Primary and secondary postoperative hemorrhage in pediatric tonsillectomy

Tonsillectomy is the most common procedure for treatment of pediatric recurrent acute tonsillitis and tonsillar enlargement that contributes to obstructive sleep apnea hypopnea syndrome.Postoperative hemorrhage of tonsillectomy is a lifethreatening complication.AIM To identify the risk factors that may contribute to primary and secondary postoperative hemorrhage in pediatric tonsillectomy.METHODS The clinical data from 5015 children,3443 males and 1572 females,aged 1.92-17.08 years,with recurrent tonsillitis and/or tonsil hypertrophy who underwent tonsillectomy in our hospital from January 2009 to December 2018 were retrospectively collected.The variables including sex,age,time of onset,diagnosis,method of tonsillectomy,experience of surgeon,time when the surgery started and monthly average air temperature were abstracted.The patients with postoperative hemorrhage were classied into two groups,the primary bleeding group and the secondary bleeding group,and their characteristics were compared with those of the nonbleeding group separately.Statistical analysis was performed by chi-square test with SPSS 20.RESULTS Ninety-two patients had post-tonsillectomy hemorrhage,and the incidence rate of post-tonsillectomy hemorrhage was 1.83%.The mean age was 5.75 years.Cases of primary hemorrhage accounted for approximately 33.70%(31/92),and cases of secondary hemorrhage occurred in 66.30%(61/92).The rate of reoperation for bleeding was 0.92%,and the rate of rehospitalization for bleeding was 0.88%in all patients.Multiple hemostasis surgery was performed in 6.52%(3/46)of patients.The method of tonsillectomy(coblation tonsillectomy)and experience of the surgeon(junior surgeon with less than 5 years of experience)were significantly associated with primary hemorrhage(χ^(2)=5.830,P=0.016,χ^(2)=6.621,P=0.010,respectively).Age(over 6 years old)and time of onset(more than a 1-year history)were significantly associated with secondary hemorrhage(χ^(2)=15.242,P=0.000,χ^(2)=4.293,P=0.038,respectively).There was no signicant difference in sex,diagnosis,time when the surgery started or monthly average air temperature.There was a signicant difference in the intervention measures between the primary bleeding group and the secondary bleeding group(χ^(2)=10.947,P=0.001).The lower pole and middle portion were the common bleeding sites,followed by the upper pole and palatoglossal arch.CONCLUSION The incidence rate of post-tonsillectomy hemorrhage is low.Coblation tonsillectomy and less than 5 years’experience of surgeon contribute to the tendency for primary hemorrhage.Age and time of onset are responsible for secondary hemorrhage.

Nursing Care of a Case of Mediastinal Tumor Resection Combined with Postoperative Thoracic Hemorrhage after Video-assisted Thoracoscopic Surgery(VATS)

Objective: To summarize the nursing experience of a patient withpostoperative intrathoracic hemorrhage after thoracoscopic-assistedresection of the right upper mediastinal tumor through the original incision.Methods: Summarize the main points of nursing care of postoperativeintrathoracic hemorrhage after thoracoscopic mediastinal surgery, includingobservation and nursing when internal hemorrhage occurs after operation,respiratory management, activity management and pain managementmeasures. Result: After careful care, the patient recovered and dischargedsmoothly. Conclusion: It is particularly important to observe the overallobservation and take timely corresponding nursing measures for patientswith intrathoracic hemorrhage after thoracoscopic mediastinal surgery.

Postoperative bleeding in patients on antithrombotic therapy after gastric endoscopic submucosal dissection

To investigated the relationship between postoperative bleeding following gastric endoscopic submucosal dissection (ESD) and individual antithrombotic agents. METHODSA total of 2488 gastric neoplasms in 2148 consecutive patients treated between May 2001 and June 2016 were studied. The antithrombotic agents were categorized into antiplatelet agents, anticoagulants, and other antithrombotic agents, and we included combination therapies [e.g., dual antiplatelet therapy (DAPT)]. The risk factors associated with post-ESD bleeding, namely, antithrombotic agents overall, individual antithrombotic agents, withdrawal or continuation of antithrombotic agents, and bleeding onset period (during the first six days or thereafter), were analyzed using univariate and multivariate analyses. RESULTSThe en bloc resection and complete curative resection rates were 99.2% and 91.9%, respectively. Postoperative bleeding occurred in 5.1% cases. Bleeding occurred in 10.3% of the patients administered antithrombotic agents. Being male (P = 0.007), specimen size (P < 0.001), and antithrombotic agent used (P < 0.001) were independent risk factors for postoperative bleeding. Heparin bridging therapy (HBT) (P = 0.002) and DAPT/multidrug combinations (P < 0.001) were independent risk factors associated with postoperative bleeding. The bleeding rate of the antithrombotic agent continuation group was significantly higher than that of the withdrawal group (P < 0.01). Bleeding within postoperative day (POD) 6 was significantly higher in warfarin (P = 0.015), and bleeding after POD 7 was significantly higher in DAPT/multidrug combinations (P = 0.007). No thromboembolic events were reported. CONCLUSIONWe must closely monitor patients administered HBT and DAPT/multidrug combinations after gastric ESD, particularly those administered multidrug combinations after discharge.

Clinical Experience Sharing Of 218 Cases without Hemorrhage after Procedure for Prolapse and Hemorrhoids

Objective:To summarize the experience without hemorrhage after PPH of 218 patients with mixed hemorrhoid.Methods:PPH(Procedure for prolapse and hemorrhoids)was performed routinely.During operation,it is paid attention that the hemorrhoid artery should be completely mutilated,the anastomat should be squeezed before and after the anastomosis,the anastomosis should be carefully examined,the hemostasis should be completely performed,and relevant hemostasis measures should be taken after the operation.Results:None of the 218 patients had postoperative hemorrhage.Conclusion:Relevant measures can be taken after operation to prevent the occurrence of postoperative hemorrhage.

Time Course of Postoperative Complications in Low-Risk Women after Planned Cesarean Section

Objectives: Length of hospital stay after cesarean section is today much shorter than previously, and a stay of only 1 day is used in many departments. However, complications requiring immediate treatment must be diagnosed before leaving hospital. We assessed the time interval from planned cesarean section to diagnosis of major complications in low-risk women to estimate a safe time of discharge. Methods: We performed a retrospective observational study among 5633 women undergoing planned cesarean section from 2001-2017 at Aarhus University Hospital, Denmark. The inclusion criterion was postoperative complication graded as Clavien-Dindo ≥ II. Exclusion criteria were preoperative comorbidity or problems during surgery indicative of need for prolonged stay. Time from cesarean section to suspicion of a postoperative complication was the primary endpoint. Results: The study population consisted of 116 women with unexpected postoperative complications, 47 classified as Clavien-Dindo II and 69 as Clavien-Dindo III-IV. In 63 of the 116, the diagnoses were suspected within 24 hours (Clavien-Dindo II: 25, Clavien-Dindo III-IV: 38). These included all cases of relaparotomy and uterine atony with immediate need of medical treatment. Acute colonic pseudo-obstruction was diagnosed within 2 days, while other complications were suspected and treated 2 to 10 days postoperatively. Conclusions: Among low-risk women with a postoperative complication, all cases requiring relaparotomy and medically treated uterine atony were suspected within 24 hours after surgery. Discharge 24 hours after planned cesarean section seems safe in low-risk patients.

Sevoflurane Preconditioning and Total Knee Arthroplasty Bleeding: Randomized Controlled Trial

Background: Total knee arthroplasty (TKA) is a highly complex and effective surgery even though its perioperative bleeding may increase the need for blood transfusion and its associated infection risk, cardiovascular overload, increased costs, and mortality. As the tourniquet reduces intraoperative bleeding, it may be associated with postoperative bleeding, venous thrombosis, and distal ischemia. The reperfusion may trigger a local and systemic inflammatory response. Anesthetic preconditioning (APC) with sevoflurane minimizes ischemia-reperfusion syndrome (IRS). This study evaluated the effects of APC with sevoflurane on perioperative bleeding in TKA. Methods: We allocated 30 patients into two groups: a sevo group (sevoflurane 2% for 15 minutes before the tourniquet) and a control group (propofol infusion). Laboratory tests were collected right before the tourniquet (LAB PRE, in the operating room) and after its release at four moments: LAB POST (immediately after), LAB 2 (two hours after), LAB 12 (12 hours after), and LAB 24 (24 hours after). The volume of the suction drain was measured at one, two, 12, and 24 hours after the end of the surgery. Antifibrinolytics were not administered. Results: There was no statistically significant difference in bleeding-related variables, such as drained volume and hemoglobin and hematocrit measurements. Drainage volume was higher in the first two hours after the procedure, while hematocrit decreased pre- to postoperatively and between two and 12 hours post-procedure. Conclusion: Sevoflurane as an anesthetic preconditioning did not reduce postoperative bleeding in TKA surgery.

等离子扁桃体切除术后出血相关因素的研究

目的研究等离子扁桃体切除术后出血的相关风险因素,为临床实践提供指导。方法回顾性分析479例等离子扁桃体切除术患者的临床资料,其中38例患者术后出血(出血组),441例无出血(非出血组)。对两组患者年龄、性别、手术季节、病种、术后发热情况、术前中性粒细胞数量、术前APTT情况、术前血小板数量以及出血侧别和出血侧扁桃体的肿大程度进行统计学分析,探讨扁桃体术后出血可能的风险因素。结果 38例患者发生术后继发性出血,术后出血率为7.93%,卡方检验及二项Logistic回归分析均提示年龄、术后发热与术后出血显著相关(P均<0.05)。结论扁桃体切除术后出血是一常见并发症,年龄及术后发热是其危险因素。

Renal functional outcomes are not adversely affected by selective angioembolization following percutaneous nephrolithotomy

Objective:Selective angioembolization(SAE)effectively diagnoses and treats iatrogenic vascular complications following percutaneous nephrolithotomy(PCNL).Methods:We retrospectively reviewed 1329 consecutive PCNLs and identified patients who underwent SAE following PCNL with at least 12-month follow-up.Estimated glomerular filtration rate(eGFR)was calculated for all patients preoperatively,postoperatively and at last followup.A 1:2 matched cohort analysis was performed.Results:Twenty-three patients underwent SAE and matched to 46 controls.There was no statistically significant difference in preoperative,postoperative,and follow-up eGFR when comparing patients who underwent SAE and those with an uneventful course.Conclusion:Long-term eGFR is comparable in patients who undergo uncomplicated PCNL and those requiring SAE.

Immediate post-operative complications(I):Post-operative bleeding;vascular origin:Thrombosis pancreatitis

Simultaneous pancreas-kidney transplantation is the treatment of choice forinsulin-dependent diabetes that associates end-stage diabetic nephropathy, sinceit achieves not only a clear improvement in the quality of life, but also provides along-term survival advantage over isolated kidney transplant. However, pancreastransplantation still has the highest rate of surgical complications among organtransplants. More than 70% of early graft losses are attributed to technical failures,that is, to a non-immunological cause. The so-called technical failures includegraft thrombosis, bleeding, infection, pancreatitis, anastomotic leak and pancreaticfistula. Pancreatic graft thrombosis leads these technical complications as the mostfrequent cause of early graft loss. Currently most recipients receive postoperativeanticoagulation with the aim of reducing the rate of thrombosis. Hemoperitoneumin the early postoperative period is a frequent cause of relaparotomy, but it is notusually associated with graft loss. The incidence of hemoperitoneum is clearlyrelated to the use of anticoagulation in the postoperative period. Post-transplantpancreatitis is another cause of early postoperative complications, less frequentthan the previous. In this review, we analyze the most common surgicalcomplications that determine pancreatic graft losses.

Classic clamp-and-tie total thyroidectomy for large goiters in the modern era:To drain or not to drain?

AIM: To evaluate the role of drains in clamp-and-tie total thyroidectomy(c TT) for large goiters. METHODS: A hundred patients were randomized into group D(drains maintained for 24 h) and ND(no drains). We recorded epidemiological characteristics, thyroid pathology, hemostatic material, intraoperative events, operative time and difficulty, blood loss, biochemical and hematological data, postoperative vocal alteration and pain, discomfort, complications, blood in drains, and hospitalization.RESULTS: The groups had comparable preoperative characteristics, pathology, intraoperative and postoperative data. Hemostatic material was used in all patients of group ND. Forty patients in group D and 9 in ND felt discomfort(P < 0.001). CONCLUSION: Drains in c TT for large goiters give no advantage or disadvantage to the surgeon. The only "major disadvantage" is the discomfort for the patient. Inversely, drains probably influence surgeons' serenity,especially when c TT is performed in nonspecialized departments.

Delayed liver laceration following transjugular intrahepatic portosystemic shunt for portal hypertension

The transjugular intrahepatic portosystemic shunt(TIPS) is an acceptable procedure that has proven benefits in the treatment of patients who have complications from portal hypertension due to liver cirrhosis.Delayed liver laceration is a rare complication of the TIPS procedure.We describe a patient with portal hypertension due to liver cirrhosis,who suddenly presented with abdominal hemorrhage and liver laceration 8 d after TIPS.Few reports have described complications after TIPS placement.To the best of our knowledge,this is the first report describing delayed liver laceration.This potential and serious complication appears to be specific and fatal for TIPS in portal hypertension.We advocate careful attention to the technique to avoid this complication,and timely treatment is extremely important.

氨甲环酸在人工关节外科领域的应用

关节外科手术失血量一般较大,初次人工全膝关节置换术(total knee arthroplasty,TKA)后的失血量可达到1000~1790 ml[1],初次人工全髋关节置换术(total hip arthroplasty,THA)失血量更大,平均可达到1944ml[2],脊柱外科手术亦有大量出血的风险。随着外科手术技术的提高,例如小切口全髋关节置换术(minimal incision THA,MIS-THA)等骨科微创手术,以及自体血回输、术后引流血回输、急性等溶性血液稀释。