The long-term fate of epistaxis patients with exposure to antithrombotic medication

The goal of this study was to evaluate independent risk factors for long-term epistaxis recurrences and their severity. Individual retrospective cohort study-2b level of evidence. The medical information of 603 emergency epistaxis patients was acquired during a former study. This cohort has been contacted 6 years later by conventional mail and asked to answer a specific paper questionnaire. The following parameters were evaluated: recurrent epistaxis episodes, need for a surgical intervention to stop the recurrent bleeding, patient's history for hypertension and diabetes, intake of hemostasis impairing medication now and in the past. One hundred and six (106) patients were included in the study (35.8 % response rate). The mean observation period was 76.58 months. Almost half of the patients (41.5 % = 44/106) reported at least one recurrent epistaxis episode. Patients with exposure to VKA (vitamin K antagonists) showed significantly more frequently a recurrent epistaxis episode. The binary logistic regression confirmed the intake of VKA as an independent and significant risk factor with an odds ratio of 11.6. Every single patient who had to undergo a surgical intervention to stop a recurrent bleeding stated ASA (Acetylsalicylic Acid) intake. We provide evidence that the intake of a vitamin K antagonist is an independent long-term risk factor for recurrent epistaxis episodes. The intake of ASA is a risk factor for the severity of recurrent epistaxis with the increased need for a surgical intervention not only in a short- but also in a long-term perspective.

LEVEL OF EVIDENCE

This prognostic investigation, designed as a combined prospective and retrospective cohort study, reaches level 2b level of evidence as it includes retrospective aspects.

Successful use of extracorporeal life support and hemadsorption in the context of venlafaxine intoxication requiring cardiopulmonary resuscitation: a case report

Venlafaxine is a serotonin and noradrenalin reuptake inhibitor prescribed as an antidepressant. Overdose clinically manifests with neurological, cardiovascular and gastrointestinal abnormalities based on, amongst others, serotonin syndrome and can be life-threatening due to cardiovascular collapse. Besides immediate decontamination via gastric lavage and inhibition of enteral absorption through active charcoal, successful hemadsorption with CytoSorb® has been reported. We present the case of a 17-year-old female who required extracorporeal life support (ECLS) for cardiovascular collapse as a result of life-threatening venlafaxine intoxication. Serial serum blood concentrations of venlafaxine/desmethylvenlafaxine on admission at a tertiary hospital (approx. 24 h after ingestion) and subsequently 6 h and 18 h thereafter, as well as on days 2 and 4, were measured. CytoSorb® was initiated 6 h after admission and changed three times over 72 h. The initial blood concentration of venlafaxine/desmethylvenlafaxine was 53.52 µmol/l. After 6 h, it declined to 30.7 µmol/l and CytoSorb® was initiated at this point. After 12 h of hemadsorption, the blood level decreased to 9.6 µmol/l. On day 2, it was down to 7.17 µmol/l and decreased further to 3.74 µmol/l. Additional continuous renal replacement therapy using CVVHD was implemented on day 5. The combination of hemadsorption, besides traditional decontamination strategies along maximal organ supportive therapy with ECLS, resulted in the intact neurological survival of the highest venlafaxine intoxication reported in the literature to date. Hemadsorption with CytoSorb® might help to reduce blood serum levels of venlafaxine. Swift clearance of toxic blood levels may support cardiovascular recovery after life-threatening intoxications.

Systematic follow-up of newborns with idiopathic respiratory distress syndrome. Results in 197 patients born 1971 to 1976

347 patients with idiopathic respiratory distress syndrome, born 1971 to 1976, were included into a prospective follow-up study. 71 patients (20%) died in the neonatal period, 197 out of 276 survivors (71%) had a complete follow-up for the first year of life, 112 survivors have so far been investigated up to the age of four years. According to neurological findings the patients were classified as normal, doubtful (age 6-12 months) or minimal brain dysfunction (4 years), mild cerebral paresis (CP), or severe cerebral damage, respectively. At the age of one year 3 patients (1.5%) had severe cerebral damage, 14 (7%) showed mild CP and another 56 (28%) had doubtful findings. Very low birth weight of very short period of gestation increased the risk for abnormal neurological findings only slightly. The need for mechanical ventilation, especially for more than 14 days, increases the risk for CP. Serious complications during the neonatal period, particularly implicating cerebral stress, significantly reduces medium-term prognosis. Perinatal asphyxia, neonatal acidosis, hypoxia or hypercapnia did not correlate with impaired cerebral prognosis. Preliminary findings at the age of four years demonstrate good correlation with neurological findings obtained at the age of 12 months. One patient initially classified as normal (2%) and 5 doubtful babies (15%) had developed mild CP. Another initially doubtful baby had severe cerebral damage at the age of four years. 62 out of 78 children tested (79%) showed normal intelligence, 14 (18%) had an IQ of 70--90, and 2 (3%) less than 70.