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.

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.

Herbal medications and plastic surgery: a hidden danger.

Herbal medicine is a multibillion-pound industry, and surveys suggest that ~10% of the UK population uses herbal supplements concurrently with prescription medications. Patients and health care practitioners are often unaware of the adverse side effects of herbal medicines. In addition, because many of these herbal supplements are available over the counter, many patients do not disclose these when listing medications to health care providers. A 39-year-old nurse underwent an abdominoplasty with rectus sheath plication after weight loss surgery. Postoperatively, she experienced persistent drain output, and after discharge, a seroma developed requiring repeated drainage in the clinic. After scar revision 10 months later, the woman bled postoperatively, requiring suturing. Again, a seroma developed, requiring repeated drainage. It was discovered that the patient had been taking a herbal menopause supplement containing ingredients known to have anticoagulant effects. Complementary medicine is rarely taught in UK medical schools and generally not practiced in UK hospitals. Many supplements are known to have anticoagulant, cardiovascular, and sedative effects. Worryingly, questions about herbal medicines are not routinely asked in clinics, and patients do not often volunteer such information. With the number and awareness of complementary medications increasing, their usage among the population is likely to increase. The authors recommend specific questioning about the use of complementary medications and consideration of ceasing such medications before surgery. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Perioperative management based on kinetics of bleeding during total primary arthroplasty]. / Cinétique du saignement en chirurgie orthopédique majeure : implications pour la prise en charge périopératoire.

INTRODUCTION: Management of the perioperative hemorrhagic risk is of major interest in patients undergoing total arthroplasty of the lower limb. Anemia in the postoperative period of that increasingly performed surgery carries its own morbidity and mortality. Better anticipation of its occurrence could be done with a refined knowledge of bleeding kinetics. PATIENTS AND METHODS: We conducted a retrospective study in a single centre on 451 consecutive patients undergoing elective unilateral primary total hip or knee arthroplasty for osteoarthritis. Volume of total blood loss according to Mercuriali's formula and variations of haemoglobin levels were calculated between day 0 (D0) and postoperative day 8 (D8), and during subdivided periods between D0-D1, D1-D3 and D3-D8. Frequency and volume of autologous and homologous blood transfusions were also analyzed. Comparisons were done taking into account the use of intraoperative tranexemic acid (TA). RESULTS: Seventy to 75% of blood loss occurred between D0 and D1. Bleeding occurred mostly between the end of surgery and morning of D1, and tended to stop at D3. TA significantly reduced blood loss in the first 3days, mostly after knee prosthesis surgery. However, the bleeding kinetics were the same with or without TA. CONCLUSION: Loss of haemoglobin occurred mostly in the early postoperative period. To avoid transfusion delays, haemoglobin levels should be monitored regularly until the third postoperative day after total arthroplasty, especially when D1 haemoglobin is close to the transfusion threshold. Furthermore, our results support the routine use of TA.

Evaluation of Epsilon amino-caproic acid (EACA) and autologous blood as blood conservation strategies in patients undergoing cardiac surgery.

BACKGROUND: To evaluate the effects of autologous blood and Epsilon amino-caproic acid on intra-operative and post-operative blood loss and homologous blood product requirements in patients undergoing cardiac surgery. METHODS: Patients were randomly allocated to two groups of 30 each. In the Epsilon amino-caproic acid (EACA) group, the drug was administered in a loading dose of 100 mg/kg before skin incision followed by an infusion of 1/5 th the loading dose hourly and terminated 3 h after heparin neutralization. In the autologous transfusion (AT) group, 10% of the calculated whole blood volume was collected intra-operatively before cardiopulmonary bypass and re-infused after its termination. RESULTS: Haemoglobin values were comparable pre-operatively, on cardiopulmonary bypass, off cardiopulmonary bypass and post-operatively on day two in both groups. Intra-operative blood loss was not significantly different (643.3+/-129.14 ml in group EACA versus 710+/-145.5 ml in group AT, p = 0.66). Although the chest drainage was more in group AT during 0-3 h (71.3+/-54.3 ml versus 112.6+/-79.3.6 ml, p = 0.006) it was comparable amongst in the first 24 h (231.1+/-98.3 ml in group AT versus 235+/-101.4 ml in group EACA, p = 0.88). Homologous blood product requirements were similar in both groups. CONCLUSION: Autologous blood is as efficacious as Epsilon amino-caproic acid for blood conservation in cardiac surgery.

Sonothrombolysis: experimental evidence.

Reopening of the occluded artery is the primary therapeutic goal in hyperacute ischemic stroke. Systemic treatment with tissue recombinant plasminogen activator (tPA) has been shown to be beneficial at least in a 3-hour door to needle window. Intra-arterial thrombolysis is favorable and opens the window of treatment up to at least 6 h but consequences invasive intra-arterial angiography in a high number of patients, of whom a significant number do not finally receive thrombolysis. The combination of ultrasound with thrombolytic agents may enhance the potential benefit by means of enzyme-mediated thrombolysis. When ultrasound is applied externally through skin or chest, attenuation will be very low. Attenuation, however, is significantly higher if penetration through the skull is required. Attenuation is frequency dependent, with ultrasound intensity being <10% of the output intensity for diagnostic frequencies (>1 MHz). This ratio nearly reverses in the kiloHertz range (>500 kHz). Ultrasound insonation is efficient for accelerating enzymatic thrombolysis within a wide range of intensities, from 0.5W/cm2 (MI approximately 0.3) to several watts per square centimeter, particularly in the nonfocused ultrasound field. Insonation with ultrasound increased tPA-mediated thrombolysis up to 20% in a static model, while it enhanced the recanalization rate from 30 to 90% in a flow model. Results from embolic rat models suggest that low-frequency ultrasound with 0.6W/cm2 significantly reduces infarct volume compared to pure tPA treatment. Safety of ultrasound exposure of the brain for therapeutic purposes has to address hemorrhage, heating, and direct tissue damage. Since animal studies suggested no increase of bleeding rate or harm to the blood-brain barrier, a clinical phase II study applying low-frequency ultrasound at approximately 300 kHz found a high number of secondary hemorrhages. Heating depends critically on the characteristics of the ultrasound. The most significant heating of the brain tissue itself is >1 degrees C per hour using a 2W/cm2 probe; however, no significant heating could be found when using an emission protocol pulsing the ultrasound. The current experimental data helps to identify the optimal ultrasound characteristics for sonothrombolysis and supports the hypothesis combined treatment being a perspective in optimizing thrombolytic therapy in acute stroke.

Prophylactic tranexamic acid in elective, primary coronary artery bypass surgery using cardiopulmonary bypass.

OBJECTIVE: Perioperative use of tranexamic acid (TA), a synthetic antifibrinolytic drug, decreases perioperative blood loss, and the proportion of patients receiving blood transfusion in cardiac surgery, but the results may vary in different clinical settings. The primary objective of the present study was to determine the efficacy of TA to decrease chest tube drainage and the proportion of patients requiring perioperative allogeneic transfusions following primary, elective, on-pump coronary artery bypass grafting (CABG) in patients with a low baseline risk of postoperative bleeding. METHODS: In a double-blinded, prospective, placebo-controlled study, 46 patients were randomized into two groups. One group received TA 1.5 g as a bolus, followed by a constant infusion of 200 mg/h until 1.5 g. The other group received placebo (0.9% saline). Among exclusion criteria were treatment with acetylsalicylic acid, non-steroidal anti-inflammatory drugs or other platelet inhibitors within 7 days before surgery. RESULTS: Preoperative demographics, biochemical and surgical characteristics were comparable between groups. At 6 h postoperatively, there was a trend towards a greater blood loss (median and interquartile range) in the placebo group (710 and 460-950 ml) compared to the TA group (400 and 350-550 ml), but the difference did not reach statistical significance. Neither were transfusion rates and the amount of autotransfused shed mediastinal blood different between the groups postoperatively. Postoperative d-dimer concentrations were significantly higher in the placebo group compared to the TA group (P < 0.001) This difference could not be explained by differences in the amount of autotransfused shed mediastinal blood alone. Plasma concentrations of beta-thromboglobulin and platelet factor 4 were significantly increased postoperatively in both groups, but without any intergroup differences. Seven patients (15%), one in the TA group and six in the placebo group, were reoperated due to excessive bleeding. Surgical correctable bleeding was found in all except two patients from the placebo group. CONCLUSIONS: An antifibrinolytic effect following prophylactic use of TA in elective, primary CABG among patients with a low risk of postoperative bleeding, did not result in any significant decrease in postoperative bleeding compared to a placebo group.

[Intra-abdominal bleeding after myocardial infarction with cardiopulmonary resuscitation and thrombolytic therapy]. / Intraabdominale Blutung nach Myokardinfarkt mit kardiopulmonaler Reanimation und Thrombolysetherapie.

Adverse effects of resuscitation due to closed-chest cardiac massage are common, and the incidence is increased when an incorrect technique is used. Nevertheless, thrombolytic therapy of a myocardial infarction can become necessary even after cardiopulmonary resuscitation (CPR). In these patients, the risk of thrombolytic therapy-induced bleeding is immanent. CASE REPORTS. Within 9 months, two male patients aged 44 and 52 years were admitted to the intensive care unit after out-of-hospital CPR for myocardial infarction with cardiac arrest. In both cases, thrombolytic therapy was undertaken due to the cardiovascular situation or echocardiographic results. Thrombolytic therapy was successful with regard to the ECG changes, but a few hours later both patients demonstrated increasing cardiovascular instability. After abdominal sonography, intra-abdominal bleeding was suspected. Emergency laparotomy became unavoidable, although the coagulation profile was severely impaired in both patients (Tables 1 and 2). Anaesthetic management was characterised by introduction of central venous and intra-arterial catheters, replacement of volume and oxygen carriers using large-bore IV lines, restoration of coagulation factors with fresh frozen plasma, and the choice of "modified neuroleptanaesthesia" with blood pressure-adjusted, small doses of fentanyl, midazolam, and pancuronium. Intraoperatively, a liver injury due to closed-chest cardiac massage was found in both cases. The postoperative courses were complicated by respiratory problems, which led to prolonged mechanical ventilation, but both patients survived without remarkable neurological deficits. CONCLUSION. In patients with thrombolytic therapy after CPR and persisting cardio-vascular instability, a resuscitation injury with consequent haemorrhagic shock should be suspected. For diagnosis, chest X-ray films and abdominal and thoracic sonography are useful and practicable, even at the bedside. Anaesthetic management should focus on adequate monitoring, replacement of volume and oxygen carriers, fast restoration of plasma coagulation, and careful, blood pressure-adjusted maintenance of anaesthesia.