Determinants of mortality in patients with cirrhosis and uncontrolled variceal bleeding.

BACKGROUND & AIMS: Failure to control oesophago-gastric variceal bleeding (OGVB) and acute-on-chronic liver failure (ACLF) are both important prognostic factors in cirrhosis. The aims of this study were to determine whether ACLF and its severity define the risk of death in OGVB and whether insertion of rescue transjugular intrahepatic shunt (TIPS) improves survival in patients with failure to control OGVB and ACLF. METHODS: Data on 174 consecutive eligible patients, with failure to control OGVB between 2005 and 2015, were collected from a prospectively maintained intensive care unit registry. Rescue TIPS was defined as technically successful TIPS within 72 hours of presentation with failure to control OGVB. Cox-proportional hazards regression analyses were applied to explore the impact of ACLF and TIPS on survival in patients with failure to control OGVB. RESULTS: Patients with ACLF (n = 119) were significantly older, had organ failures and higher white cell count than patients with acute decompensation (AD, n = 55). Mortality at 42-days and 1-year was significantly higher in patients with ACLF (47.9% and 61.3%) than in those with AD (9.1% and 12.7%, p <0.001), whereas there was no difference in the number of endoscopies and transfusion requirements between these groups. TIPS was inserted in 78 patients (AD 21 [38.2%]; ACLF 57 [47.8%]; p = 0.41). In ACLF, rescue TIPS insertion was an independent favourable prognostic factor for 42-day mortality. In contrast, rescue TIPS did not impact on the outcome of patients with AD. CONCLUSIONS: This study shows that in patients with failure to control OGVB, the presence and severity of ACLF determines the risk of 42-day and 1-year mortality. Rescue TIPS is associated with improved survival in patients with ACLF. LAY SUMMARY: Variceal bleeding that is not controlled by initial endoscopy is associated with high risk of death. The results of this study showed that in the occurrence of failure of the liver and other organs defines the risk of death. In these patients, insertion of a shunt inside the liver to drain the portal vein improves survival.

Evaluation of a Powered Vascular Stapler in Video-Assisted Thoracic Surgery Lobectomy.

BACKGROUND: A narrow-profile powered vascular stapler (PVS) was developed to provide superior access and precise staple placement in thoracic procedures. The objective of this study was to determine if the PVS would yield an equivalent rate of hemostatic interventions compared with standard of care (SOC) staplers in video-assisted thoracoscopic surgery lobectomy. MATERIALS AND METHODS: A randomized, controlled, multicenter study was conducted comparing PVS with SOC staplers in lobectomies performed for non-small cell lung cancer. The primary performance endpoint was the incidence of intraoperative hemostatic interventions, and the primary safety endpoint was the frequency of postoperative bleeding-related interventions. RESULTS: A total of 98 subjects participated in the SOC group and 103 in the PVS group. Rates of intraoperative hemostatic interventions were 5.3% and 8.3% for the SOC and PVS groups, respectively. These rates were not statistically different (P = 0.137), although the upper bound of the 95% confidence interval for the difference in intervention rates between PVC and SOC exceeded a predefined 3% criterion for equivalence. Simple compressions were performed more frequently in the PVS subjects, which accounted for the higher intervention rate in this group. Postoperative interventions for bleeding were required in one SOC subject (1.0%) and one subject from the PVS group (0.9%). Procedure-related adverse events occurred in 21 (21.9%) SOC subjects and 23 (21.9%) PVS subjects, with no adverse events related to use of the study devices. CONCLUSIONS: The PVS exhibited similar overall safety and effectiveness to SOC staplers in video-assisted thoracoscopic surgery lobectomy.

Sternotomy for Hemorrhage Control in Trauma.

BACKGROUND: Little is known about the injuries, mechanisms, and outcomes in trauma patients undergoing sternotomy for hemorrhage control (SHC). The purpose of this study was to identify predictors of mortality for SHC and provide a descriptive analysis of the use of SHC in trauma. We hypothesize blunt trauma is associated with higher mortality compared with penetrating trauma among trauma patients requiring SHC. METHODS: The Trauma Quality Improvement Program (2013-2016) database was queried for adult patients undergoing SHC within 24 h of admission. Patients with blunt and penetrating trauma were compared using chi-square and Mann-Whitney U-test. A multivariable logistic regression model was used to determine the risk of mortality. RESULTS: Of 584 patients undergoing SHC, 322 (55.1%) were involved in penetrating trauma, and 69 (11.8%) were involved in blunt. The blunt trauma group had a higher median injury severity score (31.5 versus 25.0; P < 0.001) compared with the penetrating group. The median time to hemorrhage control was longer in those with blunt compared with penetrating trauma (84.6 versus 49.8 min; P < 0.001). The mortality rate was higher in patients with blunt compared with penetrating trauma (29.0% versus 12.7%; P < 0.001). However, after adjusting for covariates, there was no difference in risk of mortality between blunt and penetrating trauma (P = 0.06). CONCLUSIONS: Trauma patients requiring SHC after blunt trauma had a higher mortality rate than those in penetrating trauma. After adjusting for predictors of mortality, there was no difference in risk of mortality despite nearly double the time to hemorrhage control in patients presenting after blunt trauma.

Early identification of the need for major intervention in patients with traumatic hemorrhage: development and internal validation of a simple bleeding score.

BACKGROUND: Failure to rapidly identify bleeding in trauma patients leads to substantial morbidity and mortality. We aimed to develop and validate a simple bedside score for identifying bleeding patients requiring escalation of care beyond initial resuscitation. METHODS: We included patients with major blunt or penetrating trauma, defined as those with an Injury Severity Score greater than 12 or requiring trauma team activation, at The Ottawa Hospital from September 2014 to September 2017. We used logistic regression for derivation. The primary outcome was a composite of the need for massive transfusion, embolization or surgery for hemostasis. We prespecified clinical, laboratory and imaging predictors using findings from our prior systematic review and survey of Canadian traumatologists. We used an AIC-based stepdown procedure based on the Akaike information criterion and regression coefficients to create a 5-variable score for bedside application. We used bootstrap internal validation to assess optimism-corrected performance. RESULTS: We included 890 patients, of whom 133 required a major intervention. The main model comprised systolic blood pressure, clinical examination findings suggestive of hemorrhage, lactate level, focused assessment with sonography in trauma (FAST) and computed tomographic imaging. The C statistic was 0.95, optimism-corrected to 0.94. A simplified Canadian Bleeding (CAN-BLEED) score was devised. A score cut-off of 2 points yielded sensitivity of 97.7% (95% confidence interval [CI] 93.6 to 99.5) and specificity 73.2% (95% CI 69.9 to 76.3). An alternative version that included mechanism of injury rather than CT had lower discriminative ability (C statistic = 0.89). CONCLUSION: A simple yet promising bleeding score is proposed to identify highrisk patients in need of major intervention for traumatic bleeding and determine the appropriateness of early transfer to specialized trauma centres. Further research is needed to evaluate the performance of the score in other settings, define interrater reliability and evaluate the potential for reduction of time to intervention.

CONTEXTE: Les délais dans la détection des saignements actifs chez les patients en traumatologie entraînent une morbidité et une mortalité élevées. L'objectif était d'élaborer et de valider une échelle simple, à utiliser en contexte clinique pour repérer les patients qui présentent un saignement actif et qui nécessitent une intensification des soins après la réanimation initiale. MÉTHODES: Les critères d'inclusion étaient les suivants : admission à l'Hôpital d'Ottawa entre septembre 2014 et septembre 2017 pour un traumatisme contondant ou pénétrant, et score de gravité de la blessure supérieur à 12 ou mobilisation de l'équipe de traumatologie. Nous avons fait la dérivation par régression logistique. Le principal critère d'évaluation était la nécessité d'une transfusion massive, d'une embolisation ou d'une opération pour rétablir l'hémostase. Nous avons établi les facteurs prédictifs décelables en clinique, en laboratoire et à l'imagerie en fonction des résultats que nous avons obtenus dans le cadre d'une revue systématique et d'un sondage mené auprès de traumatologues canadiens. Nous avons utilisé une procédure avec ajustement selon le critère d'information d'Akaike (AIC) et des coefficients de régression afin de créer une échelle à 5 variables applicable en contexte clinique. Pour ce qui est de la validation interne, nous avons ajusté les valeurs dites « optimistes ¼ à l'aide de la méthode d'autoamorçage (bootstrap). RÉSULTATS: Nous avons inclus 890 patients, dont 133 nécessitaient une intervention majeure. Le modèle de base intégrait la pression artérielle systolique, les constatations cliniques indiquant une hémorragie, le taux de lactate, les résultats de l'échographie ciblée en traumatologie (FAST) et les résultats de la tomodensitométrie (TMD). La statistique C s'élevait à 0,95 (0,94 après ajustement). Nous avons conçu une échelle canadienne simplifiée d'évaluation des saignements actifs (CANBLEED). Un seuil de 2 points a généré une sensibilité de 97,7 % (intervalle de confiance [IC] à 95 % de 93,6 à 99,5) et une spécificité de 73,2 % (IC à 95 % de 69,9 à 76,3). Une deuxième version, qui tient compte du mécanisme de blessure plutôt que des résultats de la TMD, avait un pouvoir de discrimination inférieur (statistique C = 0,89). CONCLUSION: Nous proposons une échelle d'évaluation des saignements actifs simple, mais prometteuse. Celle-ci vise à repérer les patients à haut risque qui nécessitent une intervention majeure pour un saignement d'origine traumatique ainsi qu'à déterminer la pertinence d'un transfert précoce dans un centre de traumatologie. Des études complémentaires seront nécessaires afin d'évaluer l'échelle dans d'autres milieux, d'établir sa fiabilité interévaluateurs et d'évaluer le potentiel de réduction des délais d'intervention.

A High Ratio of Plasma: RBC Improves Survival in Massively Transfused Injured Children.

BACKGROUND: Massive transfusion protocols with balanced blood product ratios have been associated with improved outcomes in adult trauma. The impact on pediatric trauma is unclear. MATERIAL AND METHODS: A retrospective review of the Pediatric Trauma Quality Improvement Program data set was performed using data from January 2015 to December 2016. Trauma patient's ≤ 18 y of age, who received red blood cells (RBCs) and were massively transfused were included. Children with burns, dead on arrival, and nonsurvivable injuries were excluded. Outcome data and mortality were assessed based on low (<1:2), medium (≥1:2, <1:1), and high (≥1:1) plasma and platelet to RBC ratios. RESULTS: There were 465 children included in the study (median age, 8 [2-16] y; median injury severity score, 34 [29-34]; mortality rate, 38%). Those transfused a medium plasma:RBC ratio received the greatest blood product volume in 24 h (90 [56-164] mL/kg; P < 0.01). Those in the low plasma:RBC group underwent fewer hemorrhage control procedures [56 (34%); P < 0.01], but ratio was not significant when controlling for age and other variables. Survival was improved for those who received a high plasma:RBC ratio (P = 0.02). Platelet transfusions were skewed toward lower ratios (95%) with no difference in clinical outcomes between the groups. CONCLUSIONS: A high ratio of plasma:RBC may result in decreased mortality in severely injured children receiving a massive transfusion. Prospective, multicenter studies are needed to determine optimal resuscitation strategies for these critically ill children.

Desmopressin and bleeding risk after percutaneous kidney biopsy.

BACKGROUND: Desmopressin is used to reduce bleeding after kidney biopsy but evidence supporting its use is weak, especially in patients with elevated creatinine. The present study was undertaken to evaluate efficacy of desmopressin in reducing bleeding after percutaneous kidney biopsy. METHODS: Retrospective cohort study. 269 of 322 patients undergoing percutaneous kidney biopsy between January 1, 2014 and January 31, 2018 were included. Patients had normal bleeding time, platelet count and coagulation profile. Primary outcome was defined as composite of hemoglobin drop ≥1 g/dL, hematoma on post biopsy ultrasound, gross hematuria, erythrocyte transfusion or angiography to stop bleeding. Association of desmopressin with outcomes was assessed using linear (for continuous variables) and logistic (for binary variables) regression models. Propensity score was used to minimize potential confounding. RESULTS: Desmopressin was administered to 100/269 (37.17%) patients. After propensity score adjustment patients who received desmopressin had increased odds of post biopsy bleeding [OR 3.88 (1.95-7.74), p < 0.001]. Creatinine at time of biopsy influenced bleeding risk; gender, emergent vs elective biopsy, obesity, AKI, diabetes, hypertension or bleeding time did not influence bleeding risk. Administration of desmopressin to patients with serum creatinine ≥1.8 mg/dL decreased bleeding risk [OR 2.11 (95% CI 0.87-5.11), p = 0.09] but increased bleeding risk when serum creatinine was < 1.8 mg/dL (OR 9.72 (95% CI 2.95-31.96), p < 0.001). CONCLUSION: Desmopressin should not be used routinely prior to percutaneous kidney biopsy in patients at low risk for bleeding but should be reserved for patients who are at high risk for bleeding.

Do changing trends in tonsil surgery affect hemorrhage rates? A longitudinal study covering 1,452,637 procedures.

PURPOSE: To evaluate whether changing trends in tonsil surgery between 2005 and 2017 in Germany were associated with different age- and gender-specific hemorrhage rates. METHODS: A longitudinal population-based inpatient cohort study was performed including all patients who had undergone tonsillectomy (with or without adenoidectomy), tonsillotomy, abscess-tonsillectomy, removal of tonsillar remnants and surgical treatment to achieve hemostasis following tonsil surgery. The population was stratified by age (groups of 5 years) and gender. Operation rates were calculated in relation to the end-year population number according to the German Federal Office of Statistics. RESULTS: The surgical rates per 100,000 had significantly decreased from 170.39 to 90.95 (46.62%) in female patients and from 147.33 to 88.19 (40.14%) in male patients within the study period (p < 0.001). A total of 42.352 female patients had required surgical treatment to achieve hemostasis following 783,005 procedures (5.41%). In contrast, only 669,632 operations were performed in male patients but were complicated by hemorrhage in 51.185 cases (7.64%) which was significantly different (p < 0.001). The male-to-female ratio of the surgical rates had increased from 0.86:1 to 0.93:1. Hemorrhage rates differed significantly between age groups (p < 0.001). Male gender is a significant risk factor for bleeding at all ages < 85 years with greatest differences in 20- to 25-year-old patients (12.19% male vs. 6.26% female). CONCLUSIONS: Changing trends in tonsil surgery are not associated with increased rates of bleeding complications. Hemorrhage following tonsil surgery is significantly related to age and gender and this should be noted when reported hemorrhage rates in the literature are appraised by the reader.

A novel secure transfixing blood vessel occluder: comparison with the hemoclip in the porcine model.

BACKGROUND: Secure vessel occlusion is critical to the success of all surgical and interventional procedures. The purpose of this study was to compare in vivo the use of the Amsel Vessel Occluder (AVO), a novel occlusion clip device for secure blood vessel closure, with one of the many commercially available hemoclips, the Ligaclip, in the porcine model. METHODS: Vessel closure of arteries and veins was performed on 10 swine to compare the ease of use, safety, and efficacy of the AVO with the Ligaclip as well as the tissue response at 7 and 30 d. After heparinization, the targeted vessels (carotid/femoral/brachial arteries and jugular/femoral/brachial veins) were occluded with two clips, either two AVO's or two Ligaclip's, and the vessels transected between the two clips. Any bleeding was recorded. At sacrifice, gross and histopathologic findings were examined for evidence of bleeding or injury to adjacent structures. The tissue response and healing were evaluated by a prospective randomized histopathologic study for the effects of any biological incompatibilities. At time of sacrifice, occluded vessel segments were subjected to nonphysiological pressures ("holding" pressures) to compare efficacy of occlusion in fresh, nonoccluded vessels, and the ability to dislodge the clips once applied. RESULTS: Twenty veins and 20 arteries between 2-mm and 7-mm outer diameter were occluded in 10 pigs. Each vessel was occluded with either AVO or Ligaclip. Our study confirmed easy and safe AVO application with no dislodgment of any AVO clips once deployed. The AVO showed no intraoperative or postoperative bleeding (AVO = 0/40), while one Ligaclip dislodged resulting in a fatal hemorrhage 16 h after surgery (Ligaclip = 1/40), and on two occasions where, with obvious slippage of the Ligaclip, immediately after deployment, additional clips were placed. The holding pressures for the two clips were similar but unlike the AVO, the Ligaclip was easily dislodged. Histopathologic examination showed no difference in the tissue response and healing of the two clips. CONCLUSIONS: The AVO is simple to deploy and securely maintains occlusion by transfixing the targeted vessel, unlike the widely used, nontransfixing Ligaclip, that has a tendency to dislodge. As such, the Amsel secure vessel occluder opens up numerous treatment opportunities in both the venous and arterial systems to minimize open, laparoscopic, robotic surgical and interventional procedures, and reduce patient morbidity and its associated health care costs.

Outcomes of endoscopic ethmoidectomy performed on a day-case basis: a prospective bi-centric study.

Evaluation of endoscopic ethmoidectomy performed as a day-case in terms of security, quality, and satisfaction of the patient. This prospective observatory bi-centric study over 1 year included 74 patients undergoing an ethmoidectomy respecting the eligibility criteria of ambulatory care. We recorded patients' demographic data, operative details, satisfaction, postoperative course, and follow-up results. Nasal symptoms were evaluated by SNOT-22 on preoperative appointment and postoperatively at D30. No non-absorbable nasal packing was used, eventually in the case of preoperative-bleeding absorbable gelatine packing. The postoperative follow-up took place at D1 by phone call and at D10 and D30 to assess complications, Visual Analogue Scale, and state of ethmoidal corridors by endoscopic exam. Patients benefited of bilateral ethmoidectomy in 82.4 % cases associated with septoplasty in 42 %. The majority (95 %) was discharged on the same day. Only one patient had bleeding at D0 and was kept in standard hospitalization, such as three other patients for medical or organizational reasons not related to surgery. At D1, 23 % described postoperative light bleeding but needed no revisit and pain was estimated at 1.3 (VAS). No readmission was observed, and no major complication was noted. SNOT-22 decreased successfully by 56 %, statistically related to postoperative treatment of corticosteroids and in the case of Samter triad. 97 % of patients were satisfied of the ambulatory care. These results suggest that within an experienced and dedicated day-case medical and paramedical team, ethmoidectomy can be safely performed on a day-case basis with high quality of taking care and satisfaction of patients.

Safety and Cost-Effectiveness in Thyroidectomy Using the HARMONIC Scalpel Compared to Traditional Hemostasis: A Controlled Clinical Assay.

INTRODUCTION: The aim of this clinical control trial is to analyze the cost-effectiveness and to understand the efficacy of the HARMONIC FOCUS®+ (Ethicon Inc., Somerville, New Jersey) scalpel as the only system to cut and coagulate in thyroidectomy. MATERIALS AND METHODS: One hundered patients of the thyroid clinic of the Mexico City General Hospital were included. All patients underwent surgery and were divided into two randomized groups. In Group 1, the HARMONIC scalpel was the only device used for cut and coagulate (50 patients), and in Group 2 clamp, tie, and electrocautery (50 patients) were used. Surgical bleeding, operative time, complications, diagnosis, thyroid size, and hospital stay were evaluated in both groups. The statistical analysis was done using central trend measurements, Student's t-, chi-squared, and Fisher's exact test, with a significance level of p < 0.05. The cost-effectiveness analysis was completed by determining the total cost of the surgical procedure per hour in US dollars, and the evolution to compare efficacy will be the number of re-interventions due to postoperative bleeding. RESULTS: The use of the HARMONIC scalpel in thyroid surgery had the same results as the traditional method when comparing complications, reoperation, hospital stay, and hypoparathyroidism. In total thyroidectomy patients, the bleeding in Group 1 was 55.16ml ( ± 32.97) and 85.4ml ( ± 69.41) in Group 2 , p=0.034. Operative time in Group 1 was 74.6 minutes (± 23.39) and 104.09 minutes (± 34.66) in Group 2, p= 0.0001. In both groups, there were no statistical differences in lobectomy. Cost-effectiveness analysis implies an adequate hemostasis if we are using a hemostatic device, and above all, the avoidance of a re-intervention due to hematoma, and the cost-effectiveness with regard to the re-intervention as a result of a hematoma implies that $161 US more is spent for each re-intervention. CONCLUSION: The utilization of the HARMONIC scalpel device is similar to the traditional technique of ligature and knots as far as cost-effectiveness is concerned, due to the fact that the greater expense of the device is compensated by the lower expense in time and surgical re-intervention.

[Influence of external pelvic stabilization on hemodynamically unstable pelvic fractures]. / Einfluss der externen Beckenstabilisierung bei hämodynamisch instabilen Beckenfrakturen.

BACKGROUND: In the treatment of complex pelvic fractures hemorrhage control is of primary importance; however, studies regarding the localization of bleeding are contradictory so that various treatment approaches are recommended. The primary aim of external pelvic compression applied in the trauma room is to reduce the pelvic volume and counteract blood loss through self-induced tamponade. This study examined the influence of external pelvic compression on mortality and outcome in cases of hemodynamically unstable pelvic fractures in a larger number of cases. MATERIAL AND METHODS: The current study used the TraumaRegister DGU® (TR-DGU) to retrospectively evaluate the records of 104 patients treated between 2002 and 2011. All patients suffered severe injury with an injury severity score (ISS) of at least 16 points. In addition, the patients were hemodynamically unstable with confirmed relevant isolated pelvic injuries. To evaluate the effectiveness of external pelvic compression, patients with and without external pelvic stabilization were compared. RESULTS: Of the investigated patients 26.9 % died of their injuries and of these the mortality was 78.6 % within the first 6 h of admission to the trauma room. External pelvic stabilization was performed in 45.2 % of patients. The mortality was 19.1 % in patients with external pelvic stabilization and in contrast, the mortality in the group of patients without external pelvic stabilization was 33.3 %. During the course of hospitalization, surviving patients with external pelvic stabilization were significantly more likely to develop sepsis or multiple organ failure and required longer periods of intensive care. CONCLUSION: External pelvic stabilization seems to be an important instrument for the initial treatment of hemodynamically unstable pelvic fractures and showed a positive effect on patient mortality.

[Organization and results of surgical care for ulcerative gastroduodenal bleeding in the hospitals of Central Federal District]. / Organizatsiya i rezul'taty khirurgicheskoi pomoshchi pri yazvennom gastroduodenal'nom krovotechenii v statsionarakh tsentral'nogo federal'nogo okruga.

AIM: To present treatment of 52 149 patients with ulcerative gastroduodenal bleeding (UGDB) who were treated in different regions of Central Federal District (CFD) for the period 2011-2014. It is noted that UGDB incidence per 100 thousands is increased proportionally from 32.9 to 77.8 according to population less than 20 and over 100 thousands, respectively. In hospitals of small and medium settlements the number of UGDB patients without surgery reaches 81.6 and 81.1%, the number of operated patients - 18.4 and 18.9% respectively. In hospitals of large settlements this ratio is 90.1 and 90.6%, the number of operated patients - 9.9 and 9.4%, respectively. In areas of Central Federal District the mortality rate in patients without surgery is 3.9-8.2%, in operated patients - 17.4-36.9%. RESULTS: Structured analysis of the organization of surgical care in Central Federal District revealed the relationship between outcomes and efficient use of endoscopic diagnostics and haemostasis. In municipal hospitals of Central District endoscopic technologies are insufficiently used for final elimination of ulcerative bleeding.

[Poor outcome factors associated to patients with lower digestive bleeding in a public hospital]. / Factores asociados a mal pronóstico en pacientes con sangrado digestivo bajo en un hospital público.

BACKGROUND: Lower gastrointestinal bleeding (LGIB) is an event that has shown an increase in complications and mortality rates in the last decades. Although some factors associated with poor outcome have been identified, there are several yet to be evaluated. OBJECTIVE: To identify risk factors for poor outcome in patients with LGIB in the Hospital Edgardo Rebagliati Martins of Lima, Peru. MATERIAL AND METHODS: A prospective analytic observational cohort study was made, and a census was conducted with all patients with acute LGIB between January 2010 and December 2013. The main variables were heart rate ≥100/min, systolic blood pressure <100 mmHg and low hematocrit (≤35%) at admission. Poor outcome was defined as any of the following: death during hospital stay, bleeding requiring transfusion of ≥4 blood packs, readmission within one month of hospital discharge, or the need for hemostatic surgery. RESULTS: A total of 341 patients with LGIB were included, of which 27% developed poor outcome and 2% died. Variables found to be statistically related to poor outcome were: heart rate ≥ 100/min at admission (RR: 1.75, IC 95% 1.23- 2.50), systolic blood pressure <100 mmHg at admission (RR: 2.18, IC 95% 1.49-3.19), hematocrit ≤35% at admission (RR: 1.98, IC 95% 1.23-3.18) and LGIB of unknown origin (RR: 2.74, IC 95% 1.73-4.36). CONCLUSIONS: Elevated heart rate at admission, systolic hypotension at admission, low hematocrit at admission and having a LGIB of unknown origin are factors that increase the risk of developing poor outcome, and these patients should be monitored closely due to their higher risk of complications.

[Balance of hemostasis and anticoagulation therapy techniques for hip arthroplasty].

UNLABELLED: Studied a rational balance of prevention and control of blood loss and antithrombotic therapy in hip arthroplasty. MATERIAL AND METHODS: In view of literature data about significant blood loss during and after the intervention, as well as the formation of the group of patients who refuse blood transfusions for social (including religious) reasons, taken innovative methods for reducing blood loss and needs for blood transfusions. RESULTS: Complex of techniques, including conducting spinal anesthesia, controlled hypotension with nitroglycerin and pentamine, intraoperative use of systemic hemostatic and preventive use of erythropoietic stimulating agents, was formed in our proprietary technology to reduce blood loss. Its use has allowed to reach a statistically significant reduction of blood loss and transfusion rate in hip arthroplasty patients.

Effect of dementia on outcomes of elderly patients with hemorrhagic peptic ulcer disease based on a national administrative database.

BACKGROUND: Little information is available on the effect of dementia on outcomes of elderly patients with hemorrhagic peptic ulcer disease at the population level. AIMS: This study aimed to investigate the effect of dementia on outcomes of elderly patients with hemorrhagic peptic ulcer based on a national administrative database. METHODS: A total of 14,569 elderly patients (≥80 years) who were treated by endoscopic hemostasis for hemorrhagic peptic ulcer were referred to 1073 hospitals between 2010 and 2012 in Japan. We collected patients' data from the administrative database to compare clinical and medical economic outcomes of elderly patients with hemorrhagic peptic ulcers. Patients were divided into two groups according to the presence of dementia: patients with dementia (n = 695) and those without dementia (n = 13,874). RESULTS: There were no significant differences in in-hospital mortality within 30 days and overall mortality between the groups (odds ratio; OR 1.00, 95 % confidence interval; CI 0.68-1.46, p = 0.986 and OR 1.02, 95 % CI 0.74-1.41, p = 0.877). However, the length of stay (LOS) and medical costs during hospitalization were significantly higher in patients with dementia compared with those without dementia. The unstandardized coefficient for LOS was 3.12 days (95 % CI 1.58-4.67 days, p < 0.001), whereas that for medical costs was 1171.7 US dollars (95 % CI 533.8-1809.5 US dollars, p < 0.001). CONCLUSIONS: Length of stay and medical costs during hospitalization are significantly increased in elderly patients with dementia undergoing endoscopic hemostasis for hemorrhagic peptic ulcer disease.

Prospective, Randomized Trial to Evaluate Efficacy of a Bipolar Sealer in Direct Anterior Approach Total Hip Arthroplasty.

Total hip arthroplasty can be associated with substantial blood loss requiring allogenic transfusions. Intraoperative blood loss patterns in DAA differ from other approaches. This study evaluated the hemostatic efficacy of a bipolar sealer in DAA THA on surgical blood loss and transfusion requirements. 118 patients were enrolled in this prospective, randomized, double-blinded trial. Primary outcome measure was transfusion rate, while secondary measures included calculated blood loss. A lower transfusion rate was found in the treatment group (3.5 % vs 16.4%, P=.03). There were differences in Hemoglobin-drop (P=.04), calculated blood loss (P=.02), and hidden blood loss (P=.02), favoring the treatment group. The use of a bipolar sealer decreased intraoperative blood loss and transfusion requirements in the study population.

Real-world outcomes of hemostatic matrices in cardiac surgery.

OBJECTIVE: While hemostatic matrices are efficacious in achieving hemostasis, outcomes research is limited; therefore, this study analyzed clinical outcomes of flowable hemostatic matrices in a real-world cardiac surgical population. DESIGN: Retrospective database analysis of cardiac surgical cases from 2006 to 2012. SETTING: Data were extracted from Premier's United States (US) Perspective Database, developed for quality and utilization benchmarking and containing approximately 25% of US hospital discharges. PARTICIPANTS: Coronary artery bypass grafting (CABG), aortic, valve, or valvular with CABG surgery cases in which FLOSEAL or SURGIFLO was included. INTERVENTIONS: Three study groups were formed, given usage of hemostatic matrices: (1) FLOSEAL or SURGIFLO, exclusively; (2) FLOSEAL or SURGIFLO, with fibrin sealants, sealants, or powder hemostats; and (3) FLOSEAL or SURGIFLO, with nonflowable hemostats with or without thrombin. Outcomes included complications, transfusions, surgical revisions, mortality, length of stay (LOS) and surgery time. MEASUREMENTS AND MAIN RESULTS: Group A included 4,480 FLOSEAL and 326 SURGIFLO cases. Results suggested SURGIFLO cases were associated with significantly higher risk of multiple adverse outcomes, including major (odds Ratio [OR] 2.12; 95% CI 1.34-3.35; p = 0.001) and minor complications (OR 1.84; 95% CI 1.33-2.55; p<0.001); surgical revisions (OR 2.01; 95% CI 1.03- 3.94; p = 0.042); transfusions for any blood products (OR 4.90; 95% CI 3.50-6.87; p<0.001); and longer surgery times (adjusted mean difference = 64 minutes, p<0.001) than the FLOSEAL group. There were no significant differences in mortality and LOS. Results were similar in groups B and C. CONCLUSIONS: These retrospective outcomes suggested FLOSEAL was associated with fewer negative consequences than SURGIFLO in this surgical population.

Intraoperative bleeding and haemostasis during pelvic surgery for locally advanced or recurrent rectal cancer: a prospective evaluation.

BACKGROUND: This study aimed to prospectively quantify the frequency of serious bleeding during pelvic surgery for locally advanced or recurrent rectal cancer and review the surgical methods used to control this. METHODS: Consecutive cases of pelvic surgery for curative resection of locally advanced or recurrent rectal cancer were prospectively evaluated over a nine-month period. The procedures undertaken included multivisceral resections, sacrectomies or ultra-low anterior resections. Multivisceral resections were defined as pelvic exenterations, extra-levator abdominoperineal resections (ELAPER) and recurrent anterior resections. The primary endpoint was the proportion of patients sustaining major blood loss, defined as ≥1,000 ml. The secondary endpoint was the blood transfusion rate. Haemostatic adjunct use was recorded. RESULTS: Twenty-six patients underwent surgery, comprising 11 pelvic exenterations, 3 ELAPERs, 1 recurrent anterior resection, 5 abdominosacral resections and 6 ultra-low anterior resections. The median intraoperative blood loss was 1,250 ml with 53.8 % of the patients sustaining a loss ≥1,000 ml. Fifty per cent of patients required a blood transfusion within 24 h, and one or more haemostatic adjuncts were necessary in 50 % of the cases. Adjuncts used included a fibrinogen/thrombin haemostatic agent in 38.5 % of patients, temporary intraoperative pelvic packing in 11.5 % of patients and preoperative internal iliac artery embolization in 7.7 % of patients. CONCLUSIONS: This patient group is at a high risk of intraoperative haemorrhage, and such patients are high consumers of blood products. Haemostatic adjunct use is often necessary to minimize blood loss. We describe our local algorithm to assist in the assessment and intraoperative management of these challenging cases.

Uterine packing in the management of complete placenta praeuvia.

BACKGROUND: Complete (type 4) placenta praevia is a major cause of haemorrhage in Obstetrics. Uterine packing is an effective but underutilized life-saving intervention in situation of uncontrolled haemorrahage due to major placenta praevia. OBJECTIVES: To reappraise the effectiveness of uterine packing in the management of complete placenta praevia in order to popularize the practice. METHODS: Seven case series of complete placenta praevia were managed with uterine packing in Enugu, Nigeria between January 2, 2012 and February 28, 2013. RESULTS AND INTERPRETATION: Previous Caesarean delivery (85.71%) was the commonest identified risk factor for complete placenta praevia. Uterine packing was effective in preventing blood transfusion in 57.14% of the cases, and further post-operative intervention in 85.71%.Peripartum hysterectomy and maternal death were 100% avoidable. CONCLUSIONS: Uterine packing is an effective life-saving intervention in management of complete placenta praevia. The technique should be considered whenever there is uncontrollable haemorrage following complete placenta praevia.

[Radiodiagnosis and knee joint replacement in hemophilic arthropathies in Kazakhstan residents].

AIM: To assess complex radiodiagnosis and highly specialized medical care as knee joint replacement (KJR) to patients with hemophilic arthropathies (HA) who live in the Republic of Kazakhstan. SUBJECTS AND METHODS: The results of examination and treatment were analyzed in 40 patients with knee HA who were treated at the specialized Polytrauma Unit, Republican Research Center for Emergency Health Care. All patients with hemophilia A underwent joint X-ray study, computed tomography and magnetic resonance imaging (MRI), X-ray densitometry and ultrasound osteometry on admission and after KJR. RESULTS: Joint X-ray studies and computed tomography revealed that all the patients had Grades II-III arthroses with severe dysfunction of joints, their multiple involvements of different grades, which depended on the rate of recurrent hemarthrosis. Ultrasound study (USS) is the only mini-invasive method to control surgical hemostasis in hemophiliac patients after KJR. Osteodensitometry revealed osteopenia and osteoporosis in all the patients with hemophilia, which was a basis for prescribing calcium preparations in the early postoperative period for the prevention of instability of endoprosthetic components. We elaborated an algorithm for combination treatment in HA patients, which involved knee joint replacement. CONCLUSION: Highly specialized medical care to hemophilic patients and active introduction of the early surgical rehabilitation of the affected joint in their combination treatment contributed to the increased number of positive results, by restoring the quality of life in the patients: excellent, good, and satisfactory anatomic and functional results were obtained in 26.7, 51.1, and 22.2%, respectively. USS and MRI could evaluate joint changes in HA in detail, which plays an important role in the estimation of the course time of the disease, in the planning of endoprosthetic replacement, and in the timely prevention of severe complications of HA. Osteodensitometry makes it possible to monitor bone mineral density around the prosthesis and to postoperatively prevent endoprosthetic instability.