Ongoing Bleeding Research Articles

Postoperative complications for complicated malignant tumours of the stomach

Objective — to determine the frequency and structure of postoperative complications for malignant tumours of the stomach accompanied by gastrointestinal bleeding. Materials and methods. The study analysed the treatment outcomes of 101 patients with a malignant tumour of the stomach complicated by bleeding (84 cases), perforation (6 cases), or stenosis (19 cases, with 8 of them having both stenosis and bleeding). These patients underwent inpatient treatment at the Kyiv City Centre for Gastrointestinal Bleeding and the Kyiv City Clinical Hospital of Emergency Medical Help between 2015 and 2020. Out of the patients, 78 (77.2%) had histologically confirmed cancer, 11 (10.9%) had GIST, and 12 (11.9%) had malignant lymphoma. Results. During the peak period of ongoing and recurrent bleeding, 5 (6%) patients required emergency surgery, including 2 (40%) radical and 3 (60%) non‑radical procedures. After proper preoperative preparation and a comprehensive follow‑up assessment, 58 (57.4%) patients underwent radical surgical interventions for stomach cancer complicated by acute gastrointestinal bleeding in the early delayed period. In the early postoperative period, 4 (15.4%) patients experienced complications after 26 radical gastrectomies combined with jejunogastroplasty. In the delayed period, early postoperative complications occurred in 9 (28.1%) patients after 32 radical gastric resections. The total postoperative mortality after emergency surgical interventions was 20.0%. The total postoperative mortality in the early‑term period was 5.7% (5 patients out of 88), which is 3.5% less compared to emergency operations (the difference is statistically significant, p ≤0.05). Conclusions. When urgent surgical interventions are carried out at the peak of ongoing and recurrent bleeding, the mortality rate from postoperative complications is 3.5 times higher than when operations are performed in the early delayed period after adequate preparation and comprehensive patient monitoring. The death rate after radical operations is 2.1 times lower than that after palliative and symptomatic operations. As the operations conducted during the peak bleeding period are associated with high postoperative mortality, we believe that they pose a high risk to patients with malignant tumours of the stomach.

Celiac disease as a rare source of recurrent small intestinal bleeding

Aim: study of the effectiveness of endoscopic interventions in complicated celiac disease.Material and methods. An electronic literature search was performed using databases: PubMed, Medline, Cochrane Library. A clinical case of a patient with small intestinal bleeding and celiac disease is described.Results. This literature review includes case reports, retrospective studies, and literature reviews. Presented is a clinical case of a patient who noted periodic discharge of blood from the anal canal for 2 years. According to esophagogastroduodenoscopy, erosive gastritis was detected, complicated by bleeding (the source was not identified) with suspected celiac disease. According to the histological conclusion, celiac disease is excluded. During hospitalization, it was decided to perform capsule endoscopy with balloon-assisted enteroscopy followed by a biopsy. According to the data of a comprehensive endoscopic examination of the small intestine, various defects of the mucous membrane with signs of ongoing bleeding were revealed. Endoscopic clipping of the identified defects was performed and a biopsy was taken. According to the results of histological examination, celiac disease complicated by small intestinal bleeding was diagnosed.Conclusions. The use of endoscopic therapeutic techniques avoids surgical interventions, and preserves the quality of life of the patient.

Management of Decreased Consciousness Caused by Hypovolemic Shock ec Postpartum Hemorrhage in Critical Care Setting

Introduction: Postpartum hemorrhage life-threatening condition, with a prevalence of approximately 1%-10% of all deliveries. Postpartum hemorrhage is one of the leading causes of maternal death.
 Case presentation: A 33-year-old female patient came to the emergency department with decreased consciousness 1 hour before hospital admission, with postpartum hemorrhage, placental abruption following cesarean section, and uterine atonia following B-Linch. The patient underwent a B-Linch operation after undergoing a cesarean section at a previous Hospital due to antepartum hemorrhage and placental abruption. The patient also experienced ongoing bleeding during the treatment due to uterine atonia. Following surgery, a post-operative laboratory evaluation revealed significant thrombocytopenia (platelets: 45.000/mm3) and anemia (Hb: 4,6 g/dl). 
 Conclusion: The management of postpartum hemorrhage, especially with shock, requires comprehensive critical care management. Appropriate management with good multidisciplinary team involvement will improve patient outcomes and prevent multi-organ failure.

Ruptured abdominal aortic aneurysms early recognition, hemodynamic stabilization, and emergency vascular surgery

Ruptured abdominal aortic aneurysms (rAAAs) are extremely dangerous. Require attention. This thorough review explores the management of rAAA, focusing on the detection stabilizing blood flow and emergency vascular surgery. Recognizing symptoms such as intense abdominal pain, low blood pressure, a pulsating mass in the abdomen, signs of reduced blood flow to the lower limbs, and back pain is crucial for quick identification. Diagnostic imaging techniques like ultrasound and computed tomography angiography (CTA) play a role in confirming the diagnosis and assessing the risk involved. Properly managing hemodynamics by balancing resuscitation efforts with approaches is essential to control ongoing bleeding. Emergency vascular surgery options include aneurysm repair (EVAR) and open repair; the choice depends on factors like anatomy, stability of blood flow, and surgical expertise. Prioritizing optimization to address any health conditions and closely monitoring patients after surgery greatly contribute to overall success rates. A collaborative approach among healthcare professionals ensures a multidisciplinary strategy during the period emphasizing effective communication. This comprehensive approach aims for outcomes in dealing with challenging rAAAs while considering advancements in research and clinical practices.

Paralytic Ileus as a Presentation of Antiphospholipid Syndrome in a Patient with Renal Angiomyolipoma: A Case Report

Antiphospholipid syndrome (APS) is one of the many causes of hypercoagulability which often presents with vascular thrombosis in the presence of antiphospholipid antibodies. Symptoms vary depending on the location of the thrombosis. Gastrointestinal symptoms such as paralytic ileus is one of the rare symptoms in APS. The main therapy for APS is use of anticoagulants, but this becomes difficult when there is ongoing bleeding. We report a successful but challenging treatment of a 42-year-old patient who presented with paralytic ileus due to APS with cofounded on-going renal bleeding caused by renal angiomyolipoma.

Damage Control in Penetrating Liver Trauma: Fear of the Unknown

The liver is the most commonly affected solid organ in cases of abdominal trauma. Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of damage control surgery accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible computed tomography as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management in hemodynamically stable trauma victims with liver injuries. However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage. The aim of this article is to perform an extensive review of the literature and to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus. It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver.

Aortic annulus rupture after transcatheter aortic valve replacement: successful management of a dangerous complication

ObjectiveAortic annulus rupture remains one of the most fatal complications of TAVR. While attempts have been made to describe and predict this complication, the data remains insufficient without evidence-based guidelines for management of this rare complication.MethodsHere we describe a series of 3 aortic annulus ruptures after TAVR which were managed successfully to hospital discharge.ResultsPatient 1 suffered annulus rupture during balloon valvuloplasty prior to TAVR. The patient became hypotensive, and echocardiogram showed pericardial effusion. The patient underwent pericardiocentesis which transiently improved the blood pressure, but bleeding continued. The patient was transitioned to an open surgical aortic valve replacement due to ongoing hemorrhage. The chest was left open with delayed closure on post-op day 2. The patient was discharged on post-op day 15. Patient 2 was undergoing TAVR valve expansion. The patient became hypotensive. An echocardiogram revealed pericardial effusion. Pericardiocentesis yielded 200 mL of blood. SURGIFLO (Johnson & Johnson Wound Management, Somerville, NJ) was injected into the pericardial space. Aortic root angiography confirmed no further contrast extravasation. A pericardial drain was left in place for 2 days, and the patient was discharged on post-op day 7. Patient 3 received a TAVR valve and post-placement dilation due to paravalvular leak. The echocardiogram showed a pericardial effusion. Pericardiocentesis was performed, yielding 500 cc of blood. The patient’s healthcare proxy declined emergent surgery; thus, a pericardial drain was placed. No hemostatic agents were used, and drainage reduced over several hours. The drain was removed on post-op day 3, and the patient was discharged on post-op day 8.ConclusionsBased on the timelines in these three cases, and interventions used, the following steps may be employed in the event of annulus rupture: identification of hemodynamic instability, echocardiogram to confirm pericardial effusion, emergent pericardiocentesis, pericardial drain placement for evacuation of the pericardial space and use of hemostatic agents, repeat aortogram to rule out ongoing extravasation. If hemostasis is unable to be achieved and/or the patient becomes hemodynamically unstable at any point, rapid transition to emergent surgical management is necessary. This management strategy proved successful for this case series and warrants further investigation.

Abstract 100: Endovascular treatment of a traumatic near‐miss vessel injury

Introduction Traumatic injuries are a common cause of death, representing nearly 8% of all deaths worldwide(1). Vascular injury can occur in about 3% to 20% of the patients that suffer from a blunt or penetrating craniocervical injury (2). The most commonly injured arteries from penetrating trauma include CCA, ICA, and ECA (73%,22%, and 5% respectively)(3). Embolization is now a well‐established endovascular technique to treat traumatic hemorrhagic injuries(4). We present a case of a patient with a near‐miss injury treated endovascularly. Methods We present the case of a 29‐year‐old male who was found unconscious with a knife embedded in his left face. On arrival at the hospital, the patient was hemodynamically stable with no ongoing hemorrhage or respiratory distress. CTA did not reveal any vascular injury; however, due to the knife's location, the neurointerventional radiology team was consulted and performed an embolization of the proximal third of the internal maxillary artery. The patient was later taken to the operating room for the removal of the knife. Results The non‐serrated end of the knife had resulted in impingement of the distal left ECA just proximal to the bifurcation of the superficial temporal artery and internal maxillary artery and resulting in approximately 80% narrowing of the vessel. Given the extent of impingement of the foreign object on the distal portion of the left ECA, after discussing with the otolaryngology team, a decision was made to proceed with coil embolization of the vessel due to concerns for vessel injury which can result in life‐threatening hemorrhage or pseudoaneurysm during removal of the foreign object in the OR. A total of 4 HydroFrame coils were deployed from the proximal one‐third of the internal maxillary artery into the ECA covering the superficial temporal artery to the origin of the occipital artery. 2 MicroPlex 5mm x 22cm Cosmos 10 bare platinum coils were placed intact to the left ECA extending proximally just distal to the occipital artery. Final AP projection of the left ECA post coil embolization was performed showing complete occlusion of the vessel across the area of impingement at the distal ECA proper. Retrograde filling of the internal maxillary artery was noted. The left middle meningeal artery is occluded and no longer visualized as its origin is being covered by coils. Patient underwent foreign object removal by ENT and had a good functional outcome. Conclusion Endovascular intervention prior to foreign object removal can improve outcomes and decrease the risk of severe vascular injury.

A100Simulating to manage post thyroidectomy haematoma safely: Improving fidelity whilst reducing cost

Simulation training sessions were designed at the University Hospital of Wales in order to implement the new national guidelines for the management of suspected haematoma following thyroid surgery [1]. Opportunities included on site portable training with a part task trainer and high-fidelity scenarios simulating patient deterioration following thyroid surgery in an immersive environment. Our initial design for the high-fidelity set-up included a simulated neck haematoma achieved by using a second generation supraglottic airway device (SAD) with an inflatable cuff placed in the manikin’s neck with the laryngeal opening outwards and tubing inside the chest. The opening was filled with red jelly, covered by simulated strap muscles (made from simulated small bowel with interrupted sutures) and simulated neck skin (which presented a sutured incision complete with steri-strips). Ongoing bleeding was simulated by injecting liquid jelly through the SAD’s gastric port via a long connecting tube in the manikin’s thorax. This simulation training increased confidence and familiarity with the steps required to manage post thyroid surgery haematomas in 100% (15/15) of candidates, with 73% grading the mannikin ≥4/5 for realism. However, it was costly to provide and time-consuming to set up. It was decided to try to make the set-up cheaper and easier to reproduce without impairing quality. Equipment costs were reviewed and alternative options identified. Expensive components included the SAD and bowel material, which were replaced with a cheaper SAD and a disposable tourniquet fashioned as shown in Making the simulation larynx and strap muscles. A step by step guide The cost of disposable props used in each session was reduced from £133.04 to £8.52 with the new equipment. The designers also felt it was significantly more robust and easier to reproduce. This approach could also be easily adapted for mobile part-task training, improving multi-disciplinary access to training. Feedback showed 47% of candidates felt the new set-up to be better, and 47% reported non-inferiority. Changing to new equipment resulted in a design that was significantly cheaper, easier to source and set-up, while being at least as realistic and offering training opportunities outside the high-fidelity environment. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

Finding the Right Balance: Partial REBOA in a Swine Model of Uncontrolled Vascular Injury.

We have previously shown that partial REBOA (pREBOA) deployment in the thoracic aorta is safe for 2 to 4 hours, but it is unclear whether the distal blood flow after partial aortic occlusion would lead to ongoing hemorrhage. The objective of this study was to evaluate the hemostatic efficacy of pREBOA in a model of uncontrolled vascular injury. Female Yorkshire swine (n = 10, 40 to 45 kg) were anesthetized and instrumented. A through-and-through injury was created in the common iliac artery. The animals were randomly assigned to: (1) pREBOA-PRO deployment after 3 minutes and (2) control. Both groups were given normal saline resuscitation for hypotension. The pREBOA was adjusted to partial occlusion (distal mean arterial pressure of 30 mmHg), and then left without titration for 2 hours. Then, fresh frozen plasma was transfused and the vessel repaired. The balloon was deflated and the animals were monitored for 2 hours. In the critical care period, 2 L of normal saline was infused, norepinephrine was given for mean arterial pressure ≤55, and electrolytes and acidosis were corrected. Organs were examined for gross and histologic evidence of ischemic injuries. The primary endpoint was post-inflation blood loss. All the pREBOA animals survived until the end, whereas control animals had a mean survival time of 38.2 minutes (p < 0.05). The pREBOA group showed significantly less bleeding after balloon deployment (93.8 vs 1,980.0 mL, p < 0.05), and had appropriate lactate clearance, with minimal histologic distal organ ischemia. Partial aortic occlusion with the newly designed balloon can achieve the desired balance between effective hemorrhage control and adequate distal flow, without a need for ongoing balloon titration.

SAT396 Transgender Care From The VA Perspective

Abstract Disclosure: P.R. Nayak: None. Background: Medically necessary care for transgender and gender non-conforming veterans was officially mandated in 2011 by the Veterans Health Administration. However, access to care can be difficult and tortuous to navigate. Additionally, the healthcare disparities experienced by transgender veterans extend beyond medical therapy; mental health services, appropriate sexual health education, and population specific needs and screenings are often inadequate. In 2019, providers and staff at our VA medical center formed a multi-disciplinary team to provide coordinated and whole health focused gender-affirming care for this unique population. The team consists of an endocrinologist, mental health providers, social workers, clinical pharmacist, speech therapist, primary care provider, and a prosthetic representative.Case: A 32 year old transmale veteran with depression and bipolar disorder met with our social worker after expressing his desire to continue his transition. He had come out to his community and presented as male for over a year. He was referred to the endocrinologist who recommended egg harvesting prior to starting hormone replacement therapy per veteran's desire for biologic children. A social worker coordinated his consultation with a reproductive endocrinologist for the procedure. Simultaneously, a prosthetics representative helped veteran obtain a chest binder and a stand-to-pee device. Upon completion of egg harvesting, he started testosterone therapy, titrated to therapeutic levels.A year after starting hormones, he pursued top surgery and completed this locally. Due to ongoing menstrual bleeding on intramuscular testosterone, he was referred to ob-gyn and subsequently underwent hysterectomy and left oophorectomy. Post hysterectomy, he and his partner began experiencing relationship problems. They were referred to the sex therapist to work on their physical intimacy and sexuality. Three years on hormone therapy, veteran reported difficulty with the voice variations, though his voice had deepened to his liking far earlier in his medical transition. He started working with a speech therapist for voice masculinization with improvement noted at follow up. Conclusion: A multi-disciplinary approach to gender-affirming care is beneficial in providing patients with the care they deserve in a timely, respectful and coordinated manner. Our patient experienced a smoother and supportive transition due to the team of providers who were able to provide gender appropriate care across several disciplines during each phase of his transition. Without a team approach, this population often face several hurdles and delays to their transition. Since 2019, we have served over 50 transgender and gender non-confirming veterans in their transition. While not all have met their transition goals, most have benefited from the support and guidance of our team. Presentation: Saturday, June 17, 2023

Vascular injury during lumbar discectomy: risk factors, diagnosis, methods of surgical correction, features of anaesthetic management and intensive care

One of the priority tasks in neurosurgery is to reduce the frequency of postoperative complications and mortality. Lumbar discectomy is the most frequently performed intervention in spinal neurosurgery and it is a fairly safe procedure. One of the possible intraoperative surgical complications, that threatens the patient’s life is vascular injury. The first clinical case of damage to the large vessels during discectomy was described in 1945. It is believed that the frequency of this complication is 1‒5 cases per 10,000 surgical interventions, but the literature notes that these figures may be significantly underestimated. Some authors indicate that the frequency of this complication, despite the development of surgical techniques over the past 50 years, has not significantly decreased, so it is important for surgeons to be informed and alert about the possibility of such a problem. Among the factors that significantly increase the risk of vascular damage congenital, acquired and technical are determined. Variability of clinical symptoms of damage to lagre vessels is due to different localization of injury, type (arterial, venous or combined) and scale of vascular disaster. For each level of surgical intervention, the "most typical" vessel damage is identified. Vascular injury during discectomy can occur according to three clinical and pathomorphological scenarios: manifestation of vessel rupture symptoms, arteriovenous fistula or a pseudoaneurysm formation. According to different authors, the frequency of these findings varies significantly. This review examines the symptoms of possible variants of vascular damage development during discectomy and describes the characteristics of surgical correction methods. Along with clarifying the location and variant of vascular damage, the critical thing is assessing the amount of blood loss and the rate of ongoing bleeding. In the case of suspected massive bleeding, the paramount importance is the involvement of additional medical personnel for the surgical haemostasis and providing sufficient blood for haemotransfusions. In case of a vascular accident, the key requirement for adequate anaesthetic management is the maintenance of permissive arterial hypotension until the moment of surgical haemostasis. Targeted treatment of haemorrhagic shock in case of damage to large vessels consists of rapid haemostatic resuscitation including blood components and products in a balanced 1:1:1 ratio, such as plasma, red blood cells, fresh frozen plasma, platelets, and coagulation factors. In Ukraine, obtaining a sufficient amount of blood components and products (according to the protocol of massive haemotransfusion) in case of unpredicted blood loss is a difficult task, therefore, in the absence of certain components or blood products, whole blood can be used as an alternative. The number and severity of complications and outcomes primarily depend on the efficiency and timeliness of blood transfusions, along with the speed of surgical arrest of bleeding. This publication describes in detail the main points of management of patients with massive bleeding according to modern international standards and Ukraine regulatory documents.

The Role for Preperitoneal Pelvic Packing in Low-to-Middle-Income Countries: A 16-Year Experience at a Johannesburg Trauma Unit.

Preperitoneal pelvic packing for early pelvic haemorrhage control reduces mortality. Bleeding noted with pelvis fractures is predominantly due to associated venous complex injuries. More studies are advocating for angiography as first-line therapy for haemodynamic instability in pelvic fractures; however, these facilities are not in abundance in middle- and low-income countries. We hypothesized that PPP improves outcomes under these circumstances. Retrospective analysis of data from the patients charts over a period of 16years from 01 January, 2005 to 31 December, 2020. All patients over the age of 18years who presented with haemodynamic instability from a pelvic fracture and required PPP were included. The demographics, physiological parameter in emergency department, blood products transfused, morbidity and mortality were analysed. There were 110 patients identified in the study period who underwent pelvic preperitoneal packing for refractory shock or ongoing bleeding. The majority (75.5%) of patients were men (n = 83). The median age was 38years. The most common mechanism of injury was pedestrian vehicle collision (51%), followed by motor vehicle collisions (27.3%). The median ISS and NISS were 35 and 40, respectively. The median RTS in ED was 4.8(3-6.8). None of our patients rebleed after pack removal and no one needed repacking or adjunct angioembolization in our study group. The in-hospital mortality rate was 43.6% (n = 48) in patients who underwent preperitoneal pelvic packing. The operating room table mortality was 20% (n = 22/110), and the mortality rate of those who survived to ICU transfer was 29.5% (n = 26/88). Pelvic preperitoneal packing has a role in the acute management of haemodynamically abnormal patients with pelvic fractures in our environment. In the absence of immediate angioembolization, preperitoneal packing can be lifesaving.

Neocapsular reconstruction for challenging partial nephrectomy: A feasibility study in a porcine model and recent clinical experience.

Multifocal renal masses and large central-endophytic tumors can be challenging for partial nephrectomy (PN) due to the paucity of capsule remaining after tumor removal. Our objective was to develop a neocapsule to provide tamponade and test its feasibility/safety in a porcine model. Eight live pigs (50-70 kg) underwent unclamped open right flank PN. Renal defects were 1 cm deep and had moderate ongoing venous bleeding. A 6 × 9 inch sheet of Nu-knit® was used for neocapsular reconstruction with Fibrillar™ packing to provide modest tamponade and preclude ongoing bleeding. Blood chemistry and hemoglobin (Hb) levels were drawn preoperatively and postoperative Days 3/5/8. On postoperative Day 8, euthanasia was performed, and both kidneys were inspected and analyzed for histologic changes. PN defects ranged from 1 × 1 × 1 cm to 4 × 2 × 1 cm; four pigs had PN performed in both poles and four in one pole. Neocapsular reconstruction was successful (n = 8), with no perioperative complications. Median baseline Hb was 10.4 g/dL, and median Hb postoperative Days 3/5/8 were 10.0/10.8/10.6 g/dL, respectively. Median baseline serum creatinine (SCr) was 1.9 mg/dL, and median SCr postoperative Days 3/5/8 were 1.5/1.4/1.5 mg/dL, respectively. At sacrifice, no significant hematomas were observed. Other than adjacent to the PN site, there were no significant histologic changes in the parenchyma for operative kidneys versus controls. Based on our experience, we recently performed neocapsular reconstruction safely/effectively after extensive PN for multifocal tumors and for an allograft with difficult-to-manage subcapsular hematoma. Neocapsular reconstruction after PN or capsular trauma appears feasible and safe and may be considered to reduce the risk of perioperative bleeding. However, further study will be needed to confirm the utility/efficacy of this approach.

Transition ofResuscitative Endovascular Balloon Occlusion ofthe Aorta from Zone 3 to Zone 1 to Treat Hemodynamic Collapse during Continued Hemorrhage.

Noncompressible torso hemorrhage (NCTH) accounts for most potentially survivable deaths on the battlefield. Treatment of NCTH is challenging, especially in far-forward environments with limited capabilities. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has shown promise in the care of patients with NCTH. REBOA involves introducing a balloon catheter into the descending aorta in a specific occlusion region (zones 1, 2, or 3) and acts as a hemorrhage control adjunct with resuscitative support. The balloon is placed in zone 3 in the infrarenal aorta for high junctional or pelvic injuries and in zone 1 proximal to the diaphragm for torso hemorrhage. Zone 1 REBOA provides more resuscitative support than zone 3; however, the potential for ischemia and reperfusion injuries is greater with zone 1 than with zone 3 REBOA placement. This study aims to determine the possible benefit of transitioning the REBOA balloon from zone 3 to zone 1 to rescue a patient with ongoing venous bleeding and impending cardiovascular collapse. Yorkshire male swine (70-90 kg, n = 6 per group) underwent injury to the femoral artery, which was allowed to bleed freely for 60 s, along with a simultaneous controlled venous hemorrhage. After 60 s, the arterial bleed was controlled with hemostatic gauze and zone 3 REBOA was inflated. Five hundred milliliters of Hextend was used for initial fluid resuscitation. The controlled venous bleed continued until a mean arterial pressure (MAP) of 30 mmHg was reached to create an impending cardiovascular collapse. The animals were then randomized into either continued zone 3 REBOA or transition from zone 3 to zone 1 REBOA. Following 30 min, a "hospital phase" was initiated, consisting of cessation of the venous hemorrhage, deflation of the REBOA balloon, and transfusion of one unit of whole blood administered along with saline and norepinephrine to maintain a MAP of 60 mmHg or higher. The animals then underwent a 2-h observation period. Survival, hemodynamics, and blood chemistries were compared between groups. No significant differences between groups were observed in hemodynamic or laboratory values at baseline, postinitial injury, or when MAP reached 30 mmHg. Survival was significantly longer in animals that transitioned into zone 1 REBOA (log-rank analysis, P = .012). The average time of survival was 14 ± 10 min for zone 3 animals vs. 65 ± 59 min for zone 1 animals (P = .064). No animals in the zone 3 group survived to the hospital phase. Zone 1-treated animals showed immediate hemodynamic improvement after transition, with maximum blood pressure reaching near baseline values compared to those in the zone 3 group. In this swine model of NCTH, hemodynamics and survival were improved when the REBOA balloon was transitioned from zone 3 to zone 1 during an impending cardiovascular collapse. Furthermore, these improved outcome data support the pursuit of additional research into mitigating ischemia-reperfusion insult to the abdominal viscera while still providing excellent resuscitative support, such as intermittent or partial REBOA.

Two Cases of Life-Threatening Hemobilia Following Removal of Biliary Stents Treated with Covered Self-Expandable Metal Stents

Biliary stent removal can cause hemobilia due to injury to the adjacent vessel, but it is rarely reported. If significant hemobilia occurs during stent removal, samesession covered self-expandable metal stent (CSEMS) insertion may be useful as a rescue or bridge therapy before angiography. Here, we report two cases of lifethreatening hemobilia following stent removal successfully treated by CSEMS. The first case was a Klatskin tumor bismuth type IV patient who required biliary stenting for resolving malignant biliary obstruction. The second case was a hepatocellular carcinoma patient who had undergone multiple transarterial chemoembolization and required biliary stents for liver abscess. In this situation, inserting a CSEMS at a higher level than the expected bleeding site and recognizing stenting as a temporary therapy with its limitations are important. Also, it is crucial to consider pre-procedural imaging in high-risk patients, and perform post-procedural imaging to evaluate for ongoing bleeding or vascular abnormalities.

Penyuluhan dan Pelatihan Kegawatdaruratan Dental Serta Penanganannya Kepada Guru-guru SDI Assalam Joglo Jakarta Barat

Dental emergencies are potentially life-threatening conditions and immediate treatment is needed to stop ongoing bleeding, reduce pain and also uncontrolled bleeding, cellulitis or bacterial tissue infection causing swelling in the mouth or mouth area and trauma to the bones in the facial area . Delay in treatment of trauma to the teeth can lead to treatment failure. Delay in emergency dental treatment after trauma will increase the risk of complications, non-vital teeth and an unpredictable prognosis.Dental emergencies often occur at the elementary school level and the most common cases are loose or avulsed teeth due to falls and impacts. Teachers in schools not only have a central role as educators, but teachers also act as first aid agents in dealing with health problems in schools. In addition, teachers also play a role and assist health workers in collecting data and also as the first emergency referral before being handled by health workers.SDI Assalaam has a staff of 46 teachers and 250 students. Having students who are actively moving has a risk of accidents such as falling and so on which can cause injury, especially the oral cavity, while knowledge of dental emergencies and their management according to the Principal of SDI Assalaam has never been received by the teachers who teach at SDI Assalaam , so that if there is a dental emergency the teachers don't know what action to take.To overcome the lack of knowledge about dental emergencies and their management. So the teachers of SDI Assalam are given counseling and training about dental emergencies and their handling so that the importance of dental emergencies is socialized so that teachers at SDI Assalaam can increase their knowledge about dental emergencies and their management.Based on the evaluation results of community service activities. There was a significant increase in the level of knowledge of SDI Assalaam teachers regarding dental emergencies and their treatment.

Transjugular intrahepatic portosystemic shunt for pediatric portal hypertension: A meta-analysis.

To evaluate the feasibility of transjugular intrahepatic portosystemic shunt (TIPS) in children with portal hypertensive complications, PubMed and Cochrane Library were queried to identify clinical studies evaluating TIPS in patients <18 years old. Baseline clinical characteristics, laboratory values, and clinical outcomes were extracted. Eleven observational studies totaling 198 subjects were included in the study. The pooled technical success rate and hemodynamic success rate were 94% (95% confidence interval [CI]: 86-99%) and 91% (95% CI: 82-97%), respectively; ongoing variceal bleeding resolved in 99.5% (95% CI: 97-100%); refractory ascites was improved in 96% (95% CI: 69-100%); post-TIPS bleeding rate was 14% (95% CI: 1-33%); 88% of patients were alive or successfully received liver transplant (95% CI: 79-96%); and shunt dysfunction rate was 27% (95% CI: 17-38%). Hepatic encephalopathy occurred in 10.6% (21/198), though 85.7% (18/21) resolved with medical management only. In conclusion, based on moderate levels of evidence, TIPS is a safe and effective intervention that should be considered in pediatric patients with portal hypertensive complications. Future comparative studies are warranted.

Hemorrhagic Shock After Endoscopic Biopsy of Sigmoid Cancer: Pseudoaneurysm of the Rectal Superior Artery.

CASE REPORT An 86-year-old man without significant comorbidity presented with weight loss, diarrhea, and iron deficiency anemia. No signs of gastrointestinal bleeding were noticed. Colonoscopy was performed, and sigmoid cancer was suspected (a). Biopsies were obtained, which confirmed colonic adenocarcinoma. Eight hours after the endoscopy, the patient developed massive hematochezia, followed by hemodynamic instability (blood pressure 60/30 mm Hg; heart rate 120 bpm; and hemoglobin drop from 9.8 g/dL to 6.1 g/dL within 2 hours). After stabilization with intravenous fluids, norepinephrine, and transfusion of 1 unit of red blood cells, endoscopy was repeated and ruled out ongoing bleeding. A computed tomography scan confirmed a mass of the sigmoid colon, which extended along the inferior mesenteric artery and to the os sacrum. Within the sigmoid wall, extravasation of the contrast medium was seen into a structure of 2.3 × 1.7 cm. Computed tomography reconstructions suspected pseudoaneurysm of the inferior mesenteric artery (Figures B, C). In the absence of distant metastases, surgical resection was attempted urgently. However, owing to infiltration of the aortic wall, curative resection was impossible and colostomy was performed. Angiography confirmed a large pseudoaneurysm of the rectal superior artery, and embolization was performed successfully. The further course was unremarkable. Pseudoaneurysm of the inferior mesenteric artery is rare. To our knowledge, a case with hemorrhagic shock after endoscopic biopsy caused by cancer-associated pseudoaneurysm has not been reported so far. DISCLOSURES Author contributions: A. Probst: conception and design, analysis and interpretation of the data, drafting of the article. M. Ayoub, F. Sommer, and F. Schwarz: analysis and interpretation of the data. H. Messmann: critical revision of the article, final approval of the article. Financial disclosure: None to report. Informed consent was obtained for this case report.

PEDS9: Bleeding in Pediatric Patients on Extracorporeal Membrane Oxygenation-Use of Procoagulant Factors

Background: Bleeding complications remain common in extracorporeal membrane oxygenation (ECMO) and can be associated with adverse outcomes. Effect of excessive shear stress on vasculature may increase bleeding risk associated with preferential loss of high molecular weight von Willebrand factor (high molecular weight (vWF) multimers; acquired vW syndrome, AVWS) and may also be associated with platelet dysfunction. Some pediatric patients may have a pre-existing increased risk of shear-related abnormalities which may further increase bleeding risk on ECMO. We aimed to review bleeding events requiring intervention in a pediatric ECMO cohort. Methods: Retrospective review of pediatric ECMO patients who underwent treatment of bleeding beyond simple transfusion in conjunction with ECMO anticoagulation consultation (EAC) between June 2020 and December 2022 was conducted. Results: Fifty patients required ECMO for 53 runs (52 VA, 2 VV, 1 VAV). Median weight was 4.3 kg (2.4-131 kg). Mean duration of ECMO was 11 days (2-97). 60% (30/50) of patients had congenital heart disease (CHD), and within these 30 patients, 27% of them had bleeding requiring procedural intervention. Ten patients with bleeding were screened for AVWS guided by EAC with 100% meeting criteria for AVWS. Platelet transfusions were administered as first line bleeding therapy with thrombocytopenia or platelet dysfunction and plasma or prothrombin complex concentrate (PCCC) in volume-sensitive patients for coagulopathy. With ongoing bleeding despite transfusion, antihemophilic factor/vWF complex (Humate P) was administered to 4 patients guided by EAC (figure 1). Of these 4 patients, 75% had CHD and 100% had valve abnormalities with 50% having new mechanical valves placed within 1 month prior to ECMO. Initial Humate P dose was given on mean day 14, with mean number of 8 doses. No circuit or mechanical valve thrombosis occurred. Platelet counts and function improved with a decrease in platelet transfusions and clinical bleeding in all patients following Humate P. Conclusion: Bleeding remains a common complication but is often multifactorial and may be difficult to determine specific etiologies. AVWS and thrombocytopenia commonly occur during pediatric ECMO. However, not all patients have clinical bleeding, such that additional risk factors may contribute to increased bleeding risk in these patients. Given impact of recurrent transfusions due to bleeding on morbidity and mortality, as well as cost consideration and potential thrombosis risk of vWF or PCCC supplementation, development of an expert-guided (EAC) algorithm for screening and treatment criteria for such agents appears to be safe, cost-effective and may be associated with decreased bleeding and transfusions. Further research into etiologies and consequences of ECMO-induced bleeding as well as treatment is needed.Figure 1. Algorithm for Assessment of Persistent Bleeding and Consideration of Humate P Administration (pilot).