Intraoperative Blood Research Articles

Dutta’s Scoring Technique for Early Detection and Management of Uterine Atony during Emergency LSCS – A Randomized Trial

Background: Uterine atony accounts for 80 % of causes of PPH and is one of the important cause of maternal death. Objective: To analyze the efficacy of Dutta’s score for early detection and management of uterine atony during emergency LSCS to prevent PPH. Study methods: This study was undertaken at JNM, NSGN, CN at Kalyani, Nadia, West Bengal India from 1st January 2007 to 31st December 2011. Three hundred cases undergoing emergency LSCS were selected for randomized trial. Clinical observations were made after placental expulsion for scoring which includes shape and size of uterus, rugosity, tone, placental localization and time of placental expulsion. Score of 0, 1, 2 were given on each observation. Three groups are created depending on scoring-Group A (130) -8 to 10, Group B (N-100) -5 to 7 and Group C (N-70) - <5 for better management. Management protocols were formulated in the three groups for prevention of PPH Group A:- Oxytocin 10U (5U IM + 5U IV 40drops/min in Ringer Lactate 500ml) Group B:- Oxytocin 15U (5U IM + 10U IV 40drops/min in Ringer lactate 500 ml) + methyl ergometrine (0.25mg IM) + anterior posterior uterine wall compression Group C:- Oxytocin 20 U- (5U IM plus 15 U IV 40 drops in Ringer Lactate 500 ml) + methyl ergometrine (0.5mg IM) + carboprost (250 mcg IM) + lateral followed by anterior posterior uterine wall compression + compression of isthmic region of uterus + misoprostol 800mg per rectal during post operative period. Results: After adopting Dutta’s score and management protocols it was interesting to observe that intra and post operative blood loss within 2hr were found to be significantly reduced in group A-69.3% (<300CC), 84.6%(<200CC) and group B-70%(<300cc), 72%(<200CC). Intra operative blood loss >500cc were also found to be reduce in group A- 7.6%, group B-14%. In group C intra operative blood loss >500cc were seen in 47.1 % and post operative -32.9% cases. Hemoglobin level <11gms after 24 hrs of LSCS was found to be minimally reduced (in comparison to preoperative hemoglobin level) in group A (1.5%), group-B (2%) and group C (11.4%). Conclusion: Early diagnosis and management of uterine atony during emergency LSCS after adopting Dutta’s score were found to be not only reduce intra and post operative blood loss but also was found to maintain a satisfactory hemoglobin level and hemodynamic status. Maternal mortality was found to be nil. This randomized trial highlighted the importance of prompt treatment in group C to reduce intra and post operative blood loss and maternal morbidity and mortality. DOI: http://dx.doi.org/10.3126/ajms.v5i2.8531 sian Journal of Medical Science, Volume-5(2) 2014: 40-45

Clinical study of free auxiliary device of hand assisted laparoscopic splenectomy and intraoperative autologous splenic blood transfusion

Objective To investigate the feasibility and advantage of hand assisted laparoscopic splenectomy for giant spleens without auxiliary device and the clinical value of intraoperative autologous splenic blood transfusion.Methods From October 2007 to October 2011,48 cases of liver cirrhosis splenomegaly were analyzed retrospectively according to operation method including hand assisted laparoscopic splenectomy group with free auxiliary device (HALS) (n =30) and conventional laparoscopic splenectomy (CLS) (n =12),and they were divided into two groups:severe splenomegaly group (the length of the spleen more than 20 cm) and moderate splenomegaly (the length of the spleen less than 20 cm).The intraoperative bleeding,operation time,the spleen removal time and transit operation rate were compared in these patients.The blood transfusion machine was used for autologous splenic blood transfusion.Results Free auxiliary device saved at least 2000 yuan without affecting the maintenance of pneumoperitoneum during operation.There was no significant difference in the average blood loss between HALS group and CLS group [(88.1 ± 16.3) ml vs.(107.5 ± 11.6) ml,P ＞0.05].The average operation time was significantly shorter [(75.2 ± 13.3) min vs.(120.7 ± 20.5) min,P ＜ 0.05],and the spleen removal time was markedly shorter [(8.0 ±3.1) min vs.(25.2 ±2.8) min,P ＜0.05] in HALS group than in CLS group.The transit operation rate of severe splenomegaly (50％) was significantly higher than moderate splenomegaly (20％) (P ＜ 0.01),and the intraoperative bleeding too [(103.8 ± 25.0) ml vs.(70.4 ± 10.3) ml,P ＜0.01].Intraoperative autologous splenic blood transfusion significantly elevatedf hemoglobin level on the first day after operation [(2.07 ± 0.25) g/L,P ＜ 0.05].Conclusion HALS significantly facilitates the surgical procedure and reduces the operational risk,while maintaining the advantages of CLS.Hand-assisted laparoscopic splenectomy is a safe and effective technique especially for the management of severe splenomegaly.Intraoperative autologous splenic blood transfusion shows obvious special advantage in ascending hemoglobin. Key words: Hand-assisted laparoscopic splenectomy; Splenomegaly; Splenic blood transfusion

The clinical effect of laparoscopic retrograde cholecystectomy and retrograde reserved cholecystectomy in complex bile duct lesions

Objective To discuss the clinical effect of laparoscopic retrograde cholecystectomy and retrograde reserved cholecystectomy in complex bile duct lesions.Methods 128 patients were divided into group A and group B according to surgical approach.Group A received laparoscopic retrograde cholecystectomy,while group B received laparoscopic retrograde reserved cholecystectomy.Compared operative time,intraoperative fluid volume (ml),blood loss,gastrointestinal function recovery time,postoperative drainage,hospital stay,bile duct injury and gastroduodenal injury of two groups.Results Operative time,intraoperative fluid volume (ml),blood loss and bile duct injury in group B were significantly lower than those in group A (P ＜ 0.05).There were no statistical significant differences in gastrointestinal function recovery time,postoperative drainage,hospital stay and gastroduodenal injury between two groups (P ＞ 0.05).Conclusions Laparoscopic retrograde reserved cholecystectomy is effective in complex bile duct lesions,with less bleeding,shorter operative time,less intraoperative fluid,simpler operation,quicker recovery compared with laparoscopic retrograde cholecystectomy,without bile duct injury or gastroduodenal complications. Key words: Laparoscopy; Retrograde cholecystectomy; Retrograde reserved cholecystectomy; Complex bile duct lesions; Efficacy

Factores asociados a morbilidad precoz en cirugía colorrectal laparoscópica

Factors associated with early morbidity in laparoscopic colorectal surgery Introduction: Different factors have been associated with increased risk of complications in laparosco- pic colorectal surgery. The aim of this study is to identify these factors in our series. Method: Retrospective cohort. All patients undergoing laparoscopic colorectal surgery between January 2000 and June 2012 were included. Patients who had postoperative complications until 30 days postoperatively were identified and analyzed by univariate and multivariate logistic regression. A p value less than 0.2 was used was used as a criteria for entry into the multivariate model. Results: The series consists of 848 patients with a median age of 58 ± 22 years. Main surgical indications were: neoplasia (42.3%), diverticular disease (27.8%) and infla - mmatory bowel disease (8.8%). Most frecuently-performed procedures were: sigmoidectomy (39.5%), ante- rior resection of the rectum (13.4%), right hemicolectomy (13%) and total colectomy (8.7%). On univariate analysis, factors associated with complications were age over 75 years (OR 1.82, 95% CI 1.02 to 3.25) and red blood cell transfusion (OR 8.47, 95% CI 3.69 to 19.43). On multivariate analysis, red blood cell transfusion (OR 7.9 95% CI 1.78 to 35.88) and ASA III or IV (OR 3.26 95% CI 1.01 to 17.23) were independent factors associated with postoperative complications. Conclusion: Intraoperative red blood cell transfusion and ASA score III or IV are independent risk factors associated with complications in laparoscopic colorectal surgery.

Relation Between the Interval from Coronary Angiography to Selective Off-Pump Coronary Artery Bypass Grafting and Postoperative Acute Kidney Injury

The aim of this study was to investigate whether there are effects of intervals between elective off-pump coronary artery bypass grafting (OPCABG) and coronary angiography (CAG) on postoperative acute kidney injury (AKI). The clinical data of patients undergoing OPCABG and CAG from June 2010 to December 2011 in Beijing Anzhen Hospital were retrospectively analyzed. All the patients were divided into AKI and non-AKI groups. Univariate analysis was performed to find possible factors associated with AKI. Multivariate logistic regression analysis was used to identify whether the short interval was one of the independent risk factors of AKI after adjusting for potential confounding variables. Of 1,513 patients, 529 patients (34.9%) developed AKI. The mortality rate in AKI group (4.9%) was >5× higher than that in non-AKI group (0.9%). The incidence of AKI was highest (56.1%) in patients in whom OPCABG was performed ≤24 hours after CAG. Multivariate logistic regression analysis showed that the interval of ≤24 hours between OPCABG and CAG did increase the risk of AKI (odds ratio 2.15, 95% confidence interval 1.10 to 4.20) after adjusting for the following confounding variables: diabetes mellitus, New York Heart Association heart function class III and IV, lower estimated glomerular filtration rate, numbers of coronary artery bypass grafts ≥3, intraoperative or postoperative intra-aortic balloon pump, intraoperative and postoperative red blood cells transfusion of >3 units, postoperative hypotension, dosage of furosemide of >100 mg/day. In conclusion, it was one of the independent risk factors of postoperative AKI that the OPCABG was performed ≤24 hours after CAG.

Dexmedetomidine, morphine, propofol vs midazolam, morphine, propofol for conscious sedation in rhinoplasty under local anesthesia. A prospective, randomized study

BackgroundMonitored anesthesia care (MAC) has been proposed as one of the suitable techniques for rhinoplasty. In this study our aim was to compare the effects of dexmedetomidine with morphine and propofol vs benzodiazepines with morphine and propofol as adjuncts to local anesthesia – on analgesia, sedation, respiratory and hemodynamics variables and surgeon and patient satisfaction.MethodsIn this prospective, double-blind, comparative study, 60 patients undergoing rhinoplasty by local anesthesia randomly received intravenous sedation of either: dexmedetomidine (Dex group) or midazolam (Mid group) in combination with morphine and propofol. Level of sedation was assessed by using the Observer’s Assessment Alertness/Sedation Scale (OAA/S). Pain on local anesthesia injection was assessed by a visual analog scale. Surgeon’s satisfaction also can be assessed by using a 3-grades score, the surgeon assessed the quality of surgical bleeding. Mean Arterial Pressure (MAP) and heart rate (HR) were assessed and recorded. Patients’ satisfaction, visual analog scale for intraoperative pain, and total amount of propofol used intraoperatively. Adverse effects were also recorded.ResultsIn Mid group patients were earlier to reach adequate sedation level than in Dex group, but they felt more pain either on local anesthetic injection or during operation. Intraoperative mean arterial blood pressure and heart rate in Dex group were lower than their baseline values and the corresponding values in Mid group. The total amount of propofol needed for Mid group was much higher than in Dex group. Patient satisfaction was higher in Dex group. Time of surgery was longer in Mid group. Both groups were similar in sedation recovery and ward discharge times, as well as, incidence of side effects.ConclusionDexmedetomidine sedation with morphine and propofol in rhinoplasty performed under local anesthesia was associated with shorter surgery time, greater patient and surgeon satisfaction, and lower pain scores with no adverse effects, when compared to midazolam sedation with morphine and propofol.

The learning curve of endoscopic transsphenoidal pituitary surgery

Objective To investigate the learning curve of endoscopic transsphenoidal pituitary surgery by comparing the effects of endoscopic transsphenoidal pituitary surgery at different stages.Methods From September 2002 to December 2006,180 patients undergoing endoscopic transsphenoidal pituitary surgery,performed by a single team,were retrospectively evaluated.The patients were divided into groups A to C (n =60) based on the surgery data; operation time,intraoperation blood loss,conversion to microsurgery,total removal,improvement of postoperative vision,complications,and postoperative hospital stay were compared Results No statistical differences were found among the group in age,gender,turnor size,and pathological type; the significant differences were found in the operation time between group A,B,andC (P ＜0.05),but the operation time in group A was significantly longer than that in groups B and C (P ＜0.05).Compared with that in group A,the number of conversion to microsurgery decreased significantly in groups B and C.2 patients in group B and another in group C developed severe postoperative complications.The intraoperation blood loss,total removal,postoperative vision,complications,and postoperative hospital stay showed no differences amongst the three groups.Conclusions Endoscopic transsphenoidal pituitary surgery needs a minimum case-load of 60 patients to help go beyond the steep phase of the learning curve. Key words: Endoscope; Pituitary adenoma; Endonasal transsphenoidal surgery; Learning curve

Reduction of blood loss with the use of a new combined intra-operative and post-operative autologous blood transfusion system compared with no drainage in primary total hip replacement

Autologous retransfusion and no-drainage are both blood-saving measures in total hip replacement (THR). A new combined intra- and post-operative autotransfusion filter system has been developed especially for primary THR, and we conducted a randomised controlled blinded study comparing this with no-drainage. A total of 204 THR patients were randomised to autologous blood transfusion (ABT) (n = 102) or no-drainage (n = 102). In the ABT group, a mean of 488 ml (sd 252) of blood was retransfused. The mean lowest post-operative haemoglobin level during the hospital stay was higher in the autotransfusion group (10.6 g/dl (7.8 to 13.9) vs 10.2 g/dl (7.5 to 13.3); p = 0.01). The mean haemoglobin levels for the ABT and no-drainage groups were not significantly different on the first day (11.3 g/dl (7.8 to 13.9) vs 11.0 g/dl (8.1 to 13.4); p = 0.07), the second day (11.1 g/dl (8.2 to 13.8) vs 10.8 g/dl (7.5 to 13.3); p = 0.09) or the third day (10.8 g/dl (8.0 to 13.0) vs 10.6 g/dl (7.5 to 14.1); p = 0.15). The mean total peri-operative net blood loss was 1464 ml (sd 505) in the ABT group and 1654 ml (sd 553) in the no-drainage group (p = 0.01). Homologous blood transfusions were needed in four patients (3.9%) in the ABT group and nine (8.8%) in the no-drainage group (p = 0.15). No statistically significant difference in adverse events was found between the groups. The use of a new intra- and post-operative autologous blood transfusion filter system results in less total blood loss and a smaller maximum decrease in haemoglobin levels than no-drainage following primary THR.

The correlation between intra-operative estimated blood loss and bone mineral density during minimally invasive posterior lumbar interbody fusion

Objective To investigate the correlation between intra-operative estimated blood loss (EBL) and bone mineral density (BMD) during minimally invasive posterior lumbar interbody fusio,n (PLIF).Methods In this retrospective case control study,61 consecutive patients suffering from mono-segment low back disorders were treated by minimally invasive PLIF from 2005 to 2010.The patients' parameters including age,gender,operation time (OT),BMD,EBL,prothrombin time were collected.According to BMD of the lumbar spine,all the patients were divided into two groups: the normal group and the osteopenia group.The differences of the EBL and other parameters between the two groups were analyzed by student's t test and Pearson's Chi-square test.Besides,the correlation between intra-operative EBL and each of the other parameters except for gender were analyzed among all the patients.To detect the relationship between intra-operative EBL and gender,patients were divided by gender and the intra-operative EBL of two groups were examined by student's t test.Finally,a probable model about intra-operative EBL and the other parameters was proposed using stepwise linear regression analysis.Results The average intra-operative EBL of the normal group and the osteopenia group were (346.41±199.53) ml and (552.62±300.21) ml,respectively.The difference was significant.However,the other parameters including post-operative EBL had no significant differences between two groups.A negative correlation between intra-operative EBL and BMD (r=-0.37,P=0.035)and a positive correlation between intra-operative EBL and OT (r=0.34,P=0.008) were found.But none of the other parameters was correlated with intra-operative EBL.The similar result was observed by the stepwise linear regression analysis.Intra-operative EBL was influenced by BMD and OT under the control of this research,and the relationship might be formulated with the equation,EBL=-0.63×BMD+1.46×OT.Conclusion BMD should be considered an important predictor of intra-operative EBL in PLIF. Key words: Lumbar vertebrae; Bone density; Blood loss, surgical; Spinal fusion

Effects of blood transfusion on gastrointestinal anastomosis - Our experience in 52 patients

Background: Patients, operative technique and instrumental factors, all affect the intestinal anastomosis outcome. Preoperative, intraoperative and postoperative blood transfusion influences the very common surgical procedure. Blood transfusion is discriminated from other risk factors in that; its intentionally added risk factor. Objectives: the effect of intra-operative and post-operative blood transfusion on elective gastrointestinal anastomosis mainly evaluated by following factors; (1) surgical site complications (2) anastomosis leak (3) fecal fistula and (4) death. Material and methods: To evaluate the effect of blood transfusion (Intraoperative and Postoperative) in outcome of Gastrointestinal anastomosis at Government General Hospital. Data collected from fifty two patients who underwent elective gastro intestinal anastomosis at our hospital. Result: The total number of patients was 52, 28male and 24 female. Mean age was 43 years, 17.3% were underwent small bowel anastomosis, 83.7% were underwent large bowel anastomosis, and 15.38% were transfused intraoperative and 26.92% were transfused postoperatively. Regardless other risk factors the incidence of surgical site infection was significantly high in transfused patients (25%), also there was a high rate of other complications in transfused patients. Conclusion: Intraoperative and post-operative blood transfusion is a good predictor for development of complications in elective intestinal anastomosis. There were some limitations in this study, as other risk factors might change the outcome and the effect of blood amount wasn’t considered, so more precise studies have to be done to give more support to our results.

Modified duodenum-preserving pancreas head resection for low-grade malignant lesion in the pancreatic head

Background/objectivesOur institution has utilized a duodenum-preserving pancreas head resection (DPPHR) procedure for management of low-grade malignant lesions within the head of the pancreas, but this has resulted in a higher rate of postoperative complications, including pancreatic fistula and ischemic bile duct injury. To avoid these complications we recently modified DPPHR to resect all the parenchyma around the pancreatic head and to preserve the epicholedochal plexus around the bile duct. The goal of this study was to investigate outcomes with postoperative complications and disease control following this modified procedure. MethodsTwenty-one consecutive patients underwent DPPHR between 1994 and 2011. Patients were retrospectively classified into one of two groups: the conventional DPPHR group (cDPPHR) or the modified DPPHR group (mDPPHR). Perioperative factors and postoperative complications were compared between these two groups. ResultsThe median age of the 21 patients was 61 (23–77) years, and the median follow-up period was 51 months. Intra-operational blood loss was significantly smaller and duration of hospital stay was significantly shorter in the mDPPHR group than in the cDPPHR group, respectively. The rate of pancreatic fistula was markedly lower in the mDPPHR group (2/13; 15%) than in the cDPPHR group (7/8; 88%) (P = 0.0022). For neoplastic lesions, the surgical margin was negative in all cases, and local recurrence has not occurred in either group. ConclusionsFor selected patients, modified DPPHR may provide clinical benefits in terms of less complications associated with shorter hospital stay.

Modified transperitoneal laparoscopic radical prostatectomy : clinical study of 285 cases

Objective To evaluate the technique and clinical outcomes of modified transperitoneal laparoscopic radical prostatectomy. Methods A total of 285 patients received the operation with mean age of 67 years (50-76 years) from January 2008 to April 2012.Mean level of PSA was 15.7 μg/L (1.8 -50.0 μg/L),and mean prostatic volume was 44 ml (26 -74 ml). No lymph node or seminal vesicle involvement was found by CT or MR and radionuclide bone scan revealed no metastasis.271 cases were confirmed diagnosis by prostatic biopsy and 14 were detected through pathological studies of TURP specimens.Gleason score ranged from 6 to 8.14 cases were in clinical stage T1b,29 cases in T1c,214 cases in T2 and 28 cases in T3a.Transperitoneal approach and modified technique involving bladder neck dissection,nervesparing technique and vesicoureteral anastomosis were applied on patients. Results Mean operative time was 105 min (55 -150 min).Mean intraoperative estimated blood loss was 240 ml (50-800 ml).Rectal injures occurred in 2 cases and were repaired under laparoscopy.Drainage tube and urinary catheter were removed 48 -72 h and 5 -8 d postoperatively.Postoperative hospital stay was 7 d (5 - 11 d).Positive surgical margin was present in 58 patients.Mean follow-up time was 29 months (3 -50 months).Complete continence were found in 208 patients immediately after catheter removal.68 patient recovered continence within 3 months and 9 patients remained incontinence 3 months after surgery. Normal erection presented in 42 of the 57 cases with nerve-sparing. Conclusions Transperitoneal laparoscopic radical prostatectomy is safe and efficient.Higher efficiency and lower complication rate have been achieved through modified laparoscopic technique involving bladder neck dissection,nerve-sparing technique and vesicoureteral anastomosis. Key words: Prostatic neoplasms; Laparoscopy; Transperitoneal approach; Radical prostatectomy

The effects of combined epidural and general anesthesia on the autonomic nervous system and bioavailability of nitric oxide in patients undergoing laparoscopic pelvic surgery

Pneumoperitoneum during laparoscopic surgery is known to affect visceral blood flow and result in oxidative stress. Whether epidural anesthesia will effectively reduce visceral ischemia and oxidative stress by blocking the sympathetic nervous system (SNS) during laparoscopic surgery has not been proven. Forty-five patients who were to undergo robot-assisted laparoscopic prostatectomy were randomly assigned to the combined general-epidural anesthesia group (group GE, n = 22) or to the general anesthesia group (group G, n = 23). Blood pressure, heart rate, and the balance between sympathetic and parasympathetic nervous system activity as measured by heart rate variability were recorded at 10 min after induction of anesthesia (T1), 60 (T2) and 120 (T3) min after intra-abdominal CO(2) insufflation, and 10 min after returning the patient to the supine position following CO(2) exsufflation (T4). Arterial blood gas analysis and blood sampling for measurements of nitrite (NO(2-)) and malondialdehyde (MDA) were performed at all time points. Intraoperative mean blood pressure was significantly lower in group GE compared with group G. The low-frequency to high-frequency ratio was significantly increased after induction of pneumoperitoneum in group G but was unchanged in group GE. Plasma levels of nitrite decreased after pneumoperitoneum induction in group G while there was no change in group GE. A significant increase in MDA levels was seen in group G after pneumoperitoneum induction and were higher than group GE at T3 and T4. The 24-h urine output was higher in group GE than in group G on POD 1. The 24-h CrCl was higher in group GE on POD 1 but was not different between groups on POD 2. Combined epidural and general anesthesia effectively blocks SNS stimulation during laparoscopic surgery and reduces NO inactivation and oxidative stress.

First-Line Therapy With Coagulation Factor Concentrates Combined With Point-of-Care Coagulation Testing is Associated With Decreased Allogeneic Blood Transfusion in Cardiovascular Surgery

INTRODUCTION Blood transfusion is associated with increased morbidity and mortality. We developed and implemented an algorithm for coagulation management in cardiovascular surgery based on first-line administration of coagulation factor concentrates combined with point-of-care thromboelastometry/impedance aggregometry. METHODS In a retrospective cohort study including 3,865 patients, we analyzed the incidence of intraoperative allogeneic blood transfusions (primary endpoints) before and after algorithm implementation. RESULTS Following algorithm implementation, the incidence of any allogeneic blood transfusion (52.5 vs. 42.2%; P < 0.0001), packed red blood cells (49.7 vs. 40.4%; P < 0.0001), and fresh frozen plasma (19.4 vs. 1.1%; P < 0.0001) decreased, whereas platelet transfusion increased (10.1 vs. 13.0%; P = 0.0041). Yearly transfusion of packed red blood cells (3,276 vs. 2,959 units; P < 0.0001) and fresh frozen plasma (1986 vs. 102 units; P < 0.0001) decreased, as did the median number of packed red blood cells and fresh frozen plasma per patient. The incidence of fibrinogen concentrate (3.73 vs. 10.01%; P < 0.0001) and prothrombin complex concentrate administration (4.42 vs. 8.9%; P < 0.0001) increased, as did their amount administered per year (179 vs. 702 g; P = 0.0008 and 162 × 10³ U vs. 388 × 10³ U; P = 0.0184, respectively). Despite a switch from aprotinin to tranexamic acid, an increase in use of dual antiplatelet therapy (2.7 vs. 13.7%; P < 0.0001), patients' age, proportion of females, emergency cases, and more complex surgery, the incidence of massive transfusion [(≥10 units packed red blood cells), (2.5 vs. 1.26%; P = 0.0057)] and unplanned reexploration (4.19 vs. 2.24%; P = 0.0007) decreased. Composite thrombotic/thromboembolic events (3.19 vs. 1.77%; P = 0.0115) decreased, but in-hospital mortality did not change (5.24 vs. 5.22%; P = 0.98). CONCLUSIONS First-line administration of coagulation factor concentrates combined with point-of-care testing was associated with decreased incidence of blood transfusion and thrombotic/thromboembolic events.

Combined Spinal Epidural Anesthesia for Total Hip Replacement Surgery in Birendra Army Hospital

Introduction: Total Hip Replacement surgery is one of the most commonly performed surgeries worldwide. Epidural anaesthesia have shown decrease incidence of DVT in these patient. Hence, combined spinal epidural spinal anesthesia is now a preferred technique over spinal anesthesia alone. We have been practicing combined spinal epidural anesthesia routienely in total joint replacement, but have not analyzed the result. The aim of this study was to analyse various aspect of combined spinal epidura anesthesia. Methods: thirteen cases of ASA I and II who underwent Total Hip Arthroplasty under combined spinal epidural anesthesia were analysed. First epidural was given in space L2-3/L3-4 and patency was confirmed with test dose with InjXylocaine 2% with Adrenaline 3 ml, followed by Spinal anesthesia one space below with Bupivacaine 0.5% 3 ml. Results: Intra operative Mean Blood Pressure had dropped up to 55 mm of Hg.To maintain Blood pressure, Intravenous Fluid was given in average is 2423.077 ml and Vasopressure drug (Mephenteramine Maleate) was given in average of14.769 mg. Dura was accidentally puncture in one patient during epidural insertion and two epidural failed to provide post operative analgesia. Post operative rehabilitation was easy, one one patient developed DVT after 4 weeks of surgery. Conclusion: Combined epidural analgesia effectively manages postoperative pain, allows early ambulation and reduces the risk of deep vein thrombosis and thromboembolism, Although significant drop of Blood pressure was noted in all cases. DOI: http://dx.doi.org/10.3126/mjsbh.v10i1.6447 Medical Journal of Shree Birendra Hospital Jan-June 2011 10(1) 32-36

Effect of improved posterolateral minimally invasive approach combined with modular femoral head prosthesis in treatment of femoral neck fractures in elderly patients

Objective To compare the clinical effects of improved posterolateral minimally invasive approach and traditional posterolateral approach combined with modular femoral head prosthesis in the treatment of femoral neck fractures in the elderly. Methods The study involved 70 patients with femo- ral neck fractures （ 26 males and 44 females ; at age range of 67-95 years, mean 78.3 years） treated from October 2008 to June 2010. There were 62 patients with fresh femoral neck fractures and eight with old femoral neck fractures （2-4 months post-injury）, all of whom were type Ⅲor Ⅳ fractures according to the Garden＇ s classification. All surgeries were completed by the same operation group. The improved posterolateral minimally invasive approach group involved 32 patients including 12 males and 20 females and the traditional posterolateral approach group involved 38 patients including 14 males and 24 females. The two groups were compared in aspects of incision size, operative time, perioperative complications, prosthesis stability and hip functional recovery. Results All patients were followed up for an average of 16 weeks （range, 12-18 weeks）. The differences between the two groups were significant regarding the incision length, perioperative blood loss, and blood product transfusio amount （ P 〈 0.01 ） , but insignifi- cant in operative time （ P 〉 0.05 ）. All patients were able to take weight-bearing walk six weeks postoperatively. The two groups showed significant difference in the hip joint function by Charnley＇s criteria six weeks postoperatively （ P 〈 O. 05 ）, but insignificant difference in the hip joint function by Harris＇ s crite- ria at the last follow-up （P 〈 0.05 ）. Conclusion The modified posterolateral minimally invasive ap- proach combined with modular femoral head prosthesis is a satisfactory method in treatment of femoral neck fractures in senile patients, for it can result in less intra-operative soft tissue damage and blood loss,as well as shorter rehabilitation time. Key words: Femoral neck fractures ; Surgical procedure, minimally invasive; Arthoplasty,replacement, hip; Modular femoral head

Laparoscopic Splenectomy and Esophagogastric Devascularization Is a Safe, Effective, Minimally Invasive Alternative for the Treatment of Portal Hypertension With Refractory Variceal Bleeding

Open splenectomy and esophagogastric devascularization (OSED) is a typical surgery for portal hypertension. Because of the high morbidity associated with it, it is desirable to develop a minimally invasive alternative. To investigate the safety and effect of laparoscopic splenectomy and esophagogastric devascularization (LSED), we performed LSED for 24 patients suffering from portal hypertension with refractory variceal bleeding while conducting OSED for 30 patients. The perioperative data and follow-up results were analyzed. Operation times were similar in both groups. Less intraoperative blood and faster return of gastrointestinal function were found in the LSED group. The LSED group had lower levels of alanine aminotransferase, aspartate aminotransferase, and total bilirubin after surgery. In both groups, the levels of platelet count, white blood cell count, or hemoglobin were increased after operation dramatically. During the follow-up period (range = 3-36 months), no patient had recurrent hypersplenism or variceal bleeding. Hence, LSED is a safe and minimally invasive intervention for portal hypertension with refractory variceal bleeding.

Evaluation of the efficacy of tranexamic acid on blood loss in orthognathic surgery. A prospective, randomized clinical study

The purpose of this prospective, randomized, double blind study was to assess the effect of tranexamic acid on blood loss, quality of surgical field and duration of surgery in adolescent orthognathic surgery patients. 50 consecutive patients, scheduled for orthognathic surgery were included. The study group (n=25) received tranexamic acid 10mg/kg as a bolus preoperatively followed by 1mg/kg as a maintenance dose intra operatively; the control group (n=25) received placebo (normal saline). All patients received moderate hypotensive anaesthesia with nitroglycerin and had surgery according to a standard protocol. Intra operative blood loss, duration of surgery, quality of surgical field, blood transfusion and complications, if any, were recorded. The mean total blood loss was 166.1±65.49ml in the study group and 256.4±77.80ml in the control group. The results showed statistically significant reduction in blood loss (p<0.001) and improved quality of surgical field (p<0.001) in the study group. There was no significant difference in duration of surgery and transfusion requirements between the two groups. In conclusion, preoperative and intra operative administration of the antifibrinolytic agent, tranexamic acid, is effective in controlling blood loss and improving the quality of the surgical field.

Successful laparoscopic management of hemoperitoneum due to spontaneous venous rupture overlying a uterine fibroid

Spontaneous venous rupture overlying a uterine fibroid is a rare cause of hemoperitoneum. A 38-year-old woman presented to the emergency department with acute onset of abdominal pain. The ultrasound revealed multiple fibroids and free fluid in the peritoneum. There was a significant drop of the hemoglobin and hematocrit. The patient underwent emergent exploratory laparoscopy. A subserosal uterine leiomyoma was found, with a bleeding vein on its basis and massive hemoperitoneum. Laparoscopic myomectomy was successfully performed with local injection of vasopressin and intraoperative autologous blood transfusion. This case suggests that spontaneous intraperitoneal haemorrhage associated with uterine fibroids, although rare, should be considered in women with hypovolemic shock and a pelvic mass.

Direct access to the renal artery for transperitoneal laparoscopic radical nephrectomy: the safety and feasibility

Objective To compare different methods for blockage of renal artery in transperitoneal laparoscopic radical nephrectomy,and evaluate the safety and feasibility of direct access to the renal artery.Methods From May 2008 to December 2010,64 patients with T1N0M0-T2N0M0 stage renal carcinoma underwent transperitoneal laparoscopic radical nephrectomy using a standard procedure to isolate and block renal artery(group A,33 patients) or a direct access to the renal artery via ligament of Treitz(left side) or aorta-inferior vena cava(right side;group B,31 patients).The age,gender,body mass index(BMI),history of previous abdominal surgery,tumor side,tumor maximum diameter,and preoperative TNM stages were all matchable between the two groups.Results One patient in group A was conversed to open surgery due to extensive perirenal adhesion and the others successfully received transperitoneal laparoscopic radical nephrectomy.The operation time,estimated blood loss,intraoperative and postoperative complications,postoperative TNM stage,postoperative fasting time,postoperative indwelling time of drainage tube,postoperative hospital stay and pathological types were similar between the two groups.Patients with T2 stage tumors in Group B had less intraoperation blood loss than those in Group A(P0.05).Conclusion Direct access to the renal artery is feasible and safe of transperitoneal laparoscopic radical nephrectomy.The method not only fulfils the tumor-free principles and reduces intraoperative blood loss,but also broadens the indications of laparoscopic operations for renal cell carcinoma.