Intravenous Tranexamic Acid Reduces Post-Operative Bleeding and Blood Transfusion in Patients Undergoing Aortic Surgery: A PRISMA-Compliant Systematic Review and Meta-Analysis.

Background: Tranexamic acid (TXA), an antifibrinolytic agent, has been demonstrated to reduce blood loss and transfusion requirements in both cardiac and non-cardiac surgery. However, the evidence regarding the efficacy of intravenous TXA in aortic surgery has been seldomly analyzed. Therefore, the current study was performed to address this question. Methods: Searches of PubMed, EMBASE, OVID, Cochrane Library and CNKI were conducted comprehensively for randomized controlled trials (RCTs) comparing intravenous TXA versus no-TXA. Independently and in duplicate, we reviewed titles, abstracts and full-text articles, extracted data and evaluated bias risks. A random effect or fixed effect model was utilized to pool data. Results: The database search yielded 4 RCTs involving 273 patients. Meta-analysis revealed that, there was a significant reduction in bleeding volume within the first 4 hours post-operatively [(weighted mean difference (WMD) = -74.33; 95% confidence interval (CI): -133.55 to -15.11; p = 0.01)], and the first 24 hours post-operatively [(WMD = -228.91; 95% CI: -352.60 to -105.23; p = 0.0003)], post-operative red blood cell (RBC) transfusion volume [(WMD = -420.00; 95% CI: -523.86 to -316.14; p < 0.00001)], fresh frozen plasma (FFP) transfusion volume [(WMD = -360.35; 95% CI: -394.80 to -325.89; p < 0.00001)] and platelet concentrate (PC) transfusion volume [(WMD = -1.27; 95% CI: -1.47 to -1.07; p < 0.0001)] following intravenous TXA administration. In addition, intravenous TXA administration significantly decreased the incidence of postoperative complications (53/451 (8.2%) vs. 75/421 (13.9%); odds ratio (OR) = 0.47; 95% CI: 0.30 to 0.75; p = 0.001), according to this present meta-analysis. Conclusions: The current study preliminarily demonstrated that, TXA significantly reduced postoperative bleeding, blood transfusion requirements and postoperative complications among patients undergoing aortic surgery. More well-designed studies are warrant to confirm the efficacy and safety of intravenous TXA in patients undergoing aortic surgery.

Comparative study between oxytocin and combination of tranexamic acid and ethamsylate in reducing intra-operative bleeding during emergency and elective cesarean section after 38 weeks of normal pregnancy.

OBJECTIVE: Cesarean Section (CS) is associated with an increased risk of hemorrhage. Many drugs are used to decrease this risk. We aim to compare the combination of ethamsylate and tranexamic acid, oxytocin, and placebo in women undergoing CS. METHODS: We conducted a double-blinded, randomized, placebo-controlled trial between October and December 2020 in four university hospitals in Egypt. The study included all pregnant women in labor without any complications who accepted to participate in the study between October and December 2020. The participants were divided into three groups. The subjects were randomly allocated to receive either oxytocin (30 IU in 500 ml normal saline during cesarean section), combined one gram of tranexamic acid with 250 mg of ethamsylate once before skin incision, or distilled water. Our main outcome was the amount of blood loss during the operation. The secondary outcomes were the need for blood transfusion, hemoglobin and hematocrit changes, hospital stay, operative complications, and the need for a hysterectomy. The one-way ANCOVA test was used to compare the quantitative variables between the three groups while the Chi-square test was used to compare the qualitative variables. Post hoc analysis then was performed to compare the difference between every two groups regarding the quantitative variables. RESULTS: Our study included 300 patients who were divided equally into three groups. Tranexamic acid with ethamsylate showed the least intra-operative blood loss (605.34 ± 158.8 ml) compared to oxytocin (625.26 ± 144.06) and placebo (669.73 ± 170.69), P = 0.015. In post hoc analysis, only tranexamic acid with ethamsylate was effective in decreasing the blood loss compared to placebo (P = 0.013); however, oxytocin did not reduce blood loss compared to saline (P = 0.211) nor to tranexamic acid with ethamsylate (P = 1). Other outcomes and CS complications showed no significant difference between the three groups except for post-operative thrombosis which was significantly higher in the tranexamic and ethamsylate group, P < 0.00001 and the need for a hysterectomy which was significantly increased in the placebo group, P = 0.017. CONCLUSION: The combination of tranexamic acid and ethamsylate was significantly associated with the least amount of blood loss. However, in pairwise comparisons, only tranexamic acid with ethamsylate was significantly better than saline but not with oxytocin. Both oxytocin and tranexamic acid with ethamsylate were equally effective in reducing intra-operative blood loss and the risk of hysterectomy; however, tranexamic acid with ethamsylate increased the risk of thrombotic events. Further research with a larger number of participants is needed. TRIAL REGISTRATION: The study was registered on Pan African Clinical Trials Registry with the following number: PACTR202009736186159 and was approved on 04/09/2020.

Protamine dose to neutralize heparin at the completion of cardiopulmonary bypass can be reduced significantly without affecting post-operative bleeding.

BACKGROUND: Systemic anticoagulation with heparin during cardiopulmonary bypass (CPB) should be neutralized by protamine administration to restore normal hemostasis. Our previous study showed the protamine-to-heparin ratio (P-to-H) of 1:1 (1 mg protamine:100 IU circulating heparin; 1.0 Ratio) is likely an overestimation. Thus, we reduced the P-to-H in the HMS Plus Hemostasis Management System to 0.9:1 (0.9 Ratio) for 5 months and then to 0.8:1 (0.8 Ratio). We monitored post-operative (post-op) bleeding in the setting of reduced protamine dose (PD). METHODS: We performed a retrospective study of 632 patients (209 for the 1.0 Ratio, 211 for 0.9 Ratio, 212 for 0.8 Ratio group) who underwent cardiac surgery to measure the reduction of PD and how it affects 24-hour (24 h) post-op chest tube output. We also analyzed the entire data set to explore whether further reduction of P-to-H is warranted. RESULTS: While there was no difference in the indexed heparin dose among the three groups, we achieved a significant reduction in the indexed actual protamine dose (APDi) by 24% (0.9 Ratio) and 31% (0.8 Ratio) reductions compared to the 1.0 Ratio group. On average, APDi was 88 ± 22, 67 ± 18, and 61 ± 15 mg/m2 in the 1.0, 0.9, and 0.8 Ratio groups, respectively. We found no significant difference in 24 h post-op bleeding among the three groups. CONCLUSION: 1.0 Ratio at the completion of CPB is likely an excessive administration of protamine. With the stepwise reduction of PD, we observed no increase in post-op bleeding, which may indicate that no meaningful increase in heparin rebound occurred. In addition, further analysis of the entire data set demonstrates that a 0.75 Ratio is likely sufficient to neutralize the heparin completely.

Effects of intraoperative blood loss during liver resection on patients' outcome: a single- center experience

Background/aim: Operative bleeding is one of the major determinants of outcome in liver surgery. This study aimed to describe the impact of intraoperative blood loss on the postoperative course of liver resection (LR). Materials and methods: The data of 257 patients who were treated with LR between January 2007 and October 2018 were retrospectively analyzed. LRs were performed via intermittent portal triad clamping (PTC) under low central venous pressure. Results: LRs were performed for 67.7% of patients with a malignant disease and 32.3% of patients with a benign disease. Major LR was performed in 89 patients (34.6%). The mean PTC period was 20.32 min (±13.7). The median intraoperative bleeding amount was 200 mL (5­3500 mL), the 30-day mortality rate was 4.3%, and the morbidity rate was 31.9%. The hospital stay (p = 0.002), morbidity (p = 0.009), and 30-day mortality (p = 0.041) of patients with a bleeding amount of more than 500 mL significantly increased. Conclusion: Surgeons should consider the adverse effects of intraoperative bleeding during liver resection on patients' outcome. Favorable outcomes would be obtained with diligent postoperative care.

Outcomes of congenital diaphragmatic hernia repair on extracorporeal life support.

PURPOSE: Extracorporeal life support (ECLS) is applied to refractory pulmonary hypertension in congenital diaphragmatic hernia (CDH). We evaluate the single-center outcomes of infants with CDH to determine the utility of late repair on ECLS versus repair post-decannulation. METHODS: Records of infants with CDH (2004-2014) were retrospectively reviewed. RESULTS: CDH was diagnosed in 177 infants. Sixty six (37%) underwent ECLS, of which, 11 died prior to repair, 33 were repaired post-decannulation, and 22 were repaired on ECLS. Repair was delayed in patients on ECLS (19 versus 10 days, p < 0.001). Patients repaired on ECLS had longer ECLS runs (22 versus 12 days, p < 0.001) and higher rates of bleeding and mortality than those repaired post-decannulation. Survival was 54% in infants undergoing ECLS, 65% in those who underwent repair, 36% in those repaired during ECLS, and 85% in those who were decannulated prior to repair. Eighteen percent (N = 4) of deaths after repair on ECLS were attributable to surgical bleeding. The remainder was due to pulmonary hypertension or sepsis. CONCLUSION: Infants who underwent CDH repair post-decannulation had excellent outcomes and no mortalities attributable to repair. Neonates who underwent repair on ECLS late on bypass had the lowest survival rate with only 18% of mortality in this cohort attributable to surgical bleeding.

Topical administration of tranexamic acid in hip arthroplasty.

PURPOSE: The purpose of this study was to assess the efficacy of a newly designed topical administration of tranexamic acid (TXA) in reducing post-operative bleeding in total hip arthroplasty (THA) and bipolar hip hemiarthroplasty (BHA). METHODS: A consecutive series of 160 patients who underwent hip arthroplasty was enrolled in this study. Topical administration of TXA was done in group 1 (40 patients underwent THA and 40 BHA). We compared the amount of blood loss and rates of post-operative transfusion in group 1 with those of group 2 (40 cases of THA and 40 cases of BHA) in which TXA solution was not applied. RESULTS: The total amount of blood loss in THA group 1 and THA group 2 was 793 ± 50 mL and 1086 ± 73 mL, respectively (p = 0.001). The transfusion rates of THA group 1 and THA group 2 was 27.5 % and 50 %, respectively (p = 0.039). The transfusion rates of BHA group 1 and BHA group 2 was 45 % and 60 %, respectively (p = 0.179). The amounts of blood loss through the drainage tube were 186 ± 22 mL and 257 ± 24 mL in THA group 1 and THA group 2, respectively, and 101 ± 11 mL and 147 ± 16 mL in BHA group 1 and BHA group 2, respectively, showing statistical significance. No complications such as infection, deep vein thrombosis or cardiovascular disease were observed during the hospital stay and the last follow-up. CONCLUSION: Topical administration of TXA is an effective and safe method to reduce post-operative bleeding and transfusion rates in hip arthroplasty.

Does the development of chronic kidney disease and acute kidney injury affect the prognosis after living donor liver transplantation?

BACKGROUND AND AIMS: Chronic kidney disease (CKD) and acute kidney injury (AKI) have been discussed as complications following living donor liver transplantation (LDLT). The aim of this study was to clarify the relationships among CKD, AKI, and the prognosis after LDLT. METHODS: This study included 118 patients who underwent LDLT in our department. A low eGFR (<60 mL/min/1.73 m(2) ) was regarded to indicate CKD. AKI 1 and AKI 2 were characterized by an increase in the serum creatinine level of 0.5 and 1.0 mg/dL, respectively, within one wk after LDLT. We investigated the risk factors for and the relevance of CKD and AKI on the prognosis. RESULTS: AKI 1 was associated with sepsis and intra-operative bleeding (p = 0.0032, p = 0.001). AKI 2 was associated with sepsis and hepatitis C infection (p < 0.001, p = 0.027). A pre-operative eGFR of 60-89 and diabetes were the risk factors for the development of CKD in POY 2 (p = 0.018, p = 0.002). AKI 2, sepsis, and diabetes were the risk factors for the patient death within one yr after LDLT (p = 0.010, p = 0.002, p = 0.022). AKI 2 and sepsis were the risk factors for death within two yr after LDLT (p = 0.005, p = 0.018). CONCLUSIONS: Recognizing the risk factors and careful management for preventing both AKI and CKD may improve the prognosis of patients following LDLT.

Hemostatic effects of tranexamic acid in cardiac surgical patients with antiplatelet therapy: a systematic review and meta-analysis.

BACKGROUND: The purpose of the current study was to assess the efficacy of tranexamic acid (TXA) on reducing bleeding in cardiac surgical patients with preoperative antiplatelet therapy (APT). METHODS: Five electronic databases were searched systematically for randomized-controlled trials (RCTs) assessing the impact of intravenous TXA on post-operative bleeding on cardiac surgical patients with preoperative APT until May 2024. Primary outcome of interest was post-operative blood loss. Secondary outcomes of interest included the incidence of reoperation due to post-operative bleeding, post-operative transfusion requirements of red blood cells (RBC), fresh-frozen plasma (FFP), and platelet concentrates. Mean difference (MD) with 95% confidence interval (CI) or odds ratios (OR) with 95% CI was employed to analyze the data. Subgroup and meta-regression analyses were performed to assess the possible influence of TXA administration on reducing bleeding and transfusion requirements. RESULTS: A total of 12 RCTs with 3018 adult cardiac surgical patients (TXA group, 1510 patients; Control group, 1508 patients) were included. The current study demonstrated that TXA significantly reduced post-operative blood loss (MD = - 0.38 L, 95% CI: - 0.73 to - 0.03, P = 0.03; MD = - 0.26 L, 95% CI: - 0.28 to - 0.24, P < 0.00001; MD = - 0.37 L, 95% CI: - 0.63 to - 0.10, P = 0.007) in patients receiving dual antiplatelet therapy (DAPT), aspirin, or clopidogrel, respectively. Patients in TXA group had significantly lower incidence of reoperation for bleeding as compared to those in Control group. The post-operative transfusion of RBC and FFP requirements was significantly lower in TXA group than Control group. Subgroup analyses showed that studies with DAPT discontinued on the day of surgery significantly increased the risk of post-operative blood loss [(MD: - 1.23 L; 95% CI: - 1.42 to - 1.04) vs. (MD: - 0.16 L; 95% CI: - 0.27 to - 0.05); P < 0.00001 for subgroup difference] and RBC transfusion [(MD: - 3.90 units; 95% CI: - 4.75 to - 3.05) vs. (MD: - 1.03 units; 95% CI: - 1.96 to - 0.10); P < 0.00001 for subgroup difference] than those with DAPT discontinued less than 5-7 days preoperatively. CONCLUSIONS: This meta-analysis demonstrated that TXA significantly reduced post-operative blood loss and transfusion requirements for cardiac surgical patients with preoperative APT. These potential clinical benefits may be greater in patients with aspirin and clopidogrel continued closer to the day of surgery. TRIAL REGISTRATION NUMBER: CRD42022309427.

The impact of anti-thrombotic therapy on bleeding outcomes and thrombosis following laparoscopic cholecystectomy: a meta-analysis.

Acute cholecyctitis is a common condition which requires immediate or elective surgical interventions and this condition is one among the common causes for emergency hospitalization among the elderly population. However, controversies have been observed with the use of anti-thrombotic agents in patients undergoing laparoscopic cholecyctectomy. Few studies have reported increased risk of bleeding in patients with anticoagulants whereas other studies have reported no significant bleeding outcomes. Nevertheless, the lack of evidence-based guidelines further complicates decision-making. In this analysis we aimed to systematically assess the impact of anti-thrombotic therapy on bleeding outcomes and thrombosis following laparoscopic cholecystectomy. MEDLINE, EMBASE, Cochrane database, Google scholar, Web of Science and http://www.ClinicalTrials.gov were searched for relevant publications based on anti-thrombotic therapy among patients who underwent laparoscopic cholecystectomy. The endpoints in this analysis included: intra-operative bleeding, post-operative bleeding, blood loss, patients requiring blood transfusion and thrombotic complications. The Revman 5.4 software was used to analyze data in this analysis. Risk ratio (RR) with 95% confidence intervals (CIs) were used to represent the data following analysis. A total number of 4008 participants (enrollment period 2002-2019) were included in this analysis whereby 756 participants were assigned to an anti-thrombotic therapy and 3592 participants were in the control group. Our results showed that antithrombotic therapy was associated with significantly higher risk of intra-operative bleeding (RR: 2.23, 95% CI: 1.77-2.79; P = 0.00001), post-operative bleeding (RR: 4.77, 95% CI: 1.13-20.10; P = 0.03), and blood loss (RR: 3.01, 95% CI: 1.13-8.06; P = 0.03). Patients requiring blood transfusion (RR: 4.80, 95% CI: 1.90-12.13; P = 0.0009) were also significantly higher in the anti-thrombotic group. However, thrombotic complications (RR: 2.17, 95% CI: 0.50-9.42; P = 0.30) were not significantly higher. Through this analysis, we concluded that anti-thrombotic therapy was associated with significantly increased risks of intra-operative and post-operative bleeding events following laparoscopic cholecystectomy. Patients requiring blood transfusion were also significantly higher. Therefore, stopping anti-thrombotic agents prior to laparoscopic cholecystectomy could significantly minimize bleeding risks.

Evaluation of postoperative bleeding control employing Surgicel: a clinical trial.

INTRODUCTION: Various techniques have been developed for the rapid control of bleeding as a potential surgical complication. Research shows that the Surgicel has a significant effect on reducing bleeding in most surgeries; however, in our experimental observations on patients undergoing open prostatectomy, not only no significant reduction was seen in the amount of bleeding, but in some cases, Surgicel led to infection. Therefore, in this study, the effect of the Surgicel on infection and bleeding in open prostatectomy was investigated. MATERIALS AND METHODS: Thirty patients undergoing open prostatectomy were randomly divided into two groups. To control bleeding after suturing the bladder neck, the Surgicel was installed in the first group, while it was not in the second group. Hemoglobin, hematocrit, PT, PTT, INR, bleeding rate, and postoperative complications were evaluated in all patients. RESULTS: In the studied groups, hemoglobin level and hematocrit percentage before surgery and on the first and second days after surgery, along with coagulation status, were compared in terms of PT, PTT, and INR. There were no significant differences between the studied variables and baseline variables. CONCLUSION: The present study revealed that the Surgicel in open prostatectomy was ineffective in controlling bleeding and can lead to infection.

Sternal protection technique for open chest management.

On some occasions, postoperative mediastinal bleeding or right ventricular failure forces surgical teams to pursue a strategy of open-chest management and delayed sternal closure. One notable source of postoperative bleeding is the sternum, either due to medullar bleeding or bone margin oozing, which may be difficult to control. Furthermore, in cases with right ventricular failure or dilatation needing an open-chest strategy, sternal margins might erode and injure the right ventricular anterior wall. We propose a simple but effective sternal protection technique during open-chest management and further delayed chest closure. Using leftover tubing from the cardiopulmonary bypass circuit or a mediastinal 32 Fr drain, both sternal margins are covered and secured with sutures. Moreover, in case of profuse bleeding, a thrombin-derived haemostatic agent can be applied between the bone marrow and the tube for an additional level of haemostasis. The sternal wound is isolated with a latex membrane and covered with transparent sterile adhesive sheets to achieve vacuum sealing.

Comparison Of Outcome Between Open Haemorrhoidectomy Versus Trans-Anal Doppler Guided Hemorrhoidal Artery Ligation With Recto-Anal Repair In 3rd And 4th Degree Haemorrhoids.

BACKGROUND: Haemorrhoids are very common but their exact prevalence is not known as most of the people suffering from them do not seek medical or surgical advice. The literature states their prevalence to be about 39% and commonly affect people aged between 45-65 years of age. Objective of the study was to compare the outcomes of open haemorrhoidectomy Vs Trans anal Doppler ultrasound guided hemorrhoidal artery ligation with recto-anal repair in 3rd and 4th degree haemorrhoids. It was a Randomized control trial, conducted at the Department of Surgery, King Edward Medical University, Lahore; from October 2019 to March 2021. METHODS: This was a randomized control trial study where the results of 70 patients of haemorrhoids including 3rd and 4th degree disease fulfilling the selection criteria, who underwent open haemorrhoidectomy (OH) and Doppler guided haemorrhoidal artery ligation with rectoanal repair (HAL RAR) procedure on elective and emergency operating lists, were analyzed with regards to post-operative pain, bleeding and hospital stay. RESULTS: From our seventy patients the minimum age was 23 and maximum age limit was 55 years (mean: 35.09±7.47). There were 49 (70%) males and 21 (30%) females. Mean post-op pain on day 7 for OH was 1.12±0.72 and for HAL RAR it was 1.06±0.52. Post-op bleeding (POB) occurred in 4 (10%) patients in OH group and 2(6.66%) patients in HAL RAR group. Mean hospital stay for OH group was 2±0.45 and for HAL RAR it was 1.20±0.40, for POB, it was 1.9±0.30 in OH group and 1.86±0.34 in HAL-RAR group. CONCLUSIONS: There was no significant difference in mean post-op pain on day seven, and post-op bleeding, but there was significant difference in terms of mean hospital stay between the two groups.

The Effectiveness and Safety of Autologous Platelet Concentrates as Hemostatic Agents after Tooth Extraction in Patients on Anticoagulant Therapy: A Systematic Review of Randomized, Controlled Trials.

One of the common challenges in oral surgery is dealing with patients who are taking oral anticoagulant/antiaggregant drugs. Several local hemostatic agents have been proposed as an alternative to conventional suturing. Among these, autologous platelet concentrates (APCs) have been widely used to decrease the risk of hemorrhage after dental extraction. Nevertheless, there is a lack of consensus regarding the superiority of any one specific hemostatic agent over the others. This systematic review is aimed at evaluating the effectiveness of APCs as hemostatic agents after tooth extraction in patients on anticoagulant therapy. A literature search was conducted of articles published before March 2023 on PubMed, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL). Studies on the use of APCs in patients undergoing dental extractions and being treated with anticoagulant drugs were included. Only randomized, controlled trials (RCTs) published up to March 2023 were included; the outcomes assessed were the time to hemostasis, the presence of post-operative bleeding and pain, and the effectiveness of wound healing. The risk of bias for each RCT was assessed by using the 'risk of bias' tool (RoB 1.0). The research revealed 6 RCTs. The findings indicated that patients on anticoagulant therapy who received APCs without discontinuing their medication experienced a decreased post-operative bleeding, a shorter hemostasis time, reduced pain, and accelerated wound healing. However, due to the high/unclear risk of bias of the studies included, no definitive conclusions can be drawn on the superiority of APCs as hemostatic agents over other similar products. Additional studies are required to validate these findings.

Assessment of Rotational Thromboelastometry and Thrombin Generation Assay to Identify Risk of High Blood Loss and Re-Operation After Cardiac Surgery.

Introduction: We aimed to investigate parameters for prediction of post-operative blood loss and re-operation in patients who underwent cardiopulmonary bypass. Methods: Thrombin generation assay, activated partial thromboplastin time, activated clotting time and rotational thromboelastometry (ROTEM) tests were performed at 4 time points in 65 patients: before skin incision (T1), after heparin injection (T2), after protamine reversal (T3) and before skin closure (T4). Results: Pre-operative endogenous thrombin potential (ETP) and peak thrombin levels were significantly lower in patients with high post-operative blood loss (≥ 800 mL) within 24 h than in those with low blood loss (< 800 mL). Clotting time (CT), maximal clotting firmness, clotting firmness time and alpha angle values of ROTEM measured at T2, T3 or T4 were significant predictors for high post-operative blood loss. An increase in CT-EXTEM over 4 time points was significant in patients who had a re-operation within 48 h compared to their counterparts. Conclusions: This study indicates that pre-operative ETP could predict high post-operative blood loss and that intra-operative ROTEM also helps to stratify risks of high post-operative blood loss and re-operation.

Effect of anti-platelet therapy on peri-operative blood loss in patients undergoing off-pump coronary artery bypass grafting.

Purpose: The purpose of this study was to review the effect of the pre-operative use of clopidogrel and aspirin on peri-operative bleeding, blood product transfusion, and resource utilization after coronary artery bypass grafting (CABG). Materials and Methods: A total of 1200 patients who underwent off-pump CABG (OPCABG) between 2010 and 2012 were retrospectively studied. Patients were divided into three groups: group 1: discontinued aspirin and clopidogrel 6 days prior to surgery (n = 468), group 2: discontinued both drugs 3 to 5 days prior to surgery (n = 621), and group 3: discontinued both drugs 2 days prior to surgery (n = 111). The bleeding pattern and blood product transfusion were studied and compared between the groups. Patients having history of other drugs affecting the coagulation profile, other organ dysfunction, on-pump CABG, and the combined procedure were excluded from the study. Results: Group 2 patients had a higher rate of bleeding and a reduced mean value of hemoglobin (Hb) as compared to other groups. The same results were seen in blood and blood product transfusion. Patients of group 2 and group 3 were associated with higher blood loss in terms of drainage at 12 and 24 hours. Post-operatively, this was statistically significant. Re-exploration was statisitically significant in group 3 patients (9.01%) than in group 2 (2.58%) and group 1 (1.07%) patients. Conclusion: The pre-operative use of clopidogrel and aspirin in patients undergoing OPCABG showed limited clinical benefits; however, its use significantly increased the risk of bleeding and blood transfusion, thus increasing morbidity and resource utilization. Hence, clopidogrel and aspirin should be stopped at least 6 days prior to surgery.

Incidence of fever and bleeding after percutaneous nephrolithotomy: a prospective cohort study.

OBJECTIVE: Despite relative agreement on the need for immediate peri-operative antibiotic prophylaxis in percutaneous nephrolithotomy (PCNL), there is no consensus regarding antibiotic use the days leading up to PCNL. This study aimed to report the incidence of complications during and after PCNL based on a cohort study design. MATERIAL AND METHODS: We included 101 patients in a prospective schedule for PCNL. Patients were divided into 2 groups. In the exposed patients (positive urine culture) the antibiotic was indicated according to the antibiogram report, 7 days before surgery, and 7 days after surgery, and in the non-exposed patient's intravenous antibiotic empirically was administered 8 h and 1 h before surgery. RESULTS: The incidence of complications for both groups was 19%. The exposed group presented complications in 27%, and 16% for the non-exposed. The relative risk of complications, in general, was 1.68 (95% CI, 0.77-3.6), the attributable risk was 11.09, and the percentage of attributable risk was 40.68%. CONCLUSIONS: The presence of positive urine culture is the main risk factor for the development of post-PCNL fever. Each treatment center needs to standardize its protocols to reduce the morbidity associated with surgery and to identify the main risk factors.

OBJETIVO: El objetivo de este estudio es reportar la incidencia de complicaciones durante y después de la nefrolitotomía percutánea (NLP) con base en un diseño de cohorte prospectivo. MATERIAL Y MÉTODOS: Se incluyeron 101 pacientes de forma prospectiva programados para NLP. Los pacientes fueron divididos en 2 grupos. En el grupo de expuestos (cultivo de orina positivo) el antibiótico se indicó según el reporte del antibiograma, 7 días antes y 7 días después de la cirugía. En los pacientes no expuestos (cultivo de orina negativo) se administró empíricamente antibiótico intravenoso 8 h y 1 h antes de la cirugía. RESULTADOS: La incidencia de complicaciones para ambos grupos fue del 19%. El grupo de expuestos presentó ­complicaciones en 27% mientras que para los no expuestos fue de 16%. El riesgo relativo de complicaciones en general fue de 1.68 (IC 95%, 0.77-3.6), el riesgo atribuible fue de 11.09 y el porcentaje de riesgo atribuible fue de 40.68%. CONCLUSIONES: la presencia de urocultivo positivo es el principal factor de riesgo para el desarrollo de fiebre post-NLP. Es importante que cada centro de tratamiento estandarice sus protocolos para reducir la morbilidad asociada con la cirugía e identificar los principales factores de riesgo.

A Literature Review to Assess Blood Loss in Minimally Invasive Liver Surgery Versus in Open Liver Resection.

Aim and objectives The aim of the study was to assess the amount of blood loss in minimally invasive hepatectomy and open liver resection for both benign and neoplastic conditions. Introduction Minimally invasive surgery has progressively developed to a stage where once-novel and highly specialized surgical techniques are now common practice. Colorectal surgery is the key example that has shown minimally invasive surgery as highly beneficial. Successes in the colorectal laparoscopic approach have now been integrated into the speciality of hepatopancreaticobiiary (HPB) surgery. In this review, we will compare the amount of blood loss in minimally invasive liver resection with the more traditional approach of open liver resection. Methods A literature review was conducted which included the length of patient mobilization as a postoperative complication following laparoscopic and open liver resections. Medline, PubMed, and Cochrane were accessed to review previously published studies. Twelve studies were selected, and all of them were in English, ranged from the year 2000 to 2020. Results Eleven out of the 12 included studies indicated that minimally invasive liver resection is associated with reduced blood loss. Conclusion In comparing both minimally invasive liver resection and classic open surgery, minimally invasive liver resection was shown to have reduced blood loss; this was seen in both malignant and benign tumours. Therefore, laparoscopic liver resection could be favoured over the classical open approach to avoid excessive blood loss intra-operatively.

Does topical application of tranexamic acid reduce intraoperative bleeding in sinus surgery during general anesthesia?

INTRODUCTION: Tranexamic acid is a hemostatic agent, which inhibits fibrin degradation, which may be beneficial in controlling bleeding during surgery. OBJECTIVES: The purpose of this study was to provide a meta-analysis and review of the effects of tranexamic acid on hemorrhage and surgical fields and side effects on patients during endoscopic sinus surgery. METHODS: Two authors independently searched six databases (Medline, Scopus, Embase, Web of Science, Google Scholar and Cochrane library) from the start of article collection until July 2018. Postoperative complications such as intraoperative bleeding, operative time, hypotension, nausea, vomiting, and coagulation profile were included in the analysis of tranexamic acid (Treatment Group) and placebo (Control Group) during the operation. RESULTS: The amount of blood loss during surgery was statistically lower in the treatment group compared to the placebo group, and the surgical field quality was statistically higher in the treatment group than in the placebo group. On the other hand, there was no significant difference in operation time, hemodynamics, or coagulation profile between groups. In addition, tranexamic acid had no significant effect on vomiting and thrombosis compared to the Control Group. CONCLUSION: This meta-analysis has shown that topical administration of tranexamic acid can reduce the amount of bleeding during surgery and improve the overall quality of the surgery. Hemodynamic instability during surgery, vomiting after surgery, or abnormal clotting profile were not reported. Additional studies are needed to confirm the results of this study because there are fewer studies.

Is Day Care Tonsillectomy a Safe Procedure?

Tonsillectomy with or without adenoidectomy is the commonest procedure performed by an otolaryngologist. It has been performed as an in-patient procedure. To present our experience of 15 years of day care tonsillectomy with or without adenoidectomy and to assess the safety of tonsillectomy as a day care procedure. Design: retrospective study. A retrospective study of all day care tonsillectomies with or without adenoidectomies operated at a Secondary care ENT Hospital from 2002 to 2016 has been carried out. In last 15 years, we have operated 1207 tonsillectomies with or without adenoidectomies as a day care procedure. Postoperatively, the patients were discharged after observing for 6 to 8 h. Out of 1207 patients, 3 patients required readmission due to bleeding and 5 due to pain. Hence the overall readmission rate following tonsillectomy was 8/1027, which equals to 0.778 percent. Two patients with postoperative bleeding within 6 h were taken up for exploration and control of hemostasis. One patient of secondary haemorrhage was managed conservatively. None of the patients required blood transfusion. Day care tonsillectomy with or without adenoidectomy is a safe procedure as long as the patients are carefully selected. It is also cost effective. Level of evidence: Level 4.

Novel minimally invasive transoral surgery bleeding model implemented in a nationwide otolaryngology emergencies bootcamp.

Post-operative hemorrhage is the most concerning complication after minimally invasive transoral surgery, as can result in airway compromise. Simulation-based medical education provides trainees with structured learning in an intensive and immersive environment allowing deliberate practice of skills and behaviors in the management of real-life situations. We implemented a novel post-oropharyngeal surgery bleeding model in a nationwide otolaryngology emergencies bootcamp, to teach and evaluate technical and non-technical skills required to competently manage this clinical scenario. 28 Otolaryngology residents from 11 programs in Canada participated in the annual Otolaryngology Emergencies Bootcamp of Western University in London, Ontario. After teaching technical aspects of emergency surgical airways in models, the course culminated with a complex scenario of a post-minimally invasive transoral surgery bleeding model using a fresh cadaver. The Non-Technical Skills for Surgeons (NOTSS) rating scale was applied to video analysis and a scenario-specific Medical Expert Checklist was implemented. The model design in a cadaveric torso is described for use in a simulation of a high-volume oropharyngeal bleed after a minimally invasive approach. Participants agreed that the model evoked an elevated degree of realism and conveyed the emotion of a life-threatening event. NOTSS analysis identified a marginal score in the domains of decision-making and communication and teamwork. Critical action checklist analysis highlighted the early mobilization of available resources and time to decision for surgical airway. We present the first report of a post-minimally invasive transoral surgery bleeding model. It was successful in recreating with high fidelity such a high-stake event and to teach technical and non-technical skills.