionnaire (PBQ) is a validated and sensitive tool in diagnosing children with abnormal hemostatic functions, and the objective of our study was to assess its utility as a preoperative screening tool for predicting posttonsillectomy bleeding. STUDY DESIGN Prospective single-blinded cohort study. SETTING Tertiary care hospital system. METHODS All children scheduled for tonsil surgery between 2017 and 2019 in the Galilee Medical Center were included. The PBQ was completed by the caregivers prior to surgery, and all children underwent coagulation tests. Each PBQ item is scored on a scale of -1 to 4, and the total score per candidate is based on summation of all items. RESULTS An overall 272 patients were included in the study with a mean age of 5.2 years; 57.7% were boys. The main finding was that in a multivariable model adjusted to age, a PBQ score of 2 is correlated with increased postoperative bleeding risk (odds ratio, 10.018 [95% CI, 1.20-82.74]; P = .046). The results of the PBQ demonstrated better predictive ability when compared with abnormal coagulation test results (odds ratio, 1.76 [95% CI, 0.63-4.80]; P = .279). Sex was not found to be significant (odds ratio, 1.45 [95% CI, 0.70-3.18]; P = .343). CONCLUSIONS This study demonstrated that a PBQ score ≥2 has a higher yield for detecting children at risk for posttonsil surgery bleeding as compared with coagulation studies.
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Affiliation(s)
- Einat Levy
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Amir Kuperman
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel.,Blood Coagulation Service and Pediatric Hematology Clinic, Galilee Medical Center, Nahariya, Israel
| | - Eyal Sela
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Adham Kashkoush
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel
| | - Abeer Dabbah Miari
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel
| | - Randa Yawer Hana
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel
| | - Ieva Freilich
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel
| | - Ahmad Bader
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Maayan Gruber
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
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6
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Johnson M, Pouratian N, Garrett M. An evidence-based approach to monitoring serum sodium in patients following non-pituitary cerebral neoplasm resection. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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7
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O'Brien SH, Badawy SM, Rotz SJ, Shah MD, Makarski J, Bercovitz RS, Hogan MJS, Luchtman-Jones L, Panepinto JA, Priola GM, Witmer CM, Wolfson JA, Yee M, Hicks LK. The ASH-ASPHO Choosing Wisely Campaign: 5 hematologic tests and treatments to question. Pediatr Blood Cancer 2021; 68:e28967. [PMID: 34047047 DOI: 10.1002/pbc.28967] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Choosing Wisely is a medical stewardship and quality-improvement initiative led by the American Board of Internal Medicine Foundation in collaboration with leading medical societies in the United States. The American Society of Hematology (ASH) has been an active participant in the Choosing Wisely project. In 2019, ASH and the American Society of Pediatric Hematology/Oncology (ASPHO) formed a joint task force to solicit, evaluate, and select items for a pediatric-focused Choosing Wisely list. By using an iterative process and an evidence-based method, the ASH-ASPHO Task Force identified 5 hematologic tests and treatments that health care providers and patients should question because they are not supported by evidence, and/or they involve risks of medical and financial costs with low likelihood of benefit. The ASH-ASPHO Choosing Wisely recommendations are as follows: (1) avoid routine preoperative hemostatic testing in an otherwise healthy child with no previous personal or family history of bleeding, (2) avoid platelet transfusion in asymptomatic children with a platelet count 10 × 103 /μL unless an invasive procedure is planned, (3) avoid thrombophilia testing in children with venous access-associated thrombosis and no positive family history, (4) avoid packed red blood cells transfusion for asymptomatic children with iron deficiency anemia and no active bleeding, and (5) avoid routine administration of granulocyte colony-stimulating factor for prophylaxis of children with asymptomatic autoimmune neutropenia and no history of recurrent or severe infections. We recommend that health care providers carefully consider the anticipated risks and benefits of these identified tests and treatments before performing them.
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Key Words
- COAGULATION/coagulation, COAGULATION/venous thromboembolism prophylaxis, diagnosis, and treatment, PLATELETS/disorders of platelets, PHAGOCYTES/neutrophils, RED CELLS/anemia
- clinical: nutritional
- iron, cobalamin, folate, anemia, autoimmune neutropenia, iron deficiency, platelets, pre-operative coagulation, thrombophilia
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Affiliation(s)
- Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, OH
| | - Sherif M Badawy
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, OH
| | - Mona D Shah
- Division of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Julie Makarski
- Independent consultant methodologist, Hamilton, ON, Canada
| | - Rachel S Bercovitz
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mary-Jane S Hogan
- Department of Pediatrics, Section of Hematology and Oncology, Yale School of Medicine, New Haven, CT
| | - Lori Luchtman-Jones
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.,Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Julie A Panepinto
- Division of Pediatric Hematology/Oncology, Children's Wisconsin/Medical College of Wisconsin, Milwaukee, WI
| | - Ginna M Priola
- Division of Pediatric Hematology/Oncology, Mission Children's Hospital, Asheville, NC
| | - Char M Witmer
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Julie A Wolfson
- Division of Pediatric Hematology-Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama, Birmingham, AL
| | - Marianne Yee
- Division of Hematology/Oncology, Department of Pediatrics, Emory University, Atlanta, GA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Lisa K Hicks
- Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON, Canada
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8
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Risk Factors for Postoperative Bleeding after Adenoidectomy. CHILDREN-BASEL 2021; 8:children8030242. [PMID: 33801025 PMCID: PMC8003889 DOI: 10.3390/children8030242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/08/2021] [Accepted: 03/19/2021] [Indexed: 01/23/2023]
Abstract
IMPORTANCE: Postoperative bleeding is a common and potentially life-threatening complication. Precise identification of risk factors in addition to the basic ones, such as coagulation parameters, is certainly very desirable. OBJECTIVE: The aim of this study was to identify other possible risk factors for bleeding after adenoidectomy in children. DESIGN: This observational prospective study enrolled children undergoing adenoidectomy from October 2019 to February 2020, then evaluated the influence of possible risk factors for bleeding. SETTING: Tertiary pediatric otorhinolaryngology center. PARTICIPANTS: A total of 288 children aged 0–18 years undergoing adenoidectomy for recurrent upper respiratory tract infections, recurrent acute otitis media, secretory otitis media, and obstructive sleep apnea syndrome. MAIN OUTCOMES AND MEASURES: Increased blood pressure and time of surgery were identified as risk factors for bleeding after adenoidectomy. RESULTS: Elevated systolic (p = 0.046), diastolic (p = 0.012), and mean arterial blood pressure (p = 0.007) (Mann–Whitney U test) as adjusted for age-specific distributions and with corrections for height and weight, as well as time length of surgery (p < 0.001) (Fisher’s exact test) were revealed as statistically significant risk factors for postoperative bleeding. Atmospheric pressure, surgeon’s level of experiences, chronic inflammatory content in adenoid vegetation (AV), size of AV, recidivism of AV, recurrent infections of the upper respiratory tract, type of anesthesia, long-term using of drugs, and positive coagulation questionnaire or pathology in standard coagulation tests were not found to be risk factors for bleeding after adenoidectomy. CONCLUSIONS AND RELEVANCE: In this prospective study within a well-defined population of children, we evaluated increased blood pressure and time of surgery as risk factors for bleeding after adenoidectomy. These data bring new information that complements current knowledge in this field.
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9
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Scharf RE. Hemostasis Laboratory Diagnostics: Characteristics, Communication Issues, and Current Challenges Resulting from Centralization of Laboratory Medicine. Hamostaseologie 2020; 40:403-412. [DOI: 10.1055/a-1249-8767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
AbstractLaboratory diagnostics of patients with bleeding and thrombotic disorders can be a delicate task, which requires special skills and expertise. In this article, characteristic features of hemostasis testing are reviewed, including staged protocols and synoptic assessment of the patient history, clinical symptoms, and laboratory findings. Despite major progress in the diagnostic and therapeutic management, centralized testing of hemostasis can be associated with substantial challenges, resulting from the current dissociation between the clinical and laboratory world. To address some of these challenges, possible solutions are discussed, including adaptation of an established working paradigm.
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Affiliation(s)
- Rüdiger E. Scharf
- Program in Cellular and Molecular Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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10
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Stupp F, Grossi AS, Lindemann J. [Diagnostics and treatment of adenotonsillar hyperplasia in children]. HNO 2020; 68:215-226. [PMID: 32095844 DOI: 10.1007/s00106-020-00826-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Adenoidectomy, paracentesis, and tonsillar interventions are the most common operations in childhood. Hypertrophy of the lymphatic tissue of Waldeyer's ring can lead to individually distinct, acute, and chronic symptoms as well as anatomical and functional changes. When presented with affected children in otolaryngologic practice, the combination of parental interview, questionnaire-based screening for obstructive sleep apnea syndrome, and physical examination including ear microscopy, inspection of the oropharynx and, if necessary, the nasopharynx, has proven its worth. Audiometric diagnosis for detection of tympanic effusion should be mandatory. The treatment of choice is adenoidectomy, if necessary plus tonsillotomy and paracentesis with a tympanic tube insert. However, the indication remains controversial, as the effectiveness of the interventions seems to depend on the preoperative severity of symptoms. With a correct indication, effective symptom reduction, improvement in quality of life, and high parent satisfaction can be expected.
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Affiliation(s)
- F Stupp
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Ulm, Frauensteige 12, 89075, Ulm, Deutschland.
| | - A-S Grossi
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Ulm, Frauensteige 12, 89075, Ulm, Deutschland
| | - J Lindemann
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Universitätsklinikum Ulm, Frauensteige 12, 89075, Ulm, Deutschland
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11
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Archer NM, Forbes PW, Dargie J, Manganella J, Licameli GR, Kenna MA, Brugnara C. Association of Blood Type With Postsurgical Mucosal Bleeding in Pediatric Patients Undergoing Tonsillectomy With or Without Adenoidectomy. JAMA Netw Open 2020; 3:e201804. [PMID: 32232448 PMCID: PMC7109594 DOI: 10.1001/jamanetworkopen.2020.1804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Blood type (BT) O has been identified as a risk factor for bleeding complications, while non-O BTs may increase risk for thromboembolic events. Limited data are available in children undergoing tonsillectomy with or without adenoidectomy. OBJECTIVE To determine whether BT O is associated with hemorrhage after tonsillectomy with or without adenoidectomy. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of patients younger than 22 years who underwent tonsillectomy with or without adenoidectomy at a single institution between January 1, 2008, and August 7, 2017. Statistical analysis was performed from November 2017 to January 2019. MAIN OUTCOMES AND MEASURES Prevalence of hemorrhage following surgery was defined as any bleeding requiring cauterization up to 1 month after the procedure. Data on sex, age, von Willebrand disease (VWD) status, BT, white blood cell counts, and platelet counts closest to date of surgery were collected from an electronic medical record system, and the association of these factors with hemorrhage following surgery was investigated. RESULTS A total of 14 951 pediatric patients (median [range] age, 5.6 [0.8-21.9] years; 6956 [46.5%] female) underwent tonsillectomy with or without adenoidectomy. Prevalence of hemorrhage following the procedure was 3.9% (578 patients) for the full cohort and 2.8% (362 of 13 065) for patients with no BT identified or preprocedure VWD panel results at baseline. Children who had a BT identified and/or a VWD panel before surgery had higher bleeding rates (BT only, 14.9% [172 of 1156]; preprocedure VWD panel only, 4.6% [28 of 607]; and BT and preprocedure VWD panel, 13.0% [16 of 123]), all of which were significantly different from the baseline bleeding rate (P < .001). While the bleeding rates in children with BT O were not statistically different from those with non-O BT (14.8% and 14.6%, respectively; P > .99), mean von Willebrand factor values were statistically different (mean [SD] von Willebrand factor antigen level in O group, 86.9 [42.4] IU/dL in the O group vs 118.0 [53.8] IU/dL in the non-O group; P = .002; and mean [SD] von Willebrand factor ristocetin-cofactor in the O group, 72.2 [44.3] IU/dL vs 112.6 [68.0] IU/dL in the non-O group; P = .001). In addition, children older than 12 years had increased bleeding rates in the full cohort (8.3% vs 3.2%), in the testing-naive cohort (6.5% vs 2.3%), and in those with a preprocedure VWD panel only (13.5% vs 3.1%) compared with children aged 12 years or younger. CONCLUSIONS AND RELEVANCE Type O blood was not a risk factor associated with hemorrhage after tonsillectomy with or without adenoidectomy despite lower baseline von Willebrand factor antigen and von Willebrand factor ristocetin-cofactor values in children with BT O vs those with non-O BT in our study cohort. No association was found between VWD status and bleeding, and there was no difference in VWD panel values in those who experienced hemorrhage vs those who did not within BT groups. Further studies elucidating the utility of von Willebrand factor values for children undergoing tonsillectomy with or without adenoidectomy are needed.
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Affiliation(s)
- Natasha M. Archer
- Pediatric Hematology, Oncology Dana-Farber, Children’s Hospital Blood Disorders and Cancer Center, Boston, Massachusetts
| | - Peter W. Forbes
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts
| | - Jenna Dargie
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Juliana Manganella
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Greg R. Licameli
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Margaret A. Kenna
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Carlo Brugnara
- Laboratory Medicine, Boston Children's Hospital, Boston, Massachusetts
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12
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Abt NB, Sethi RK, Puram SV, Varvares MA. Preoperative laboratory data are associated with complications and surgical site infection in composite head and neck surgical resections. Am J Otolaryngol 2018; 39:261-265. [PMID: 29398185 DOI: 10.1016/j.amjoto.2018.01.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 01/19/2018] [Accepted: 01/28/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVES 1) Describe normal/abnormal preoperative laboratory testing incidence in head and neck (H&N) composite resections and 2) determine complication, surgical site infection (SSI), and transfusion predictors by laboratory test. METHODS The 2006 to 2013 NSQIP databases were queried for H&N composite resections. Laboratory data was categorized within, under, or above the normal reference range according to NSQIP definitions. Overall complications and SSI were analyzed with multivariable logistic regression analysis. RESULTS From 2006 to 2013, there were 1193H&N composite resections, of which 1135 (95.1%) underwent ≥1 preoperative laboratory test. Complete blood counts were obtained in 92.3%, basic metabolic panels in 90.7%, coagulation studies in 56.2%, and liver function tests (LFTs) in 52.6%. Low sodium was found in 11.5%, increasing complication odds by 2.30 (p = 0.005). High AST comprised 10.0% and increased complication odds (OR = 2.93, p = 0.012). Additionally, 9.2% had a high white blood cell (WBC) count and 3.5% had high platelets, increasing complications by 1.92 (p = 0.030) and 3.13 (p = 0.015), respectively. BUN, creatinine, total bilirubin, albumin, alkaline phosphatase, INR, PT, and aPTT abnormal values did not affect postoperative complications. Increased SSI odds were appreciated with low sodium (OR: 2.83, p = 0.002), high AST (OR: 6.85, p < 0.001), and high alkaline phosphatase (OR: 5.46, p = 0.007). Importantly, INR had no effect on transfusion rates. High PT, aPTT, or low platelets did not change transfusion odds. CONCLUSION Inflammatory markers are associated with complications but not SSI. High LFTs and low sodium are associated with complications and SSI. Coagulopathies did not increase transfusion rates. These findings identify laboratory studies to focus on during H&N resection preoperative assessments.
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Affiliation(s)
- Nicholas B Abt
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA.
| | - Rosh K Sethi
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Sidharth V Puram
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Mark A Varvares
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
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Shif Y, Kung JW, McMahon CJ, Mhuircheartaigh JN, Lin YC, Anderson ME, Wu JS. Safety of omitting routine bleeding tests prior to image-guided musculoskeletal core needle biopsy. Skeletal Radiol 2018; 47:215-221. [PMID: 28983679 DOI: 10.1007/s00256-017-2784-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/21/2017] [Accepted: 09/24/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the safety of withholding preprocedure international normalized ratio (INR) and platelet testing in patients undergoing musculoskeletal (MSK) core needle biopsy (CNB). MATERIAL AND METHODS Initially, a retrospective review of 1,162 consecutive patients undergoing MSK CNB with preprocedural INR and platelet testing was performed. Clinical (age, gender, bleeding disorder, liver disease, anticoagulation use, INR > 2, platelet count <50,000/ul) and biopsy factors (imaging modality, lesion type, biopsy needle gauge, number biopsy samples) were tested for association with bleeding complications. During the second phase, an additional 188 biopsies performed without preprocedural coagulation testing were studied. Categorical variables were compared using Chi-squared or Fisher's exact tests, continuous variables with a student t-test. Multivariate analysis was performed using logistic regression. RESULTS In the first phase, there was a complication rate of 2.6%, 30/1162. Of the 11 clinical and biopsy factors, soft tissue lesions (p = 0.029) and lesions biopsied under ultrasound (p = 0.048) had a higher rate of bleeding than bone lesions or lesions biopsied under CT, respectively. Only three patients had an INR >2, 0.3% (3/1162) and only four patients had platelet count <50,000/ul, 0.3% (4/1162). No patient with a bleeding complication had an abnormal preprocedure bleeding test. In the second phase, there was a bleeding complication rate of 1.1% (2/188). CONCLUSION Bleeding complications from MSK biopsy are low, even when preprocedure coagulation testing is omitted.
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Affiliation(s)
- Yuri Shif
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Justin W Kung
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Colm J McMahon
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | | | - Yu Ching Lin
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA.,Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Keelung and Chang Gung University, 5 Fu-Shin Street Kueishan, Taoyuan, 333, Taiwan
| | - Megan E Anderson
- Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Jim S Wu
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA.
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Beloeil H, Ruchard D, Drewniak N, Molliex S. Overuse of preoperative laboratory coagulation testing and ABO blood typing: a French national study. Br J Anaesth 2017; 119:1186-1193. [DOI: 10.1093/bja/aex268] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2017] [Indexed: 11/13/2022] Open
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Ge Z, Xia Z, Yuefang W, Zhigui M. Necessity of preoperative activated partial thromboplastin time test as a predictor for surgical hemorrhage in obstetric and gynecological patients in China. Clin Chim Acta 2017; 473:21-25. [PMID: 28807540 DOI: 10.1016/j.cca.2017.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 06/26/2017] [Accepted: 08/10/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND On an international scale, the necessity of preoperative coagulation screen remains controversial, yet in China, coagulation screen is still a routine test before surgery required by the Ministry of Health of China. METHODS A retrospective review of 26,807 patients >18y presenting with problems related to the areas of gynecology and obstetrics from March 2013 to July 2015 was performed, and the rate of major bleeding and the amount of blood lost during surgery were compared among groups of patients grouped according to the values of preoperative APTT, the departments the patients belonged to, or the measures for intervention. RESULTS Groups with increased APTT had higher rates of major bleeding (9.80% & 26.14% vs 2.77%, P<0.001) and more blood loss (862.9 and 1455.6ml vs 194.0ml, P<0.001). And the same conclusion could be induced in both the obstetric and gynecological patients when they were taken into account separately. For obstetric patients, once those with high bleeding risks, e.g., placental abruption, placental implantation, or preoperative massive hemorrhage were excluded, groups with increased APTT would no longer demonstrated the higher rate of major bleeding (0.91% & 2.38% vs 0%, P=0.409 & 0.833) and would even have a lower amount of blood loss (202.76 and 228.09ml vs 322.13ml, P=0.003 and 0.027). In increased APTT patients without bleeding or bleeding tendency, FFP intervention would not make a difference in the rate of major bleeding (7.69% vs 8.37%, P=0.203) and the amount of blood loss (271.35ml vs 306.63, P=0.865). CONCLUSION For Chinese patients from the Obstetrics and Gynecology Departments, APTT is a good screen test to predict surgical hemorrhage.
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Affiliation(s)
- Zhang Ge
- Department of Pediatrics, West China Second University Hospital, Sichuan University No. 20, Section 3, Ren Min Nan Lu, Chengdu, Sichuan 610041, PR China
| | - Zhang Xia
- Department of Pediatrics, West China Second University Hospital, Sichuan University No. 20, Section 3, Ren Min Nan Lu, Chengdu, Sichuan 610041, PR China
| | - Wang Yuefang
- Department of Pediatrics, West China Second University Hospital, Sichuan University No. 20, Section 3, Ren Min Nan Lu, Chengdu, Sichuan 610041, PR China
| | - Ma Zhigui
- Department of Pediatrics, West China Second University Hospital, Sichuan University No. 20, Section 3, Ren Min Nan Lu, Chengdu, Sichuan 610041, PR China.
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Woll C, Smith PB, Fox JW. Epidemiology of preoperative hematologic assessment of children cared for in a pediatric emergency department. Am J Emerg Med 2017; 36:33-37. [PMID: 28669694 DOI: 10.1016/j.ajem.2017.06.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/16/2017] [Accepted: 06/27/2017] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE To assess frequency of preoperative hematologic testing in a tertiary care pediatric emergency department (PED) and how often these values predict clinical outcome or change management decisions. METHODS Single-center retrospective cohort study in a tertiary-care children's hospital PED. Patients 0-18years old, presenting between July 1, 2009-July 1, 2011, ultimately undergoing a surgical procedure within 48h of presentation were included. Patients were defined as having "preoperative" hematologic assessment if these studies were performed solely because the child was going to the operative suite. Patients who met trauma team activation criteria, underwent neurosurgical procedures, or had laboratory studies performed prior to PED arrival were excluded. The primary outcome was the prevalence of preoperative laboratory assessment. RESULTS 528 children were included, of whom 301 (57%) underwent preoperative hematologic laboratory evaluations. Of these 301 patients, 115 (38%) had abnormal hematologic parameters, and only 3 (1%) of these patients had their perioperative management changed. One additional child had intraoperative bleeding that required blood products but did not undergo preoperative hematologic assessment. All four children had medical histories that would have identified their risk for perioperative bleeding events. CONCLUSION Preoperative hematologic laboratory assessment occurs frequently in children initially cared for in a tertiary care pediatric emergency department who subsequently undergo operative interventions. Although age-based abnormal hematologic values are often found, rarely are these abnormalities clinically significant. This study suggests that children cared for in a PED without a history concerning for an increased risk of perioperative bleeding does not require preoperative hematologic assessment.
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Affiliation(s)
- Christopher Woll
- Department of Pediatrics, Duke University School of Medicine, 3201 Erwin Road, Durham, NC, USA, 27710.
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, 3201 Erwin Road, Durham, NC, USA, 27710.
| | - James Walter Fox
- Department of Pediatrics, Duke University School of Medicine, 3201 Erwin Road, Durham, NC, USA, 27710.
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Lee AJ, Kim SG. Utility of preoperative in vitro platelet function tests for predicting bleeding risk in patients undergoing functional endoscopic sinus surgery. J Blood Med 2016; 7:235-238. [PMID: 27799837 PMCID: PMC5085293 DOI: 10.2147/jbm.s117669] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background It is necessary to predict the bleeding risk in patients undergoing functional endoscopic sinus surgery (FESS). To evaluate the adequacy of primary hemostasis, preoperative hemostatic screening tests are used. In the present study, we determined whether there is a positive correlation between prolonged closure time (CT) with collagen/epinephrine (CT-epi), prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (aPTT) and bleeding during FESS. Patients and methods We reviewed the medical records of 90 patients without bleeding histories who had undergone FESS from March 2013 to June 2014. More than 200 mL of blood loss was defined as moderate bleeding during surgery. With respect to bleeding during surgery, we determined the sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of CT-epi, PT, INR and aPTT. Results Of the 90 patients, 17 (18.9%) patients had preoperative prolonged CT values and three (17.6%) patients had bleeding. In comparison, five (6.8%) of the 73 (81.1%) patients who had undergone FESS with preoperative normal PFA values experienced bleeding (P=0.171). On the other hand, patients with prolonged PT values (2, 2.2%), prolonged INR values (3, 3.3%) or prolonged PTT values (1, 1.1%) had no bleeding episode. Preoperative CT had low sensitivity (44.4%) and PPV (23.5%). Conclusion During preoperative period, the hemostatic screening may not be helpful to detect the bleeding tendency in adult patients undergoing FESS. Routine measurement of CT-epi, PT, INR and aPTT for preoperative screening may not be recommended for FESS patients.
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Affiliation(s)
- A-Jin Lee
- Department of Laboratory Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Sang-Gyung Kim
- Department of Laboratory Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
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Silberstein E, Shir-Az O, Reuveni H, Krieger Y, Shoham Y, Silberstein T, Bogdanov-Berezovsky A. Defensive Medicine Among Plastic and Aesthetic Surgeons in Israel. Aesthet Surg J 2016; 36:NP299-NP304. [PMID: 27277272 DOI: 10.1093/asj/sjw094] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2016] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Defensive medicine (DM) includes medical practices that are aimed at avoiding liability rather than benefitting the patient. DM has not been well characterized among plastic surgeons. OBJECTIVES The authors examined the extents of intended and unintended DM among members of the Israeli Society of Plastic and Aesthetic Surgery (ISPAS) and identified risk factors for DM. METHODS A total of 108 ISPAS members were asked to complete a questionnaire that addressed physician attitudes toward DM and intended or unintended DM practices. RESULTS Seventy-eight surgeons (72.2% response rate) returned the questionnaire, although some questionnaires were returned incomplete. Forty respondents acknowledged practicing DM (ie, DM group), and 33 respondents did not (ie, non-DM group). There were no between-group differences in gender, years of practice, or number of previous litigations. Thirty-one percent of respondents in the DM group indicated that they avoid certain surgical procedures, compared with 6% of respondents in the non-DM group (P = .008). In private practice, 66.2% of respondents stated that they obtain written informed consent twice before surgery, and 100% request preoperative blood-coagulation testing. In contrast, 40% and 74% of respondents in public practice, respectively, acknowledged these behaviors (for consent, P = .027; for testing, P = .0059). Sixty-three percent of respondents prescribe antibiotics for more than 24 hours postoperatively, and this practice was slightly more common in the DM group (34 prescribe antibiotics vs 21 in the non-DM group; P = .079). CONCLUSIONS DM is highly integrated into the daily medical practices of plastic surgeons in Israel.
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Affiliation(s)
- Eldad Silberstein
- Dr Eldad Silberstein is an Attending Plastic Surgeon, Department of Plastic and Reconstructive Surgery, and Chief of the Head and Neck Reconstruction Unit, Soroka University Medical Center, Beer Sheva, Israel. Mr Shir-Az is a medical student, Faculty of Health Sciences, Ben-Gurion University of the Negev. Prof Reuveni is a Faculty Member, Faculty of Health Sciences. Drs Krieger and Shoham are Attending Plastic Surgeons, Department of Plastic and Reconstructive Surgery, Soroka University Medical Center. Prof Silberstein is a Faculty Member, Faculty of Health Sciences, Ben-Gurion University of the Negev. Dr Bogdanov-Berezovsky is Chief of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Soroka University Medical Center
| | - Ofir Shir-Az
- Dr Eldad Silberstein is an Attending Plastic Surgeon, Department of Plastic and Reconstructive Surgery, and Chief of the Head and Neck Reconstruction Unit, Soroka University Medical Center, Beer Sheva, Israel. Mr Shir-Az is a medical student, Faculty of Health Sciences, Ben-Gurion University of the Negev. Prof Reuveni is a Faculty Member, Faculty of Health Sciences. Drs Krieger and Shoham are Attending Plastic Surgeons, Department of Plastic and Reconstructive Surgery, Soroka University Medical Center. Prof Silberstein is a Faculty Member, Faculty of Health Sciences, Ben-Gurion University of the Negev. Dr Bogdanov-Berezovsky is Chief of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Soroka University Medical Center
| | - Haim Reuveni
- Dr Eldad Silberstein is an Attending Plastic Surgeon, Department of Plastic and Reconstructive Surgery, and Chief of the Head and Neck Reconstruction Unit, Soroka University Medical Center, Beer Sheva, Israel. Mr Shir-Az is a medical student, Faculty of Health Sciences, Ben-Gurion University of the Negev. Prof Reuveni is a Faculty Member, Faculty of Health Sciences. Drs Krieger and Shoham are Attending Plastic Surgeons, Department of Plastic and Reconstructive Surgery, Soroka University Medical Center. Prof Silberstein is a Faculty Member, Faculty of Health Sciences, Ben-Gurion University of the Negev. Dr Bogdanov-Berezovsky is Chief of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Soroka University Medical Center
| | - Yuval Krieger
- Dr Eldad Silberstein is an Attending Plastic Surgeon, Department of Plastic and Reconstructive Surgery, and Chief of the Head and Neck Reconstruction Unit, Soroka University Medical Center, Beer Sheva, Israel. Mr Shir-Az is a medical student, Faculty of Health Sciences, Ben-Gurion University of the Negev. Prof Reuveni is a Faculty Member, Faculty of Health Sciences. Drs Krieger and Shoham are Attending Plastic Surgeons, Department of Plastic and Reconstructive Surgery, Soroka University Medical Center. Prof Silberstein is a Faculty Member, Faculty of Health Sciences, Ben-Gurion University of the Negev. Dr Bogdanov-Berezovsky is Chief of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Soroka University Medical Center
| | - Yaron Shoham
- Dr Eldad Silberstein is an Attending Plastic Surgeon, Department of Plastic and Reconstructive Surgery, and Chief of the Head and Neck Reconstruction Unit, Soroka University Medical Center, Beer Sheva, Israel. Mr Shir-Az is a medical student, Faculty of Health Sciences, Ben-Gurion University of the Negev. Prof Reuveni is a Faculty Member, Faculty of Health Sciences. Drs Krieger and Shoham are Attending Plastic Surgeons, Department of Plastic and Reconstructive Surgery, Soroka University Medical Center. Prof Silberstein is a Faculty Member, Faculty of Health Sciences, Ben-Gurion University of the Negev. Dr Bogdanov-Berezovsky is Chief of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Soroka University Medical Center
| | - Tali Silberstein
- Dr Eldad Silberstein is an Attending Plastic Surgeon, Department of Plastic and Reconstructive Surgery, and Chief of the Head and Neck Reconstruction Unit, Soroka University Medical Center, Beer Sheva, Israel. Mr Shir-Az is a medical student, Faculty of Health Sciences, Ben-Gurion University of the Negev. Prof Reuveni is a Faculty Member, Faculty of Health Sciences. Drs Krieger and Shoham are Attending Plastic Surgeons, Department of Plastic and Reconstructive Surgery, Soroka University Medical Center. Prof Silberstein is a Faculty Member, Faculty of Health Sciences, Ben-Gurion University of the Negev. Dr Bogdanov-Berezovsky is Chief of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Soroka University Medical Center
| | - Alexander Bogdanov-Berezovsky
- Dr Eldad Silberstein is an Attending Plastic Surgeon, Department of Plastic and Reconstructive Surgery, and Chief of the Head and Neck Reconstruction Unit, Soroka University Medical Center, Beer Sheva, Israel. Mr Shir-Az is a medical student, Faculty of Health Sciences, Ben-Gurion University of the Negev. Prof Reuveni is a Faculty Member, Faculty of Health Sciences. Drs Krieger and Shoham are Attending Plastic Surgeons, Department of Plastic and Reconstructive Surgery, Soroka University Medical Center. Prof Silberstein is a Faculty Member, Faculty of Health Sciences, Ben-Gurion University of the Negev. Dr Bogdanov-Berezovsky is Chief of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Soroka University Medical Center
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Jo JH, Son DW, Jeon IS. Significance of Lupus Anticoagulant in Children with Prolonged Prothrombin Time/activated Partial Thromboplastin Time. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2016. [DOI: 10.15264/cpho.2016.23.1.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jeong Hyun Jo
- Department of Pediatrics, Graduate School of Medicine, Gachon University, Incheon, Korea
| | - Dong Woo Son
- Department of Pediatrics, Graduate School of Medicine, Gachon University, Incheon, Korea
| | - In-Sang Jeon
- Department of Pediatrics, Graduate School of Medicine, Gachon University, Incheon, Korea
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Adekwu A, Adoga AS, Gav TA. Our experience with pre-operative haemostatic assessment of paediatric patients undergoing adenotonsillectomy at Federal Medical Centre, Makurdi. Afr J Paediatr Surg 2016; 13:69-72. [PMID: 27251655 PMCID: PMC4955445 DOI: 10.4103/0189-6725.182559] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In 2-4% of all patients requiring adenoidectomy, tonsillectomy or adenotonsillectomy, pre-operative screening tests for coagulation disorders are indicated to detect surgical bleeding complications. However, because of cost effect on the patients, the usefulness of these tests is being challenged. We therefore highlight our experience in paediatric patients undergoing adenoidectomy, tonsillectomy or both in our centre. PATIENTS AND METHODS This is a 3½-year analysis of the data of 165 paediatric patients who had adenoidectomy, tonsillectomy or both over the study period. The data collected included age, sex, procedure done and detailed clinical bleeding history. RESULTS A total of 165 children had either adenoidectomy or tonsillectomy, or both. There were 76 males and 89 females giving a male to female ratio of 1:1.2. Their ages ranged from 10 months to 18 years. Eighty-five (51.5%) patients had adenotonsillectomy, 48 (29.1%) and 32 (19.4%) had only tonsillectomies and adenoidectomies, respectively. Only 11 (6.7%) families volunteered the history of either prolonged bleeding with minor injury on the skin or occasional slight nose bleeding. Six (3.6%) patients including 3 of the children with positive family history had posttonsillectomy bleed, out of which 4 (66.7%) were moderate whereas the remaining 2 (33.3%) were severe bleeding, which was not statistically significant (P = 0.041). The two cases of severe bleeding had fresh whole blood transfused whereas the rest that had no bleeding issues were discharged home 48 h postoperatively. CONCLUSION Our experience in this study suggests that detailed bleeding history is necessary as well as pre-operative haemostatic assessment, if available and affordable for paediatric patients undergoing adenotonsillectomy.
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Affiliation(s)
- Amali Adekwu
- Department of Surgery, College of Health Sciences, Benue State University, Makurdi, Nigeria
| | - Agida Samuel Adoga
- Department of Otorhinolaryngology Head and Neck Surgery, College of Medical Sciences, University of Jos, Jos, Nigeria
| | - Terna Ambrose Gav
- Department of Surgery, Benue State University Teaching Hospital, Makurdi, Nigeria
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Thiele T, Kaftan H, Hosemann W, Greinacher A. Hemostatic management of patients undergoing ear-nose-throat surgery. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 14:Doc07. [PMID: 26770281 PMCID: PMC4702056 DOI: 10.3205/cto000122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Perioperative hemostatic management is increasingly important in the field of otolaryngology. This review summarizes the key elements of perioperative risk stratification, thromboprophylaxis and therapies for bridging of antithrombotic treatment. It gives practical advice based on the current literature with focus on patients undergoing ENT surgery.
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Affiliation(s)
- Thomas Thiele
- Institute for Immunology and Transfusion Medicine, Section of Transfusion Medicine, University Medicine of Greifswald, Germany
| | - Holger Kaftan
- Department of Otolaryngology, Head & Neck Surgery, University Medicine of Greifswald, Germany
| | - Werner Hosemann
- Department of Otolaryngology, Head & Neck Surgery, University Medicine of Greifswald, Germany
| | - Andreas Greinacher
- Institute for Immunology and Transfusion Medicine, Section of Transfusion Medicine, University Medicine of Greifswald, Germany
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Park JH, Yoo KY, Jung HJ, Park JE. The Benefit for Preoperative Coagulation Screening Test in Children. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2015. [DOI: 10.15264/cpho.2015.22.2.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ji Hye Park
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| | | | - Hyun Ju Jung
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| | - Jun Eun Park
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
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Farach SM, Danielson PD, Chandler NM. Preprocedural Coagulation Studies in Pediatric Patients Undergoing Percutaneous Intervention for Appendiceal Abscesses. Am Surg 2015. [DOI: 10.1177/000313481508100917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The literature reports poor correlation between coagulation screening and prediction of bleeding risk in children. Our aim is to determine whether there is a role for coagulation studies in children undergoing percutaneous intervention for appendiceal abscesses. A retrospective review of 1805 patients presenting with a diagnosis of appendicitis from September 2008 to September 2013 was performed. Patients presenting with appendiceal abscess who underwent percutaneous intervention were selected for further review (n = 131). A total of 76 patients (58%) had normal coagulation studies, whereas 55 (42%) had elevated values. An international normalized ratio ≥ 1.3 was found in 26 patients. Patients with normal coagulation values had an incidence of bleeding of 1.3 per cent. In the abnormal coagulation group, 8 patients received fresh frozen plasma before intervention, whereas 47 did not. There was one hematoma noted in each group with an incidence of bleeding of 3.6 per cent. The overall incidence of hematoma was 2.3 per cent with no significant difference in bleeding risk between the normal and abnormal coagulation groups. In conclusion, although many patients are found to have elevated coagulation studies, most do not have bleeding complications after intervention. There is poor correlation between coagulation screening and postprocedural outcomes evidenced by the low risk of bleeding.
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Affiliation(s)
- Sandra M. Farach
- Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, Saint Petersburg, Florida
| | - Paul D. Danielson
- Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, Saint Petersburg, Florida
| | - Nicole M. Chandler
- Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, Saint Petersburg, Florida
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Pan YN, Liang XX, Niu LY, Wang YN, Tong X, Hua HM, Zheng J, Meng DY, Liu XQ. Comparative studies of pharmacokinetics and anticoagulatory effect in rats after oral administration of Frankincense and its processed products. JOURNAL OF ETHNOPHARMACOLOGY 2015; 172:118-123. [PMID: 26117531 DOI: 10.1016/j.jep.2015.06.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 05/21/2015] [Accepted: 06/16/2015] [Indexed: 06/04/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Frankincense (FRA), Ruxiang, is the resin of Boswellia carterii Birdw and Boswellia bhaw-dajiana Birdw which has been used for centuries as formulas to improve the circulation and to relieve pain against carbuncles. Stir-fried Frankincense (SFF) and vinegar processed Frankincense (VPF) are two major processed Frankincense, and the processing procedures reportedly enhance the curative efficacy or reduce the side effects of FRA. This paper describes the comparisons in plasma pharmacokinetic behaviors of 11-keto-β-boswellic acid (KBA) and 3-acetyl-11-keto-β-boswellic acid (AKBA) in FRA and its processed products, and their effects on coagulation factors and blood clotting tetrachoric, using an acute cold blood-stasis animal model after oral administration of FRA, SFF, and VPF. MATERIALS AND METHODS For pharmacokinetic study, Sprague-Dawley (SD) rats were randomly divided into three groups, including group FRA, group SFF and group VPF. And the plasma samples were analyzed by HPLC. For study of anticoagulatory effect, SD rats were randomly divided into six groups, including control, acute cold blood-stasis model, Fu-fang-dan-shen tablet- (0.75g/kg), FRA-, SFF-, and VPF-treated (2.7g/kg) groups, respectively. The serum contents of thrombin-antithrombin complex (TAT), D-dimer (D-D), and prostacyclin (PGI2) of each group were measured by ELISA. The values of prothrombin time (PT), thrombin time (TT), activated partial thromboplastin time (APTT) and fibrinogen (FIB) were also assessed by hematology analyzer. RESULTS Significantly increased levels of Cmax, AUC, T1/2, and MRT were found in rats treated with the processed products. In addition, decreased levels of D-D and TAT and increased contents of PGI2 were observed in rats given FRA and its processed products, compared with that of the model group. Moreover, VPF improved anticoagulation more than SFF in the animals. CONCLUSIONS The observed improvement of anticoagulation by processed FRA may result from the increased absorption and bioavailability of triterpenoids.
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Affiliation(s)
- Ying-Ni Pan
- School of Traditional Chinese Materia Medica, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang, China
| | - Xiao-Xu Liang
- School of Traditional Chinese Materia Medica, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang, China
| | - Li-Ying Niu
- School of Traditional Chinese Materia Medica, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang, China
| | - Yan-Nian Wang
- School of Traditional Chinese Materia Medica, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang, China
| | - Xin Tong
- School of Traditional Chinese Materia Medica, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang, China
| | - Hui-Ming Hua
- School of Traditional Chinese Materia Medica, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang, China
| | - Jiang Zheng
- School of Pharmacy, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang, China; Center for Developmental Therapeutics, Seattle Children's Research Institute, Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98102, USA
| | - Dong-Ya Meng
- Clinical Laboratory, Shenyang Military Region General Hospital, No. 83, Wenhua Road, Shenyang, China
| | - Xiao-Qiu Liu
- School of Traditional Chinese Materia Medica, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang, China.
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Prothrombin Time and Activated Partial Thromboplastin Time Testing: A Comparative Effectiveness Study in a Million-Patient Sample. PLoS One 2015; 10:e0133317. [PMID: 26261992 PMCID: PMC4532488 DOI: 10.1371/journal.pone.0133317] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 06/25/2015] [Indexed: 12/18/2022] Open
Abstract
Background A substantial fraction of all American healthcare expenditures are potentially wasted, and practices that are not evidence-based could contribute to such waste. We sought to characterize whether Prothrombin Time (PT) and activated Partial Thromboplastin Time (aPTT) tests of preoperative patients are used in a way unsupported by evidence and potentially wasteful. Methods and Findings We evaluated prospectively-collected patient data from 19 major teaching hospitals and 8 hospital-affiliated surgical centers in 7 states (Delaware, Florida, Maryland, Massachusetts, New Jersey, New York, Pennsylvania) and the District of Columbia. A total of 1,053,472 consecutive patients represented every patient admitted for elective surgery from 2009 to 2012 at all 27 settings. A subset of 682,049 patients (64.7%) had one or both tests done and history and physical (H&P) records available for analysis. Unnecessary tests for bleeding risk were defined as: PT tests done on patients with no history of abnormal bleeding, warfarin therapy, vitamin K-dependent clotting factor deficiency, or liver disease; or aPTT tests done on patients with no history of heparin treatment, hemophilia, lupus anticoagulant antibodies, or von Willebrand disease. We assessed the proportion of patients who received PT or aPTT tests who lacked evidence-based reasons for testing. Conclusions This study sought to bring the availability of big data together with applied comparative effectiveness research. Among preoperative patients, 26.2% received PT tests, and 94.3% of tests were unnecessary, given the absence of findings on H&P. Similarly, 23.3% of preoperative patients received aPTT tests, of which 99.9% were unnecessary. Among patients with no H&P findings suggestive of bleeding risk, 6.6% of PT tests and 7.1% of aPTT tests were either a false positive or a true positive (i.e. indicative of a previously-undiagnosed potential bleeding risk). Both PT and aPTT, designed as diagnostic tests, are apparently used as screening tests. Use of unnecessary screening tests raises concerns for the costs of such testing and the consequences of false positive results.
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Li R, Swaelens C, Vandermijnsbrugge F, Cantinieaux B. Applying a direct aPTT ratio (PlatelinLS/ActinFS) permits to identify rapidly and reliably a bleeding-related factor deficiency or a lupus anticoagulant sequential to an isolated prolongation of aPTT in paediatric pre-operative screening. Eur J Haematol 2015; 96:578-85. [DOI: 10.1111/ejh.12634] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2015] [Indexed: 01/01/2023]
Affiliation(s)
- Rong Li
- Laboratory of Haematology; iris-Lab; Institut Jules Bordet and Saint Pierre University Hospital; Université Libre de Bruxelles; Brussels Belgium
| | - Caroline Swaelens
- Laboratory of Haematology; iris-Lab; Institut Jules Bordet and Saint Pierre University Hospital; Université Libre de Bruxelles; Brussels Belgium
| | - Francine Vandermijnsbrugge
- Laboratory of Haematology; iris-Lab; Institut Jules Bordet and Saint Pierre University Hospital; Université Libre de Bruxelles; Brussels Belgium
| | - Brigitte Cantinieaux
- Laboratory of Haematology; iris-Lab; Institut Jules Bordet and Saint Pierre University Hospital; Université Libre de Bruxelles; Brussels Belgium
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Becke K. Anesthesia for ORL surgery in children. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 13:Doc04. [PMID: 25587364 PMCID: PMC4273165 DOI: 10.3205/cto000107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
ORL procedures are the most common operations in children – an optimal anesthetic management provides an uncomplicated, safe perioperative process with as little discomfort for the child as possible. Children at risk must already be identified preoperatively: the combination of ORL surgery, airway susceptibility and age below 3 years can increase the risk of perioperative respiratory adverse events. Postoperatively, it is important to prevent complications such as pain and PONV by dedicated prevention and treatment strategies, as well as to recognize and treat respiratory or circulatory complications competently. Interdisciplinary guidelines and agreements as well as the overall competence of the team have the potential to improve patient safety and outcome in children.
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Affiliation(s)
- Karin Becke
- Abteilung für Anästhesie und Intensivmedizin, Klinik Hallerwiese/Cnopf'sche Kinderklinik, Diakonie Neuendettelsau, Nürnberg, Germany
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Levy JH, Szlam F, Wolberg AS, Winkler A. Clinical Use of the Activated Partial Thromboplastin Time and Prothrombin Time for Screening. Clin Lab Med 2014; 34:453-77. [DOI: 10.1016/j.cll.2014.06.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
The value of routine coagulation testing instead of bleeding history alone in children, to predict bleeding risk prior to tonsillectomy and adenoidectomy has been questioned. Our objectives are to identify the causes of abnormal PT and/or aPTT in these patients, and to determine whether routine preoperative coagulation testing is effective in identifying children with a clinically significant coagulation abnormality prior to undergoing a procedure. In this study, data were extracted by chart review for 854 patients referred to the pediatric hematology service at Stony Brook University for the evaluation of an elevated PT and/or aPTT on preoperative testing. Seven hundred and ninety two of 854 reviewed charts (92.7%) contained sufficient data for analysis. On repeat testing, 393 (49.6%) had a laboratory abnormality identified. A potentially significant coagulation abnormality was identified in 32 of 792 patients (4%). For the remaining 760 patients, the most common diagnosis was a lupus anticoagulant (n = 98, 24.6%) or a "presumed" lupus anticoagulant (n = 166, 41.6%). A positive personal or family bleeding history was documented in 268 patients (268/792 = 33.8%). Of these patients, only 107 (39.9%) had an abnormality identified on further work-up. Seventeen of the 32 patients with clinically significant bleeding disorders identified were found to have a positive bleeding history (17/32 = 53.1%). Routine preoperative coagulation testing identifies only a small number of children at increased risk for surgical bleeding. However, a "positive" bleeding history identifies only 60% of children found to have a clinically significant coagulation abnormality. Routine preoperative coagulation testing may serve as a useful adjunct to clinical history.
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Affiliation(s)
- Neha Bhasin
- 1Pediatrics, University of Iowa, Iowa City, Iowa, USA
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Windfuhr JP. Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2013; 12:Doc08. [PMID: 24403976 PMCID: PMC3884543 DOI: 10.3205/cto000100] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN). METHODS A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany. RESULTS The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2). CONCLUSION Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.
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Affiliation(s)
- Jochen P. Windfuhr
- Department of Otorhinolaryngology, Plastic Head and Neck Surgery, Kliniken Maria Hilf, Mönchengladbach, Germany
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Pre-interventional haemostatic assessment: Guidelines from the French Society of Anaesthesia and Intensive Care. Eur J Anaesthesiol 2013; 30:142-62. [PMID: 23435255 DOI: 10.1097/eja.0b013e32835f66cd] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Recently the French Society of Anaesthesia and Intensive Care (Société Française d'Anesthésie et de Réanimation [SFAR]) issued recommendations for the prescription of routine preoperative testing before a surgical or non-surgical procedure, requiring any type of anaesthesia. Thirty clinical specialists performed a systematic analysis of the literature, and recommendations were then developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. One part of these guidelines is dedicated to haemostatic assessment. The goal of pre-anaesthetic screening for congenital or acquired haemostatic disorders is to prevent perioperative haemorrhagic complications through appropriate medical and surgical management. Preoperative assessment of bleeding risk requires a detailed patient interview to determine any personal or family history of haemorrhagic diathesis, and a physical examination is necessary in order to detect signs of coagulopathy. Laboratory investigation of haemostasis should be prescribed, not systematically, but depending on clinical evaluation and patient history. Standard tests (prothrombin time, activated partial thromboplastin time, platelet count) have a low positive predictive value for bleeding risk in the general population. Patients with no history of haemorrhagic diathesis and no conditions liable to interfere with haemostasis should not undergo pre-interventional haemostasis testing. Conversely, the existence of a positive history or a disease that could interfere with haemostasis should be an indication for clinically appropriate testing.
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McGillicuddy EA, Maxfield MW, Salameh B, Stein LH, Ahmad U, Longo WE. Bleeding diatheses and preoperative screening. JOURNAL OF SURGICAL EDUCATION 2013; 70:423-431. [PMID: 23618454 DOI: 10.1016/j.jsurg.2012.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 12/09/2012] [Accepted: 12/27/2012] [Indexed: 06/02/2023]
Abstract
Bleeding disorders pose a significant perioperative risk. Surgeons and surgical consultants should have a working knowledge of the cell-based coagulation model. Careful screening for bleeding diatheses begins with a careful history and physical examination. It is paramount to ascertain what medications and nonprescribed supplements and herbal preparations a patient is taking, as these medications can have significant effects on perioperative bleeding tendencies. Finally, screening laboratory-based coagulation assays are available. These must be used judiciously with regard to a patient's history and the clinical circumstances surrounding the surgical stressor.
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Affiliation(s)
- Edward A McGillicuddy
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut 06520-8062, USA.
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Wilhelm T, Hilger G, Begall K, Lautermann J, Kaschke O, Mir-Salim P, Zahnert T. [S1 Clinical guideline"adenoids and adenoidectomy"]. HNO 2013; 60:746-52. [PMID: 22864901 DOI: 10.1007/s00106-012-2555-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
On behalf of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery, a clinical guideline for adenoids and adenoidectomy was developed in 5 consensus meetings after taking into consideration the current literature. This guideline was released by the presidium on 13 April 2011. Anatomy, pathology and pathophysiology, symptoms, diagnosis, therapy, and course are presented.
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Affiliation(s)
- T Wilhelm
- Chefarzt der Klinik für HNO-Heilkunde, Kopf-/Hals- und plastische Gesichtschirurgie, HELIOS Klinikum Borna, Rudolf-Virchow-Str. 2, 04552, Borna, Deutschland.
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Levine AI, Govindaraj S, DeMaria, Jr. S. Pediatric Otolaryngology. ANESTHESIOLOGY AND OTOLARYNGOLOGY 2013. [PMCID: PMC7121951 DOI: 10.1007/978-1-4614-4184-7_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Otolaryngologic procedures are commonly performed on children. In fact, pressure equalizing tube placement (ear tubes) and adenotonsillectomy are among the most frequent surgical interventions in the pediatric population. Therefore, every anesthesiologist who manages children undergoing otolaryngologic procedures must be familiar with the special implications of sharing the pediatric airway with an otolaryngologist working in the head and neck region. In addition, it is imperative to be skilled in the challenges of compassionately yet safely managing anxious young patients and their parents from the time of preoperative assessment until discharge from the post anesthesia care unit.
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Affiliation(s)
- Adam I. Levine
- Otolaryngology, and, Structural & Chemical Biology, Department of Anesthesiology,, The Mount Sinai School of Medicine, New York, 10029 New York USA
| | - Satish Govindaraj
- Head and Neck Surgery, Department of Otolaryngology -, The Mount Sinai Medical Center, New York, 10029 New York USA
| | - Samuel DeMaria, Jr.
- Department of Anesthesiology, The Mount Sinai School of Medicine, New York, 10029 New York USA
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Dützmann S, Geßler F, Marquardt G, Seifert V, Senft C. On the value of routine prothrombin time screening in elective neurosurgical procedures. Neurosurg Focus 2012; 33:E9. [DOI: 10.3171/2012.7.focus12219] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors performed a study to evaluate whether preoperative assessment of prothrombin time (PT) is mandatory in patients undergoing routinely planned neurosurgical procedures.
Methods
The charts of all patients admitted to general wards of the authors' department for routinely planned surgery (excluding trauma and ICU patients) between 2006 and 2010 were retrospectively reviewed. The authors assessed preoperative PT and the clinical courses of all patients, with special consideration for patients receiving coagulation factor substitution. All cases involving hemorrhagic complications were analyzed in detail with regard to pre- and postoperative PT abnormalities. Prothrombin time was expressed as the international normalized ratio, and values greater than 1.28 were regarded as elevated.
Results
Clinical courses and PT values of 4310 patients were reviewed. Of these, 33 patients (0.7%) suffered hemorrhagic complications requiring repeat surgery. Thirty-one patients (94%) had a normal PT before the initial operation, while 2 patients had slightly elevated PT values of 1.33 and 1.65, which were anticipated based on the patient's history. In the latter 2 cases, surgery was performed without prior correction of PT. Preoperatively, PT was elevated in 78 patients (1.8%). In 73 (93.6%) of the 78 patients, the PT elevation was expected and explained by each patient's medical history. In only 5 (0.1%) of 4310 patients did we find an unexpected PT elevation (mean 1.53, range 1.37–1.74). All 5 patients underwent surgery without complications, while 2 had received coagulation factor substitution preoperatively, as requested by the surgeon, because of an estimated risk of bleeding complications. None of the 5 patients received coagulation factor substitution postoperatively, and later detailed laboratory studies ruled out single coagulation factor deficiencies. There was no statistically significant association between preoperatively elevated PT levels and the occurrence of hemorrhagic complications (p = 0.12). Before the second procedure but not before the initial operation, 4 (12%) of the 33 patients had elevated PT.
Conclusions
The findings suggest that the value of preoperative PT testing is limited in patients in whom a normal history can be ascertained. Close postoperative PT control is necessary in every neurosurgical patient, and better tests need to be developed to identify patients who are prone to hemorrhagic complications.
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Erratum zu: S1-Leitlinie „Adenoide Vegetationen/Rachenmandelhyperplasie“. HNO 2012. [DOI: 10.1007/s00106-012-2589-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Mizrak A, Karatas E, Saruhan R, Kara F, Oner U, Saricicek V, Baysal E. Does dexmedetomidine affect intraoperative blood loss and clotting tests in pediatric adenotonsillectomy patients? J Surg Res 2012; 179:94-8. [PMID: 23122669 DOI: 10.1016/j.jss.2012.09.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 09/02/2012] [Accepted: 09/07/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND We hypothesize that dexmedetomidine (DEX), a selective α(2) adrenergic receptor agonist, may affect the intraoperative blood loss and clotting tests such as prothrombin time, activated partial thromboplastin time, and international normalized ratio in children undergoing adenotonsillectomy (ADT). METHODS Sixty patients scheduled for elective ADT under general anesthesia. The patients were randomly assigned to receive either DEX 0.5 μg/kg (group D) or placebo bolus (group C) with a total volume of 10 mL, 10 min before the induction of anesthesia. Mean arterial pressure (MAP), heart rate, blood loss, preoperatively and immediately after awakening clotting tests, agitation, sedation, visual analog scale, and analgesic requirement, were assessed and recorded. RESULTS The postoperative hemoglobin was significantly lower than the preoperative value in both groups (P < 0.05). The postoperative agitation scale and analgesic requirement and visual analog scale at the 15th min were significantly lower in group D than those in group C (P < 0.05). Total blood loss and postoperative sedation score in group D was significantly higher than that in group C (P < 0.05). The postoperative prothrombin time, activated partial thromboplastin time, international normalized ratio tests between the groups, additionally pre-postoperative MAP, heart rate, and clotting tests were similar in each group. CONCLUSIONS The premedication with DEX 0.5 μg/kg decreased postoperative agitation, pain, and analgesic requirement without significant change in the clotting tests and MAP but increased bleeding slightly during ADT.
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Affiliation(s)
- Ayse Mizrak
- Department of Anesthesiology and Reanimation, Faculty of Medicine, University of Gaziantep, Gaziantep, Turkey
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An evidence-based threshold for thrombocytopenia associated with clinically significant bleeding in pediatric intensive care unit patients. Pediatr Crit Care Med 2012; 13:e316-22. [PMID: 22760429 DOI: 10.1097/pcc.0b013e31824ea28d] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the epidemiology and identify the risk factors for clinically significant bleeding in the pediatric intensive care unit. DESIGN A retrospective cohort study over 6 months with up to 7 days of observation for each patient. SETTING The pediatric intensive care unit in a tertiary care children's hospital. PATIENTS Three hundred twenty-six consecutive patients admitted to the pediatric intensive care unit during the study period, with 214 eligible for inclusion. MEASUREMENTS AND MAIN RESULTS Clinically significant bleeding, defined using a composite of outcomes. Clinically significant bleeding occurred in 19 patients (8.9%). Recursive partitioning identified a platelet count <100 × 10/L as being associated with clinically significant bleeding. Other factors associated with increased risk included mechanical ventilation, antibiotic and antacid medications, the performance of multiple procedures, and cardiac surgery. Episodes of clinically significant bleeding were observed at a median of 9.8 hrs after admission. CONCLUSIONS Clinically significant bleeding is a more common complication for pediatric intensive care unit patients than has been previously reported. The evidence-based threshold for thrombocytopenia identified as a risk factor should be further investigated in a prospective study.
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Sarny S, Ossimitz G, Habermann W, Stammberger H. Preoperative coagulation screening prior to tonsillectomy in adults: current practice and recommendations. Eur Arch Otorhinolaryngol 2012; 270:1099-104. [PMID: 22791470 DOI: 10.1007/s00405-012-2099-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 06/18/2012] [Indexed: 11/28/2022]
Abstract
The hypotheses of the study are: (1) a positive history of coagulopathy predicts a higher postoperative haemorrhage risk, (2) a positive laboratory screening for coagulopathy can forecast a higher haemorrhage risk and (3) the haemorrhage risk in patients with known bleeding disorder is elevated. In a multicentre study information on 3,041 tonsillectomies in adults over 9 months, from 1st October 2009 until 30th June 2010, was evaluated. The outcome variables were patient characteristics, postoperative haemorrhage, history of coagulopathy and laboratory screening for coagulopathy. A history of coagulopathy and laboratory screening for coagulopathy were performed in almost all patients (98.6 %, 2,998/3,041). The overall haemorrhage rate was 16 %, including all bleeding episodes after extubation, with 4.8 % returning to theatre. A positive history was reported in 2 % (55/3,041) and a positive laboratory screening in 3 % (94/3,041) of all patients. A positive history is significantly associated with a higher risk of postoperative haemorrhage (31 %, 17/55, p < 0.002) compared to patients with a negative history (16 %, 387/2,497). A positive laboratory for coagulopathy was not significantly associated with an increased haemorrhage risk (20 %, 19/94, p < 0.235) compared to patients with a negative laboratory (16 %, 390/2,249). The haemorrhage risk for adults with a bleeding disorder is twice as high (31 %, 17/55) as for adults without bleeding disorder (16 %, 476/2,973). In conclusion, an adult patient's history of coagulopathy should be taken prior to tonsillectomy as a positive history doubles the haemorrhage risk while a laboratory screening for coagulopathy has no significant power to predict an elevated haemorrhage risk. Bleeding disorders double the risk of postoperative haemorrhage.
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Affiliation(s)
- Stephanie Sarny
- Department of General Oto-Rhino-Laryngology, Head and Neck Surgery, Medical University of Graz, Auenbruggerplatz 26-28, 8036, Graz, Austria.
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Seicean A, Schiltz NK, Seicean S, Alan N, Neuhauser D, Weil RJ. Use and utility of preoperative hemostatic screening and patient history in adult neurosurgical patients. J Neurosurg 2012; 116:1097-105. [PMID: 22339164 DOI: 10.3171/2012.1.jns111760] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The utility of preoperative hemostasis screening to predict complications is uncertain. The authors quantified the screening rate in US neurosurgery patients and evaluated the ability of abnormal test results as compared with history-based risk factors to predict hemostasis-related and general outcomes. METHODS Eleven thousand eight hundred four adult neurosurgery patients were identified in the 2006-2009 American College of Surgeons National Surgical Quality Improvement Program database. Multivariate logistic regression modeled the ability of hemostatic tests and patient history to predict outcomes, that is, intra- and postoperative red blood cell [RBC] transfusion, return to the operating room [OR], and 30-day mortality. Sensitivity analyses were conducted using patient subgroups by procedure. RESULTS Most patients underwent all 3 hemostatic tests (platelet count, prothrombin time/international normalized ratio [INR], activated partial thromboplastin time), but few had any of the outcomes of interest. The number of screening tests undergone was significantly associated with intraoperative RBC transfusion, a return to the OR, and mortality; an abnormal INR was associated with postoperative RBC transfusion. However, all tests had low sensitivity (0.09-0.2) and platelet count had low specificity (0.04-0.05). The association between patient history and each outcome was approximately the same across all tests, with higher sensitivity but lower specificity. Combining abnormal tests with patient history accounted for 50% of the mortality and 33% of each of the other outcomes. CONCLUSIONS This is the first study focused on assessing preoperative hemostasis screening as compared with patient history in a large multicenter sample of adult neurosurgery patients to predict hemostasis-related outcomes. Patient history was as predictive as laboratory testing for all outcomes, with higher sensitivity. Routine laboratory screening appears to have limited utility. Testing limited to neurosurgical patients with a positive history would save an estimated $81,942,000 annually.
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Affiliation(s)
- Andreea Seicean
- Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Bay Village, Ohio 44140, USA.
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Zaher G, Al-Noury K. The value of routine preoperative testing in the prediction of operative hemorrhage in adenotonsillectomy. Indian J Otolaryngol Head Neck Surg 2011; 66:30-6. [PMID: 24533357 DOI: 10.1007/s12070-011-0285-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 08/12/2011] [Indexed: 11/27/2022] Open
Abstract
Medical records were reviewed to identify subjects who ranged in age from 1 to 18 years and who had undergone tonsillectomy with or without adenoidectomy. Data obtained included patient demographic information, relevant medical history, history of hemorrhage, family history of hemorrhagic disorders, and drug history. Laboratory data obtained included a baseline coagulation screening to determine prothrombin time, activated partial thromboplastin time, and platelet count. Values were classified as within normal limits or as abnormally prolonged according to the local laboratory reference values. The incidence of postoperative hemorrhage in healthy subjects was evaluated, and the correlation between having a medical history of hemorrhage and an abnormal coagulation screen was assessed. We found that the medical history of the patients studied had positive predictive value of 42.8%, and a negative predictive value of 99.1%. The preoperative coagulation screening had a positive predictive value of 50%, and a negative predictive value of 93.6%.
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Affiliation(s)
- Galila Zaher
- Departments of Hematology, King Abdulaziz University Hospital, 80205, Jeddah, 21589 Saudi Arabia
| | - Khaled Al-Noury
- Department of Otolaryngology, Head and Neck Surgery, King Abdulaziz University Hospital, 80205, Jeddah, 21589 Saudi Arabia ; 35135, Jeddah, 21488 Saudi Arabia
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Significance of advanced haemostasis investigation in recurrent, severe post-tonsillectomy bleeding. The Journal of Laryngology & Otology 2011; 125:952-7. [DOI: 10.1017/s0022215111000879] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:To evaluate the significance of advanced post-operative haemostasis investigation in cases of recurrent, severe post-tonsillectomy bleeding.Materials and methods:Of the 120 patients treated at our tertiary centre between 2006 and 2010 due to post-tonsillectomy haemorrhage, 22 with recurrent, severe episodes of bleeding underwent further, advanced haemostasis investigation.Results:Underlying haemorrhagic disease was not diagnosed in any case. Isolated abnormal clotting factor levels were identified in two patients. Decreased fibrinogen concentration due to dilutional coagulopathy was found in nine cases (40.9 per cent).Conclusion:Recurrent, severe post-tonsillectomy haemorrhage is rarely related to undiagnosed haemostatic disorders. Thus, advanced haemostasis studies have little therapeutic relevance. However, repetitive post-tonsillectomy bleeding may be related to decreased fibrinogen levels due to dilutional coagulopathy. Therefore, fibrinogen concentration should be tested, and dilutional coagulopathy treated promptly.
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Revel A, Schejter-Dinur Y, Yahalomi SZ, Simon A, Zelig O, Revel-Vilk S. Is routine screening needed for coagulation abnormalities before oocyte retrieval? Fertil Steril 2011; 95:1182-4. [PMID: 21067719 DOI: 10.1016/j.fertnstert.2010.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 10/01/2010] [Accepted: 10/04/2010] [Indexed: 11/30/2022]
Abstract
A cross-sectional retrospective study was performed to question the utility of coagulation screening to prevent procedure-related bleeding before oocyte retrieval in IVF. Among 1,032 patients evaluated we found that 534 coagulation tests were needed to prevent one case of bleeding associated with an abnormal coagulation test result.
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Affiliation(s)
- Ariel Revel
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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An assessment of the utility of unselected coagulation screening in general hospital practice. Blood Coagul Fibrinolysis 2011; 22:106-9. [DOI: 10.1097/mbc.0b013e3283432fb7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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West KL, Adamson C, Hoffman M. Prophylactic correction of the international normalized ratio in neurosurgery: a brief review of a brief literature. J Neurosurg 2011; 114:9-18. [DOI: 10.3171/2010.7.jns091857] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Prophylactic fresh-frozen plasma (FFP) transfusion is often undertaken in hemodynamically stable patients with a minimally elevated international normalized ratio (INR) prior to invasive procedures, despite little evidence in support of this practice. The authors review the current literature in an attempt to clarify best clinical practice with regard to this issue. Although the activated partial thromboplastin time and prothrombin time–INR are useful laboratory tests to measure specific clotting factors in the coagulation cascade, in the absence of active bleeding or a preexisting coagulopathy, their utility as predictors of overall bleeding risk is limited. Several studies have shown an imperfect correlation between mild elevations in the INR and subsequent bleeding tendency. Furthermore, FFP transfusion is not always sufficient to achieve normal INR values in patients who have mild elevations (< 2) to begin with. Finally, there are risks associated with FFP transfusion, including potential transfusion-associated [disease] exposures as well as the time delay imposed by laboratory testing and transfusion administration prior to initiation of procedures. The authors propose that the current concept of a “normal” INR value warrants redefinition to make it a more meaningful clinical tool. Based on their review of the literature, the authors suggest that in a hemodynamically stable patient population there is a range of mildly prolonged INR values for which FFP transfusion is not beneficial, and is potentially harmful.
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Affiliation(s)
| | - Cory Adamson
- 2Surgery (Neurosurgery), and
- 3Neurobiology, Duke University and Durham Veterans Administration Medical Centers, Durham, North Carolina
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Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for the transfusion management of patients in the peri-operative period. I. The pre-operative period. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2011; 9:19-40. [PMID: 21235852 PMCID: PMC3021395 DOI: 10.2450/2010.0074-10] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Giancarlo Maria Liumbruno
- Units of Immunohaematology, Transfusion Medicine and Clinical Pathology, San Giovanni Calibita Fatebenefratelli Hospital, Rome, Italy
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Cooper JD, Smith KJ, Ritchey AK. A cost-effectiveness analysis of coagulation testing prior to tonsillectomy and adenoidectomy in children. Pediatr Blood Cancer 2010; 55:1153-9. [PMID: 20672369 DOI: 10.1002/pbc.22708] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The American Society of Pediatric Otolaryngology recommends pre-operative coagulation testing only when indicated by history or physical exam. Nevertheless, many surgeons test all children scheduled for tonsillectomy and/or adenoidectomy (T&A). Studies of pre-operative screening have had conflicting results. A decision analysis model was constructed to address the costs and health outcome states of pre-operative screening strategies in children. PROCEDURE A 14-day Markov model evaluated three strategies: (1) test all children for coagulation disorders; (2) test only those children with a pertinent history; and (3) perform no pre-operative testing. A literature search and a review of national databases estimated probabilities, costs, and utility data. Parameters then were varied widely in sensitivity analyses. Using a societal perspective and a cycle length of 1 day, we compared the strategies based on total costs and quality-adjusted life years (QALYs). RESULTS Total costs for the strategies were $3,200 for testing all children, $3,083 for testing only those with a history finding, and $3,077 for not testing. Total utilities were 0.02579, 0.02654, and 0.02659 QALYs, respectively. Cost-effectiveness ratios were most sensitive to variation in the cost of post-operative care and the probability of post-operative bleeding. The strategy of not testing was dominant in all sensitivity analyses. CONCLUSIONS Our results demonstrate that not performing preoperative testing is the most cost-effective strategy. This was persistent in sensitivity analyses, indicating that the model was robust. These data may be helpful to institutions and organizations to formulate policies regarding pre-operative coagulation for children without previous diagnoses of bleeding disorders.
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Affiliation(s)
- James D Cooper
- Division of Hematology/Oncology/BMT, Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15224, USA.
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Abstract
OBJECTIVE Since the previous comprehensive radiology review on coagulation concepts that was done in 1990, many studies have been published in the medical and surgical literature that can guide the approach of a radiology practice. The purpose of this article is to provide an analysis of these works, updating the radiologist on proper use and interpretation of coagulation assessment tools, medications that modify the hemostatic system, and the use of transfusions prior to interventions. CONCLUSION The basic tools for coagulation assessment have not changed; however, results from subspecialty research have suggested ways in which the use of these tools can be modified and streamlined to safely reduce time and expense for the patient and the health care system.
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