Significant Postoperative Bleeding Research Articles

Decreased plasma ADAMTS-13 activity as a predictor of postoperative bleeding in cyanotic congenital heart disease

OBJECTIVE:To analyze the preoperative plasma antigenic concentration and activity of von Willebrand factor and its main cleaving protease ADAMTS-13 in pediatric patients with cyanotic congenital heart disease undergoing surgical treatment and investigate possible correlations with postoperative bleeding.METHODS:Plasma antigenic concentrations (von Willebrand factor:Ag and ADAMTS-13:Ag) were measured using enzyme-linked immunoassays. Collagen-binding assays were developed to measure biological activities (von Willebrand factor:collagen binding and ADAMTS-13 activity). The multimeric structure of von Willebrand factor was analyzed using Western immunoblotting. Demographic, diagnostic, and general and specific laboratory data and surgery-related variables were subjected to univariate, bivariate, and multivariate analysis for the prediction of postoperative bleeding.RESULTS:Forty-eight patients were enrolled, with ages ranging from 9 months to 7.6 years (median 2.5 years). The plasma concentrations of von Willebrand factor:Ag and ADAMTS-13:Ag were decreased by 65 and 82%, respectively, in the patients compared with the controls (p<0.001). An increased density of low-molecular-weight fractions of von Willebrand factor, which are suggestive of proteolytic degradation (p = 0.0081), was associated with decreased ADAMTS-13 activity, which was likely due to ADAMTS-13 consumption (71% of controls, p = 0.0029) and decreased von Willebrand factor:collagen binding (76% of controls, p = 0.0004). Significant postoperative bleeding occurred in 13 patients. The preoperative ADAMTS-13 activity of <64.6% (mean level for the group), preoperative activated partial thromboplastin time, and the need for cardiopulmonary bypass were characterized as independent risk factors for postoperative bleeding, with respective hazard ratios of 22.35 (95% CI 1.69 to 294.79), 1.096 (95% CI 1.016 to 1.183), and 37.43 (95% CI 1.79 to 782.73).CONCLUSION:Low plasma ADAMTS-13 activity is a risk factor for postoperative bleeding in children with cyanotic congenital heart disease, particularly in children undergoing cardiopulmonary bypass.

1539 TUBELESS PERCUTANEOUS NEPHROLITHOTOMY FOR COMPLEX RENAL CALCULI AND COMPLICATED PROCEDURES

INTRODUCTION AND OBJECTIVES: Tubeless PCNL is underutilized, usually as an option in nonbleeding, uncomplicated monotracts with complete stone clearance & decided intraoperatively. In this study we evaluated its feasibility, safety and efficacy in a tertiary teaching institute. METHODS: Forty (40) patients were alternately randomized (1:1) into tube (T) and tubeless (TL) PCNL groups. Tract dilatations were done using Alken metal dilators, no sealant or electrocautery was used for hemostasis and a 6 Fr JJ stent was kept. In T group 24 Fr nephrostomy tubes were placed. In TL group JJ stent was removed at 48 hours after operation and in tube group it was removed 1 week after drying of nephrostomy site. In TL group deep skin stitched were applied. Analgesic (intravenous tramadol) requirement and Visual Analogue Scores (noted every 3 hours) were recorded in first 48 hours (hrs). Postoperative X-ray KUB (on Day1) and ultrasound scans (on postoperative days 1, 2, 3 and 3 weeks) were done in all to see stone clearance and perinephric/puncture tract/intrarenal collection or hematoma. RESULTS: Demographic data and outcomes are shown in table 1. One procedure in TL required conversion to tube because of intraoperatively diagnosed pleural violation. Despite complicated calculi (55%) and high risk situations (50%), none in TL group had any significant perinephric collection or severe postoperative bleeding requiring any intervention. Patient age, size and type of stones, punctures, stone clearance rate, hematuria clearance time, mean haemoglobin drop, transfusion requirements, and complication rate were similar in both groups. TL-PCNL is superior (p values 0.05) to T-PCNL in terms of VAS pain scores and analgesic requirement in first 48 hrs, leak from tract site and hospital stay. CONCLUSIONS: In TL PCNL, deep skin stitches with JJ stenting for 48 hrs ensure a good local bleeding control and a dry tract site. TL-PCNL may be considered a new standard for PCNL. Nephrostomy should only be used for specific purposes like intraoperative pleural violation, major pelvicalyceal injury, balloon tamponading or relook. Parameter Tube group Tubeless group Number of patients(Right/left side) 20(13/7) 20(11/9) Age in years(mean/range) 33.2(15-55) 36.7(17-52) Sex(M:F) 2.3:1 3:1 Stone burden(maximum diameter in cms) (mean/range) 2.72(1.8-3.8) 2.56(1.9-4.2) No. of patients with Simple Calculi(Pelvis/ Calyceal) 8(6/2) 9(7/2) No. of patients with Complex Calculi(Multiple pole calculi/ Staghorns) 12(7/5) 11(7/4) No.of punctures(mean/range) 1.4(1-3) 1.3(1-3) Tracts: single/multiple(No.of pts.) 14/6 15/5 High risk situations : Infundibular tear/ Extravasation & tract loss/ Obvious bleeding/ Stone guided punctures (No.of pts.) 2/1/4/1 2/1/5/2 Operative time in minutes (mean/range) 106(60-170) 108(80-130) Hemoglobin drop in gm/dl (mean/range) 1.36(0-4.1) 1.21(0-3.1) VAS score in 0-24 hrs & 25-48 hrs(mean/range) 3.5(2.1-4.6) & 2.5(1-3.5) 2.4(0-3.8) & 1.9(0.5-2.5) Analgesic (tramadol in mg)requirement in 0-48 hrs (mean/range) 165(100-250) 85(50-100) Hematuria settling time in hrs(mean/range) 29.1(6-192) 36(3-160) Nephrostomy removal time in hrs(mean/range) 42.6(30-72) Not applicable(NA) Tract site leak duration in hrs(mean/range) 13.8(0-72) 0 Hospital stay in hrs(mean/range) 121.4(50-168) 88.3(52-210) Blood transfusion(No.of pts.) 4 3 Complications:Hydro-pneumothorax/ UTI/Late hematuria(No.of pts.) 1/3/0 1/2/1 Complete stone clearance rate : after first procedure/ after relook/ At 3 weeks follow up(in %) 70/80/90 70/NA/85

Endoscopically assisted extraction of the impacted maxillary third molars via inferior meatal antrostomy

This article reports a case of the extraction of impacted third molars in maxillary sinus through endoscopy assisted inferior meatal antrostomy. A 25-year-old female patient was referred for the management of the impacted third molars. On computed tomography image, both the right and left maxillary third molars were medially located close to the posterior wall of maxilla, and osseous connections proceeding inferiorly to the floor of maxilla were observed. A transnasal endoscopic approach through inferior meatal antrostomy was performed, and the maxillary third molar was extracted with careful dissection. The patient did not present significant post-operative bleeding or edema and she was able to breathe through her nose without problem, and she also presented an excellent post-operative recovery. We report the endoscopy assisted transnasal extraction of maxillary third molar which is minimally invasive and shows less morbidity rates compared to conventional lateral sinus approach.

Patients get more long-term benefit from central pancreatectomy than distal resection: A meta-analysis

Central pancreatectomy (CP) protects more normal pancreatic parenchyma than distal pancreatectomy (DP), but the safety, feasibility and long-term benefit of CP are inconclusive. This meta-analysis aims to ascertain the relative merits of CP. A systematic literature research was performed to identify comparative studies on CP and DP. Perioperative and long-term outcomes constituted the end points. Pooled risk ratios (RR) and weighted mean differences (WMD) with 95% confidence intervals (95% CI) were calculated using either fixed effects or random effects model. Nine studies with 735 patients were included in this meta-analysis. Although CP cost more operative time than DP, the two groups had no significant differences in the volume of intraoperative blood loss, rate of intraoperative blood transfusion and length of postoperative hospital stay. According to the postoperative outcomes, although the CP group had higher overall complication rate (Fixed effects model; RR: 1.30; 95% CI: 1.05-1.62; P<0.05) as well as overall pancreatic fistula rate (Fixed effects model; RR: 1.58; 95% CI: 1.20-2.08; P<0.05), the two groups did not differ significantly in the fateful surgical complications such as clinically significant pancreatic fistula (Grades B and C), postoperative bleeding, reoperation and intra-abdominal effusion/abscess. Furthermore, the perioperative mortality rate was comparable between the two groups. During the follow-up period, the patients after DP were more likely to suffer pancreatic exocrine insufficiency (Fixed effects model; RR: 0.53; 95% CI: 0.32-0.86; P<0.05) and endocrine impairment (Fixed effects model; RR: 0.19; 95% CI: 0.11-0.33; P<0.05). CP was still an acceptable and feasible procedure, especially when considering the postoperative pancreatic function preservation ability by CP.

Reconstruction of an extensive peri-orbital defect secondary to mucormycosis in a patient with myelodysplasia

We present the case of a 68-year old gentleman with previously diagnosed myelodysplastic syndrome with pancytopenia who presented with exophthalmia, rhinorrhea, and ophthalmoplegia. Nasal endoscopy revealed black necrotic lesions. He was diagnosed with rhino-orbital mucormycosis and commenced on intravenous antifungals. Despite this therapy he progressed to have total unilateral loss of visual acuity and cutaneous necrosis. He underwent emergency orbital exenteration and extensive cheek and sinus debridement. Necrotic lesions were found in the orbit, the maxillary and ethmoidal sinuses. He underwent reconstruction of this defect using a free myocutaneous ALT flap with a segment of vastus lateralis. Prior to surgery his anemia and thrombocytopenia were addressed with packed red cell and platelet transfusions as well as preoperative thromboelastography (TEG) to measure functional fibrinogen to platelet ratio. Intraoperative platelet administration was guided by repeated TEG analysis. There were no significant intraoperative or postoperative bleeding complications and both flap and donor site healed unremarkably. Few reports exist in the literature related to free tissue transfer in patients with hematological disorders but low platelet count has been implicated in an increased complication rate.

Percutaneous Nephrolithotomy with Retrograde Nephrostomy Access: A Forgotten Technique Revisited

We retrospectively assessed outcomes in a single institution series of percutaneous nephrolithotomy using retrograde nephrostomy access. We retrospectively evaluated the records of 333 consecutive patients treated between May 2003 and July 2008. Measured variables included patient demographics, retrograde nephrostomy site, postoperative drainage, operative time, stone clearance rate and degree, requirement for secondary procedures, stone composition and complications. A total of 333 patients were included in study, including 162 females and 171 males with a median age of 56 years (range 17 to 87). Median hospital stay was 2 days (range 1 to 13). Antegrade access was required in 14 patients (4%) due to difficult or suboptimal anatomy. A nephrostomy tube was placed in 33 of 329 patients (10%), mainly for postoperative irrigation. Mean operative time was 76 minutes (range 25 to 246). Of the patients 79% achieved complete clearance, 19% had residual fragments 4 mm or less and 2% had significant persistent stones greater than 4 mm. Postoperatively 11 patients (3%) required shock wave lithotripsy. Analysis revealed calcium oxalate in 57% of stones, uric acid in 24%, struvite in 5% (infection stones) and other in 21%. Complications included 4 patients (1%) with significant postoperative hemorrhage, including angioembolization in 2, transfusion of 4 U packed red blood cells in 1 and observation in 1. The retrograde technique to establish a percutaneous nephrostomy tract for percutaneous nephrolithotomy is safe and effective with stone clearance and complication rates comparable to those of antegrade access.

Anwendung von Surgisis® zur Optimierung und Vereinfachung der Nierenteilresektion bei größeren renalen Neoplasmen

With lower rates of postoperative renal failure, diabetes and cardiovascular disease, partial nephrectomy achieves longer overall survival and equally long tumor-specific survival. It is thus the current gold standard treatment for renal tumors and now also for those ≥4cm in size. The main complications of nephron-sparing surgery, particularly for large and centrally located tumors, are postoperative parenchymal bleeding and urinary fistulas after opening the urinary collecting system (UCS). Between August 2003 and April 2012, 76 partial nephrectomies for tumors ≥4cm in size were performed using porcine small intestinal submucosa (SIS, Surgisis®) to close the capsular, renal and in some cases, UCS defects. The median tumor size was 5.0cm (range 4.0-13.0cm) and the intervention was performed with warm ischemia in 25 cases (32.8%), with cold perfusion in 16 cases (21.2%) and without ischemia in 35 cases (46.0%). A total of 4 patients (5.5%) developed postoperative urinary fistulas and 4 (5.5%) required revision surgery because of significant postoperative bleeding. There were no local infections or allergic reactions to the foreign material. Surgisis® enables a quick and technically uncomplicated closure of the renal defect after partial nephrectomy for tumors. It has the potential to further minimize postoperative bleeding and urinary fistulas and to facilitate the intervention to the extent that nephron-sparing surgery will gain broader acceptance even in patients with tumors ≥4cm in size.

Clinical and Economic Impact of Pre-Operative Coagulation Screening in Children

AbstractAbstract 3379 Background:The literature in the past has recommended pre-operative (PRE-O) coagulation screening only when indicated by history or physical exam. Despite these recommendations, surgeons continue to order PT and PTT prior to surgery, especially in children, because they have often not been hemostatically challenged. We evaluated the usefulness of screening tests in identifying significant bleeding risk and associated cost. Methods:We performed a retrospective audit on children referred to the hemophilia center sent for further evaluation of abnormal PT and PTT on PRE-O screening. We reviewed 62 patients who had 80 procedures, out of which 70 procedures were evaluable with complete data. Age, personal and family history of bleeding, coagulation tests, PRE-O and post-operative (PO) treatment, and immediate PO bleeding were assessed. Results:The most common procedure that led to PRE-O screening was tonsillectomy/adenoidectomy at 61% (49/80). Other procedures included orthopedic, GI, oral, dental extractions, and myringotomies. Only 2.5% (2/80) were cardiac procedures. The mean patient age was 6 years (range 1–16). 55% (34/62) had no personal or family history of bleeding. 22.5% (14/62) had a family history of mild bleeding such as epistaxis or menorrhagia. 8% (5/62) had a family history of major bleeding disorders such as Von Willebrand disease (VWD) or hemophilia. 14.5% (9/62) had a personal history of bleeding, mild or major. The most common abnormal screening test was the PT at 40% (25/62). 27% (17/62) had an abnormal PTT (3.2% 262 with a significantly abnormal PTT above 50). 22.5% (14/62) were referred for abnormal PT/PTT. 8% (5/62) with an abnormal PT and/or PTT corrected on repeat studies. The remaining 9.6% (6/62) were referred for other reasons such as positive family or personal history and a high risk procedure. Additional coagulation tests ordered because of prolonged PT or PTT varied and included additional factor assays (Table 1). The mean cost of additional testing was >$1000.Abnormal Screening TestNumber of PatientsNumber of Additional Tests Per Patient (mode)Cost of Additional Testing Per Patient – US dollars (mean)Number of Patients with Post-Op bleedingPT254 (0–10)$1,0910PTT177 (1–7)$1,5880PT/PTT149 (3–9)$2,3180Factor VII was the most common factor deficiency identified with a mean activity of 47% (27–54%) (normal 55–163%) followed by factor XII deficiency with a mean activity of 39% ( 19–49%) (normal 46–168%). PRE-O, 5 patients received support with either Humate P, Stimate, Amicar, or DDAVP, 4 with a diagnosis of VWD and 1 with Jacobsen Syndrome; 3 of these patients received PO Amicar. PO, 69/70 procedures were completed with minimal (2–45 mL) bleeding. Only 1/70 procedures had significant PO bleeding, despite normal tests. This patient did not have any significant immediate PO bleeding, but had delayed bleeding reported at day 7 requiring cauterization. No other cases of delayed PO bleeding were reported to our clinic. Conclusion:In patients who undergo routine screening by laboratory testing only, the most common abnormality found was a prolonged PT. Subsequent workup of patients with abnormal screening tests identified factor VII or factor XII deficiencies most frequently. Only one patient with abnormal PT/PTT was diagnosed with a significant bleeding disorder, VWD. Major bleeding occurred rarely. This study demonstrates that the cost of extensive PRE-O coagulation testing is high with minimal clinical impact. Disclosures:No relevant conflicts of interest to declare.

Thromboelastography in the Assessment of Bleeding Following Surgery for Congenital Heart Disease

Perioperative bleeding is common in pediatric cardiac surgery patients. Traditional laboratory tests do not adequately characterize coagulation derangements in patients with bleeding. We sought to establish preoperative thromboelastography parameters in children prior to cardiopulmonary bypass, to compare thromboelastography assessment with standard coagulation parameters postoperatively, and to assess thromboelastography in children with significant hemorrhage. Sixty patients requiring cardiopulmonary bypass were enrolled in a prospective observational study of perioperative thromboelastography. Thromboelastography measures were obtained preoperatively, intraoperatively after protamine administration, upon admit to the intensive care unit, and when patients were treated for bleeding. Thromboelastography measures were not used for clinical care. Postoperative thromboelastography measurements were compared with the standard coagulation parameters. Intraoperative thromboelastography, postoperative thromboelastography, and clinical outcomes were compared among patients who did and did not have significant postoperative bleeding. Preoperative thromboelastography parameters were similar to other published normal values for pediatric patients. Transfusion recommendations based on thromboelastography measurements were significantly different from those based on the standard coagulation testing. Thromboelastography measures after initial protamine administration were significantly different in patients with postoperative bleeding. This difference was not present upon arrival to the intensive care unit. Patients with significant bleeding tended to cease bleeding when clinical interventions were in agreement with recommendations based on thromboelastography. Pediatric patients with significant postoperative bleeding after surgery are more likely to have abnormal thromboelastography early after cessation of cardiopulmonary bypass. Thromboelastography illustrates derangements in the coagulation system and may aid in the treatment of postoperative bleeding.

Closure of palatal fistula with local double-breasted mucoperiosteal flaps

Despite improvement to surgical techniques of cleft-palate surgery, palatal fistulas remain a challenge. Many surgical procedures have been described for repair of these fistulas either by using the local tissue or by importing a new tissue from adjacent areas. In this report, we describe our technique for closure of palatal fistula using double-breasted mucoperiosteal flaps based on the greater palatine artery. Eight patients with oronasal fistulas located in the posterior two-thirds of the hard palate following cleft-palate repair were treated by double-breasted mucoperiosteal flaps with an overlapping zone of 1-2 cm. All fistulas successively healed, none of our patients developed any significant postoperative bleeding, infection or fistula recurrence. Double breasated mucoperiostial flap is a simple successful option for correction of oronasal fistula.

A Spectrum of Clinical and Laboratory Findings and Treatment Modalities in Patients with Factor VII Deficiency- A Single Medical Center Experience,

Abstract 3306▪▪This icon denotes a clinically relevant abstract Introduction:Factor VII, a vitamin K dependent glycoprotein serine protease secreted by the liver, has a fundamental role in the activation of the extrinsic coagulation pathway. It is found in the plasma as a zymogen, and is activated by tissue factor and calcium. Hereditary factor VII deficiency is a rare coagulation disorder with autosomal recessive inheritance found approximately at a prevalence of 1:500,000. In Israel, factor VII deficiency is found mostly in Sephardic Jews of Iranian, Moroccan and Tunisian origin as well as in the Druze population. Bleeding symptoms usually occur in homozygotes or compound heterozygotes. In symptomatic patients, the clinical severity of bleeding ranges from mild to severe (such as intracranial bleeding) and does not always correlate with plasma levels of factor VII activity. However, patients with factor VII activity of less than 1% may present with symptoms similar to severe hemophilia. Patients with factor VII activity of 5% or more usually present with milder bleeding such as epistaxis, gingival bleeding, menorrhagia or bruising. Therapy for factor VII deficiency depends on severity and type of the bleeding. Treatment includes fresh frozen plasma (FFP), tranexamic acid and recombinant factor VIIa (Novoseven). Aims:The study goal was to find correlation between level of factor VII activity, bleeding complications and treatment modalities that were used in symptomatic patients or in those undergoing surgical procedures. Patients and methods:We performed a retrospective study of 125 patients with decreased levels of factor VII, referred to our department between 1990–2010. 56 patients with isolated deficiency of factor VII were included in the study. Patients with combined deficiencies or liver disease were excluded. Demographics, clinical symptoms and their correlation to levels of factor VII, as well as treatment modalities were investigated. A factor VII activity level below 50 % was considered as decreased. The data collection was performed after approval of hospital Helsinki committee. Results:Of 56 patients with isolated factor VII deficiency there were 29 males and 27 females. 31/56 (55.4%) of the patients were Jews of Sephardic origin. 18/56 (32%) of the patients had relatives with known factor VII deficiency. The activity of factor VII ranged from <1%-49%. There was no significant difference in factor VII activity levels between the symptomatic (mean = 20.87, SD = 17.9) and the asymptomatic patients (mean = 23.13, SD = 17.4). 11/56 (19.6%) of the patients had clinical symptoms of bleeding, 6 of them had factor VII level<10 %. No life threatening bleeding was reported. Most episodes of bleeding related to factor VII deficiency were epistaxis and menorrhagia. Less common bleeding included hematoma and gingival bleeding. Only 9% of the symptomatic patients required treatment with FFP or tranexamic acid. Recommendation for prophylactic treatment such as FFP and/or tranexamic acid prior to surgical procedure was given in 19 patients. The post operative period was uneventful in all the patients. 5 patients did not receive any prophylactic treatment for different surgical procedures and no significant post operative bleeding was observed. Conclusions:Though factor VII deficiency had been described in the literature as a rare disease, we collected and analyzed a large cohort of 56 patients with this disorder in a single medical center. Most of our patients were Sephardic Jews. There had been several reports of excessive bleeding which complicated surgery, especially of the oropharynx and urogenital tract in patients with factor VII deficiency. Levels of 15–25% are recommended for surgery, but the plasma factor VII level required for surgery has been not formally established. We did not find statistically significant differences in factor VII activity levels between the symptomatic patients and the asymptomatic ones (P value<0.36). No life threatening bleeding occurred; only one patient required acute treatment to stop the bleeding. There was no uniform protocol used for prophylactic treatment, which was usually based on “old” drugs such as FFP and tranexamic acid. There was no need for Novoseven. We conclude that treatment guidelines based on the family, personal, surgical history and laboratory results are required for optimal treatment of patients with inherited factor VII deficiency. Disclosures:No relevant conflicts of interest to declare.

A Randomized Comparison of the Effect of Partial and Total Wound Closure Techniques on Postoperative Morbidity After Mandibular Third Molar Surgery

To compare the effect of total and partial wound closure techniques on immediate postoperative tissue reactions and complications after mandibular third molar surgery. This prospective, randomized, controlled study was carried out at the Department of Oral and Maxillofacial Surgery, National Hospital, Abuja, Nigeria. Patients were randomly allocated to partial (group I) and total (group II) wound closure groups. Data were collected on pain, trismus, swelling, and complications experienced by the patients. Data analysis was carried out with SPSS software for Windows (version 13.0; SPSS, Chicago, IL) and GenStat (Discovery Edition, 2005; VSN International Ltd, Hemel Hempstead, UK). We studied 82 patients, consisting of 54 female and 28 male patients, with mandibular third molar teeth impaction. There were 40 patients (48.8%) in group I and 42 patients (51.2%) in group II. A statistically significant reduction in facial swelling (P = .001) was found in group I compared with group II, but no difference was recorded for pain and trismus. Group I presented with significant postoperative reactionary bleeding (P = .007), but no difference was recorded between the 2 groups regarding dry socket and socket infection. The partial wound closure technique after third molar surgery was considered to be associated with more postoperative morbidity, in view of the distressing nature of reactionary bleeding that was found to be associated with it. However, patients should be adequately informed about the possibility of attendant facial swelling each time the technique of total wound closure is used.

Postoperative Bleeding after AB0-incompatible Living Donor Kidney Transplantation

Background Since 2007, we have performed 14 AB0-incompatible (AB0i) living kidney transplantations to increase the number of living kidney transplantations. Methods To prevent clotting, donor kidneys were perfused with an HTK/heparin solution with heparin washed out immediately pretransplantation. However, in 4/14 recipients, significant postoperative diffuse hemorrhage occurred with the need for surgical intervention in 3 patients. To analyze the cause of postoperative diffuse bleeding, sequentially before and after opening the graft anastomosis, we prospectively performed coagulation studies: partial thromboplastin time (PTT), thrombin time, thromboplastin time, fibrinogen, antithrombin, d- dimers, plasminogen, and thrombelastography. Results We found no clotting disturbances owing to blood group–specific immunoadsorption. However, 3/4 patients with bleeding complications showed elevated PTT values even 2 hours after opening the anastomosis, which was proven to be a heparin effect by in vitro application of heparinase. Hyperfibrinolysis and disturbances of platelet aggregation were not detected. Because of these results, we lowered the heparin dose administered after donor nephrectomy from initially 10,000–20,000 to 4000 IU resulting in significantly lower PTT values at 2 hours (34.6 ± 4.5 s among patients 6–14 vs 69.0 ± 16.3 s among patients 1–5; P = .012). There were no further bleeding complications. Lowering the heparin dosage had no impact on graft function: serum creatinine at discharge of 1.5 ± 0.1 versus 1.6 ± 0.2 mg/dL. Conclusion Our data indicated that postoperative hemorrhage after AB0i kidney transplantation was associated with the amount of heparin used for graft perfusion after donor nephrectomy. The use of antifibrinolytic agents may be harmful; no hyperfibrinolysis takes place in the AB0i transplant setting.

Safety and Utility of Scheduled Nonnarcotic Analgesic Medications in Children Undergoing Craniotomy for Brain Tumor

We have reported that a scheduled nonnarcotic analgesic regimen after dorsal lumbar rhizotomy and Chiari I malformation decompression is efficacious in managing postoperative pain in children. To date, this regimen has not been analyzed in children after brain tumor biopsy or resection. To elucidate the safety and utility of such an analgesic protocol in these patients. A database review was conducted to identify children who received a scheduled dose of alternating acetaminophen and ibuprofen after craniotomy for tumor biopsy or resection, and postoperative imaging was evaluated. Fifty-one children who met the inclusion criteria were identified. On postoperative imaging, 17.67% had routine, postoperative blood in the resection cavity according to both radiology and neurosurgical review. One patient had moderate postoperative bleeding in the tumor cavity. Overall, 44 of the 51 patients (86.3%) required no or minimal narcotic medication for pain. A scheduled regimen of nonsteroidal antiinflammatory drugs given in alternating doses immediately after craniotomy for tumor biopsy or resection and throughout hospitalization did not result in any significant postoperative hemorrhage in our patient series.

Predictors of post operative bleeding and blood transfusion in cardiac surgery

In spite of the recent advances in heart surgery, patients undergoing cardiac surgery with cardiopulmonary bypass are at risk of developing significant post-operative bleeding and substantial blood requirements. To evaluate the impact of some perioperative predictors of post-operative bleeding, and blood transfusion after heart surgery and offer suggestions on preventive measures. A prospective analytical study. The perioperative factors studied were haemoglobin level, international normalised ratio (INR), platelet count, and total bypass time. Eighty-seven consecutive patients who underwent heart surgery in the year 2004 were selected. Each patient had laboratory work up which included full blood count, clotting profile, kidney and liver function tests. The total blood loss within the first twenty-four hours and the total units of blood transfused before the patient was discharged were also recorded. Pre-operative haemoglobin was significant in determining the total units of blood received by a patient. Increasing total bypass time caused a significant increase in the percentage reduction of the pre-operative platelet count (p <0.004). However even though there was an increasing trend of post-operative bleeding with increase in total bypass time, this was not significant from the analysis (p<0.069). The percentage reduction in platelet count and immediate postoperative platelet count were significant predictors of postoperative bleeding (p <0 .009) and (p <0.003) respectively. Pre-operative haemoglobin, percentage reduction in the platelet count after cardiopulmonary bypass and immediate postoperative platelet count are significant predictors of postoperative bleeding and blood requirements.

Laparoscopic Resection of Periadrenal Paraganglioma Mimicking an Isolated Adrenal Hydatid Cyst

We present the case of a 64-year-old female with a periadrenal paraganglioma. The mass was diagnosed during abdominal ultrasonography performed to investigate right flank pain. Magnetic resonance imaging showed a lesion 48mm in diameter with an irregular hyperintense central margin, thickened septa, centrally located cystic component, and contrast enhancing peripheral portions. These findings made us think it was an isolated adrenal hydatid cyst. The mass was excised via laparoscopy without complications. Histopathological examination was consistent with periadrenal paraganglioma. We believe that the paraganglioma can mimic the radiological appearance of an isolated adrenal hydatid cyst, which should be taken into consideration during diagnosis.

Postoperative High-Dose Intravenous Iron Sucrose with Low Dose Erythropoietin Therapy after Total Hip Replacement

Erythropoietin combined with parenteral iron sucrose therapy is an alternative to blood transfusion in anemic patients. It was shown to be effective in surgical patients in several previous studies when used in conjunction with other methods. However, there are no guidelines about safety limits in dosage amounts or intervals. In this study, we report a case of significant postoperative hemorrhage managed with high dose parenteral iron sucrose, low dose erythropoietin, vitamin B12, vitamin C, and folic acid. An 80-year-old female patient presented for severe anemia after a total hip arthroplasty and refused an allogenic blood transfusion as treatment. The preoperative hemoglobin of 12.2 g/dL decreased to 5.3 g/dL postoperatively. She received the aforementioned combination of iron sucrose, erythropoietin, and vitamins. A total of 1,500 mg of intravenous iron sucrose was given postoperatively for 6 consecutive days. Erythropoietin was also administered at 2,000 IU every other day for a total of 12,000 IU. The patient was discharged in good condition on the twelfth postoperative day with a hemoglobin of 8.5 g/dL. Her hemoglobin was at 11.2 g/dL on the twentieth postoperative day.

Evolution of Sinonasal Symptoms Following Transnasal Endoscopic Skull Base Surgery Using a Pedicled Nasoseptal Mucosal Flap

Transnasal endoscopic surgery of the anterior skull base has been increasingly used by skull base surgeons in recent years. A dual-surgeon approach, with an otolaryngologist and neurosurgeon operating together, provides excellent visualization and operative maneuverability. To counter cerebrospinal fluid (CSF) leaks, pedicled nasoseptal mucosal flaps (PNSMFs) have been proposed to augment the closure. Sinonasal complaints are expected sequelae of this technique. We describe the evolution of sinonasal symptoms in a series of patients who have undergone this type of surgery, as documented by the Sinonasal Outcomes Test (SNOT-20), a widely used disease-specific, health-related quality-of-life measure for rhinosinusitis. From January 2008 through May 2009, 85 adult patients underwent transnasal endoscopic surgery using a PNSMF for a variety of diseases. The most common diagnosis was pituitary tumor, but others included Rathke's cleft cyst, meningiomas, chordomas, and hypothalamic lesions. Postoperative complications were rare. Six patients (7%) had CSF leaks requiring reoperation. Significant postoperative nasal bleeding occurred in one patient, and this was successfully managed in the emergency room with cautery and packing. All patients performed daily nasal saline irrigations at home and returned at regular intervals for debridement of their sinus cavities. They filled out the SNOT-20 at regular intervals after surgery, describing their postoperative nasal symptoms. The vast majority did not have significant sinus disease preoperatively. Sinonasal complaints were universal during the first month and included crusting, congestion, rhinorrhea, and sinus pressure, but they gradually diminished over the ensuing months. Scores for the symptoms of sneezing, postnasal discharge, runny nose, and thick nasal discharge showed significant improvement over time. Scores for most other sinonasal symptoms showed improvement over time, but did not reach statistical significance. All patients had a temporary loss of smell, but this returned to near normal levels within 3–6 months.

Intravitreal Injection of Bevacizumab before Vitrectomy for Proliferative Diabetic Retinopathy

To evaluate the use of preoperative intravitreal bevacizumab (IVB) injection in patients undergoing pars plana vitrectomy for complications of proliferative diabetic retinopathy (PDR). In this prospective surgeon-masked randomized clinical trial, 40 eyes of 40 diabetic patients who were candidates for vitrectomy were randomly assigned to receive 2.5 mg IVB 3-5 days before operation (injected group) or no injection before operation (noninjected group). A preoperative complexity score (CS) was recorded. Best-corrected visual acuity, number of endodiathermy applications, backflush needle applications, duration of surgery, and postoperative vitreous hemorrhage were recorded. Twenty-two patients with a CS of 6+/-0.95 in the injected group and 18 patients with a CS of 5.7+/-1.1 in the noninjected group (p=0.3) were studied. Postoperative visual acuities were significantly better than preoperative visual acuities. Preoperative and 3-month postoperative visual acuities were the same for both groups; however, in the last follow-up examinations (mean 7+/- 3.6 months) the injected group had better visual acuities than the noninjected group (1.1+/-0.4 and 1.4+/-0.3 logMAR, respectively, p=0.006). Mean surgical time was 62+/-57.3 minutes in the injected group vs 95.5+/-36 minutes in the noninjected group (p=0.03): endodiathermy applications 6.0+/-4.3 vs 11.0+/-5.8 (p=0.004), backflush cannula applications 11.0+/-7.2 vs 18.1+/-7.8 (p=0.004). In non-silicone-filled eyes, no patient in the injected group developed significant postoperative vitreous hemorrhage obscuring the fundus details, while 7 eyes of noninjected eyes had this complication (p=0.01). IVB injection before vitrectomy for PDR facilitates the surgery, and may decrease the rate of postoperative vitreous hemorrhage and improve the visual acuity results of the operation.

Use of Recombinant Factor VIIa (NovoSeven) in Pediatric Cardiac Surgery

Significant post-operative bleeding can be encountered in a small population of pediatric surgical patients requiring cardiopulmonary bypass (CPB). Recombinant factor VIIa (Novo-Seven) has been advocated as a possible off-label rescue therapy for these individuals when conventional blood component therapy alone is inadequate. This study retrospectively evaluates rFVIIa administration for the treatment of severe bleeding in pediatric patients immediately after cardiac surgical procedures requiring CPB. The records of 15 patients receiving rFVIIa for excessive rates of bleeding refractory to conventional blood component therapy were studied. Blood product utilization, rates of blood loss, and evidence of pathologic sequelae were compared with matched historical controls in retrospective fashion. NovoSeven doses ranged from 76 to 282 μg/kg (group 1 &lt;30 kg) and 26 to 956 μg/kg (group 2 &gt;30 kg). Blood product administration patterns were not significantly different (p &gt; .05) in the intensive care unit (ICU) between patient groups receiving rFVIIa and those not treated. Bleeding rates (mL/kg/h) for the first 2 hours after admission to the ICU remained statistically unchanged but were significantly increased for those time periods &gt;3 hours in patients &lt;30 kg treated with NovoSeven. Patients &gt;30 kg did not exhibit statistical differences in the rate of bleeding or the administration of blood products compared with matched controls. A significant reduction in prothrombin time (p = .001) and partial thromboplastin time (p = .02) was noted in patients &lt;30 kg receiving rFVIIa. There were no pathologic sequelae directly attributed to the administration of rFVIIa in any patients treated. Trends in the improvement of bleeding disturbances were noted in the ICU in patients &lt;30 kg treated with rFVIIa, subsequent to blood component therapy. The rate of bleeding (mL/kg/h) was improved in patients &lt;30 kg for the first 2 hours in the ICU. For individuals &gt;30 kg, there was no apparent benefit from the administration of rFVIIa.