Intraoperative blood pressure lability carries a higher risk of headache after carotid endarterectomy.

OBJECTIVE: Cerebral hyperperfusion syndrome (CHS) is a rare but potentially devastating complication after carotid endarterectomies (CEA). Its symptoms range from new-onset unilateral headache (HA) to intracranial hemorrhage (ICH). Risk factors for CHS in the literature to date have not yet yielded a consensus. This study examines intraoperative and postoperative blood pressure variations as potential risk factors for HA. METHODS: A single-center retrospective review at a tertiary care center from January 2010 to November 2019 was performed. Inclusion criteria were all patients undergoing CEA for symptomatic or asymptomatic carotid disease. Patients with incomplete charts were excluded. Primary endpoints were new-onset unilateral HA or postoperative ICH. Data on intraoperative and postoperative mean arterial pressure (MAP), systolic blood pressure (SBP), the mode of endarterectomy, shunt placement, and contralateral carotid status were collected. RESULTS: There were 735 patients who met the inclusion criteria: 430 patients underwent modified eversion CEA (59%) and 305 patients for patch angioplasty (42%). The incidence of HA was 19% (n = 142) in our total cohort. Of the 19% with HA, 1.5% (n = 11) demonstrated no relief with analgesics and strict blood pressure control; noncontrast head computed tomography scans were performed subsequently. One patient (0.1%) had an ipsilateral ICH. Univariate analysis demonstrated that greater intraoperative MAP peak had the highest risk for HA (odds ratio [OR], 1.014; 95% confidence interval [CI], 1.007-1.022; P = .0002), followed by intraoperative MAP variability (OR, 1.011; 95% CI,1.005-1.018; P ≤ .0008), and peak intraoperative SBP (OR, 1.01; 95% CI, 1.004-1.015; P = .0011). An unpaired Student t test identified change in intraoperative MAP (P < .005), change in the SBP (P < .005), and peak SBP (P < .001) were significantly associated with HA. Interestingly, there was no significant difference between postoperative MAP variability and HA (P = .1). The mode of endarterectomy showed no statistically significant difference in risk for developing HA (OR, 1.165; 95%; 95% CI, 0.801-1.694; P = .42). CONCLUSIONS: Greater intraoperative variability in blood pressures are significantly associated with a higher risk of HA. Adhering to stricter intraoperative blood pressure parameters and limiting blood pressure variability may be beneficial at decreasing the incidence of CHS and its complications.

Association of Satellite Sign with Postoperative Rebleeding in Patients Undergoing Stereotactic Minimally Invasive Surgery for Hypertensive Intracerebral Haemorrhage.

There are few studies regarding imaging markers for predicting postoperative rebleeding after stereotactic minimally invasive surgery (MIS) for hypertensive intracerebral haemorrhage (ICH), and little is known about the relationship between satellite sign on computed tomography (CT) scans and postoperative rebleeding after MIS. This study aimed to determine the value of the CT satellite sign in predicting postoperative rebleeding in patients with hypertensive ICH who undergo stereotactic MIS. We retrospectively examined and analysed 105 patients with hypertensive ICH who underwent standard stereotactic MIS for hematoma evacuation within 72 h following admission. Postoperative rebleeding occurred in 14 of 65 (21.5%) patients with the satellite sign on baseline CT, and in 5 of the 40 (12.5%) patients without the satellite sign. This difference was statistically significant. Positive and negative values of the satellite sign for predicting postoperative rebleeding were 21.5% and 87.5%, respectively. Multivariate logistic regression analysis verified that baseline ICH volume and intraventricular rupture were independent predictors of postoperative rebleeding. In conclusion, the satellite sign on baseline CT scans may not predict postoperative rebleeding following stereotactic MIS for hypertensive ICH.

Symptomatic Intracranial Hemorrhage after Dural Tear in Spinal Surgery-A Series of 10 Cases and Review of the Literature.

OBJECTIVE: Intracranial hemorrhage (IH) after spinal surgery is a rare but potentially life-threatening complication. Knowledge of predisposing factors and typical clinical signs is essential for early recognition, helping to prevent an unfavorable outcome. METHODS: A retrospective analysis was performed of patients with IH after spinal surgery treated in our institution between 2012 and 2018. The literature dealing with IH complicating spinal surgery was reviewed. RESULTS: Our investigation found 10 patients with IH (6 female and 4 male). To the best of our knowledge, this is the largest series reported so far. The assumable incidence of IH after spinal surgery in our population was 0.0657%. Durotomy was noticed in 6 patients, all of whom were treated according to a local standard protocol. In 4 patients, the dural tear was occult. Hemorrhage occurred mostly in the cerebellar compartment. Eight of 10 patients had long-standing arterial hypertension, which seems to be a risk factor (hazard ratio, 1.58). Five patients were treated conservatively, whereas 3 required a cerebrospinal fluid (CSF) diversion procedure. In 2 patients, revision surgery with duraplasty was necessary. Seven patients were discharged with little to no neurologic symptoms, and 3 had significant deterioration. One patient died because of brainstem herniation. Review of the literature identified 54 articles with 72 patients with IH complicating spinal surgery. CONCLUSIONS: Patients with intraoperative CSF loss should be kept under close supervision postoperatively. After opening of the dura, a watertight closure should be attempted. The use of subfascial suction drainage in cases of a dural tear as well as preexistent arterial hypertension seems to be a risk factor for the development of IH. Intracranial bleeding must be considered in every patient with unexplained neurologic deterioration after spinal surgery and should be ruled out by cranial imaging. To ensure early recognition and prevent an unfavorable outcome, a high index of suspicion is required, especially in revision spinal surgery. The treatment is specific to the extent and location of the IH, thus dictating the outcome. In most patients, conservative treatment led to a good outcome. CSF diversion measures may be necessary in patients with compression or obstruction of the fourth ventricle. Large hematomas with mass effect may require decompressive surgery.

The effect of bleeding on children's haemodynamic indices: an analysis of previous post-tonsillectomy bleeding cases.

OBJECTIVE: Post-surgical bleeding after tonsillectomy occurs in 2-7 per cent of cases. This study examined whether heart rate and haematocrit changes are associated with the amount of bleeding. METHOD: In this retrospective analytical study, data were collected from the medical charts of patients admitted with post-surgical bleeding. RESULTS: Over the course of 10 years, there were 218 cases of post-operative bleeding in children aged under 18 years. There was a significant increase in heart rate after the bleeding had started, and a significant decrease in both haemoglobin and haematocrit levels (p < 0.05). There was no significant correlation between the differences in haemoglobin and haematocrit and changes in heart rate. CONCLUSION: No correlation was found between the differences in haemoglobin and haematocrit levels and the changes in heart rate from before the surgery to after the bleeding had started. The monitoring of paediatric patients' heart rate after tonsillectomy surgery solely for the purpose of predicting acute blood loss is therefore discouraged.

Effect of direct angioplasty therapy on acute middle cerebral artery occlusion with good leptomeningeal collateral.

OBJECTIVE: The objective of this study was to investigate and discuss the effect of direct angioplasty therapy on acute middle cerebral artery occlusion (MCAO) patients with good leptomeningeal collateral circulation in 4.5 h. PATIENTS AND METHODS: We retrospectively reviewed our acute ischemic stroke database from January 2017 to January 2019, then selected consecutive patients with evidence of the proximal M1 segments of MCAO and good leptomeningeal collateral who have received angioplasty or mechanical thrombectomy (MT). The baseline characteristics and outcome of patients was statistical analysis, included age, gender and risk factors, baseline national institutes of health stroke scale (NIHSS) scores, preoperative alberta stroke programme early CT (ASPECT) score, time from door to needle, time of door to puncture, endovascular procedure time, 7d NIHSS score and the modified treatment in cerebral infarction (m-TICI) 2b or 3, symptomatic hemorrhage, average hospital stays, modified rankin scale (mRS) score 0-2 at 3-month and mortality. All the thrombi were analyzed by histopathology. All statistical analysis was done with t-test for continuous data and χ2 test for binary data. RESULTS: A total of 93 patients were included (direct angioplasty = 41 (44.1 %), MT = 52 (55.9 %)). There was no significant difference in baseline data between the two groups. The difference in the time of door to recanalization, the time of puncture to recanalization, symptomatic hemorrhage, and average hospital stays were significantly different between groups (P < 0.05). The other agents were not significantly different between groups (P > 0.05 each). Histopathological analysis showed all thrombi contained different amounts of platelets, fibrinogen, white blood cell, and red blood cell. CONCLUSION: Direct angioplasty therapy on acute MCAO with good leptomeningeal collateral may help to shorten the time of surgery, reduce symptomatic hemorrhage, and hospital stay.

Risk factors and outcomes of management of delayed suprachoroidal haemorrhage following Ahmed glaucoma valve implantation in children.

AIMS: To assess the incidence, risk factors and outcomes of management of delayed suprachoroidal haemorrhage (DSCH) in children who had undergone Ahmed glaucoma valve implantation. METHODS: A retrospective case-control study of eyes which developed DSCH in children <18 years of age who underwent surgery between January 2009 and December 2017 with a follow-up of at least 2 months was performed. Nine cases were compared with 27 age, gender and surgeon matched controls who had undergone surgery during this period. RESULTS: The incidence of DSCH was 4.7% (95% CL 1.5% to 7.7%, 9 eyes of 191 children). There were no significant differences between cases and controls in baseline details except for the number of intraocular pressure (IOP) lowering medications (p=0.01) and follow-up period (p=0.001). Risk factors identified on univariate analysis (p≤0.1) were axial length (p=0.02), diagnosis of primary congenital glaucoma (p=0.05), postoperative hypotony (p=0.07) and aphakia (p=0.1). None of them were found to be significant on multivariate analysis. Five eyes, three with retinal apposition and two with retinal detachment, underwent surgical drainage. There were no significant differences in the outcomes of eyes which underwent drainage compared with those which did not. Failures, defined as IOP>18 mm Hg despite use of medications, loss of light perception, phthisis or removal of the implant were more frequent in cases (three eyes, 33.3%) compared with controls (four eyes, 14.8%) (p=0.002). CONCLUSIONS: None of the risk factors analysed in our series proved to be significant. Failures were more common in eyes with choroidal haemorrhage, despite surgical intervention.

Argon plasma coagulation tonsillectomy versus coblation tonsillectomy: a comparison of efficacy and safety.

BACKGROUND: Tonsillectomy is one of the most common otolaryngological procedures. Nonetheless, there is still no universally approved 'gold standard' technique. OBJECTIVE: To compare the safety and efficacy of argon plasma coagulation and coblation techniques in tonsillectomy. METHODS: A multi-institutional, retrospective cohort study was conducted, comprising 283 patients who underwent bilateral tonsillectomies performed by a single surgeon between 2014 and 2017. The outcome measures included: operative time, intra-operative blood loss, post-operative pain and post-operative haemorrhage. RESULTS: In the argon plasma coagulation group, mean operative time and post-operative haemorrhage rate were significantly reduced, p = 0.0006 and p = 0.003 respectively. There was no statistically significant difference between the two groups in terms of post-operative pain and intra-operative blood loss. CONCLUSION: The argon plasma coagulation technique is easy, safe and efficacious. Argon plasma coagulation tonsillectomy seems cost-effective compared to coblation tonsillectomy: the single-use disposable electrode tip and wand used in this study cost AUD$76.50 and AUD$380 respectively. Argon plasma coagulation appears to be a favourable alternative to current modalities such as coblation.

Association of postoperative blood pressure and bleeding after cardiac surgery.

OBJECTIVE: We sought to characterize the relationship between postoperative blood pressure on the day of surgery and metrics of bleeding. METHODS: In a preplanned secondary analysis of prospectively collected data from the Limiting IV Chloride to Reduce AKI trial (NCT02020538), univariate and multivariable regression analyses explored the association between peak systolic blood pressure, peak mean arterial pressure, and peak central venous pressure recorded postoperatively on the day of surgery and multiple metrics of bleeding. Patients at increased bleeding risk due to specific criteria were excluded from analysis. The primary outcome was chest tube drainage (milliliters per hour) on the day of surgery. Secondary outcomes included red blood cell transfusion, surgical re-exploration for bleeding, and hospital mortality. RESULTS: The study cohort comprised 793 patients. Mean ± standard deviation peak systolic blood pressure, mean arterial pressure, and central venous pressure were 125 ± 15 mm Hg, 83 ± 9 mm Hg, and 12 ± 4 mm Hg, respectively. Median (interquartile range) chest tube drainage on the day of surgery was 33 mL/hour (interquartile range, 23 mL/hour-51 mL/hour). Adjusted for prespecified variables, there was no positive association between peak systolic blood pressure and bleeding outcomes, including chest tube drainage (-2.2 mL/10 mm Hg; 95% confidence interval, -3.9 to -0.5 mL/h/10 mm Hg; P = .01) or volume of transfusion (-15 mL/10 mm Hg; 95% confidence interval, -29 to -1 mL/h/10 mm Hg; P = .04). Results remained broadly consistent across multiple secondary outcomes and regardless of whether systolic blood pressure or mean arterial pressure was the explanatory variable. CONCLUSIONS: The lack of positive association between peak systolic blood pressure or peak mean arterial pressure with metrics of bleeding after cardiac surgery promotes equipoise for testing the influence of higher blood pressure targets during the early postoperative period.

Advances in managing the noninfected open chest after cardiac surgery: Negative-pressure wound therapy.

OBJECTIVE: The objective of this study was to compare safety and clinical effectiveness of negative-pressure wound therapy (NPWT) with traditional wound therapy for managing noninfected open chests with delayed sternal closure after cardiac surgery. METHODS: From January 2000 to July 2015, 452 of 47,325 patients who underwent full sternotomy left the operating room with a noninfected open chest (0.96%), managed using NPWT in 214-with frequency of use rapidly increasing to near 100%-and traditionally in 238. Predominant indications for open-chest management were uncontrolled coagulopathy or hemodynamic compromise on attempted chest closure. Weighted propensity-score matching was used to assess in-hospital complications and time-related survival. RESULTS: NPWT and traditionally managed patients had similar high-risk preoperative profiles. Most underwent reoperations (63% of the NPWT group and 57% of the traditional group), and 21% versus 25% were emergency procedures. Reexplorations for bleeding were less common with NPWT versus traditional wound therapy (n = 63 [29%] vs 104 [44%], P = .002). Median duration of open-chest to definitive sternal closure was 3.5 days for NPWT versus 3.1 for traditionally managed patients (P[log rank] = .07). Seven patients (3.3%) were converted from NPWT to traditional therapy because of hemodynamic intolerance and 6 (2.5%) from traditional to NPWT. No NPWT-related cardiovascular injuries occurred. Among matched patients, NPWT was associated with better early survival (61% vs 44% at 6 months; P = .02). CONCLUSIONS: NPWT is safe and effective for managing noninfected open chests after cardiac surgery. By facilitating open-chest management and potentially improving outcomes, it has become our therapy of choice and perhaps has lowered our threshold for leaving the chest open after cardiac surgery.

Priming and replenishment in cardiopulmonary bypass with hydroxyethyl starch 130/0.4 decreases fluid overbalance without renal dysfunction or bleeding in adult valve surgery.

The best priming and replenishment solution in cardiopulmonary bypass remains unknown, and the efficacy and drawbacks of artificial colloid are controversial. We retrospectively compared consecutive patients undergoing elective adult valve surgery in cases wherein cardiopulmonary bypass was primed and replenished with hydroxyethyl starch 130/0.4 (n = 12) or crystalloid solution (n = 11). The fluid overbalance during cardiopulmonary bypass was much lower in the hydroxyethyl starch 130/0.4 group (mean ± standard deviation, + 95 ± 1241 mL) than in the crystalloid solution group (+ 2921 ± 1984 mL) (P < 0.001). Renal function, intraoperative and postoperative bleeding, and blood products did not deteriorate with the use of hydroxyethyl starch 130/0.4. The postoperative intubation time was shorter in the hydroxyethyl starch 130/0.4 group (16.0 ± 2.6 h) than in the crystalloid solution group (18.7 ± 2.6 h) (P = 0.018). Although prospective randomized trials are needed to verify our findings, the impact of fluid balance differences requires serious consideration.

Postoperative Blood Loss and Coagulation Changes After Balanced 6% Hydroxyethyl Starch 130/0.4 Administration During Spine Surgery: A Retrospective Study.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: The objective of this study was to investigate the effects of intraoperative balanced 6% hydroxyethyl starch (HES) 130/0.4 on postoperative blood loss and the coagulation profile. SUMMARY OF BACKGROUND DATA: The safety of colloid versus crystalloid transfusion for bleeding and coagulation during major spine surgery remains controversial and only a few studies exist. Thus, we compared the effects of balanced 6% HES 130/0.4 and crystalloid on postoperative bleeding and coagulation. METHODS: Patients undergoing spine surgery between February 1, 2015 and February 28, 2017 were divided into 2 groups: patients receiving intraoperative balanced 6% HES 130/0.4 and patients receiving crystalloid. We compared the postoperative bleeding volume with changes in the coagulation profile and length of hospital stay between these 2 groups. Propensity score (PS)-matching and multivariate stepwise linear regression were performed. RESULTS: A total of 169 patients who met the inclusion criteria were analyzed. The quantity of total colloid per patient was 10-15 mL/kg. A significant difference was observed in the total intraoperative transfused crystalloid volume between the 2 groups (colloid group, 1.394.6±1.414.0 mL; crystalloid group, 2.027.3±1.114.1 mL; P<0.001). Postoperative blood loss and coagulation profile changes were not significantly different in the 60 PS-matched paired patients. Furthermore, no differences in either postoperative transfusion requirement or length of hospital stay were observed between the groups. Multivariate stepwise linear regression revealed that operation time (ß=0.549; P<0.001) and intraoperative transfusion of packed red blood cells (ß=0.466; P=0.003) or fresh frozen plasma (ß=-0.263; P=0.041) were independently associated with postoperative blood loss. However, intraoperative colloid administration was not a predictive factor. CONCLUSIONS: Intraoperative infusion of balanced 6% HES 130/0.4 in patients undergoing spine surgery presented clinically insignificant changes in postoperative blood loss and coagulation compared to crystalloid. LEVEL OF EVIDENCE: Level III.

Perioperative Cerebral Microbleeds After Adult Cardiac Surgery.

Background and Purpose- Cerebral microbleeds (CMBs) have been observed using magnetic resonance imaging in patients with cardiovascular risk factors, cognitive deterioration, small vessel disease, and dementia. They are a well-known consequence of cerebral amyloid angiopathy, chronic hypertension, and diffuse axonal injury, among other causes. However, the frequency and location of new CMBs postadult cardiac surgery, in association with cognition and perioperative risk factors, have yet to be studied. Methods- Pre- and postsurgery magnetic resonance susceptibility-weighted images and neuropsychological tests were analyzed from a total of 75 patients undergoing cardiac surgery (70 men; mean age, 63±10 years). CMBs were identified by a neuroradiologist blinded to clinical details who independently assessed the presence and location of CMBs using standardized criteria. Results- New CMBs were identified in 76% of patients after cardiac surgery. The majority of new CMBs were located in the frontal lobe (46%) followed by the parietal lobe (15%), cerebellum (13%), occipital lobe (12%), and temporal lobe (8%). Patients with new CMBs typically began with a higher prevalence of preexisting CMBs ( P=0.02). New CMBs were associated with longer cardiopulmonary bypass times ( P=0.003), and there was a borderline association with lower percentage hematocrit ( P=0.04). Logistic regression analysis suggested a ≈2% increase in the odds of acquiring new CMBs during cardiac surgery for every minute of bypass time (odds ratio, 1.02; 95% CI, 1.00-1.05; P=0.04). Postoperative neuropsychological decline was observed in 44% of patients and seemed to be unrelated to new CMBs. Conclusions- New CMBs identified using susceptibility-weighted images were found in 76% of patients who underwent cardiac surgery. CMBs were globally distributed with the highest numbers in the frontal and parietal lobes. Our regression analysis indicated that length of cardiopulmonary bypass time and lowered hematocrit may be significant predictors for new CMBs after cardiac surgery. Clinical Trial Registration- URL: http://www.isrctn.com . Unique identifier: 66022965.

Hemodynamic change and affecting factors after shoulder arthroplasty in the Asian population.

BACKGROUND: This retrospective study was designed to compare the hemodynamics among the types of shoulder arthroplasty and to evaluate predictors of transfusion in the Asian population. METHODS: A total of 212 shoulder arthroplasties (26 fracture hemiarthroplasty (fHA), 49 anatomical total shoulder arthroplasty (aTSA), 132 reverse total shoulder arthroplasty (rTSA), and 5 revision surgery) from August 2004 to January 2016 were retrospectively reviewed. Demographics, surgical factors, and perioperative hemodynamic factors among the types of arthroplasty were compared. Multivariate analysis was conducted to determine predictors of transfusion. RESULTS: Preoperative hemoglobin and hematocrit levels were lower in the fracture hemiarthroplasty group (p < 0.001, 0.001). The overall transfusion rate of shoulder arthroplasties in Asian population was 11.3%, and transfusion rate was significantly different among the types of arthroplasty (fHA 30.8%, aTSA 10.2%, rTSA 7.6%, revision 20.0%; p = 0.010). The predictors of transfusion were preoperative hemoglobin levels <12.15 g/dL (OR = 7.404, 95% C.I. 2.420-22.653, p < 0.001) and <10.0 g/dL at postoperative day 1 (OR = 5.499, 95% C.I. 1.929-15.671, p = 0.001). CONCLUSION: The best predictors of transfusion were hemoglobin levels of perioperative periods, furthermore, total amount of drainage could not represent the quantity of perioperative hemorrhage. Therefore, careful monitoring of hemoglobin level is more crucial than monitoring the amount of drainage. Hemodynamics according to the type of arthroplasty should be considered in shoulder arthroplasty. LEVEL OF EVIDENCE: Level IV, retrospective case series.

New insights into the pathophysiology of postoperative hemorrhage in thyroid surgery: An experimental study in a porcine model.

BACKGROUND: Postoperative cervical hemorrhage is a rare but life-threatening complication that can cause severe morbidity. Different mechanisms leading to asphyxia have been described based only on clinical observation. METHODS: We performed a series of in vivo animal studies simulating post-thyroidectomy hemorrhage and its effect on respiratory drive. Three series of tests were carried out in 12 German domestic pigs under general anesthesia. The pigs were breathing spontaneously with secured airways. An additional series using functional magnetic resonance imaging of the pigs' brainstem was also conducted. RESULTS: The first experimental series carried out on 2 animals revealed an obvious difference between the effects of cervical hemorrhage and external bleeding with development of hemorrhagic shock. An experimental setting for the repeated simulation of cervical hemorrhage was established. A pressure-dependent mechanism was discovered that led to apnea in every animal despite the secured airway. In 8 of 10 animals, relief of cervical pressure led to complete respiratory recovery. The test was repeated up to 6 times per pig. Apnea was induced in 25 of 25 test procedures (100%) and was followed by respiratory recovery in 22 of 25 tests (88%). The threshold pressure at which the respiratory rate started to decrease was 47 ± 14 Torr when blood was used to increase the cervical compartment pressure. When silicone oil was used in a further experimental series, the threshold pressure was similar at 44 ± 21 Torr. The cervical compartment pressure needed to induce apnea was 74 ± 18 Torr using blood and 74 ± 39 Torr using silicone oil, both of which exceeded the mean arterial pressure by 28 Torr during apnea. Functional magnetic resonance imaging revealed a decrease in brainstem activity during phases of increased cervical compartment pressure, which suggests a possible role for cerebral vascular perfusion. CONCLUSION: Respiratory drive can be suppressed by increased pressure in the cervical compartment, possibly because of a pressure-dependent impairment in cerebral perfusion through a form of cervical compartment phenomenon or, less likely, a pressure-dependent reflex (nervous) mechanism.

Emergency bedside evacuation of a subset of large postoperative epidural hematomas after neurosurgical procedures.

Postoperative epidural hematoma (POEDH) is a known complication after neurosurgical procedures. Large POEDHs are life-threatening and require emergency evacuation, and open surgery is the mainstay of treatment. Most of POEDHs are hyperdense on computed tomography (CT). We herein report a subset of POEDHs requiring evacuation, which presented with isodense features on CT. The presenting symptoms of patients were severe headache accompanied by nausea and vomiting as well as unilateral limb weakness (n = 1) and consciousness disorder (n = 4). The Glasgow coma score of the patients was 8.4 ±â€Š3.5. All patients underwent emergency bedside burr hole evacuation through a tube, rather than open surgery. The meantime for the bedside procedures is 6.0 ±â€Š1.5 minutes. All 5 POEDHs were proven liquid and evacuated successfully. All patients recovered quickly with good outcomes. We concluded that the isodensity of the POEDHs on CT represent their liquid nature. Bedside burr hole evacuation through a tube may be a recommendable method for this subset of POEDHs requiring evacuation. Thus, an open surgery and general anesthesia may be avoided.

Risks and benefits of local anesthesia versus general anesthesia in tonsillectomy.

PURPOSE: Tonsillectomy is one of the most common surgical procedures in otorhinolaryngology. Modern general anesthetic techniques have reduced surgical risks, but performing the procedure under local anesthesia may still offer significant benefit for both the patient and surgeon. This study analyzed the risks and benefits of performing tonsillectomies under local anesthesia. METHODS: This is a retrospective longitudinal cohort study analyzing postoperative bleeding rates as a primary outcome measure. Secondary outcome measures were duration of surgery, consumption of analgesics and total surgery cost. RESULTS: The study enrolled 1112 patients undergoing tonsillectomy, with 462 (41.5%) patients treated under general and 650 (58.5%) patients treated under local anesthesia. There were 12 postoperative bleeding incidents in in the local anesthesia group and 9 cases of postoperative bleeding in the general anesthesia group. No significant differences based on gender regarding quantity of intraoperative bleeding or patient age were observed between the patients undergoing local versus general anesthesia. However, significant differences were noted between the groups in analgesic consumption, (Mann-Whitney U test, p = 0.001), duration of operating room stay (Mann-Whitney U test, p = 0.001), duration of surgery (Mann-Whitney U test, p = 0.001) and cost of surgery (Mann-Whitney U test, p = 0.001). CONCLUSIONS: The incidence of postoperative bleeding is not dependent on type of anesthesia. The results suggest that tonsillectomy performed under local anesthesia is a safe alternative to tonsillectomy under general anesthesia, with significant reduction of cost and duration of surgery.

Essential Thrombocythemia and Cardiac Surgery: A Case Series and Review of the Literature.

BACKGROUND: Essential thrombocythemia (ET) is a rare myeloproliferative disorder characterized by an unexplained thrombocytosis (>450 × 109/L) and associated vasomotor, thrombotic, and hemorrhagic manifestations. Although the literature detailing the perioperative management of patients with ET undergoing cardiac operations is sparse, major perioperative complications have been reported, particularly in poorly controlled patients presenting with platelet counts of 800 × 109/L or higher. The purpose of this study was to provide the experience at a large tertiary medical center in managing patients with ET undergoing cardiac operation and to summarize the available literature. METHODS: Patients with ET undergoing cardiac operations between January 1, 2006, and May 1, 2016, were identified. Perioperative data were exhaustively reviewed and recorded. An extensive literature search for "essential thrombocythemia" and "cardiac surgery" was performed. RESULTS: During the study period, 25 patients with ET underwent cardiac operations, and 24 had immediate preoperative platelet counts of less than 800 × 109/L. Perioperative complications related to ET occurred in 1 of 25 patients (4%). The immediate preoperative platelet count was 181 × 109/L. A literature search identified 18 patients who underwent cardiac operations, with major perioperative complications occurring in 5 (28%), of which 4 of 5 had an immediate preoperative platelet count of 800 × 109/L or higher. CONCLUSIONS: Patients with ET undergoing cardiac operations represent a complex cohort at risk for perioperative thrombotic or hemorrhagic complications, or both. Although not currently an indication for platelet reduction therapy by risk stratification criteria, preoperative cytoreduction to platelet counts of less than 800 × 109/L and perhaps lower should be considered in patients undergoing cardiac operations.

Distal Placement of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to Restore Hemodynamic Stability in a Patient With Proximal Aortic Rupture.

PURPOSE: To report unconventional use of the resuscitative endovascular balloon occlusion of the aorta (REBOA) technique to restore hemodynamic stability in a patient who was hemorrhaging from aortic injury proximal to the target zone of occlusion. CASE REPORT: A 72-year-old woman underwent urgent thoracic stent-graft repair of a ruptured 8×8-cm mycotic pseudoaneurysm. Two months later, follow-up imaging revealed that the proximal aortic stent seal zone had degenerated, so a percutaneous procedure was performed 2 months later to preemptively reinforce the segment of stented aorta. Shortly after obtaining femoral access, the patient's condition abruptly deteriorated with profound hypotension, presumably a result of an access complication. REBOA was established in the supraceliac aorta, which sustained the mean arterial pressure while the anesthesiologist resuscitated the patient. Unexpectedly, angiography showed a rupture of the descending thoracic aorta immediately proximal to the upper stent-graft. Balloon inflation distal to the rupture site was maintained while the patient's hypotension was treated. Another stent-graft was quickly placed over the area of concern, overlapping proximal to the prior grafts. Once the aortic perforation was sealed, the patient stabilized hemodynamically. Inotropic support was weaned, and the REBOA occlusion catheter was deflated. Final angiograms of the arch and thoracic aorta confirmed no extravasation; angiograms of the infrarenal aorta and iliac arteries showed no evidence of injury. CONCLUSION: This case illustrates that applying REBOA distal to the injury site in certain clinical scenarios may sufficiently increase peripheral resistance to compensate temporarily for cardiovascular collapse secondary to aortic injury.

A nomogram predicting re-operation due to secondary hemorrhage after monopolar transurethral resection of prostate.

We aim to develop a nomogram to predict re-operation due to secondary hemorrhage after Monopolar transurethral resection of the prostate (M-TURP). We identified patients undergoing M-TURP at Peking University First Hospital from 2000 to 2013. Univariate and multivariate logistic regression models were developed to predict the occurrence re-operation due to secondary hemorrhage. The discriminatory ability of the nomogram was tested using the area under the receiver operating characteristic curve (ROC), and internal validation was performed via bootstrap resampling. Of the 1901 patients who underwent M-TURP during the study period, 9.1% (173 patients) experienced hemorrhage after M-TURP, and they had a 22.0% re-operation rate (38 patients). Benign prostatic hyperplasia (BPH)-related complications (odds ratio, 0.386; 95% CI, 0.177-0.841), percent of resected prostate (OR, 0.156; 95% CI, 0.023-1.060) and suprapubic cystostomy (OR, 0.298; 95% CI, 0.101-0.881) were independently associated with re-operation. The nomogram accurately predicted re-operation (area under the ROC curve 0.718). The negative predictive value was 88.0%, while the positive predictive value was 47.9%. Re-operation due to secondary hemorrhage after M-TURP was associated with no BPH-related complications, lower percent of resected prostate and no suprapubic cystostomy and was accurately predicted with using the nomogram.