History Of Bleeding Complications Research Articles

First Case Report of Mortality Post Manual Small Incision Cataract Surgery in a Known Case of Immune Thrombocytopenic Purpura

ABSTRACT We present the first case of death due to profuse bleeding from the wound margin following manual small incision cataract surgery (SICS) in a known case of immune thrombocytopenic purpura (ITP), a rare outcome in a common case. A 62-year-old male patient presented with profuse bleeding from the surgical wound of the left eye for 2 days following manual SICS. He was a known case of ITP with a history of gastrointestinal bleeding for which he was admitted few years back but had discontinued prescribed medications and did not mention this medical history to the concerned ophthalmic surgeon before surgery. His platelet count was 5000/mm3 on admission. The patient was admitted to the general medicine ward and was infused with 8 units of random donor platelets and started on injectable high-dose corticosteroids. Despite prompt interventions, the patient succumbed to profound bleeding and multiorgan failure. This case report underscores the importance of comprehensive preoperative evaluation, especially in patients with known bleeding disorders or a history of bleeding complications. While routine cataract surgeries may not typically require extensive preoperative testing as commonly used techniques these days are bloodless and sutureless, certain high-risk patients, such as those with ITP or other bleeding disorders, warrant thorough screening to assess the patient’s hemostatic status accurately to identify and mitigate any adverse outcomes.

Acquired Factor XI Deficiency during SARS-CoV-2 Infection: Not Only Thrombosis.

An 80-year-old woman with a positive RT-PCR (reverse transcription polymerase chain reaction) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on nasopharyngeal swab was admitted to our COVID-19 department during the pandemic with fever, dyspnea, and need for oxygen therapy; two large hematomas were present bilaterally in the axillary zones. Her past medical history included Crohn's disease diagnosed 30 years ago after perforation of the ascending colon, hypertension, bilateral hip replacement, appendectomy, and tonsillectomy; no history of bleeding complications was reported during or after surgical interventions or in the postpartum, and no history of menorrhagia or easy-bruising. One month and a half before admission, she underwent right knee replacement surgery with no complications, no blood units, or plasma transfusions were required. At that time complete blood count and screening clotting test were within normal range.

Spleen and Liver Stiffness Is Positively Correlated with the Risk of Esophageal Variceal Bleeding

Background/Aims: Portal hypertension (PH) is a common complication of chronic liver disease and results in esophageal and gastric variceal bleeding, which is associated with a high mortality rate. Measurement of the hepatic venous pressure gradient (HVPG) is considered the gold standard for diagnosing PH and estimating the risk of varices and bleeding. In contrast, upper gastrointestinal (GI) endoscopy (UGE) can reliably demonstrate the presence of varices and bleeding. Both measures are invasive, and HVPG is mainly restricted to tertiary centers. Therefore, the development of noninvasive methods of assessing the severity of PH and the risk of variceal bleeding is warranted. Methods: We retrospectively examined the correlation of spleen stiffness (SSM) and liver stiffness measurements (LSM) with the incidence of variceal bleeding among 143 patients who underwent combined liver and spleen elastography between 2013 and 2015. Results: For 19 of 103 patients (16.8%), upper GI variceal bleeding was diagnosed and treated endoscopically. The median SSM of all patients was 35.3 kilopascals (kPa); the median LSM, 11.7 kPa. Patients with previous bleeding episodes had significantly higher SSM (75.0 kPa) and LSM (37.3 kPa) than those without a history of bleeding (SSM, 30.6 kPa; LSM, 8.2 kPa; p < 0.0001). Seventy-five patients (66.4%) underwent UGE in addition to SSM and LSM: 25 with no esophageal varices (EVs; SSM, 29.5 kPa; LSM, 11.4 kPa), 16 with EV grade 1 (SSM, 35.9 kPa; LSM, 33.4 kPa), 21 with EV grade 2 (SSM, 67.8 kPa; LSM, 27.0 kPa) and 13 with EV grade 3 (SSM, 75.0 kPa; LSM, 26.3 kPa). No statistically significant differences were found between respective grades of EV but were found between the presence and absence of varices. At a calculated cutoff level of 42.6 kPa (with application of 95% CI), SSM had sensitivity of 89% and specificity of 64% in determining the risk of bleeding, with a negative predictive value (NPV) of 0.97 (LSM sensitivity, 84%; LSM specificity, 80%; LSM NPV, 0.96 at LSM cutoff level of 20.8 kPa). When LSM (cutoff level, 20.8 kPa) and SSM (cutoff level, 42.6 kPa) were combined, the NPV was 1 (sensitivity, 100%; specificity, 55%). Conclusion: SSM and LSM as determined by FibroScan (a noninvasive method of detecting PH) is positively correlated with upper GI variceal bleeding (optimal SSM cutoff level, 42.6 kPa; optimal LSM cutoff level, 20.8 kPa). No patients with both SSM and LSM below cutoff levels had a history of bleeding complications.

Carotid artery stenting

From the earliest experiences with carotid artery stenting (CAS) presumptive high risk features have included thrombus-containing lesions, heavily calcified lesions, very tortuous vessels, and near occlusions. In addition patients have been routinely excluded from CAS trials if they have contra-indications to dual antiplatelet therapy (aspirin and thienopyridines), a history of bleeding complications and severe peripheral arterial disease (PAD) making femoral artery vascular access difficult. Variables that increase the risk of CAS complications can be attributed to patient characteristics, anatomic or lesion features, and procedural factors. Clinical features such as older age (≥80 years), decreased cerebral reserve (dementia, multiple prior strokes, or intracranial microangiopathy) and angiographic characteristics such as excessive tortuosity (more than two 90° bends within 5 cm of the target lesion) and heavy calcification (concentric calcification ≥ 3 mm in width) have been associated with increased CAS complications. Other high risk CAS features include those that prolong catheter or guide wire manipulation in the aortic arch, make crossing a carotid stenosis more difficult, decrease the likelihood of successful deployment or retrieval of an embolic protection device (EPD), or make stent delivery or placement more difficult. Procedure volume for the operator and the catheterization laboratory team are critical elements in reducing the risk of the procedure. In this article, we help CAS operators better understand procedure risk to allow more intelligent case selection, further improving the outcomes of this emerging procedure.

Interventioneller Vorhofohrverschluss

Stroke prevention in patients with atrial fibrillation is one of the greatest challenges in modern cardiology. Interventional left atrial appendage occlusion is an alternative to oral anticoagulation in patients with non-valvular atrial fibrillation. This procedure is currently used mainly for patients with elevated risk for bleeding complications (HAS-BLED score ≥3) or other contraindications for oral anticoagulation. The novel anticoagulants dabigatran, rivaroxaban and apixaban carry a risk for major bleeding for 2-3% of patients per year. The indications for an interventional left atrial appendage closure are therefore not affected by these substances. Several devices have been developed for this purpose; however, currently only the WATCHMAN® and AMPLATZER® cardiac plug are used in the clinical routine in Germany. The WATCHMAN® device proved to be non-inferior to oral anticoagulation with warfarin in the PROTECT-AF trial in terms of safety and efficacy. These findings are supported by data from registries with up to 5 years follow-up. For the second device currently used in clinical practice, the AMPLATZER® cardiac plug, there is increasing data from registries suggesting comparable safety and efficacy. Both devices necessitate anticoagulation during the first 3-6 months after implantation until endothelialization is completed. Due to the anatomical complexity the implantation should be performed in experienced centers with reduction of the periprocedural risk to <1%. Thus, interventional left atrial appendage occlusion is a valid option to prevent stroke or other thromboembolic events in non-valvular atrial fibrillation especially for elderly patients or those with a history of bleeding complications.

English

Introduction Thrombocytopenia, or a low blood platelet count, is encountered in 7–8% of all pregnancies1. It is the second most common blood disorder in pregnancy2,3. The first blood disorder is anaemia3. Platelets are non-nucleated cells derived from megakaryocytes in the bone marrow and normally live in the peripheral circulation for as long as 10 days. Platelets play a critical initiating role in haemostatic system1,4. The normal range of platelets in non-pregnant women is 150 000– 400 000/μL. Average platelet count in pregnancy is decreased. Change in platelet count is due to haemodilution, increased platelet consumption and increased platelet aggregation driven by increased levels of thromboxane A2. Thrombocytopenia can be defined as platelet count less than 150 000/μL or platelet count below the 2.5th percentile for pregnant patients (116 000/μL)1. Classification of thrombocytopenia in pregnancy is arbitary and not necessarily clinically relevant. Mild thrombocytopenia is 100 000– 150 000/μL, moderate thrombocytopenia is 50 000–100 000/μL and severe thrombocytopenia is less than 50 000/μL. The pathophysiology of gestational thrombocytopenia (GT) is unknown. It usually develops in the third trimester, detected incidentally, pati ents are asymptomatic with no prepregnancy history of low platelets or abnormal bleeding, it is mild thrombocytopenia (counts more than 70 000/μL)5–9. GT accounts for almost threefourths of all cases of thrombocytopenia2,10. Mode of delivery is determined by obstetric/maternal indications. Platelet counts normalize within 2–12 weeks following delivery10–12. No pathological significance for the mother or foetus is noted. No risk for foetal haemorrhage or bleeding complications is observed13–17. A low platelet count can also be associated with preeclampsia, HELLP syndrome or idiopathic thrombocytopenic purpura (ITP)18–23. The differential diagnosis between mild ITP and GT is very difficult during pregnancy5,19. ITP accounts for only approximately one case of thrombocytopenia per 1000 pregnancies and 5% of cases of pregnancy-associated thrombocytopenia, it is the most common cause of significant thrombocytopenia in the first trimester24–27. Women with ITP often have a history of bleeding complications and have thrombocytopenia on a prepregnancy platelet count16,28. We present this rare case of GT in a pregnant 30-year-old woman.