Local Tamponade Research Articles

Epistaxis After Orthognathic Surgery: Literature Review and Three Case Studies.

This is a literature review with 3 case studies. Intraoperative and postoperative bleeding are the most common complications of orthognathic surgery and have the potential to become life-threatening. The rarity of severe postoperative epistaxis has resulted in limited characterization of these cases in the literature. The purpose of this study is to 1) differentiate various presentations of epistaxis following orthognathic surgery in the literature, 2) identify management approaches, and 3) to synthesize a treatment algorithm to guide future management of postoperative epistaxis. A literature search of PubMed was conducted and 28 cases from 17 studies were assessed. Bleeding within the first week may indicate isolated epistaxis, often resolved with local tamponade. Half of cases were attributed to pseudoaneurysm rupture (n = 14), with epistaxis onset ranging from postoperative day 6 to week 9. Angiography was used in most cases (n = 17), often as the primary imaging modality (n = 11). Nasal endoscopy is a less invasive and effective alternative to angiography with embolization. Proximal vessel ligation was used in 3 cases but is not preferred because collaterals may reconstitute flow through the defect and cause rebleeding. Repeat maxillary down-fracture with surgical exploration was described in 4 cases. As outlined in our management algorithm, nasal packing and tamponade should be followed by either local electrocautery or vascular imaging. Angiography with embolization is the preferred approach to diagnosis and management, whereas surgical intervention is reserved for cases of embolization failure or unavailability.

Combination of medical and surgical management in successful treatment of caesarean scar pregnancy: a case report series

BackgroundThere is no clear consensus on the management of caesarean scar pregnancy (CSP), a complex and life-threatening condition. The objective of this study was to present a novel approach to management of CSP that combines medical therapy of multidose methotrexate and mifepristone with active surgical management by uterine curettage and consecutive local haemostasis.Case presentationWe report on a prospective case series of six women with first trimester pregnancy, in whom the diagnosis of CSP was confirmed by 2D and color Doppler transvaginal ultrasound and serial hormone chorionic gonadotropin (hCG) testing. Women were between 23 and 36 years old and had at least one previous delivery by caesarean. At admission, gestational age ranged between 6 to 14 weeks, and serum hCG levels between 397 and 23,000 mUI/ml. Upon decision of pregnancy termination, medical management was undertaken in all cases and 1 mg/kg systemic Methotrexate was administered between 1 and 5 daily doses. Mifepristone was part of the treatment in cases with live pregnancy. Surgical management was employed for the cases were an embryo was seen by ultrasound, being prompted by inadequate response to Methotrexate and/or signs of miscarriage with vaginal bleeding. Curettage combined with local isthmic balloon or vaginal pack tamponade prevented further complications. High treatment rates with preservation of fertility was achieved in all patients except one who underwent hysterectomy for invasive placentation. Ultrasound and hCG levels surveillance ensured that the resolution of pregnancy was achieved.ConclusionWomen with history of delivery by caesarean section should be carefully monitored in future pregnancies for prompt diagnosis of CSP. Early diagnosis of CSP allows selection of successful conservative therapy. Through this case series we contribute with our experience to the body of knowledge about the management of this serious complication of early pregnancy.

Failure of Initial Renal Arterial Embolization for Severe Post-Percutaneous Nephrolithotomy Hemorrhage: A Multicenter Study of Risk Factors

Severe hemorrhage after percutaneous nephrolithotomy is a rare but alarming event. If local tamponade fails to control bleeding, the current treatment of choice is superselective renal arterial embolization. If initial embolization is unsuccessful, repeat embolization or nephrectomy is often required. To our knowledge we report the first study of risk factors for failed initial superselective renal arterial embolization. We retrospectively reviewed the records of 17,619 patients who underwent a total of 19,185 percutaneous nephrolithotomies from January 2007 to April 2012 at 6 centers. Study inclusion criteria were percutaneous nephrolithotomy and severe postoperative renal hemorrhage requiring superselective renal arterial embolization. Data on patients in whom initial embolization failed were compared to those on patients with successful embolization on univariate and multivariate analysis. Of the 17,619 patients 117 (0.6%), met study inclusion criteria, including 90 males and 27 females. Initial treatment failed in 12 patients (10.3%), 8 underwent repeat superselective renal arterial embolization, 3 required 3 embolizations and 1 underwent nephrectomy. Complete bleeding cessation was achieved in all 11 repeat embolization cases. We identified 3 risk factors for failure of initial superselective renal arterial embolization, including multiple percutaneous access sites, more than 2 bleeding sites identified on renal angiogram and gelatin sponge alone used as the embolic material. Carefully selecting patients for multitract percutaneous nephrolithotomy, making an extra effort to identify all bleeding vessels during angiography and not using gelatin sponge as the only embolic material could potentially decrease the risk of failure of initial superselective renal arterial embolization after percutaneous nephrolithotomy.

Dilemmas and challenges in the management of a neonate with Adams–Oliver syndrome with infected giant aplasia cutis lesion and exsanguination: a case-based update

Aplasia cutis is a rare developmental anomaly usually involving the calvarium, associated with a variable extent of defective formation of the scalp. Adams-Oliver syndrome is a condition mainly characterized by the congenital absence of skin, known as "aplasia cutis" which is usually limited to the vertex scalp and transverse limb defects. A 17-day-old term female neonate was referred to us with an infected scalp lesion of the vertex. The lesion which is about 10 × 9 cm had signs of infection with necrotic eschar. We started the neonate on systemic parenteral antibiotics with local dressings. On day 3 of conservative management, the neonate had exsanguination due to bleeding from the midline with severe hemodynamic compromise requiring cardiopulmonary resuscitation. After controlling the bleeding with local tamponade and resuscitating the child, she was taken for early surgery. Debridement and bipedicled rotation flap of the scalp to cover the raw area was performed. On day 18, the flap started showing signs of necrosis. The neonate was taken up for debridement, and subsequently, maternal allograft of split-thickness skin was placed as a temporary wound cover. Meanwhile, the wound showed progressive epithelialization. At 1 year, the patient continued to have a non-healing area, which was later successfully covered with a split-thickness skin graft. We plan to revaluate the need for cranioplasty at around 3-4 years of age. We discuss the dilemmas and challenges involved in the successful management of a neonate with Adams-Oliver syndrome with infected aplasia cutis and an episode of life-threatening exsanguination. Aplasia cutis is a rare developmental anomaly usually involving the calvarium, associated with defective formation of the scalp to a varying extent and severity, requiring various timely strategies.

A Case Report of Massive Vaginal Variceal Hemorrhage in a Patient With Cirrhosis Secondary to Nonalcoholic Steatohepatitis Unresolved Even After Successful Liver Transplantation

Massive hemorrhage from vaginal varices in patients with cirrhosis and a previous hysterectomy can be life-threatening. In the few previous reports, the treatments have all included an initial local tamponade followed by interventional radiology procedures, transvenous intrahepatic portosystemic shunts, surgical shunt, or liver transplantation. A patient with cirrhosis secondary to nonalcoholic steatohepatitis developed massive vaginal variceal hemorrhage. Control of the bleeding was achieved initially with local tamponade. Upon admission to the intensive care unit, the patient was upgraded to urgent status on the liver transplant waiting list, which was performed on day 7. Due to a portal vein thrombosis, an interpositional vein graft to the superior mesenteric vein was required. Postoperatively despite a functional graft and normalization of coagulation system, the vaginal bleeding continued as the left-sided portal hypertension had not been decompressed by the liver transplantation. During a subsequent laparotomy, splenectomy and ligation of the inferior mesenteric vein were required to definitively control the vaginal variceal hemorrhage. The degree and anatomy of the portal hypertension play a crucial role in determining the proper course of management and treatment of vaginal varices in a cirrhotic patient.

An alternative approach for chest drainage after cardiac surgery: Redon drains

At the end of every cardiac procedure, two or three chest tubes (28F–32F) are typically placed in the mediastinum to continuously monitor postoperative blood loss and to prevent undesirable blood collection, especially in the pericardial space, which could potentially lead to cardiac tamponade. The chest tubes are connected to various drainage systems that use the underwater valve seal principle. Suction of about −20 cm H2O is usually applied. Here we present an alternative drainage system that provides distinct advantages over the commonly used systems. The drainage system consists of four or five Redon (B. Braun Melsungen AG, Melsungen, Germany) drains (2-mm inner diameter). Each drain is connected to a 600-mL reservoir with an applied suction of −800 mbar (816 cm H2O) (Figure 1). They are placed into the pericardial space (and pleural cavity, if needed) in the following sequence (Figure 2):1Drain 1 is positioned along the right heart border (right atrium), ending under the ascending aorta.2Drain 2 is positioned in front of the heart directly beneath the sternum.3Drain 3 is positioned along the diaphragmatic surface of the heart, ending over the lateral wall of the left ventricle.4Drain 4 is positioned in front of the heart (right ventricle), curving behind the pulmonary artery and ending in the sinus transversus.5Drain 5 (pleural, only if needed) is placed into the desired pleural space through a cauterized hole in the back wall of the pericardial sac, ending over the diaphragm.Figure 2Arrangement of the drains in the mediastinum.View Large Image Figure ViewerDownload Hi-res image Download (PPT) All drains exit the mediastinum through the abdominal fascia in the epigastric area. Drains are removed on the second postoperative day, being first disconnected from the reservoir to ensure that no continuous suction is applied during their removal. A total of 4297 cardiac procedures were performed between February 2002 and January 2007 at our institution. Redon drains were used for postoperative blood drainage in all cases (99.8%), regardless of the type of operation, with the only exceptions being 9 patients in whom it was not possible to control the coagulation disorder after weaning from cardiopulmonary bypass and who therefore required the use of a cell salvage device immediately after the procedure in the operating room and subsequently in the intensive care unit. Chest tubes (32F) were used in these 9 patients. The postoperative total blood losses at the time of Redon drain removal (usually on postoperative day 2) are summarized in Table 1. Postoperative bleeding complications for the cohort of 4297 patients in whom a Redon drainage system was used are listed in Table 2.TABLE 1The mean postoperative blood loss at the time of Redon drain removal (National Cardiac Surgery Registry 2002–2006)Type of procedureBlood loss (mL)CABG971.3Valves1057.6Thoracic aorta1153.9Redo procedures1497.6CABG, Coronary artery bypass grafting. Open table in a new tab TABLE 2Postoperative bleeding complications in patients in whom a Redon drainage system was used (n = 4297) (National Cardiac Surgery Registry 2002–2006)No. (%) of patientsReopening for bleeding119 (2.8%)Reopening for tamponade29 (0.7%) Open table in a new tab CABG, Coronary artery bypass grafting. Below, we summarize our experiences with the advantages and disadvantages of Redon drains relative to standard drainage approaches (using an underwater valve seal). 1The handling is more convenient. Once the drains are connected and checked for tightness (absence of air leaks), there is no need for further monitoring such as checking the water levels or the functioning of the water valve seal.2The Redon drainage system allows regions of bleeding to be detected. Each drain covers a specific area around the heart, facilitating the localization of any bleeding sources (eg, coronary suture line or left atrium suture line).3It decreases the risk of local tamponade. Positioning the drains over all the heart chambers, especially the right and left atria, decreases the risk of local tamponade.4It decreases the risk of coronary graft compression. The drains are thinner and more flexible, decreasing the risk of graft compression.5It maintains suction during patient transportation. There is no need for an external source of suction, which enables the suction to be maintained when transporting the patient from the operating room to the intensive care unit.6It is noiseless. It produces no bubbling sounds that are disturbing for both medical personnel and the patient.7It is cost-effective. The Redon drain system is five times cheaper than drainage using chest tubes. 1The Redon drain system is sensitive to air leaks. The presence of an air leak from the lung tissue will result in inadequate suction, requiring the system to be converted to the underwater drainage principle (external suction).2It cannot be used with a cell salvage system. In cases of profound bleeding resulting from coagulation disorder, the system cannot be used with a cell salvage device. Because of the distinct predominance of the advantages of the described system over its disadvantages, we highly recommend its broader use. Dr Gwozdziewicz

Large‐volume endoscopic injection of epinephrine plus normal saline for peptic ulcer bleeding

Large-volume endoscopic injection of epinephrine has been proven to significantly reduce rates of recurrent peptic ulcer bleeding. Injection of normal saline may be equally effective for the similar hemostatic effect of local tamponade. The aim of our study was to compare the therapeutic effects of large-volume (40 mL) endoscopic injections of epinephrine, normal saline and a combination of the two in patients with active bleeding ulcers. A total of 216 patients with actively bleeding ulcers (spurting or oozing) were randomly assigned to three groups (1:10,000 epinephrine, normal saline or diluted epinephrine plus normal saline). The hemostatic effects and clinical outcomes were compared between the three groups. The initial hemostatic rate was significantly lower in the normal saline group (P < 0.05). The volume of injected solution required for the arrest of bleeding was significantly larger in the normal saline group (P < 0.01). Mean duration for arrest of bleeding was significantly longer in the normal saline group (P < 0.01). There were no significant differences between the three groups with respect to the rates of recurrent bleeding, surgical intervention, 30-day mortality, amount of transfusion and duration of hospitalization. Significant elevation of systolic blood pressure (P < 0.05) and persistent high pulse rate after endoscopic injection were observed in the epinephrine group. For patients with active bleeding ulcers (spurting or oozing), we recommend a large-volume (40 mL) combination injection using diluted epinephrine to cease bleeding, followed by injection of normal saline to achieve sustained hemostasis.

Mechanism of action of injection therapy for bleeding peptic ulcer.

The effects of intramucosal injection of 1:100,000 adrenaline, 5 per cent ethanolamine and normal saline were determined in experimentally created, acutely bleeding gastric mucosal wounds in rabbits. The mean(s.d.) bleeding rate was decreased from 2.3(0.4) to 0.2(0.02) ml/min by adrenaline (P < 0.01), but increased by 1 ml 5 per cent ethanolamine to 4.0(0.6) ml/min (P < 0.05). Normal saline had no haemostatic effect, suggesting that local tamponade is not important. In separate experiments endoscopic injections of 5 per cent ethanolamine, 1:100,000 adrenaline and normal saline were made in the gastric antrum of rabbits. After 48 h the degree of inflammation was greatest with ethanolamine but, despite tissue necrosis and venous thrombosis, neither endarteritis nor arterial thrombosis occurred. Injections of 5 per cent ethanolamine and 80 per cent ethanol placed next to the ear arteries of rabbits caused local ulceration and necrosis, but endarteritis and arterial thrombosis were again absent.

Randomized trial of normal saline solution injection versus bipolar electrocoagulation for treatment of patients with high-risk bleeding ulcers: Is local tamponade enough?

Background: Endoscopic injection of normal saline solution is reportedly an effective treatment for bleeding ulcers. If it is as effective as standard therapy, low cost, wide availability, and lack of injury would make saline solution injection an attractive option. Methods: Patients with clinical evidence of major bleeding from an ulcer with active bleeding or a nonbleeding visible vessel were randomly assigned to injection with normal saline solution (1-2 mL boluses; mean volume 30 mL) or bipolar electrocoagulation (20 W, 10-sec applications; mean time 100 sec). Patients, those caring for patients, and those collecting data were blinded to therapy. Results: Further bleeding occurred in 14 (29%) of 48 patients in the saline solution group versus 6 (12%) of 52 patients in the bipolar group (95% CI [2%, 33%]; p = 0.04). Significantly more units of blood were transfused in the saline solution group (median 2 units vs. 0 units; p = 0.01). Hospital days (median 4 vs. 3) and mortality (6% vs. 2%) were not significantly different in the 2 groups. Independent risk factors for further bleeding were saline solution injection (p = 0.02), units transfused before therapy (p = 0.02), and ulcer size (p = 0.03). Conclusion: Local tamponade with saline solution injection is less effective than bipolar electrocoagulation for the treatment of bleeding ulcers. (Gastrointest Endosc 2002;55:6-10.)

Randomized trial of saline injection vs. bipolar electrocoagulation for bleeding ulcers: Is local tamponade enough?

Randomized trial of saline injection vs. bipolar electrocoagulation for bleeding ulcers: Is local tamponade enough?

Surgical Management of Hemorrhage From Rupture of the Aortic Arch

Background. Control of hemorrhage in patients with active bleeding from rupture of the aortic arch is difficult, because of the location of the bleeding and the impossibility of cross-clamping the aorta without interfering with cerebral perfusion. A precise and swift plan of management helped us salvage some patients and prompted us to review our experience. Methods. Six patients with active bleeding of the aortic arch in the mediastinum and pericardial cavity (5 patients) or left pleural cavity (1 patient), treated between 1992 and 1996, were reviewed. Bleeding was reduced by keeping the mediastinum under local tension (3 patients) or by applying compression on the bleeding site (2 patients), or both (1 patient) while circulatory support, retransfusion of aspirated blood, and hypothermia were established. The diseased aortic arch was replaced during deep hypothermic circulatory arrest, which ranged from 25 to 40 minutes. In 3 patients, the brain was further protected by retrograde (2 patients) or antegrade (1 patient) cerebral perfusion. Results. Hemorrhage from the aortic arch was controlled in all patients. Two patients died postoperatively, one of respiratory failure and the other of abdominal sepsis. Recovery of neurologic function was assessed and complete in all patients. The 4 survivors are well 8 to 49 months after operation. Conclusions. An approach relying on local tamponade to reduce bleeding, rapid establishment of circulatory support and hypothermia, retransfusion of aspirated blood, and swift repair of the aortic arch under circulatory arrest allows salvage of patients with active bleeding from an aortic arch rupture.

Prolonged evaluation of epinephrine and normal saline solution injections in an acute ulcer model with a single bleeding artery

Background: Animal studies of epinephrine or normal saline solution injection for bleeding ulcers do not consistently demonstrate local tamponade effect. Methods: We studied the change of bleeding rates of 28 acute gastric ulcers with a single bleeding artery in 10 dogs. Four injections of 1 mL epinephrine 1:10000 at 1 mm from the spurting artery (n = 7) were compared to four injections of normal saline solution 1 to 5 mL (n = 12) and to four dry needle sticks (n = 9). Bleeding rates were measured at initial arterial incision and at minutes 1, 5, 10, 15, 20, 25, and 30 after treatment. Result: Reductions in early blood loss to 24.3% ± .05 of baseline occurred with saline solution, to 17.7% ± .03 with epinephrine, and to 66.0% ± 1.8 in controls ( p < .05 for epinephrine and saline solution vs control). A tendency for saline solution injected ulcers to resume bleeding was identified, with late blood loss increasing to 26.9% ± .05 of baseline, (saline solution vs control) compared to 7.7% ± .02 in epinephrine injected ulcers ( p < .05 vs control). Conclusions: The early acute hemostatic effect of injection therapy depends on local tamponade. The prolonged hemostatic effect is a combination of tamponade and vasoconstriction, with advantage of epinephrine over saline solution. (Gastrointest Endosc 1995;42:51-5.)

Endoscopic injection for the treatment of bleeding ulcers: local tamponade or drug effect: Lai KH, Peng SN, Guo WS, et al. Endoscopy 1994;26:338–41

Endoscopic injection for the treatment of bleeding ulcers: local tamponade or drug effect: Lai KH, Peng SN, Guo WS, et al. Endoscopy 1994;26:338–41

Two techniques for the control of cardiac bleeding

Two new techniques effectively control local bleeding from the heart during heart operations. Both act by achieving local tamponade of the bleeding but through different mechanisms. In the first, a glove containing a sponge is placed against the bleeding site to provide local pressure. In the second, application of focal, high vacuum suction causes forceful apposition of adjacent soft tissue. These methods have stopped bleeding in 7 patients in whom conventional methods failed.

Cardiomyopathy and pulmonary emboli in terminal Duchenne's muscular dystrophy

should raise the possibi l i ty of a t raumat ic fistula. 1 This case was unusual in tha t prolonged survival such as this is uncommon and probably occurred because of local tamponade and occlusion of the wound by extensive thrombus. Per iphera l emboli are also an uncommon event and should alert the physician to the possibil i ty of a bul let embolus. 4 The repeated emboli in this pa t ien t reflect the friable nature of the aortic thrombus and the extensive damage tha t bul let wounds may cause to the vessel wall. 5 Angiography has been the t rad i t ional method of evaluating pathologic condit ions of the aorta, but because of the hemodynamic instabi l i ty associated with penetra t ing wounds of the aorta, it may not be safe and may cause undue delay in management of the patient . T E E is a safe bedside technique tha t has been shown to be as reliable as angiography in the evaluat ion of thoracic aortic dissections and aneurysms and superior to computed tomography scanning, s This case highlights the usefulness of TEE and also shows the advantages of recently developed biplane imaging. Longaxis scanning provided a much greater appreciat ion of the three-dimensional nature of the aortic clot and allowed the use of color flow mapping and Doppler quantif icat ion of the obstruction. T E E may reduce the need for extensive angiography and hence permi t more rapid definitive t reatment.

Massive Hemoptysis: Pathogenesis and Management

Massive hemoptysis is a life-threatening complication of many pulmonary disorders, and it occurs most com monly in association with longstanding inactive tuber culosis, bronchiectasis, lung abscess, bronchogenic car cinoma, and fungal disease. It is generally a neovascular change or local erosive effect of chronic pulmonary dis ease and may originate from either bronchial or pulmo nary circulation. Recurrent bleeding is unpredictable; therefore, diagnostic and therapeutic intervention must be undertaken with urgency. The immediate priorities must be protection of the airway to the nonbleeding lung and localization of the site of hemorrhage prefera bly by bronchoscopy, which has a high yield when per formed during active hemorrhage. Immediate control of bleeding may be obtained by local tamponade with a balloon-tipped Fogarty catheter, use of a double-lumen endotracheal tube, or angiographically guided emboliza tion. Surgical resection is the preferred definitive treat ment for those who meet operative criteria; those who lack adequate pulmonary reserve are candidates for em bolization of sites with persistent bleeding. The high mortality of conservatively treated massive hemoptysis and the current inability to predict which patients will have fatal hemorrhage mandate rapid assessment and intervention.

A Personal View of the Immediate Management of Pelvic Fracture Urethral Injuries

1. The best treatment for all but the most severe urethral injuries associated with pelvic fractures must surely be suprapubic catheter drainage without local exploration. 2. The free drainage of exudates from an injured urethra is be obstructed by the larger sizes of standard-shaft indwelling catheter; the use of a standard shaft catheter in an injured urethra requires careful consideration in relation to the individual problem and should not be a routine; however, a fenestrated catheter may have some positive advantages. 3. The results of treating the less severe fracture-dislocation injuries by suprapubic catheter are sufficiently good to make any attempt at immediate local readjustment of incomplete dislocations inadvisable for all but those with a special experience of the surgery of the traumatized urethra. 4. If abdominopelvic exploration has to be undertaken for non-urologic indications, the repositioning of a dislocated bladder base by the aligned sling-suture technique is a relatively simple procedure which can be swiftly and reliably accomplished by an emergency surgeon. 5. The treatment of a urethral injury, even if severely dislocated, is not in itself a matter of immediate urgency once suprapubic catheter drainage has been established; however, exploration for continued bleeding may be. If bleeding is controlled by local tamponade there may be considerable advantage in postponing definitive resolution of a massive urethral dislocation for a week or so because the patient is usually fitter and the procedure is less likely to be complicated by serious hemorrhage. When a particular urethral injury is considered suitable for a delayed primary repositioning, the patient may be fit enough to transfer to the care of a urologic department with special experience of these problems.

CRYOTONSILLECTOMY IN DOGS.

THIS PAPER will describe the rationale, instrument, and technique of a cryosurgicallyproduced tonsillectomy in dogs. Rationale For many years excisional tonsillectomy has proved itself to be a very successful procedure in the vast majority of instances. Its object, the removal of the diseased structures, is achieved at a very low mortality rate, and healing results in good function. Nevertheless, even its most skillful practitioners and enthusiastic supporters acknowledge that it is by no means an ideal, carefree operation. For one thing, they caution that the threat of hemorrhage is ever present. This may occur during excision, because of the difficulty of securing certain deeply-placed vessels, or in the immediate postoperative period when ligatures can slip off. Brisk bleeding can also appear even days later when the slough that forms in the tonsillar bed separates. Although these complications can usually be prevented by meticulous hemostasis during surgery or by local tamponade