Rate Of Hemorrhage In Patients Research Articles

Long-Term Hemorrhage and Reperfusion Rates of Coiled Aneurysms: A Single-Center Experience.

Background: The endovascular approach has emerged as standard therapy for many intracranial aneurysms (IAs) to prevent hemorrhage, yet its long-term durability varies considerably. The aim of this study was to evaluate the safety and effectiveness of an initially deliberate endovascular approach regarding IA hemorrhage rates over a long-term follow-up period. Methods: This retrospective single-center study included all consecutive patients with endovascularly treated IAs who presented between January 2008 and December 2020 with a follow-up of at least 12 months. The primary endpoint was the proportion of patients with long-term IA hemorrhage rates and reperfusion. The secondary endpoint was treatment-related morbidity and mortality. Independent risk factors for IA reperfusion over the long term were analyzed using multivariate logistic regression. Results: Endovascular treatment was the therapy of choice for 333 patients with IAs, among whom 188 (57%) experienced rupture upon presentation. Complete coiling (Raymond I) was noted in 162 (49%) of the patients, with primary supportive devices being used in 51 (15%) patients. After a median (±SD) follow-up time of 34 ± 41 months (range 12-265 months), IA reperfusion was noted in 158 (47%), necessitating retreatment in 105 (32%) of the patients. Over the long term, hemorrhage was noted in four (1%) patients. Multivariate analysis revealed aneurysmal multilobarity (HR 1.8, 95%CI 1.2-2.7; p = 0.004) and a patient age of ≥50 years (HR 1.7, 95% CI 1.1-2.5, p = 0.01) as independent predictors of reperfusion over time. Intervention-related morbidity was noted in 16 (4.8%) patients, namely, thrombosis formation and contrast extravasation in 8 (2.4%) patients each, while no intervention-induced mortality was observed. Conclusion: In the long term, the hemorrhage rate in patients with IA with an initially more conservative endovascular approach is low. Therefore, a deliberate endovascular treatment approach might be justified.

Comparison of Post-Tonsillectomy Hemorrhage rate in patients undergoing two commonly used Tonsillectomy Methods.

Objective: To compare the cold steel method and bipolar diathermy in tonsillectomies in terms of post-tonsillectomy hemorrhage. Study Design: Randomized Controlled Trial. Setting: Department of ENT, Head & Neck Surgery, Ayub Teaching Hospital, Abbottabad. Period: 29th October 2020 to 1st June 2022. Methods: A total of 102 patients of both genders with ages 3 to 59 years undergoing tonsillectomy were included. Patients undergoing antiplatelet therapy, experiencing bleeding diathesis, possessing a high anesthetic risk, having uncontrolled medical conditions, suffering from anemia, or currently dealing with acute infections were not included in the study. Patients were divided into two groups A & B. Group A patients were operated by the Cold steel method and Group B were operated by Bipolar diathermy. All the surgeries were performed by the same surgical team. Both tonsils were fully exposed by Boyl Devi's mouth gag under general anesthesia. Complete removal of both tonsils was done with the Cold steel method in group A and by using Bipolar diathermy in group B. Post-operative hemorrhage (occurring 24 hours after surgery) without the necessity to return to the operation theatre for intervention was assessed. Results: The mean age of patients in group A was 20.0 ± 13.83 years and in group B was 19.12 ± 13.17 years. The majority of the patients 79 (77.45%) were between 3 to 30 years of age. Out of 102 patients, 63 (61.76%) were males and 39 (38.24%) were females with male to female ratio of 1.6:1. Frequency of secondary hemorrhage in Group A (cold steel method) was found in 01 (1.96%) while in Group B (bipolar diathermy) was 06 (11.76%) (p-value = 0.050). Conclusion: This study concluded that the frequency of post-tonsillectomy hemorrhage is higher in patients operated by bipolar diathermy as compared to the cold steel method.

Outcomes of catheter-directed thrombolysis versus systemic thrombolysis in the treatment of pulmonary embolism: a meta-analysis.

To evaluate the safety and efficacy of catheter-directed thrombolysis (CDT) versus systemic thrombolysis (ST) in the treatment of pulmonary embolism (PE). The Cochrane Library, PubMed, and Embase databases were searched to collect the literature on the comparison of the results of CDT and ST in the treatment of PE from the beginning of their records to May 2020, and meta-analysis was performed by STATA software (version 15.1). Using standardized data-collection forms, the authors screened the studies and independently extracted data, and assessed the quality of the studies using the Newcastle-Ottawa Scale for cohort studies. Cohort studies that examined the following results were included in the current study: in-hospital mortality, all-cause bleeding rate, gastrointestinal bleeding rate, intracranial hemorrhage rate, the incidence of shock, and hospital length of stay. A total of eight articles, with 13,242 participants, involving 3962 participants in the CDT group and 9280 participants in the ST group were included. CDT compared with ST in the treatment of PE can significantly affect in-hospital mortality rate [odds ratio (OR) = 0.41, 95% CI: 0.30-0.56, P < 0.05], all-cause bleeding rate (OR = 1.20, 95% CI: 1.04-1.39, P = 0.012), gastrointestinal bleeding rate (OR = 1.43, 95% CI: 1.13-1.81, P = 0.003), the incidence of shock (OR = 0.46, 95% CI: 0.37-0.57, P < 0.05), and hospital length of stay [standard mean difference (SMD) = 0.16, 95% CI: 0.07-0.25, P < 0.05]. However, there was no significant effect on intracranial hemorrhage rate in patients with PE (OR = 0.70, 95% CI: 0.47-1.03, P = 0.070). CDT is a viable alternative to ST in the treatment of PE, as it can significantly reduce in-hospital mortality rate, all-cause bleeding rate, gastrointestinal bleeding rate, and incidence of shock. However, CDT may prolong hospital length of stay to a certain extent. Further research is needed to evaluate the safety and efficacy of CDT and ST in the treatment of acute PE and other clinical outcomes.

Hemorrhage rates in patients with acute ischemic stroke treated with intravenous alteplase and thrombectomy versus thrombectomy alone

BackgroundIntravenous alteplase treatment (IVT) for acute ischemic stroke carries a risk of intracranial hemorrhage (ICH). However, reperfusion of an occluded vessel itself may contribute to the risk of ICH. We...

Abstract P623: Lipid-Lowering Therapy and Intracerebral Hemorrhage Risk: Comparative Meta-Analysis of Statins and PCSK9 Inhibitors

Background: Statins were shown to increase intracerebral hemorrhage rates in patients with a first cerebrovascular event in 2006 (SPARCL), likely due to off-target antithrombotic effects, but continued to sometimes be used in elevated ICH risk patients due to absence of alternative agents. Recently, the PCSK9 inhibitors (PCK9is) have become available as potent lipid-lowering class that may not share the hemorrhagic propensity of statins. Methods: Systematic comparative meta-analysis assessing ICH rates across all completed statin and PCSK9i RCTs, following PRISMA guidelines. In addition to ICH rates across all trials, causal relation was probed by evaluating for dose-response relationships by agent (low vs high agent dose) and by degree of brain injury at inception (none vs ischemic stroke vs ICH). Results: The systematic review identified 33 statin RCTs (203,305 patients) and 4 PCSK9i RCTs (53,253 patients). Across all patient types and all agent doses, statins were associated with increased ICH: relative risk (RR) 1.15, p=0.04; PCSK9is were not (p=0.59). In the agent dose analysis (Table), higher dose statins (7 trials, 62,204 patients) were associated with magnified ICH risk: RR 1.53, p=0.002; higher dose PCSK9is (2 trials, 31,153 patients) were not (p=0.99). In the brain injury dose analysis (Table), for statins, h/o ischemic stroke was associated with a magnified risk of ICH: RR 1.40, p=0.03; and h/o initial ICH was associated with an extremely high effect estimate of risk of recurrent ICH: RR 4.06. For PCSK9is, h/o ischemic stroke was not associated with ICH (p=0.97). Conclusion: Statins increase the risk of intracerebral hemorrhage, and the risk is magnified in an agent dose- and brain injury dose-dependent manner; PCSK9is do not ICH risk. PCSK9is may be a preferred lipid-lowering agent class in patients with elevated ICH risk, including patients with intracerebral hemorrhage or multiple covert cerebral microbleeds.

Ketorolac usage in tonsillectomy and uvulopalatopharyngoplasty patients.

Postoperative pain for tonsillectomy with or without adenoidectomy or uvulopalatopharyngoplasty (UPPP) can be severe. Ketorolac is a nonsteroidal anti-inflammatory drug that can be administered for analgesia in these patients. In the literature, ketorolac has been associated with an increased risk of hemorrhage after tonsillectomy with or without adenoidectomy. Many other surgical fields have successfully utilized this medicine for postoperative pain control without increased incidence of hemorrhage. The goal of this study was to analyze the effectiveness of ketorolac after tonsillectomy with or without adenoidectomy or UPPP in adults on postoperative hemorrhage rates. Adult patients older than 18 years of age who underwent tonsillectomy with or without adenoidectomy and UPPP between 2013 and 2018 were assessed to determine hemorrhage rates. Hemorrhage rates were assessed based on patients presenting to the emergency department with complaint of hemorrhage. There was no significant difference between groups in the postoperative hemorrhage rates (P = .331) or the method of hemorrhage control. Ketorolac did not increase postoperative hemorrhage rates in patients posttonsillectomy with or without adenoidectomy or UPPP. 4 Laryngoscope, 130:876-879, 2020.

Thrombolysis Is Not Associated with a Higher Rate of Cerebral Hemorrhage in Patients with Severe Ischemic Stroke

Thrombolysis Is Not Associated with a Higher Rate of Cerebral Hemorrhage in Patients with Severe Ischemic Stroke

Efficacy analysis of Onyx embolization in combination with gamma knife surgery for the treatment of intracranial arteriovenous malformation

Objective To investigate the effectiveness and safety of Onyx embolization in combination with gamma knife surgery for the treatment of intracranial arteriovenous malformations (AVMs). Methods A total of 86 patients with AVM admitted to the Neurological intervention Center, Beijing Neurosurgery Institute, Capital Medical University and treated with Onyx embolization in combination with gamma knife surgery from April 2004 to September 2011 were analyzed retrospectively. The related complications and clinical prognosis of embolization were counted and analyzed. During the embolization of AVMs, the combined high risk of bleeding (intracranial aneurysms, hemodynamic aneurysms, and AVM-related arteriovenous fistula) were assessed and embolized. According to the risk factors and embolization or not, the intracranial AVMs with high risk factors were divided into either a targeted embolization group or a non-targeted embolization group. The effect of targeted embolization on hemorrhage risk was assessed. Results The overall annual hemorrhage rate in patients with AVM was 1.66%, and the ruptured AVM was 2.26%, the unruptured AVM was 1.08%, and the annual mortality rate was 0.74%. One of 16 patients with embolization related complications had permanent neurological dysfunction. Twenty-four of 29 patients complicated with intranidal aneurysm underwent targeted embolization; 4 of 5 patients with hemodynamic aneurysm underwent targeted embolization; and 8 of 9 patients with arteriovenous fistula underwent targeted embolization. Chi square test showed that the hemorrhage complications of the targeted embolization group was significantly lower than that of the non-targeted embolization group (P<0.01). Conclusion The targeted embolization in combination with gamma knife surgery may decrease the risk of intracranial AVM hemorrhage, improve clinical prognosis and occur less permanent complications. This method is suitable for the treatment of intracranial AVMs of larger volume and those can not be cured with a single program. Key words: Intracranial arteriovenous malformations; Cerebral angiography; Radiotherapy; Hemorrhage; Postoperative complication

Vocal fold varices and risk of hemorrhage.

To establish risk of hemorrhage in patients with varices compared to those without, determine additional risk factors, and make evidence-based treatment recommendations. Retrospective cohort study. Patients who were vocal performers presenting for care during a 24-month period were analyzed to determine incidence of hemorrhage. Patients with varices were compared to those without. Demographic information and examination findings (presence, location, character, and size of varices; presence of mucosal lesions or paresis) were analyzed to determine predictors of hemorrhage. A total of 513 patients (60.4% female, mean age 36.6 years ± 13.95 years) were evaluated; 14 patients presenting with hemorrhage were excluded. One hundred and twelve (22.4%) patients had varices; 387 (77.6%) did not. The rate of hemorrhage in patients with varices was 2.68% at 12 months compared to 0.8% in patients without. Cox proportional hazard regression analysis revealed a hazard ratio of 10.1 for patients with varix developing hemorrhage compared to nonvarix patients (P < 0.0001). The incidence rate of hemorrhage was 3.3 cases per 1,000 person-months for varix patients compared to 0.5 cases per 1,000 person-months in the nonvarix group. There was no significant difference in the incidence of paresis, mucosal lesions, location of varix (left or right side; medial or lateral), or varix morphology (pinpoint, linear, lake) between patients who hemorrhaged and those that did not. The presence of varices increases the risk of hemorrhage. Varix patients had 10 times the rate of hemorrhage compared to nonvarix patients, although the overall incidence is low. This data may be used to inform treatment of patients with varices. 4. Laryngoscope, 126:1163-1168, 2016.

Hemorrhage risks and functional outcomes of untreated brainstem cavernous malformations.

OBJECT.: Cerebral cavernous malformations have been studied widely, but the natural history of brainstem cavernous malformations (CMs) is not well defined, and hemorrhages caused by brainstem CMs are devastating. The goal of this study was to quantify the hemorrhage risks and functional outcomes of patients with brainstem CMs. This prospective, longitudinal, cohort study included patients with brainstem CMs diagnosed between 1985 and 2012. The clinical courses of all patients were recorded. Predictors of hemorrhage and the overall untreated outcomes were evaluated. A total of 331 patients (46.5% female) were included, with a mean follow-up duration of 6.5 years. The annual hemorrhage rates in patients initially presenting with hemorrhage with (n = 215) or without (n = 34) focal neurological deficits were 15.9% and 12.4%, respectively. However, the annual hemorrhage rate was 8.7% in patients initially presenting without hemorrhage (n = 82). The risk factors for hemorrhage were female sex (hazard ratio [HR] 1.445, p = 0.041), prior hemorrhage (HR 1.277, p = 0.029), and perilesional edema (HR 1.830, p = 0.002). Overall, neurological function at the most recent assessment was improved compared with neurological function at diagnosis. Additionally, 307 patients (92.7%) improved or stabilized, 268 (81.0%) lived independently, and 95 (28.7%) completely recovered. Predictors favoring complete recovery were no prospective hemorrhage (HR 1.958, p = 0.001), younger age (HR 1.268, p = 0.001), and small lesion size (HR 1.578, p = 0.004). Patients' initial presentation predicts their prospective annual hemorrhage rate. This study suggests that several strong risk factors for hemorrhage and predictors of brainstem CM outcomes may enable clinicians to evaluate the potential hemorrhage risks of their patients and design personalized treatments.

Hemorrhage after Transoral Robotic‐Assisted Surgery

An increasing number of head and neck surgeons have begun using transoral robotic-assisted surgery. Our objective was to examine the postoperative bleeding complications we have encountered to determine risk factors and to discuss the topic of hemorrhage control. Case series with chart review. Medical records were reviewed in 147 consecutive patients undergoing transoral robotic-assisted surgery for any indication at one tertiary academic medical center between March 2007 and September 2011. Eleven of 147 (7.5%) patients undergoing transoral robotic-assisted surgery experienced some degree of postoperative hemorrhage, with 9 patients requiring reoperation for examination and/or control of bleeding. Bleeding occurred at a mean of 11.1 ± 9.2 days after initial operation. Eight of 11 (72%) patients who bled were on antithrombotic medication (anticoagulants or antiplatelet agents) for other medical comorbidities. The postoperative hemorrhage rate in patients taking antithrombotic medication (8/48 patients = 17%) was significantly higher than in those not taking antithrombotics (3/99 patients = 3%), P = .0057. While the bleeding rate in salvage surgery (3/29 = 10.3%) was slightly higher than in primary surgery (8/118 = 6.8%), this difference did not reach statistical significance. Potential for postoperative bleeding in association with antithrombotic medications in patients undergoing transoral robotic-assisted surgery should be recognized. Various effective techniques for management of these patients without robotic assistance were demonstrated.

Abstract WMP111: Early Venous Thromboembolism Prophylaxis in Patients with External Ventricular Drains Does Not Increase Hemorrhagic Complications

Background: Patients undergoing placement of an external ventricular drain (EVD) are at increased risk of developing venous thromboembolisms (VTEs). Early chemical prophylaxis has shown to decrease VTE rates. However, the risks of bleeding and time of initiation have not been clearly defined in patient populations requiring EVDs. Purpose: To evaluate the safety and bleeding risks of starting chemical prophylaxis for VTEs within 24 hours of EVD placement compared to the hemorrhage rates in patients who did not receive prophylaxis within 24 hours. Methods: An IRB approved retrospective review was for performed patients who had an EVD placed with post-procedural imaging at Bellevue Hospital from January 2009 to April 2012. Demographics, diagnosis, coagulation profile, time to VTE prophylaxis and imaging, and occurrences of VTEs were collected. EVD-associated hemorrhages were graded as: Grade 0, no hemorrhage; Grade 1, petechial hyperdensity in proximity to the catheter; Grade 2, 1ml to 15ml volume of hematoma; Grade 3, greater than 15ml or epidural or subdural hematoma; or Grade 4, interventricular hemorrhage or hematoma requiring surgical intervention. Differences between groups were assessed by the Mann-Whitney U test, and a p value of ≤ 0.05 was used to identify significant differences. Results: One hundred and eleven EVDs were placed in 99 patients. Fifty-six patients received low dose unfractionated heparin (LDUH) within 24 hours of admission (early prophylaxis). Fifty-five patients received LDUH &gt; 24 hours after admission (delayed prophylaxis). There were no statistical differences across all Grades (0 to 4) amongst the early prophylaxis (n= 45, 5, 5, 1, and 0 respectively) versus delayed prophylaxis (n= 46, 4, 1, 1, and 3 respectively) groups (p=0.658). In the early prophylaxis group, 3 VTEs were discovered in 32 of 56 patients who underwent screening for suspected VTEs. In the delayed prophylaxis group, 6 VTEs were discovered in 33 of 55 patients screened for clinically suspected VTEs (p= 0.488). Conclusion: There were no increases in hemorrhagic complications with starting chemical prophylaxis within 24 hours of EVD placement. Larger randomized controlled trials are needed to assess a possible decrease in VTEs with earlier prophylaxis.

Safety of endovascular treatment beyond the 6‐h time window in 205 patients

Intra-arterial treatment (IAT) is effective when performed within 6 h of symptom onset in selected stroke patients ('T < 6H'). Its safety and efficacy is unclear when the patient has had symptoms for more than 6 h ('T > 6H') or for an unknown time (unclear-onset stroke, UOS), or woke up with a stroke (wake-up stroke, WUS). In this study we compared the safety of IAT in these four patient groups. Eight-hundred and fifty-nine patients treated with IAT were enrolled. The main outcome parameters were clinical outcome [excellent: modified Rankin Scale (mRS) 0 or 1; or favorable: mRS 0-2] or mortality 3 months after treatment. Further outcome parameters were the rates of vessel recanalization, and cerebral and systemic hemorrhage. Six-hundred and fifty-four patients were treated before (T < 6H) and 205 after 6 h or an unknown time (128 T > 6H, 55 WUS and 22 UOS). NIHSS scores were higher in UOS patients than in T < 6H patients, vertebrobasilar occlusion was more common in T > 6H and UOS patients, and middle cerebral artery occlusions less common in T > 6H than in T<6H patients. Other baseline characteristics were similar. There was no significant difference in clinical outcome and the rate of hemorrhage in multivariable regression analysis. Clinical outcome of our four groups of patients was similar with no increase of hemorrhage rates in patients treated after awakening, after an unknown time or more than 6 h. Our preliminary data suggest that treatment of such patients may be performed safely. If confirmed in randomized trials, this would have major clinical implications.

Acute Endovascular Treatment: From Target Mismatch to Clinical Scoring

The use of multimodal imaging is increasing, with the hope that it will improve patient selection for endovascular stroke treatment. This article discusses the effects of time delays on outcomes and hemorrhage rates in patients who receive noncontrast computed tomography only or multimodal CT imaging, as well as the DIFFUSE-2 and Multi MERCI Trials.

Stereotactic LINAC radiosurgery for the treatment of brainstem cavernomas

The management of deep-seated cerebral cavernous malformations (CCMs) is still controversial. Although surgery remains the treatment of choice in patients with recurrent hemorrhage, patients with CCMs located in the brainstem are in many cases not eligible for resection due to high procedure-related morbidity and mortality. We evaluated the long-term outcome of LINAC radiosurgery (LINAC-RS) for the treatment of brainstem CCMs. Between December 1992 and March 2008, 14 patients (6 men, 8 women) harboring brainstem CCMs underwent LINAC-RS. Pretreatment neuroimaging showed no associated developmental venous angiomas (DVAs) in any of our patients. Prior to treatment, all patients suffered at least from one symptomatic hemorrhage (median 1.8, range 1–3). A median follow-up of 7.1 years (range 2.0–16.8 years) could be obtained in 12 patients. We applied a median tumor surface dose of 13.9 Gy (range 11–18 Gy; median tumor volume 1.6 ml, range 0.4–4.3 ml). Following LINAC-RS, neurological outcome improved in 4 (33.3%) and remained unchanged in 8 patients (66.7%). Rebleeding with subsequent transient neurological status deterioration occurred in 4 patients (33.3%), leading to additional surgical resection in 2 patients (16.7%). The corresponding annual hemorrhage rate was 4.8% (4/82.8 patient–years). Adverse radiation effects (ARE, defined by perilesional hyperintensity on T2-weighted MR images) were revealed in 3 patients (25%), leading to transient neurological deficits in 2 patients (16.7%). There were no procedure-related complications leading to either permanent morbidity or mortality. Our results support the role of LINAC-RS as an efficient and safe treatment to significantly reduce the annual hemorrhage rate in patients suffering from brainstem CCMs not eligible to microsurgery. Compared with radiosurgery for arteriovenous malformations (AVMs), the intervention-related morbidity is higher.

Taming Glioblastoma by Targeting Angiogenesis: 3 Years Later

Taming Glioblastoma by Targeting Angiogenesis: 3 Years Later

Effects of Synchronous Nasal Surgery on Posttonsillectomy Hemorrhage

To evaluate the effects of synchronous nasal surgery on the rate of posttonsillectomy hemorrhage. Retrospective medical record review. Military tertiary referral center. Adult patients identified in our surgical database from June 1, 2000, through September 31, 2005, who had undergone tonsillectomy or uvulopalatopharyngoplasty with tonsillectomy (UPPPT) either alone or with synchronous nasal surgery. The rate of posttonsillectomy hemorrhage was reviewed in all patients who underwent tonsillectomy or UPPPT at our medical center, and an investigation was conducted to determine whether synchronous nasal surgery altered this rate. A total of 1010 patients were included in this study, with a rate of posttonsillectomy hemorrhage of 5.5%. A total of 204 patients underwent synchronous nasal surgery. No significant difference was found between the hemorrhage rate in patients who underwent tonsillectomy or UPPPT alone and those who underwent synchronous nasal surgery (6.0% and 3.9%, respectively; P = .30). When these patients were further divided into those undergoing UPPPT and those undergoing synchronous nasal surgery, no significant difference in hemorrhage rate was found (6.2% and 2.0%, respectively; P = .06). Synchronous nasal surgery does not appear to increase the rate of postoperative hemorrhage in patients who undergo tonsillectomy alone or in those who undergo UPPPT. This information may help persuade physicians to perform synchronous surgical procedures instead of staging surgical procedures. In this regard, the patient requires only 1 anesthetic and 1 postoperative course without the risk of increased postoperative hemorrhage.

Hemorrhage Rate in Patients With Spetzler-Martin Grades IV and V Arteriovenous Malformations: Is Treatment Justified?

Hemorrhage Rate in Patients With Spetzler-Martin Grades IV and V Arteriovenous Malformations: Is Treatment Justified?

Clinical analysis of surgical treatment of portal hypertension

To review the experience in surgery for 508 patients with portal hypertension and to explore the selection of reasonable operation under different conditions. The data of 508 patients with portal hypertension treated surgically in 1991-2001 in our centers were analyzed. Of the 508 patients, 256 were treated with portaazygous devascularization (PAD), 167 with portasystemic shunt (PSS), 62 with selective shunt (SS), 11 with combined portasystemic shunt and portaazygous devascularization (PSS+PAD), 9 with liver transplantation (LT), 3 with union operation for hepatic carcinoma and portal hypertension (HCC+PH). In the 167 patients treated with PSS, free portal pressure (FPP) was significantly higher in the patients with a longer diameter of the anastomotic stoma than in those with a shorter diameter before the operation (P < 0.01). After the operation, FPP in the former patients markedly decreased compared to the latter ones (P < 0.01). The incidence rate of hemorrhage in patients treated with PAD, PSS, SS, PSS+PAD, and HCC+PH was 21.09% (54/256), 13.77 (23/167), 11.29 (7/62), 36.36% (4/11), and 100% (3/3), respectively. The incidence rate of hepatic encephalopathy was 3.91% (10/256), 9.58% (16/167), 4.84% (3/62), 9.09% (1/11), and 100% (3/3), respectively while the operative mortality was 5.49% (15/256), 4.22% (7/167), 4.84% (3/62), 9.09% (1/11), and 66.67% (2/3) respectively. The operative mortality of liver transplantation was 22.22% (2/9). Five kinds of operation in surgical treatment of portal hypertension have their advantages and disadvantages. Therefore, the selection of operation should be based on the actual needs of the patients.

Continuous intravenous cimetidine decreases stress-related upper gastrointestinal hemorrhage without promoting pneumonia

To determine whether a continuous i.v. infusion of cimetidine, a histamine-2 (H2) receptor antagonist, is needed to prevent upper gastrointestinal (GI) hemorrhage when compared with placebo and if that usage is associated with an increased risk of nosocomial pneumonia. Due to the importance of this latter issue, data were collected to examine the occurrence rate of nosocomial pneumonia under the conditions of this study. A multicenter, double-blind, placebo-controlled study. Patients were randomized to receive cimetidine (n = 65) as an iv infusion of 50 to 100 mg/hr or placebo (n = 66). Intensive care units in 20 institutions. Critically ill patients (n = 131), all of whom had at least one acute stress condition that previously had been associated with the development of upper GI hemorrhage. Samples of gastric fluid from nasogastric aspirates were collected every 2 hrs for measurement of pH and were examined for the presence of blood. Upper GI hemorrhage was defined as bright red blood or persistent (continuing for > 8 hrs) "coffee ground material" in the nasogastric aspirate. Baseline chest radiographs were performed and sputum specimens were collected from all patients, and those patients without clear signs of pneumonia (positive chest radiograph, positive cough, fever) at baseline were followed prospectively for the development of pneumonia while receiving the study medication. Cimetidine-infused patients experienced significantly (p = .009) less upper GI hemorrhage than placebo-infused patients: nine (14%) of 65 cimetidine vs. 22 (33%) of 66 placebo patients. Cimetidine patients demonstrated significantly (p = .0001) higher mean intragastric pH (5.7 vs. 3.9), and had intragastric pH values at > 4.0 for a significantly (p = .0001) higher mean percentage of time (82% vs. 41%) than placebo patients. Differences in pH variables were not found between patients who had upper GI hemorrhage and those patients who did not, although there was no patient in the cimetidine group who bled with a pH < 3.5 compared with 11 such patients in the placebo group. Also, the upper GI hemorrhage rate in patients with one risk factor (23%) was similar to that rate in patients with two or more risk factors (25%). Of the 56 cimetidine-infused patients and 61 placebo-infused patients who did not have pneumonia at baseline, no cimetidine-infused patient developed pneumonia while four (7%) placebo-infused patients developed pneumonia. The continuous i.v. infusion of cimetidine was highly effective in controlling intragastric pH and in preventing stress-related upper GI hemorrhage in critically ill patients without increasing their risk of developing nosocomial pneumonia. While the number of risk factors and intragastric pH may have pathogenic importance in the development of upper GI hemorrhage, neither the risk factors nor the intragastric pH was predictive. Therefore, short-term administration of continuously infused cimetidine offers benefits in patients who have sustained major surgery, trauma, burns, hypotension, sepsis, or single organ failure.