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Introduction: This study aimed to assess the relationship between preoperative international normalized ratio (INR) levels and major postoperative bleeding events after total shoulder arthroplasty (TSA)., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for TSA from 2011 to 2020. A final cohort of 2405 patients with INR within 2 days of surgery were included. Patients were stratified into four groups: INR ≤ 1.0, 1.0 < INR ≤ 1.25, 1.25< INR ≤ 1.5, and INR > 1.5. The primary outcome was bleeding requiring transfusion within 72 hours, and secondary outcome variables included complication, revision surgery, readmission, and hospital stay duration. Multivariable logistic and linear regression analyses adjusted for relevant comorbidities were done., Results: Of the 2,405 patients, 48% had INR ≤ 1.0, 44% had INR > 1.0 to 1.25, 7% had INR > 1.25 to 1.5, and 1% had INR > 1.5. In the adjusted model, 1.0 < INR ≤ 1.25 (OR 1.7, 95% CI 1.176 to 2.459), 1.25 < INR ≤ 1.5 (OR 2.508, 95% CI 1.454 to 4.325), and INR > 1.5 (OR 3.200, 95% CI 1.233 to 8.302) were associated with higher risks of bleeding compared with INR ≤ 1.0., Discussion: The risks of thromboembolism and bleeding lie along a continuum, with higher preoperative INR levels conferring higher postoperative bleeding risks after TSA. Clinicians should use a patient-centered, multidisciplinary approach to balance competing risks., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: Postoperative acute kidney injury (AKI) is a critical issue in geriatric patients with pre-existing chronic kidney disease (CKD) undergoing orthopedic trauma surgery. The goal of this study was to investigate modifiable intraoperative risk factors for AKI., Methods: A retrospective study was conducted on 206 geriatric patients with CKD, who underwent orthopedic trauma surgery. Several variables, including intraoperative blood loss, postoperative hypoalbuminemia, intraoperative blood pressure and long-term use of potentially nephrotoxic drugs, were analyzed., Results: Postoperative AKI (KIDGO) was observed in 25.2% of the patients. The 1-year mortality rate increased significantly from 26.7% to 30.8% in patients who developed AKI. Primary risk factors for AKI were blood loss (p < 0.001), postoperative hypoalbuminemia (p = 0.050), and potentially nephrotoxic drugs prior to admission (angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, diuretics, antibiotics, NSAIDs) (p = 0.003). Furthermore, the AKI stage negatively correlated with propofol dose per body weight (p = 0.001) and there was a significant association between AKI and the use of cement (p = 0.027). No significant association between intraoperative hypotension and AKI was observed in any statistical test. Femur fracture surgeries showed the greatest blood loss (524mL ± 357mL, p = 0.005), particularly intramedullary nailing at the proximal femur (598mL ± 395mL) and revision surgery (769mL ± 436mL)., Conclusion: In geriatric trauma patients with pre-existing CKD, intraoperative blood loss, postoperative hypoalbuminemia, and pre-admission use of potentially nephrotoxic drugs are associated with postoperative AKI. The findings highlight the necessity to mitigate intraoperative blood loss and promote ortho-geriatric co-management to reduce the incidence and subsequent mortality in this high-risk population., (© 2023. The Author(s).)

Background: Coronavirus disease 2019 increased the numbers of patients requiring prolonged mechanical ventilation, with a subsequent increase in tracheostomy procedures. Coronavirus disease 2019 patients are high risk for surgical complications. This review examines open surgical and percutaneous tracheostomy complications in coronavirus disease 2019 patients., Methods: Medline and Embase databases were searched (November 2021), and the abstracts of relevant articles were screened. Data were collected regarding tracheostomy technique and complications. Complication rates were compared between percutaneous and open surgical tracheostomy., Results: Percutaneous tracheostomy was higher risk for bleeding, pneumothorax and false passage. Surgical tracheostomy was higher risk for peri-operative hypoxia. The most common complication for both techniques was post-operative bleeding., Conclusion: Coronavirus disease 2019 patients undergoing tracheostomy are at higher risk of bleeding and peri-operative hypoxia than non-coronavirus disease patients. High doses of anti-coagulants may partially explain this. Reasons for higher bleeding risk in percutaneous over open surgical technique remain unclear. Further research is required to determine the causes of differences found and to establish mitigating strategies.

Background: Although postoperative bleeding is a common and serious complication in breast cancer surgery, the risk factors remain unclear. Therefore, we examined the risk factors using a Japanese nationwide database., Methods: Patients who underwent breast cancer surgery between July 2010 and March 2020 were identified from a Japanese nationwide database. Multivariable analyses for 47 candidate risk factors (4 patient characteristics, 32 comorbidities, 5 tumor characteristics, 3 preoperative drug uses, and 3 surgical procedures) were conducted to investigate risk factors associated with postoperative bleeding requiring reoperation. Two sensitivity analyses were conducted: an analysis for postoperative bleeding with or without reoperation and an analysis for patients who underwent total mastectomy without breast reconstruction., Results: Among the 477,108 patients included, 7048 (1.5%) developed postoperative bleeding and 2357 (0.5%) underwent reoperation for postoperative bleeding. Male sex, old age, body mass index ≥ 25.0 kg/m 2 , several comorbidities (deficiency anemia, cardiac arrhythmias, hypertension, liver disease, psychoses, and valvular disease), preoperative heparin use, and several procedures were identified as risk factors. Deficiency anemia showed the highest odds ratio among the risk factors (4.41 [95% confidence interval, 3.63-5.36]). High odds ratios were also observed in total mastectomy (2.32 [2.10-2.56]), flap reconstruction (1.93 [1.55-2.40]), and preoperative heparin use (1.64 [1.26-2.14]). The results corresponded with the sensitivity analyses., Conclusions: This study identified several risk factors for postoperative bleeding in breast cancer surgery, such as high body mass index, anemia, cardiovascular diseases, liver diseases, psychoses, preoperative heparin use, and surgical procedures., (© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Individuals with chronic liver disease (CLD) have an increased risk of bleeding from thrombocytopenia and changes in hemostasis. The aim of this study was to evaluate the frequency of and the factors associated with the occurrence of bleeding in CLD patients who underwent dental surgical procedures. This was a retrospective study whose data were collected in a hospital dentistry service between 2010 and 2016. The patients were referred from the gastroenterology and liver transplantation services of a university hospital for dental treatment. The study followed the STROBE guidelines. Among the 71 surgical procedures performed, there were 17 (24%) perioperative and postoperative bleeding episodes, 14 of which were in pretransplant patients and 11 received blood transfusion before dental surgery. Individuals with a previous history of bleeding (PR = 2.67, CI = 1.07-6.67, P  = 0.035) and those with a platelet count before surgery 50 × 10 9 /l or less (PR = 7.48, CI = 1.70-32.86, P  = 0.008) had a higher prevalence of perioperative and postoperative bleeding episodes than their peers without a previous history of bleeding, and those with platelet count greater than 50 × 10 9 /l. The approach to individuals with CLD is complex and represents a challenge to the clinician. A careful anamnesis combined with laboratory screening of coagulation disorders appears to be useful to identify individuals at a major risk of bleeding. Studies identifying the predisposing factors of bleeding in CLD patients support well tolerated protocols for oral surgery in this group., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Post-thyroidectomy bleeding is rare, but potentially life-threatening complication. Early recognition with immediate intervention is crucial for the management of this complication. Therefore, it is very important to identify possible risk factors of postoperative hemorrhage as well as timing of postoperative hematoma occurrence., Methods: Retrospective review of 6938 patients undergoing thyroidectomy in a tertiary center in a ten year period (2009-2019) revealed 72 patients with postoperative hemorrhage requiring reoperation. Each patient who developed postoperative hematoma was matched with four control patients that did not develop postoperative hematoma after thyroidectomy. The patients and controls were matched by the date of operation and surgeon performing thyroidectomy., Results: The incidence of postoperative bleeding was 1.04%. On univariate analysis older age, male sex, higher BMI, higher ASA score, preoperative use of anticoagulant therapy, thyroidectomy for retrosternal goiter, larger thyroid specimens, larger dominant nodules, longer operative time, higher postoperative blood pressure and the use of postoperative subcutaneous heparin were identified as risk factors for postoperative bleeding. Sixty-nine patients (95.8%) bled within first 24 h after surgery., Conclusion: The rate of postoperative bleeding in our study is consistent with recent literature. Male sex, the use of preoperative anticoagulant therapy, thyroidectomy for retrosternal goiter and the use of postoperative subcutaneous heparin remained statistically significant on multivariate analysis (p < 0.001). When identified, these risk factors may be an obstacle to the outpatient thyroidectomy in our settings., (© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Introduction: To explore the role of balloon tamponade insertion in pregnancies complicated by placenta previa., Evidence Acquisition: Medline, Embase and ClinicalTrials.gov databases were searched electronically on October 17. Inclusion criteria were women with placenta previa undergoing, compared to those not undergoing, balloon tamponade insertion at the time of the cesarean section (CS). The outcomes observed were total, intra- and post-operative estimated blood loss (EBL), need for blood transfusion, admission to intensive care unit (ICU), hysterectomy and additional surgical or medical procedures to achieve hemostasis. Results were reported as pooled odd ratios (OR) or mean difference (MD) according to the outcome investigated., Evidence Synthesis: Four studies (593 women) were included. Total EBL was significantly lower in women undergoing balloon tamponade insertion during CS compared to controls (MD: -556.3, 95% CI -496 to -617.0, P=0.001). Likewise, women undergoing balloon tamponade insertion had significantly lower intra- (MD: -699.8, 95% CI -766.1 to -633.5, P=0.001) and post-operative (MD: -1162 mL (95% CI -1211.1 to -1134.4, P<0.001) compared to women who did undergo such procedure. Furthermore, women undergoing balloon tamponade insertion had a significantly lower risk of requiring additional surgical (OR: 0.16, 95% CI 0.1-0.5, I 2 =0%; P=0.001) or medical (OR: 0.02, 95% CI 0.003-0.1, I 2 =0; P=0.001) procedures to achieve hemostasis. Conversely, there was no significant difference in either the need for blood transfusion (P=0.071), admission to ICU (P=0.459) or need for hysterectomy (P=0.312) between women undergoing, compared to those not undergoing, balloon tamponade insertion during CS for placenta previa., Conclusions: Elective balloon tamponade insertion at the time of CS for placenta previa seems to be associated with a lower EBL and a reduced risk of additional medical and surgical procedures to control hemostasis. Large and adequately powered randomized controlled trials are needed to validate these results and introduce elective balloon tamponade insertion at the time of CS for placenta previa in clinical practice.

Objective: This study aimed to compare the perioperative indicators, treatment efficacy, and postoperative complications between tonsillotomy and tonsillectomy for children with obstructive sleep apnea hypopnea syndrome., Methods: A total of 134 children with obstructive sleep apnea hypopnea syndrome were divided into tonsillotomy group (n=66) and tonsillectomy group (n=68). The tonsillotomy group received tonsillotomy treatment with a power cutter, while the tonsillectomy group received tonsillectomy treatment. The perioperative indicators, treatment efficacy, and postoperative complications were compared between the two groups., Results: There was no significant difference in operative time between the two groups (p>0.05), with significant difference in amount of blood loss, postoperative Visual Analogue Scale score, food intake amount, and general diet-taking starting time between the two groups (p<0.05). The total effective rate of treatment had no significant difference between the two groups (p>0.05). There was significant difference in postoperative bleeding, upper respiratory tract infection, and pharyngeal scar grade between the two groups (p<0.05)., Conclusions: Compared with tonsillectomy treatment for children with obstructive sleep apnea hypopnea syndrome, tonsillotomy treatment is more beneficial to optimize the perioperative indicators, relieve the postoperative pain, facilitate the postoperative recovery, and reduce the postoperative complications, which is worthy of clinical promotion.

Objective: Post-operative bleeding is one of the most common and severe complications of turbinate surgery. This study compared post-operative bleeding following partial turbinectomy, submucosal turbinate reduction and endoscopic turbinoplasty., Methods: Post-operative bleeding was assessed in patients who underwent inferior turbinate intervention by partial turbinectomy, submucosal turbinate reduction or endoscopic turbinoplasty between January 2016 and November 2017 and had completed at least one month of follow up., Results: Of 1035 patients who underwent inferior turbinate surgery during the study period, 751 were included. Of these, 56 (7.5 per cent) presented to the emergency room with post-operative bleeding; 31 (8.4 per cent) had undergone partial turbinectomy, 19 (10.7 per cent) had undergone submucosal turbinate reduction and 6 (3.0 per cent) had undergone endoscopic turbinoplasty. The odds ratio of requiring an intervention to control bleeding was significantly lower in the endoscopic turbinoplasty group than in the submucosal turbinate reduction group (odds ratio = 3.26, 95 per cent confidence interval = 1.02-10.43)., Conclusion: Endoscopic turbinoplasty had the lowest rate of post-operative bleeding and the lowest rate of patients requiring intervention.

Objective: Postoperative intracerebral hemorrhage (ICH) after direct bypass surgery for Moyamoya disease could contribute to neurologic deterioration. The aim of this study was to evaluate the effectiveness of 5-day bed rest in reducing the occurrence of postoperative ICH., Methods: This study included 122 consecutive hemispheres in 87 Japanese adult MMD patients, composed of 80 control hemispheres from historical data and 42 hemispheres after 5-day bed rest. They all underwent direct bypass surgery. The incidence of postoperative ICH and neurologic deterioration assessed via the modified Rankin Scale were investigated and statistically analyzed., Results: Postoperative ICH was observed in 9 out of the 80 (11.3%) control patients, but not in the 42 patients with 5-day bed rest. The incidence of postoperative ICH and neurologic deterioration via the modified Rankin Scale were significantly different between the 2 groups (P = 0.0268 and 0.0078, respectively). Univariate logistic analysis revealed that 5-day bed rest significantly reduced the incidence of postoperative ICH (P = 0.0048)., Conclusions: Five-day bed rest after direct bypass surgery dramatically can reduce the incidence of postoperative ICH and neurologic deterioration after direct bypass surgery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Cerebral hyperperfusion syndrome (CHS) is a rare but potentially devastating complication after carotid endarterectomies (CEA). Its symptoms range from new-onset unilateral headache (HA) to intracranial hemorrhage (ICH). Risk factors for CHS in the literature to date have not yet yielded a consensus. This study examines intraoperative and postoperative blood pressure variations as potential risk factors for HA., Methods: A single-center retrospective review at a tertiary care center from January 2010 to November 2019 was performed. Inclusion criteria were all patients undergoing CEA for symptomatic or asymptomatic carotid disease. Patients with incomplete charts were excluded. Primary endpoints were new-onset unilateral HA or postoperative ICH. Data on intraoperative and postoperative mean arterial pressure (MAP), systolic blood pressure (SBP), the mode of endarterectomy, shunt placement, and contralateral carotid status were collected., Results: There were 735 patients who met the inclusion criteria: 430 patients underwent modified eversion CEA (59%) and 305 patients for patch angioplasty (42%). The incidence of HA was 19% (n = 142) in our total cohort. Of the 19% with HA, 1.5% (n = 11) demonstrated no relief with analgesics and strict blood pressure control; noncontrast head computed tomography scans were performed subsequently. One patient (0.1%) had an ipsilateral ICH. Univariate analysis demonstrated that greater intraoperative MAP peak had the highest risk for HA (odds ratio [OR], 1.014; 95% confidence interval [CI], 1.007-1.022; P = .0002), followed by intraoperative MAP variability (OR, 1.011; 95% CI,1.005-1.018; P ≤ .0008), and peak intraoperative SBP (OR, 1.01; 95% CI, 1.004-1.015; P = .0011). An unpaired Student t test identified change in intraoperative MAP (P < .005), change in the SBP (P < .005), and peak SBP (P < .001) were significantly associated with HA. Interestingly, there was no significant difference between postoperative MAP variability and HA (P = .1). The mode of endarterectomy showed no statistically significant difference in risk for developing HA (OR, 1.165; 95%; 95% CI, 0.801-1.694; P = .42)., Conclusions: Greater intraoperative variability in blood pressures are significantly associated with a higher risk of HA. Adhering to stricter intraoperative blood pressure parameters and limiting blood pressure variability may be beneficial at decreasing the incidence of CHS and its complications., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Unclassified bleeding disorders account for 2.6% of all new bleeding disorder registrations in the UK. The management of the bleeding phenotype associated with these disorders is poorly described. Systematic review and meta-analysis to determine the bleeding rates associated with tranexamic acid, desmopressin, platelet transfusion, plasma transfusion and recombinant activated factor VII, for patients with unclassified bleeding disorders undergoing surgery, childbirth or with menorrhagia. We searched for randomized controlled trials in MEDLINE, Embase, The Cochrane Central Register of Controlled Trials, PubMed, ISI Web of Science and the Transfusion Evidence Library from inception to 24 February 2020. Wherever appropriate, data were pooled using the metaprop function of STATA. Two studies with 157 participants with unclassified bleeding disorders were identified. The pooled risk of minor bleeding for patients undergoing surgery treated with peri-operative tranexamic acid was 11% (95% confidence interval 3--20%; n = 52; I2 = 0%); the risk for desmopressin and tranexamic acid in combination was 3% (95% confidence interval 0--7%; n = 71; I2 = 0%). There were no instances of major bleeding. In one procedure, 1 of 71 (1.4%), treated with a combination of desmopressin and tranexamic acid, the patient had a line-related deep vein thrombosis. There were too few patients treated to prevent postpartum haemorrhage or for menorrhagia to draw conclusions. The GRADE quality of evidence was very low suggesting considerable uncertainty over the results. However, both tranexamic acid, and the combination of tranexamic and desmopressin have high rates of haemostatic efficacy and have few adverse events., Protocol Registration: PROSPERO CRD42020169727., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

This case discusses an elderly female who presented acutely with compromised profunda femoris pseudoaneurysm and massive haematoma five weeks after dynamic hip screw insertion for a left neck of femur fracture. The only precipitating factor leading to this presentation was ongoing physiotherapy. She was referred from a rehabilitation hospital to the nearest vascular surgical unit for acute and definitive surgical intervention. Post-operatively, she fared incredibly well, regaining her baseline level of functioning. History taking is complex in a patient with dementia. Clinical examination should follow with a focused approach to the site of recent operation and also where complications are likely to manifest when an alteration from baseline cognitive function is noted. This is of course in addition to the complete work up required from a holistic perspective with any acute deterioration. Imaging should be arranged and prompt referral made if a treatable acute cause is identified. It is imperative to involve family and/or next of kin if possible, but this should not impede prompt decision-making in the patient's best interests by the clinical team if delays are likely to occur.

Background: Acute adrenal insufficiency is a rare but potentially lethal condition, that is important to identify promptly and treat with replacement therapy. It can be consequent to adrenal hemorrhage that can occur after major orthopedic surgery. Few data are available about potential recovery of adrenal function, as well as both timing and modality of cortisone acetate withdrawal, probably due to the assumption that adrenal failure should be definitive. The extension of adrenal damage can be different, so justifying a partial, or potentially complete, recovery of adrenal function. The aim of our article is to highlight the opportunity of a periodical revaluation of adrenal reserve in order to identify those patients which are able to interrupt replacement therapy., Case Presentation: We had recently described one case of acute adrenal insufficiency, which developed short time after hip replacement; the patient was able to discontinue cortisone acetate treatment 46 months after the diagnosis and remained untreated up to five years later. We collected other two cases of acute adrenal insufficiency, developed about one week after major orthopedic surgery. We followed such patients for about three years, repeatedly reassessing adrenal imaging and cortisol response to 250 μg ACTH test, in order to ascertain the real need of lifetime substitutive treatment with cortisone acetate. Acute adrenal insufficiency partially reverted during the follow up for both patients. We observed a reduction in adrenal glands' volume and a progressive improvement of cortisol basal levels, without response (or with a poor one) to ACTH stimulation, as well as with ACTH basal levels persistently above the normal range after 36 and 28 months respectively spent from the acute event., Conclusion: The present finding suggests the opportunity that patients developing acute adrenal insufficiency after major orthopedic surgery undergo long-term surveillance, in order to establish if steroid replacement has to be continued, or it can be safely withdrawn., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Postoperative hemorrhages are relatively common complications of surgical procedures including craniotomies, and these typically occur at or near the operative site. Bleeding in remote areas (e.g., posterior fossa) after supratentorial craniotomy can occur and may be associated with a high morbidity and mortality. Although remote cerebellar hemorrhage after craniotomy is well described, remote pontine hemorrhage is less common. We describe a bilateral internuclear ophthalmoplegia due to an RPH after otherwise uncomplicated resection of a frontal meningioma. Clinicians should be aware that neuro-ophthalmic findings can occur from hemorrhages remote from the operative site.

Objective: To compare the effectiveness of a temporary topical external haemostat (OMNI-STAT Granules, Omni-stat Medical Inc., US) versus the use of electrocautery for bleeding control in patients who have undergone surgical wound debridement. Time saved in the operating room (OR) was evaluated., Method: A prospective evaluation of use of a topical haemostat in an OR setting was compared with retrospective data collected using electrocautery to understand the time-saving benefits of using a topical haemostat versus electrocautery., Results: A total of 52 patients were treated with the topical haemostat, and 89 patients with electrocautery. The topical haemostat was shown to be as effective in achieving haemostasis post-surgical debridement as electrocautery, with the added benefits of significant time savings in the OR (reducing the mean total OR time by 19.1%). Additionally, preprocedure and surgical procedure times in patients treated with the topical haemostat were significantly reduced. The results showed that wounds treated with the topical haemostat demonstrated a more advanced stage of healing, which may be a result of the lack of tissue damage demonstrated with the topical haemostat compared with electrocautery., Conclusion: This study found that the temporary topical haemostat was equally as effective as cauterisation in achieving haemostasis. In addition, significant saving in OR time was demonstrated relative to electrocautery. The improved OR times may translate into increased cost-effectiveness, relative to electrocautery, by increasing the number of surgical cases per day and/or using resources more effectively to treat more patients. It may also enable bleeding control in the outpatient clinic or at the bedside, freeing up costly OR time and enabling more effective management of healthcare resources.

Death is defined biologically as the irreversible loss of the functioning of the organism as a whole, which typically occurs after the loss of cardiorespiratory function. In 1968, a Harvard committee proposed that death could also be defined neurologically as the irreversible loss of brain function. Brain death has been considered to be equivalent to cardiorespiratory arrest on the basis of the belief that the brain is required to maintain functioning of the organism as a whole and that without the brain, cardiorespiratory arrest and biological death are both rapid and certain. Over the past 20 years, however, this equivalence has been shown to be false on the basis of numerous cases of patients correctly diagnosed as brain-dead who nevertheless continued to survive for many years. The issue reached national attention with the case of Jahi McMath, a young woman diagnosed as brain-dead after a surgical accident, who survived for almost 5 years, mostly at home, supported with a ventilator and tube feedings. The fact that brain death is not biological death has many implications, notably including the concern that procurement of organs from brain-dead donors may not comply with the so-called dead donor rule, which requires that vital organs be procured from patients only after they are dead. In this article, I conclude with an analysis of options for moving forward and among them advocate for reframing brain death as a "social construct," with implicit societal acceptance that patients diagnosed as brain-dead may be treated legally and ethically the same as if they were biologically dead., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Acoustic respiratory rate (RRa) monitoring is a non-invasive method of monitoring respiratory rate in spontaneously breathing individuals. The aim of this report is to highlight the clinical utility of this monitoring system in post-thyroidectomy patients by presenting a case of respiratory compromise due to post-thyroidectomy hematoma, in which the alarm of the respiratory rate monitor alerted the nursing staff about the complication. A 61-year-old woman who uneventfully underwent right thyroid lobectomy for adenomatous goiter under general anesthesia with endotracheal intubation was being monitored postoperatively using the RRa monitoring system. The alarm of the monitor suddenly indicated tachypnea, with an increase in respiratory rate from 8 to 30 breaths/min over less than 3 min, although with normal oxygenation (SaO 2 99%). Physical examination revealed the presence of a hematoma due to postoperative bleeding, which was emergently treated surgically under general anesthesia with awake videolaryngoscopy-assisted endotracheal intubation, with adequate preparations for emergency tracheostomy, if required. Videolaryngoscopy before the intubation revealed mild laryngopharyngeal edema and tracheal displacement, although awake endotracheal intubation could be easily performed with a metallic tube. Thereafter, after anesthesia induction, the hematoma was drained, hemostasis was achieved, and the wound was closed after surgical drain insertion. The patient was extubated postoperatively without any further respiratory events. The information on respiratory rate disorders provided by RRa monitoring, including the tachypnea alarm, can contribute to early detection of postoperative respiratory complications and to avoiding life-threatening situations following certain operations, such as thyroidectomy.

Background: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a safe procedure and extraintestinal bleeding after EUS-FNA is rare. Two cases of biliary tract bleeding after EUS-FNA was reported, but no case of biliary hemorrhage with obstructive jaundice after EUS-FNA of pancreatic head tumor has been reported. We discuss one such case, the pitfalls encountered during EUS-FNA and how they were overcome., Case Presentation: A 78-year-old man suspected of pancreatic head cancer was introduced to our hospital for pathological examination by EUS-FNA. Because he took antithrombotic drugs, we performed EUS-FNA after withdrawal of the drugs and replacement by heparin. The next day after EUS-FNA, obstructive jaundice was suspected by hematologic examination. Endoscopic retrograde cholangio-pancreatography was carried out and biliary tract bleeding was observed. We diagnosed obstructive jaundice due to hemobilia and inserted an endonasal biliary drainage tube. During the following period, the bleeding stopped and total bilirubin decreased. On the 15th hospital day, he was transferred to another hospital for pre-operative examination., Conclusion: Biliary tract bleeding after EUS-FNA is quite rare but endosonographers must appreciate and deal appropriately with this adverse event.

Purpose: To determine whether bag-mask ventilation between induction of anaesthesia and tracheal intubation in children with post-tonsillectomy bleeding reduces the incidence of hypoxaemia and difficult direct laryngoscopy without increasing perioperative respiratory complications., Methods: Medical records, anaesthesia protocols and vital sign data were analysed from February 2005 to March 2017 for patients undergoing anaesthesia for surgical revision of bleeding tonsils. Type of rapid sequence induction and intubation (RSII; classical, ie, apnoeic, vs controlled, ie, with gentle bag-mask ventilation) was noted. Primary outcomes were incidence of moderate and severe hypoxaemia, grade of direct laryngoscopic views as well as occurrence of noted tracheal intubation difficulties. Haemodynamic alterations during RSII and perioperative adverse events such as noted gastric regurgitation, pulmonary aspiration and perioperative pulmonary morbidity were also recorded., Results: A classical RSII was performed for 22 surgical revisions in 22 children and a controlled RSII was used for 88 surgical revisions in 81 children. Patients undergoing controlled RSII had less incidence of severe hypoxaemia (1 vs 3; P = .025), better direct laryngoscopic views (P = .048) and less hypertension (5 vs 9; P < .001) than those patients managed by classical RSII. No tracheal intubation difficulties occurred. There was no significant perioperative pulmonary morbidity reported in either group., Conclusions: Controlled RSII had advantages over classical RSII in children with post-tonsillectomy bleeding and may become a strategic option in these patients to avoid hypoxaemia, difficult laryngoscopy and hypertension during induction of anaesthesia and tracheal intubation. Bag-mask ventilation in patients with bleeding tonsils did not lead to pulmonary morbidity., (© 2019 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Atypical hemolytic uremic syndrome (aHUS) is an extremely rare condition caused by an excessive activation of the complement pathway based on genetic or acquired dysfunctions in complement regulation, leading to thrombotic microangiopathy (TMA). A complement-amplifying condition (CAC) can trigger aHUS occurrence along with complement abnormality. We herein report a case of severe TMA after laparoscopic myomectomy in a healthy woman. This case was eventually diagnosed as complement-mediated TMA secondary to surgical invasive stress as a CAC, with no definitive diagnosis of aHUS despite a genetic test. The patient fully recovered after several eculizumab administrations.

Background: Olfactory and taste sensations have a high impact on the quality of life. Impaired olfactory and taste functions may have a negative effect on physical and mental well-being, personal hygiene, and nutritional satisfaction, leading to the occurrence of depressive symptoms and impaired quality of life. Therefore, the recovery period of patients with disturbed olfactory and taste functions may be prolonged, and return to active life may be delayed. We designed this study to determine whether on-pump and off-pump coronary artery bypass grafting (CABG) surgeries have any effects on olfactory and taste functions and compare these functions between the surgical groups., Methods: A total of 60 patients, who underwent elective isolated first-time CABG, were included in this study. Patients were divided into two groups as Off-Pump and On-Pump CABG groups with 30 patients in each group. In addition to patients' primary clinical and laboratory data, olfactory and taste functions were evaluated pre- and postoperatively in both groups separately, and then these functions were compared between the groups. Olfactory functions were evaluated by the Brief Smell Identification Test, while taste functions by the Burghart Taste test., Results: Olfactory functions significantly were disrupted in the postoperative period in patients undergoing on-pump CABG (P value < .05), while these functions significantly were not affected in patients undergoing off-pump CABG (P value > .05). During the preoperative period, advanced age and smoking were detected to be independent predictors of impaired olfactory function for the study population. During the postoperative period, smoking, amount of postoperative bleeding and serum low-density lipoprotein (LDL) level were found to be independent predictors of impaired olfactory function for just the On-Pump CABG Group. In both groups, no significant deterioration in taste functions occurred during the postoperative period (P value > .05)., Conclusion: Our study demonstrated that olfactory function was impaired in patients, who underwent on-pump CABG in the postoperative period, and significant impairment in taste function was present in neither off-pump nor on-pump CABG patients. However, the results of our study should be supported by more comprehensive, prospective, randomized controlled trials with more extensive patient series and by further tests.

OBJECTIVEThe goal in the study was to describe the clinical outcomes associated with robot-assisted stereoelectroencephalography (SEEG) in children.METHODSThe authors performed a retrospective, single-center study in consecutive children with medically refractory epilepsy who were undergoing robot-assisted SEEG. Kaplan-Meier survival analysis was used to calculate the probability of seizure freedom. Both univariate and multivariate methods were used to analyze the preoperative and operative factors associated with seizure freedom.RESULTSFifty-seven children underwent a total of 64 robot-assisted procedures. The patients' mean age was 12 years, an average of 6.4 antiepileptic drugs (AEDs) per patient had failed prior to implantation, and in 56% of the patients the disease was considered nonlesional. On average, children had 12.4 electrodes placed per implantation, with an implantation time of 9.6 minutes per electrode and a 10-day postoperative stay. SEEG analysis yielded a definable epileptogenic zone in 51 (89%) patients; 42 (74%) patients underwent surgery, half of whom were seizure free at last follow-up, 19.6 months from resection. In a multivariate generalized linear model, resective surgery, older age, and shorter SEEG-related hospital length of stay were associated with seizure freedom. In a Cox proportional hazards model including only the children who underwent resective surgery, older age was the only significant factor associated with seizure freedom. Complications related to bleeding were the major contributors to morbidity. One patient (1.5%) had a symptomatic hemorrhage resulting in a permanent neurological deficit.CONCLUSIONSThe authors report one of the largest pediatric-specific SEEG series demonstrating that the modern surgical management of medically refractory epilepsy in children can lead to seizure freedom in many patients, while also highlighting the challenges posed by this difficult patient population.

Robotic totally endoscopic coronary artery bypass grafting (TECAB) was introduced in 1998 and has over a period of two decades gradually emerged from single-vessel revascularization to multivessel bypass grafting. Dedicated centers have continuously evolved and further developed this minimally invasive method of coronary bypass surgery. A literature review was conducted to assess intra- and postoperative outcomes of TECAB. PubMed returned 19 comprehensive articles on TECAB. Investigation was focused on perioperative outcome parameters, i.e.: operative time, conversion to larger incision, revision for bleeding, atrial fibrillation, stroke, acute renal failure, and mortality. Outcome from the analysis of 2,397 reported cases showed an average operative time of 291 ± 57 minutes (range 112 to 1,050), conversion rate to larger incisions at 11.5%, and perioperative mortality at 0.8%. Pooled data demonstrated 4.2% operative revision rate due to postoperative hemorrhage, 1.0% stroke incidence, 1.6% acute renal failure, and 13.3% de novo atrial fibrillation. The mean length of hospital stay measured 5.8 ± 1.7 days. Conversion rates and operative times decreased over time. According to data in the literature, coronary bypass surgery carried out in completely endoscopic fashion utilizing robotic assistance can require relatively extensive operative times and conversion rates are somewhat higher than in other robotic cardiac surgery. However, major postoperative events lie in an acceptable range. TECAB remains the surgical revascularization method with the least tissue trauma and represents an opportunity for coronary artery bypass grafting via port access. Rates of major complications are at least similar to conventional surgical access procedures.

In BriefThe authors analyzed the costs associated with the three different procedures used to treat hydrocephalus in the pediatric population. They believe this study highlights the importance of patient-specific treatment decisions that are based on etiology and previous intervention. The patient-specific medical characteristics are a driving force in the cost of care.

Purpose: We aimed to estimate the usefulness of transcatheter arterial embolization (TAE) in patients with postoperative abdominal hemorrhage and to evaluate the effects of pancreatic fistula on clinical outcomes and angiographic findings., Materials and Methods: We enrolled 22 patients (20 males and 2 females; mean age 63 years; range 25-86 years), who underwent transarterial angiography for postoperative hemorrhage after abdominal surgery. This group corresponded to 28 procedures. Technical and clinical success rates were calculated, and clinical findings and outcomes were compared between patients with and without a pancreatic fistula., Results: Pre-interventional CT was performed in all patients before first angiography, and the location of the bleeding was identified in all but one patient. Active arterial bleeding, identified by extravasation of contrast agent (n = 12), pseudoaneurysm formation (n = 12), and arterial wall irregularity (n = 2) were detected in 28 angiographic procedures, and embolization was performed in 26 instances. Various embolization techniques such as isolation, packing, embolization, and stentgraft implantation were performed. The technical and clinical success rates were 96% (25/26 procedures) and 82% (18/22 patients), respectively. In hemodynamically unstable patients (shock index: heart rate/systolic blood pressure > 1), a 92% (12/13 cases) technical success rate was achieved. There were no significant differences in any evaluated parameters between patients with and without pancreatic fistula., Conclusion: TAE is a safe and effective for treating postoperative hemorrhage even in patients with hemodynamic instability and pancreatic fistula. Additionally, pre-interventional CT is useful for effective, consecutive interventions.

Anastomotic intraluminal bleeding is a well-known complication after total gastrectomy. Nevertheless, few data are published on acute bleeding obstruction pancreatitis (BOP) due to a bleeding from the jejunojejunostomy (JJ). In this paper we describe our experience. A total of 140 gastrectomies for EGJ cancer were performed in our Institute from January 2012 to January 2017. All reconstructions were performed with a Roux-en-Y anastomosis: a mechanical end-to-side esophago-jejunostomy and a mechanical end-to-side JJ. Three patients suffered from a bleeding at the JJ with a consequent BOP. We analyzed the time of diagnosis, the treatment and the outcomes. The three patients presented anemia at the laboratory findings on postoperative day (POD) 1. In patient I laboratory findings of acute pancreatitis were found in POD 2. CT scan was performed and showed signs of BOP. Endoscopic treatment was tried without success. Therefore, patient underwent surgery: JJ take down, bleeding control and anastomosis rebuild were performed. In spite of this the patient died of MOF in POD 4. Patient II had a persistent anemia treated with blood transfusions until POD 3, when laboratory tests showed increased lipase and bilirubin levels. Patient was successfully treated with endoscopy but several blood transfusions and a prolonged recovery were necessary. Patient III had laboratory findings of acute pancreatitis on POD 1. Immediate surgery was performed and patient was discharged on POD 9 without sequelae. BOP is a rare but deadly complication after Roux-en-Y anastomosis. An early diagnosis and an aggressive treatment seem to improve the outcome.

Purpose: To report two cases of retinal vascular occlusion and associated subconjunctival hemorrhage in needle optic nerve injury during local bulbar anesthesia., Methods: Surgical records of these two subjects who presented with acute vision loss after cataract extraction were studied, and systemic workup and ocular imaging were carried out to establish the cause., Results: Computerized tomography showed evidence of optic nerve injury., Conclusion: Subconjunctival hemorrhage could be an associated clinical finding in hypodermic needle injury-related retinal vascular occlusion during ocular anesthesia.

Objective: Post-operative bleeding in the head and neck area is potentially fatal. This 'real world' study sought to assess factors that increase the risk of re-operation for post-operative bleeding in head and neck cancer surgery., Methods: A total of 456 patients underwent surgery for head and neck cancer (591 operations). The primary endpoint was re-operation for bleeding., Results: The rate of re-operation for bleeding was 5 per cent of all operations. Re-operation for bleeding was an independent risk factor for 30-day mortality (odds ratio = 5.27, p = 0.014). Risk factors for re-operation because of bleeding included excessive (more than 4000 ml) fluid administration (over 24 hours) (p < 0.001), heavy alcohol consumption (p = 0.014), pre-operative oncological treatment (p = 0.017), advanced disease stage (p = 0.020) and higher tumour (T) classification (p = 0.034). Operations with more excessive bleeding (700 ml or more) were associated with an increased risk (p = 0.001) of re-operation for post-operative bleeding. Moreover, the risk of re-operation was significantly higher in patients undergoing microvascular surgery compared to those who had no oncological treatment pre-operatively (18 vs 6 per cent, p = 0.001)., Conclusion: The 30-day mortality risk increased over 5-fold in patients undergoing re-operation for bleeding.

Context: Cardiac tamponade (CT) following cardiac surgery is a potentially fatal complication and the cause of surgical reintervention in 0.1%-6% of cases. There are two types of CT: acute, occurring within the first 48 h postoperatively, and subacute or delayed, which occurs more than 48 h postoperatively. The latter does not show specific clinical signs, which makes it more difficult to diagnose. The factors associated with acute CT (aCT) are related to coagulopathy or surgical bleeding, while the variables associated with subacute tamponade have not been well defined., Aims: The primary objective of this study was to identify the factors associated with the development of subacute CT (sCT)., Settings and Design: This report describes a case (n = 80) and control (n = 160) study nested in a historic cohort made up of adult patients who underwent any type of urgent or elective cardiac surgery in a tertiary cardiovascular hospital. Methods: The occurrence of sCT was defined as the presence of a compatible clinical picture, pericardial effusion and confirmation of cardiac tamponade during the required emergency intervention at any point between 48 hours and 30 days after surgery. All factors potentially related to the development of sCT were taken into account., Statistical Analysis Used: For the adjusted analysis, a logistical regression was constructed with 55 variables, including pre-, intra-, and post-operative data., Results: The mortality of patients with sCT was 11% versus 0% in the controls. Five variables were identified as independently and significantly associated with the outcome: pre- or post-operative anticoagulation, reintervention in the first 48 h, surgery other than coronary artery bypass graft, and red blood cell transfusion., Conclusions: Our study identified five variables associated with sCT and established that this complication has a high mortality rate. These findings may allow the implementation of standardized follow-up measures for patients identified as higher risk, leading to either early detection or prevention., Competing Interests: There are no conflicts of interest

A 5-year-old male barn cat was presented with lethargy and excessive bleeding following castration. The patient developed hemolytic anemia and diagnostic tests revealed infection with feline immunodeficiency virus and Mycoplasma haemofelis. This case serves as a reminder of the importance of testing for infectious diseases and educating owners on feline infectious disease prevention and management.

We describe the successful use of cannula cricothyroidotomy and the Rapid-O2™ oxygen insufflation device (Meditech Systems Ltd, Dorset, UK) for rescue of a can't intubate/can't oxygenate (CICO) scenario in a patient with severe airway haemorrhage post-debridement of laryngeal amyloidosis. This case highlights the practical utility of a cannula technique for CICO rescue when appropriate equipment is used and when institutional measures are taken to prepare for this rare anaesthetic crisis.

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

Background: Spinal subdural hematomas (SSDHs) are rare and usually associated with bleeding diatheses, trauma, iatrogenic injury, spinal vascular malformations, or intraspinal tumors., Case Description: We report a case of a 75-year-old man who developed a symptomatic lumbosacral SSDH after undergoing resection of a right temporal glioblastoma multiforme. The patient subsequently recovered and was discharged home. Over the next 2 weeks, he developed progressively worsening symptoms of lower back pain, lower extremity weakness, and urinary retention. Although the patient had no known risk factors for developing a SSDH, magnetic resonance imaging on postoperative day 16 revealed an extensive L2-sacrum SSDH. The patient underwent L2-L5 total laminectomies for evacuation of the SSDH. His symptoms resolved after surgery. Literature review produced 26 other cases of SSDHs after intracranial surgery in patients without obvious risk factors. In our case, the lumbosacral SSDH may have originated from downward migration of intracranial blood in a gravity-dependent fashion. Radiographic evidence of blood within the posterior thecal sac of the patient's cervical spine supports this hypothesis., Conclusions: In most cases, SSDHs after intracranial surgery resolve with conservative treatment; however, as shown in our case, surgery may be required if there is progressive neurologic decline. Neurosurgeons should be aware of this potential complication after intracranial surgery; a magnetic resonance imaging of the spine may be indicated if there is unexplained lower extremity pain or weakness., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Postoperative rebleeding after thyroid surgery is a rare but a serious complication. The aim of this study was to ascertain the extent to which postoperative pressure could be used as detector for rebleeding after thyroid surgery., Methods: Thirty-two patients with thyroidectomy or hemithyroidectomy were considered prospectively. In the course of surgery, a pressure microsensor (3PN Probe Spiegelberg) was implanted into the postoperative cavity and data were collected for special activities and stress situations over the first 48 h postoperatively. Additional endpoint was the influence of drains on the determined values., Results: The overall mean pressure (MP) at rest on both postoperative days for all patients with and without drain was 0.36 ± 2.84 mmHg (range -6.7 to 6.7). The MP in all activity and stress situations on the first day was with 0.23 ± 3.71 mmHg, and on the second day, the MP was 1.33 ± 4.50. 92.13% of our values were below 7 mmHg. One patient had a hemorrhage. The pressure increases continuously up to 36 mmHg, before the patient was transferred to the operating theater., Conclusions: This is the first pilot study to consider continuous pressure measurement to be a potential tool for early detection of a postoperative rebleeding in thyroid surgery. In the strictest sense, postoperative intra-cervical pressure at rest ranges from subatmospheric to 7 mmHg. The elevation of pressure in case of a rebleeding up to 36 mmHg differs dramatically from normal postoperative pressure. The collected data will warrant further validation to be able to recommend threshold values for an early treatment decisions in rebleeding.

Objectives: In cardiac surgery, postoperative bleeding remains a frequent complication with various possible adverse outcomes. Re-exploration due to bleeding is frequent in this type of patient. Sternal wound infection is an infrequent but serious and devastating complication. Whether re-exploration due to bleeding significantly affects the incidence of sternal wound infection is uncertain. There is no consensus on allowed severity of bleeding and timing of intervention., Methods: A retrospective, observational cohort study of 15 350 consecutive patients who underwent cardiac surgical procedures from 1 April 2006 through 31 December 2013 in 3 different university hospitals in Denmark was performed. Re-exploration due to postoperative bleeding occurred in 873 patients. To adjust for possible confounders, propensity score matching and logistic regression analyses were performed based on the centre, EuroSCORE I/II factors, extracorporeal circulation time, drugs affecting bleeding and coagulation, postoperative bleeding and units of blood transfusions. Patients were matched into 2 groups of 779 patients each for further analysis. The short-term outcomes were sternum infection, 30-day mortality and acute renal failure needing dialysis. The long-term outcome was the number of deaths 6 months after surgery., Results: The incidence of re-exploration was 5.7%. In the raw data, sternal infection was higher in the re-exploration group (2.4% vs 1.4; P = 0.020). After propensity score matching, no differences in sternal infection or other measured outcomes were found between the groups, either by crude or adjusted analyses., Conclusions: Our study indicates that re-exploration is not associated with a higher frequency of severe postoperative complications. Probably the time of intervention for bleeding is important., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: We report a case of ruptured massa intermedia (MI) as a sequela of hydrocephalus., Case Description: A single case report is presented describing the sequelae of tumor bed hematoma after a posterior fossa hemangioblastoma resection in which the patient bled 3 days after surgery, resulting in secondary hydrocephalus and subsequently dilatation of the third ventricle, which resulted in rupture of the MI. The patient was managed on emergency basis with an external ventricular drain then endoscopically with a third ventriculostomy and clot extraction., Conclusions: Absent MI is not uncommon in hydrocephalic patients, and it is assumed to be the result of rupture from acute dilatation of the third ventricle. Our case report proves this assumption and documents the presence and absence of the MI before and after developing hydrocephalus., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Unlabelled: The reamer-irrigator-aspirator (RIA) is a device that has recently been developed to retrieve bone graft from the medullary canal of the femur and the tibia. As for most new surgical procedures, complications arise as part of the learning curve and/or imperfections in the design or technique. To increase awareness of potential complications and to prevent unnecessary harm to the patient, new complications need to be reported. We present case reports of 2 patients who developed severe intraoperative cardiac events presumably caused by excessive and rapid blood loss during RIA bone graft harvesting. This complication has not been described before. Increased awareness of excessive blood loss and subsequent cardiac events during an RIA procedure is warranted., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Introduction: This study was planned to investigate the impact of severe bleeding and blood transfusion on the development of stroke after coronary surgery., Methods: This cohort study includes 2357 patients undergoing isolated CABG from the prospective European Coronary Artery Bypass Grafting (E-CABG) registry. Severity of bleeding was categorized according to the Universal Definition of Perioperative Bleeding (UDPB), E-CABG and PLATO definitions., Results: Thirty patients (1.3%) suffered postoperative stroke. The amount of transfused red blood cell (RBC) (OR 1.10, 95%CI 1.03-1.18), preoperative use of unfractioned heparin (OR 4.49, 95%CI 1.91-10.60), emergency operation (OR 3.97, 95%CI 1.47-10.74), diseased ascending aorta (OR 4.62, 95%CI 1.37-15.65) and use of cardiopulmonary bypass (p = 0.043, OR 4.85, 95%CI 1.05-22.36) were independent predictors of postoperative stroke. Adjusted analysis showed that UDPB classes 3-4 (crude rate: 3.6% vs. 1.0%; adjusted OR 2.66, 95%CI 1.05-6.73), E-CABG bleeding grades 2-3 (crudes rate: 6.3% vs. 0.9%; adjusted OR 5.91, 95%CI 2.43-14.36), and PLATO life-threatening bleeding (crude rate: 2.5% vs. 0.6%, adjusted OR 3.70, 95%CI 1.59-8.64) were associated with an increased risk of stroke compared with no or moderate bleeding., Conclusions: Bleeding and blood transfusion are associated with an increased risk of stroke after CABG, which is highest in patients with severe bleeding., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

The objective of this study is to evaluate the preoperative coagulation pattern and its association to postoperative blood products transfusion in children with congenital heart disease (CHD), focusing on cyanotic patients (oxygen saturation, SATO 2  < 85%). From January to August 2014, preoperative standard coagulation tests and rotational thromboelastometry assays were performed on 81 pediatric patients (<16 years old) who underwent surgery for CHD with the aid of cardiopulmonary bypass. Sixty patients (74%) were acyanotic and 21 (26%) cyanotic. Mean age at time of surgery was 7.9 months (interquartile range 2.9-43.6 months). Cyanotic patients had a significantly higher hematocrit (P < 0.001), a reduced prothrombin activity (PT) (P = 0.01) level, and a lower platelet count (P = 0.02) than acyanotic patients. An inverse linear association was found between patient's SATO2 and clot formation time (CFT) (INTEM, P = 0.001, and EXTEM, P < 0.0001). A direct linear association was found between patient's SATO2 and maximum clot firmness (MCF) (INTEM, P = 0.04, and EXTEM, P = 0.05). Preoperative cyanosis was also associated with a lower median MCF in FIBTEM (P = 0.02). Cyanotic patients required more frequent postoperative transfusions of fibrinogen (7/21 patients, 33% vs. 4/60 patients, 6.7%, P = 0.01) and fresh frozen plasma (14/21, 67% vs. 25/60, 42%, P = 0.08). Patients with a lower presurgery PT and platelet count subsequently required more fibrinogen transfusion P = 0.02 and P = 0.003, respectively); the same goes for patients with a longer CFT (INTEM, P = 0.01 and EXTEM, P = 0.03) and a reduced MCF (INTEM, P = 0.02 and FIBTEM, P = 0.01) as well. Cyanotic patients showed significant preoperative coagulation anomalies and required a higher postoperative fibrinogen supplementation. The preoperative MCF FIBTEM has become an important factor in our postoperative thromboelastometry-guided transfusion protocols., (Copyright © 2015 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Objectives: Severe bleeding related to cardiac surgery is associated with increased morbidity and mortality. Thromboelastography (TEG) and thromboelastometry (ROTEM) are point-of-care tests (POCT). Bedside ROTEM/TEG can rapidly detect changes in blood coagulation and therefore provide a goal-directed, individualized coagulation therapy. In this meta-analysis, we aimed to determine the current evidence for or against POCT-guided algorithm in patients with severe bleeding after cardiac surgery., Methods: We performed a meta-analysis of randomized controlled trials and observational trials retrieved from a literature search in PubMed, EMBASE, and Cochrane Library. Only trials comparing transfusion strategy guided by TEG/ROTEM with a standard of care control group undergoing cardiac surgery were included. In addition, at least one clinical outcome had to be mentioned: mortality, surgical re-exploration rate, sternal wound infection, and acute kidney injury (AKI). Also, surrogate parameters such as transfusion requirements and amount of blood loss were analyzed. The pooled treatment effects (odds ratio [OR] and 95% confidence intervals [CI]) were assessed using a fixed or random-effects model., Results: The literature search retrieved a total of 17 trials (nine randomized controlled trial and eight observational trials) involving 8332 cardiac surgery patients. POCT-guided transfusion management significantly decreased the odds for patients to receive allogeneic blood products (OR 0.63, 95% CI 0.56-0.71; P < 0.00001) and the re-exploration rate due to postoperative bleeding (OR 0.56, 95% CI 0.45-0.71; P < 0.00001). Furthermore, the incidence of postoperative AKI (OR 0.77, 95% CI 0.61-0.98; P = 0.0278) and thromboembolic events (OR 0.44, 95% CI 0.28-0.70; P = 0.0006) was significantly decreased in the TEG/ROTEM group. No statistical differences were found with regard to inhospital mortality, cerebrovascular accident, or length of intensive care unit and hospital stay., Conclusions: TEG/ROTEM-based coagulation management decreases the risk of allogeneic blood product exposure after cardiac surgery. Furthermore, it results in significantly lower re-exploration rate, decreased incidence of postoperative AKI, and thromboembolic events in cardiac surgery patients. Results of this meta-analysis indicate that POCT-guided transfusion therapy is superior to the current standard of care., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Anemia is an independent predictor of bleeding complications and poor clinical outcomes after percutaneous coronary intervention. Percutaneous coronary transradial intervention (TRI) is better than percutaneous coronary transfemoral intervention (TFI) in terms of reducing bleeding complications that can affect the prognosis. This study aims to investigate the clinical outcomes between TRI and TFI for patients with anemia. We analyzed periprocedure complications, in-hospital mortality, and major adverse cardiac events for one year in the Korean TRI registry from January 2013 to April 2014. Patients with chronic kidney disease for whom TFI is preferred were excluded. Anemia was defined as hemoglobin <13 g/dl for men and <12 g/dl for women. A total of 1,279 patients were finally enrolled. Of these, 348 patients had anemia. Among them, 253 patients (72.7%) underwent TRI and 95 patients (27.3%) underwent TFI. There were no significant differences of baseline demographic characteristics between the TRI and TFI groups, except for the incidence of dyslipidemia (TRI 23.7% vs TFI 12.6%, p = 0.023). Multivariate logistic regression analysis revealed lower incidence of composite severe bleeding complications (hazard ratio 0.34, 95% CI 0.12 to 0.99, p = 0.049) and lower incidence of in-hospital mortality than TFI group (hazard ratio 0.74, 95% CI 0.62 to 0.88, p = 0.042). In conclusion, this study suggests that the TRI for patients with anemia may be translated into better prognosis in terms of lower rates of bleeding complications and in-hospital mortality., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: Infective endocarditis (IE) is associated with high mortality (20-40%) and neurological complications (20-50%). Postoperative intracranial haemorrhage (ICH) is a feared complication especially in patients with preoperative cerebral infarcts. The aim of this study was to determine the radiological characteristics of cerebral lesions that could predict the occurrence of postoperative ICH in IE patients., Methods: We retrospectively reviewed all charts, brain imaging and follow-up data from patients operated for left-sided endocarditis between January 2007 and April 2013., Results: A total of 308 patients (age 62.0 ± 13.9) underwent surgery for IE. Preoperative cerebrovascular complications were present in 122 patients (39.6%), representing stroke in 87, silent cerebral infarctions in 31 patients and transient ischaemic attacks in 4 patients. Among 118 patients with cerebral lesions, the aetiological classification of the lesions was ischaemic in 63.6%, ischaemic with haemorrhagic transformation (HT) in 17.8%, ischaemic with concomitant microbleeds in 16.1% and intracerebral bleeding in 2.5%. Postoperative ICH occurred in 17 patients and its incidence was slightly higher in patients with preoperative cerebral infarcts compared with those without preoperative cerebral infarcts [7.6 vs 4.2%, respectively, odds ratio (OR) 1.88, 95% confidence interval (CI) 0.70-5.02, P = 0.21]. However, the difference was not statistically significant. Similarly, the incidence of postoperative ICH was higher in cases of HT of ischaemic infarcts than in cases of ischaemic infarcts not complicated with HT (19.0 vs 5.3%). However, the difference was not statistically significant (P = 0.24). The radiological pattern of preoperative cerebral lesions was single in 35.6% and multiple in 60.0% of cases. Multiple cerebral lesions were associated with a non-significantly lower incidence of postoperative ICH than single lesions (5.6 vs 11.9%, respectively, OR: 0.44, CI: 0.11-1.73, P = 0.29)., Conclusions: The results suggest that the incidence of postoperative ICH in IE patients was slightly higher in the presence of preoperative cerebral infarcts. In addition, preoperative cerebral ischaemic infarcts complicated with HT tended to have a higher incidence of postoperative ICH than those not complicated with HT. However, the difference was not statistically significant. Multiple preoperative cerebral infarcts were not associated with higher incidence of postoperative ICH compared with single cerebral infarcts., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)