Postoperative bleeding after tonsillectomy – a risk factor study on 28,254 patients

Scientific and Standardization Committee Communication: Guidance document on the periprocedural management of patients on chronic oral anticoagulant therapy: Recommendations for standardized reporting of procedural/surgical bleed risk and patient‐specific thromboembolic risk

Considerations when choosing an appropriate bleeding risk assessment tool for patients with atrial fibrillation

Coronary Artery Bypass Grafting in Patients With High Risk of Bleeding

To investigate the effect of the type instrumentation used and the age and gender characteristics of patients on postoperative haemorrhage rates following tonsil and adenoid surgery. A retrospective analysis of 13 593 procedures was performed from The Patient Episode Database for Wales between 1 January 1999 and 31 March 2004. National health policy changes created four periods of different instrument usage (reusable, single-use with diathermy, single-use alone, specified single-use with diathermy). These and the age and gender distribution of the patients were examined against four categories of postoperative haemorrhage. Postoperative haemorrhage rates were expressed as the number of complications per operations performed. Primary postoperative haemorrhage that occurred during the initial admission either required a return to theatre [R1] or was managed conservatively [N1]; secondary postoperative haemorrhage that required a return to hospital either returned to theatre [R2] or was managed conservatively [N2], were compared. Primary haemorrhage with return to theatre doubled, from the baseline rate with reusable instruments, from 0.6% (CI 0.5-0.8) to 1.2% (CI 0.7-1.9) when single-use instruments were introduced and remained high at 1.4% (CI 0.9-2.1) after the withdrawal of single-use diathermy. This haemorrhage rate returned to the baseline rate (0.6% CI 0.3-1.0) when specified single-use instruments were introduced. None of the other haemorrhage rates changed significantly throughout the four observation periods. Adenotonsillectomy and tonsillectomy patients have different age and gender patterns. In a univariate analysis, males over the age of 12 years were twice as likely to have haemorrhage with return to theatre than girls of the same age, 3.8% (CI 3.0-4.7) versus 1.7% (CI 1.4-2.1). A significant rise in serious postoperative primary haemorrhage but not secondary haemorrhage was seen following the initial introduction of single-use instruments that reverted to baseline with the introduction of specified single-use instruments. Diathermy does not appear to have affected the haemorrhage rates. There is a distinct age and gender pattern for tonsil and adenoid surgery and risk of postoperative haemorrhage. The use of arbitrary divisions of age may be misleading in studies that examine post-tonsillectomy haemorrhage.

Bleeding after tonsillectomy

Perioperative Management of Warfarin Therapy: To Bridge or Not to Bridge, That Is the Question

Thirty days only double antiplatelet therapy after drug-eluting stenting: could a 'short-term' treatment be advantageous?

Tonsillitis and sore throat in children.

Personalized prophylactic anticoagulation decision analysis in patients with membranous nephropathy

Endoscopic submucosal dissection (ESD) for gastric neoplasms is a useful treatment globally. However, postoperative bleeding after gastric ESD is a serious, and sometimes life-threatening complication in patients receiving antithrombotic drugs, because antithrombotic drugs are considered to increase the risk of postoperative bleeding after gastric ESD. In contrast, withdrawal of antithrombotic drugs during the perioperative period increases the risk of thrombotic complications. Guidelines for the management of antithrombotic drugs during the periendoscopic period have been published by different countries, and recent guidelines place greater emphasis on the risk of thromboembolism with the discontinuation of antithrombotic drugs than on the risk of bleeding with the continuation of antithrombotic drugs. Several studies have reported on the validity of these guidelines, and clinical evidence is being established. Most studies reported that gastric ESD under continuation of aspirin or cilostazol did not increase the risk of bleeding, whereas heparin replacement was strongly associated with a higher risk of bleeding. However, the data regarding some clinical issues about the management of antithrombotic drugs, such as the safety of gastric ESD under continuation of thienopyridine, administration of multiple antithrombotic drugs including dual antiplatelet and anticoagulants (warfarin and direct oral anticoagulant), and effective prophylactic methods for postoperative bleeding after gastric ESD are lacking. Larger clinical data are needed to resolve the remaining issues in the future.

Effects of postoperative, nonsteroidal, antiinflammatory drugs on bleeding risk after tonsillectomy: meta-analysis of randomized, controlled trials.

Die Operation an den Gaumenmandeln ist im Kindesalter eine der haufigsten, und oftmals ist es der erste chirurgische Eingriff bei einem kleinen Patienten. Seit der medienwirksamen Haufung an Todesfallen von Kindern nach Tonsillektomie in Osterreich 2006 kommt es langsam zu einem Paradigmenwechsel in Deutschland. Da jedoch klare Leitlinien fehlen, werden Eingriffe an den Tonsillen je nach Landkreis und Vorlieben sehr inhomogen gehandhabt. In einigen Kreisen werden 8-mal so vielen Kindern die Gaumenmandeln entfernt wie in anderen. Kinder unter 6 Jahren sollten nur noch bei andauernden bakteriellen Mandelentzundungen komplett tonsillektomiert werden. Die Teilentfernung der hyperplastischen Mandeln, die Tonsillotomie, ist wesentlich risikoarmer und der Tonsillektomie vorzuziehen. Die Blutungsgefahr und die postoperativen Schmerzen sind bei der Tonsillotomie deutlich geringer als bei der Tonsillektomie. Die Tonsillotomie kann mit dem Laser, Radiofrequenzgerat, Shaver, Coblation, bipolarer Schere oder monopolarer Nadel durchgefuhrt werden. Entscheidend ist, dass die Krypten offen bleiben und lymphatisch aktives Gewebe in der Fossa tonsillaris zuruck bleibt. Die Indikation zur Tonsillektomie besteht weiterhin bei rezidivierenden bakteriellen Infekten, Antibiotikaallergie, PFAPA Syndrom (periodisches Fieber, Apthen, Pharyngitis, Adenitis) und Peritonsillarabszess (einseitig). Bei den rezidivierenden Tonsillitiden kommt es auf die Schwere und die Haufigkeit an. Bei Kindern bis zum Alter von 16 Jahren sollte man sich an die Paradise Kriterien halten: Eine Indikation zur klassischen, kompletten Tonsillektomie besteht bei 5 oder mehr Tonsillitiden in mindestens 2 aufeinander folgenden Jahren oder bei 7 oder mehr Tonsillitiden innerhalb eines Jahres. Die Diagnose Tonsillitis kann klinisch gestellt werden. Sie besteht bei Schmerzen, tonsillarem Exsudat und Fieber>38,3°C. Wandernder Schmerz, niedrigeres Fieber und Husten lassen eher an eine Viruspharyngitis denken. Im Zweifel sollte ein Abstrich oder Antigentest angelegt werden. Beim Abstrich oder Antigen-Schnelltest muss aber berucksichtigt werden, dass Viren, Bakterien und Pilze zur transienten Mundflora gehoren und 10% aller Kinder klinisch inapparente, nicht behandlungsbedurftige Dauerausscheider von Streptokokken sind. Screeningtests mittels Antistreptolysintiter, Abstrichen oder Schnelltests (wie von manchen Kindertagesstatten gefordert) sind daher sinnlos und rechtfertigen keine Antibiotikatherapie. Die akute, bakterielle Tonsillitis sollte mit nicht steroidalen Antirheumatika (z. B. Ibuprofensaft), Betalactamantibiotika (z. b. Penicillin oder Cefuroxim) und bei Kindern und Jugendlichen auch oralem Steroid (z. B. Dexamethason) behandelt werden. Hinsichtlich der Verkurzung des Krankheitsverlaufes und der Reduktion der Symptome ist die Kurzzeittherapie mit Azithromycin (20mg/kg KG) fur 3 Tage oder Clarithromycin und einem Cephalosporin fur 5 Tage der Langzeit Penicillintherapie ebenburtig. Auch das fruhzeitige Absetzen der Penicilline nach 5 Tagen zeigte keine Nachteile im Krankheitsverlauf, der Rezidivrate oder der Resistenzbildung. Aber nur die empfohlene 10 Tage Antibiotikatherapie senkt die Inzidenz des rheumatischen Fiebers (derzeit 0,5 Falle pro 100 000 Kinder in Europa) und der Glomerulonephritis signifikant. Hauptproblem bei der Tonsillektomie ist, neben dem Schmerz, die gefurchtete Spatnachblutung. Diese kann bis zum kompletten Abheilen der Wunde (i. d. R. nach drei Wochen) auftreten und lebensbedrohlich sein. Grosere Massenblutungen kundigen sich oft durch kleinere, spontan sistierende Blutungen an. Daher muss jede Nachblutung ernst genommen und der betroffene Patient stationar aufgenommen werden. Die Patienten und die Eltern sind uber das korrekte Vorgehen bei Nachblutung idealerweise vor der Operation, aber spatestens bei Entlassung, schriftlich zu informieren. Das Informationsblatt sollte Adressen, Notruftelefonnummern und Ansprechpartner enthalten. Schwere oder letale Verlaufe entstehen meist durch falsches Management der Nachblutung. Eine besondere Lebensgefahrdung besteht bei Kleinkindern, die ein geringes Blutvolumen haben und relativ viel Blut unbemerkt schlucken konnen, bzw. aspirieren. Fur den Notarzt stellt die Intubation einer massiven Nachblutung nach Tonsillektomie eine extreme Herausforderung dar, welche oft nur mit einem geeigneten starren Tonsillensauger bewerkstelligt werden kann. Alle Operationstechniken haben ein Risiko der Nachblutung und selbst der erfahrenste Operateur ist nicht davor gefeit. Jedoch zeigte die „Kalte Dissektion“ mit Ligatur oder Umstechungen die geringsten Nachblutungsraten. Nach Laser-, Coblations-, mono- oder bipolaren Techniken kommt es signifikant haufiger zu schweren Nachblutungen. Kinder mit Gerinnungsstorungen bluten haufiger nach und konnen praoperativ unentdeckt bleiben. Eine standardisierte Blutungsanamnese (17 Punkte Checkliste), wie von den Fachgesellschaften fur Padiatrie, Anasthesie und HNO empfohlen, ist sensitiver und einfacher als das Screening mittels Gerinnungsparametern. In der Realitat zeigt sich jedoch, dass in Deutschland sehr viele der operativ-tatigen HNO Arzte weiterhin harte Laborwerte wie INR und PTT bevorzugen, obwohl diese den haufigen Von-Willebrand-Faktormangel nicht detektieren ­konnen.

Correlation between hemorrhage risk prediction score and severe maternal morbidity

Objective Unwarranted variation in clinical practice is a target for quality improvement in health care, but there is no consensus on how to identify such variation or to assess the potential value of initiatives to improve quality in these areas. This study illustrates the use of a triple test, namely the comparative analysis of processes of care, costs and outcomes, to identify and assess the burden of unwarranted variation in clinical practice. Methods Routinely collected hospital and mortality data were linked for patients presenting with symptoms suggestive of acute coronary syndromes at the emergency departments of four public hospitals in South Australia. Multiple regression models analysed variation in re-admissions and mortality at 30 days and 12 months, patient costs and multiple process indicators. Results After casemix adjustment, an outlier hospital with statistically significantly poorer outcomes and higher costs was identified. Key process indicators included admission patterns, use of invasive diagnostic procedures and length of stay. Performance varied according to patients' presenting characteristics and time of presentation. Conclusions The joint analysis of processes, outcomes and costs as alternative measures of performance inform the importance of reducing variation in clinical practice, as well as identifying specific targets for quality improvement along clinical pathways. Such analyses could be undertaken across a wide range of clinical areas to inform the potential value and prioritisation of quality improvement initiatives. What is known about the topic? Variation in clinical practice is a long-standing issue that has been analysed from many different perspectives. It is neither possible nor desirable to address all forms of variation in clinical practice: the focus should be on identifying important unwarranted variation to inform actions to reduce variation and improve quality. What does this paper add? This paper proposes the comparative analysis of processes of care, costs and outcomes for patients with similar diagnoses presenting at alternative hospitals, using linked, routinely collected data. This triple test of performance indicators extracts maximum value from routine data to identify priority areas for quality improvement to reduce important and unwarranted variations in clinical practice. What are the implications for practitioners? The proposed analyses need to be applied to other clinical areas to demonstrate the general application of the methods. The outputs can then be validated through the application of quality improvement initiatives in clinical areas with identified important and unwarranted variation. Validated frameworks for the comparative analysis of clinical practice provide an efficient approach to valuing and prioritising actions to improve health service quality.

Partial nephrectomy (PN) has been established as the standard treatment for T1 kidney tumors, and postoperative hemorrhage has been reported as a potentially life-threatening complication.PurposeTo estimate the risk of bleeding requiring blood transfusion using patient characteristics in order to risk-stratify patients preoperatively and identify patients at high risk of bleeding following PN. We also aim to quantify the effect of this bleeding complication on postoperative morbidity and mortality.Materials and methodsThe demographics, associated co-morbidities, and some pre-operative variables, operation characteristics and baseline laboratory values were examined in 23,257 patients undergoing PN in the American College of Surgeons - National Surgical Quality of Improvement Program (ACS-NSQIP) dataset from 2005 to 2017. We divided our cohort into two groups based on the requirement of a blood transfusion post-operation. Multivariable logistic regression was done to evaluate pre-operative variables associated with post-operative transfusion. The secondary outcome was analyzed, using Chi-square and student t-test, to compare post-operative morbidities and mortality between groups.ResultsOf the 23,257 patients who underwent partial nephrectomy (PN), 1,287 (5.5%) experienced postoperative hemorrhage requiring transfusion. Univariate analysis revealed significant differences between the hemorrhage and non-hemorrhage groups with respect to age, race, body mass index, comorbidities, ASA class, surgical approach, year of operation, and baseline laboratory values. However, on multivariate analysis, only older age, open surgical approach, presence of a bleeding disorder, having received preoperative transfusions, higher preoperative blood urea nitrogen (BUN), lower serum albumin, lower hematocrit, and prolonged partial thromboplastin time (PTT) were independently associated with an increased risk of postoperative hemorrhage. Furthermore, patients who experienced hemorrhage had significantly higher rates of other postoperative complications compared to those who did not.ConclusionsAccurate estimation of bleeding risk is critical for decision making and informed consent prior to PN, especially given the demonstrated impact on morbidity and mortality of this complication. A risk calculator is a helpful tool to help minimize the occurrence of this complication.