Diagnostic evaluation of risk for bleeding in cardiac surgery with extracorporeal circulation.

OBJECTIVE: to identify the risk factors associated with cases of excessive bleeding in patients submitted to cardiac surgery with extracorporeal circulation. METHOD: case-control study on the factors of risk for bleeding based on the analysis of data from the medical charts of 216 patients submitted to cardiac surgery with elective extracorporeal circulation during a three-year period. RESULTS: variables that are commonly associated with excessive bleeding in studies in the field were analyzed, and the following were considered as risk factors for the nursing diagnosis "risk for bleeding" (00206) in cardiac surgery with extracorporeal circulation: Body mass index lower than 26.35kg/m² (Odds ratio = 3.64); Extracorporeal circulation longer than 90 minutes (Odds ratio = 3.57); Hypothermia lower than 32°C (Odds ratio = 2.86); Metabolic acidosis (Odds ratio = 3.50) and Activated partial thromboplastin time longer than 40 seconds (Odds ratio= 2.55). CONCLUSION: such variables may be clinical indicators of an operational nature for a better characterization of the risk factor "treatment regimen" and a refinement of knowledge related to coagulopathy induced by extracorporeal circulation, which is currently presumably incorporated into the "treatment regimen" category of the nursing diagnostic classification by NANDA International, Inc.

Is Preoperative Clopidogrel Resistance a Predictor of Bleeding and Risks in Patients Undergoing Emergency CABG Surgery?

OBJECTIVE: The aims of this study were to determine whether the detection of preoperative clopidogrel resistance in patients undergoing cardiac surgery while using clopidogrel could play a guiding role in the prediction of postoperative excessive bleeding, transfusion requirements, and risks and to provide clinically significant data. METHODS: Two hundred and twenty-two patients [median age: 59.4 (38-83) years; 38 females] undergoing emergency and elective coronary artery bypass graft (CABG) surgeries in our clinic were evaluated prospectively. Patients with multiple systemic diseases, other than diabetes mellitus (DM) and hypertension (HT), were excluded. Patients receiving clopidogrel were also evaluated for clopidogrel resistance and grouped according to the results of this test. Assessments of platelet functions were performed by multiplate impedance aggregometry method and adenosine diphosphate test. RESULTS: The use of postoperative fresh blood replacement and platelet transfusion was higher in patients receiving clopidogrel than in those not receiving it (P=0.001, P=0.018). DM, HT, myocardial infarction, and the number of presentation to the emergency room were significantly higher in patients receiving clopidogrel than in those not receiving it (P<0.05). No significant difference was determined between patients with and without clopidogrel resistance regarding the amount of bleeding during and after surgery, erythrocyte suspension and fresh-frozen plasma transfusion rates, preoperative troponin values, ejection fraction values, and length of hospital stays (P>0.05). CONCLUSION: We think that resistance studies in patients receiving clopidogrel before cardiac surgery are not efficient to predict bleeding and bleeding-related complications in patients undergoing emergency and elective CABG surgeries.

Low Fibrinogen Levels Are Associated with Bleeding After Varices Ligation in Thrombocytopenic Cirrhotic Patients.

INTRODUCTION AND AIM: EVBL is a procedure frequently performed in cirrhotic patients for primary prophylaxis of bleeding. Patients with cirrhosis display various degrees of alteration of common coagulation parameters, and it is not known whether these alterations may predict post-EVBL bleeding. To evaluate factors predictive of post-endoscopic variceal band ligation (EVBL) bleeding in cirrhotic patients with thrombocytopenia. METHODS: We included 109 patients with cirrhosis undergoing EVBL for primary prophylaxis of variceal bleeding. Common coagulation parameters (INR, fibrinogen levels) and complete haemogram were obtained in all patients and evaluated subdividing patients in bleeders and non bleeders following EVBL. RESULTS: The incidence of post-EVBL bleeding was 5.5% (6 patients). INR and platelet counts, considered as continuous or dichotomous variables according to common cut-offs (i.e., INR>1.5, platelet count <50x109/L) were not predictors of post-EVBL bleeding. Patients who bled had significantly lower fibrinogen levels [146 mg/dL (98 - 262) versus 230 mg/dL (104 - 638), P=0.009], and no other biochemical or clinical predictors of bleeding were identified. A fibrinogen cut-off of 179 mg/dL had 98.6% negative predictive value for bleeding. CONCLUSION: low fibrinogen levels are associated with an increased risk of bleeding following prophylactic EVBL in cirrhotic patients, and might be used to stratify patients' risk. However, due to their preliminary nature, these findings need to be confirmed in larger populations.

Is preoperative clopidogrel resistance a predictor of bleeding and risks in patients undergoing emergency cabg surgery?

Abstract Objective: The aims of this study were to determine whether the detection of preoperative clopidogrel resistance in patients undergoing cardiac surgery while using clopidogrel could play a guiding role in the prediction of postoperative excessive bleeding, transfusion requirements, and risks and to provide clinically significant data. Methods: Two hundred and twenty-two patients [median age: 59.4 (38-83) years; 38 females] undergoing emergency and elective coronary artery bypass graft (CABG) surgeries in our clinic were evaluated prospectively. Patients with multiple systemic diseases, other than diabetes mellitus (DM) and hypertension (HT), were excluded. Patients receiving clopidogrel were also evaluated for clopidogrel resistance and grouped according to the results of this test. Assessments of platelet functions were performed by multiplate impedance aggregometry method and adenosine diphosphate test. Results: The use of postoperative fresh blood replacement and platelet transfusion was higher in patients receiving clopidogrel than in those not receiving it (P=0.001, P=0.018). DM, HT, myocardial infarction, and the number of presentation to the emergency room were significantly higher in patients receiving clopidogrel than in those not receiving it (P<0.05). No significant difference was determined between patients with and without clopidogrel resistance regarding the amount of bleeding during and after surgery, erythrocyte suspension and fresh-frozen plasma transfusion rates, preoperative troponin values, ejection fraction values, and length of hospital stays (P>0.05). Conclusion: We think that resistance studies in patients receiving clopidogrel before cardiac surgery are not efficient to predict bleeding and bleeding-related complications in patients undergoing emergency and elective CABG surgeries.

Diagnostic evaluation of risk for bleeding in cardiac surgery with extracorporeal circulation / Avaliação diagnóstica do risco de sangramento em cirurgia cardíaca com circulação extracorpórea / Evaluación diagnóstica del riesgo de hemorragia en cirugía cardíaca con circulación extracorpórea

ABSTRACT Objective: to identify the risk factors associated with cases of excessive bleeding in patients submitted to cardiac surgery with extracorporeal circulation. Method: case-control study on the factors of risk for bleeding based on the analysis of data from the medical charts of 216 patients submitted to cardiac surgery with elective extracorporeal circulation during a three-year period. Results: variables that are commonly associated with excessive bleeding in studies in the field were analyzed, and the following were considered as risk factors for the nursing diagnosis "risk for bleeding" (00206) in cardiac surgery with extracorporeal circulation: Body mass index lower than 26.35kg/m² (Odds ratio = 3.64); Extracorporeal circulation longer than 90 minutes (Odds ratio = 3.57); Hypothermia lower than 32°C (Odds ratio = 2.86); Metabolic acidosis (Odds ratio = 3.50) and Activated partial thromboplastin time longer than 40 seconds (Odds ratio= 2.55). Conclusion: such variables may be clinical indicators of an operational nature for a better characterization of the risk factor "treatment regimen" and a refinement of knowledge related to coagulopathy induced by extracorporeal circulation, which is currently presumably incorporated into the "treatment regimen" category of the nursing diagnostic classification by NANDA International, Inc.

RESUMO Objetivo: identificar os fatores de risco associados aos casos de sangramento excessivo em pacientes submetidos à cirurgia cardíaca com circulação extracorpórea. Método: estudo de caso-controle dos fatores de risco de sangramento com análise de dados de prontuários de 216 pacientes submetidos à cirurgia cardíaca com circulação extracorpórea de caráter eletivo durante o período de três anos. Resultados: foram analisadas variáveis comumente associadas ao sangramento excessivo em estudos na área, sendo considerados como fatores de risco para o diagnóstico de enfermagem "risco de sangramento" (00206) em cirurgia cardíaca com circulação extracorpórea: Índice de massa corporal menor que 26,35kg/m² (Odds ratio = 3,64); Circulação extracorpórea maior que 90 minutos (Odds ratio = 3,57); Hipotermia menor que 32°C (Odds ratio = 2,86); Acidose metabólica (Odds ratio = 3,50) e Tempo de tromboplastina parcial ativada maior que 40 segundos (Odds ratio = 2,55). Conclusão: tais variáveis podem ser indicadores clínicos de natureza operacional para melhor caracterização do fator de risco "regime de tratamento" e de um refinamento do conhecimento relacionado à coagulopatia induzida pela circulação extracorpórea, provavelmente hoje incorporada na categoria de "regime de tratamento" da classificação diagnóstica de enfermagem da NANDA International, Inc.

RESUMEN Objetivo: identificar los factores de riesgo asociados a casos de hemorragia excesiva en pacientes sometidos a cirugía cardíaca con circulación extracorpórea. Método: estudio de caso control de los factores de riesgo de hemorragia con análisis de datos de fichas médicas de 216 pacientes, sometidos a cirugía cardíaca, con circulación extracorpórea, de carácter electivo durante el período de tres años. Resultados: fueron analizadas variables comúnmente asociadas a hemorragia excesiva, en estudios en esta área, siendo considerados como factores de riesgo para el diagnóstico de enfermería "riesgo de hemorragia" (00206) en cirugía cardíaca con circulación extracorpórea, los siguientes: Índice de masa corporal <26,35 Kg/m² (Odds ratio= 3,64); Circulación extracorpórea mayor que 90 minutos (Odds ratio = 3,57); Hipotermia menor que 32°C (Odds ratio = 2,86); Acidosis metabólica (Odds ratio = 3,50); y Tiempo de tromboplastina parcial activada mayor que 40 segundos (Odds ratio = 2,55). Conclusión: esas variables pueden ser indicadores clínicos de naturaleza operacional para caracterizar mejor el factor de riesgo "régimen de tratamiento" y para perfeccionar el conocimiento relacionado a la coagulopatía inducida por la circulación extracorpórea; probablemente, actualmente incorporada a la categoría de "régimen de tratamiento" de la clasificación diagnóstica de enfermería de la NANDA International Inc.

Acute Normovolemic Hemodilution Reduces Allogeneic Red Blood Cell Transfusion in Cardiac Surgery: A Systematic Review and Meta-analysis of Randomized Trials.

BACKGROUND: To better understand the role of acute normovolemic hemodilution (ANH) in a surgical setting with high risk of bleeding, we analyzed all randomized controlled trials (RCTs) in the setting of cardiac surgery that compared ANH with standard intraoperative care. The aim was to assess the incidence of ANH-related number of allogeneic red blood cell units (RBCu) transfused. Secondary outcomes included the rate of allogeneic blood transfusion and estimated total blood loss. METHODS: Twenty-nine RCTs for a total of 2439 patients (1252 patients in the ANH group and 1187 in the control group) were included in our meta-analysis using PubMed/MEDLINE, Cochrane Controlled Trials Register, and EMBASE. RESULTS: Patients in the ANH group received fewer allogeneic RBCu transfusions (mean difference = -0.79; 95% confidence interval [CI], -1.25 to -0.34; P = .001; I = 95.1%). Patients in the ANH group were overall transfused less with allogeneic blood when compared with controls (356/845 [42.1%] in the ANH group versus 491/876 [56.1%] in controls; risk ratio = 0.74; 95% CI, 0.62 to 0.87; P < .0001; I = 72.5%), and they experienced less postoperative blood loss (388 mL in ANH versus 450 mL in control; mean difference = -0.64; 95% CI, -0.97 to -0.31; P < .0001; I = 91.8%). CONCLUSIONS: ANH reduces the number of allogeneic RBCu transfused in the cardiac surgery setting together with a reduction in the rate of patients transfused with allogeneic blood and with a reduction of bleeding.

Unusual redo mitral valve replacement for bleeding in Glanzmann thrombasthenia.

We report the case of 23-year-old man with mitral valve regurgitation and Glanzmann thrombasthenia, who underwent mechanical mitral valve replacement. Warfarin therapy was devastating, causing bilateral hemothorax, pericardial effusion, gastrointestinal bleeding, and hematuria. Redo mitral valve replacement with a biological prosthesis was required to resolve this critical situation. To our knowledge, this is the first report of mitral valve replacement in Glanzmann thrombasthenia, highlighting the danger of oral anticoagulation in this pathology.

Duodenal hematoma following EGD: comparison with blunt abdominal trauma-induced duodenal hematoma.

BACKGROUND: Duodenal hematoma (DH) is a rare complication of esophagogastroduodenoscopy (EGD) with duodenal biopsy and uncommon, but better described following blunt abdominal trauma (BAT). We aimed to describe DH incidence and investigate risk factors for DH development post-EGD and compare its features to those post-BAT. METHODS: Multiple electronic databases were searched for the diagnosis of DH from 2000 to 2012. Inclusion criteria were patients 0 to 21 years of age who developed a DH following EGD with biopsy or BAT. Exclusion criteria were DH secondary to any other mechanism, EGD performed at another medical center, and insufficient information in the electronic medical record to determine treatments or outcomes. RESULTS: A total of 14 post-EGD and 15 post-BAT patients with DH were included in the study. There were 26,905 EGDs with duodenal biopsies performed during the study period, for an incidence of 1:1922 procedures. Thirteen of 14 (93%) post-EGD DH events occurred between 2007 and 2012 (P < 0.001). The proportion of procedures performed under general anesthesia versus moderate sedation, and performed in the supine position versus left lateral decubitus were close to but did not reach statistical significance. DH-related complications and time to hematoma resolution was similar between groups. CONCLUSIONS: In a 13-year study period, 14 patients developed DH after EGD, for an incidence of 1:1922. Method of sedation and supine positioning of the patient during endoscopy warrant further investigation as potential risks. The clinical course and time to recovery with conservative management are similar between patients with EGD and BAT-induced DH.

Validação de um escore para predição de eventos hemorrágicos em síndromes coronarianas agudas / Validation of a score for predicting bleeding events during acute coronary syndromes / Validación de un escore para predicción de eventos hemorrágicos en síndromes coronarios agudos

FUNDAMENTO: Sangramento é uma complicação grave em pacientes tratados para síndromes coronarianas agudas (SCA) com antitrombóticos e terapias invasivas. Consequentemente, o benefício dessas terapias deve ser analisado contra os potenciais riscos de complicações hemorrágicas. Desta forma, a determinação de um escore para estimar o risco individual de sangramento pode representar uma importante ferramenta na tomada de decisões clínicas. OBJETIVO: Criar e validar um escore de risco de sangramento para pacientes com SCA. MÉTODOS: Foram utilizados preditores independentes de sangramento relatados pelo Registro GRACE. Variáveis com odds ratio (OR) > 2,5 nesse Registro somaram 3 pontos (histórico anterior de sangramento), OR=1,5-2,4 somaram 2 pontos (clearance de creatinina< 30 ml/min, sexo feminino) e aquelas com OR < 1,5 somaram 1 ponto (clearance entre 30 e 60 ml/min, a cada 10 anos de idade > 30, infra ou supra-desnivelamento do segmento ST, doença arterial periférica e fumo). O escore foi validado em uma coorte de 383 indivíduos com SCA. Sangramento hospitalar foi definido como queda de hematócrito > 10 por cento, transfusão de sangue > 2 unidades, sangramento intracerebral ou sangramento fatal. RESULTADOS: A incidência de eventos hemorrágicos foi de 3,1 por cento e a estatística-C do escore foi 0,66 (IC95 por cento = 0,52-0,80), indicando capacidade preditiva para esses eventos. Aqueles com escore > 7 apresentaram 6 por cento de incidência de sangramento, comparados com 1,9 por cento se o escore era < 7 (RR=3,2; IC95 por cento=1,04-9,9; p=0,03). Houve uma interação entre um escore > 7 e um maior risco imposto pelo tratamento com Clopidogrel (p=0,02), bloqueadores IIb/IIIa (p=0,06) e revascularização cirúrgica (p < 0,001). CONCLUSÃO: O escore discrimina o risco de sangramento e é potencialmente útil na tomada de decisão clínica em SCA.

BACKGROUND: Bleeding is a major complication in patients treated for acute coronary syndromes (ACS) with antithrombotic and invasive therapies. Consequently, the benefit of such therapies should be balanced against the potential risk of hemorrhagic complications. Therefore, a score to estimate individual risk of bleeding might represent an important tool in clinical decision-making. OBJECTIVE: This study aims to create and validate a bleeding risk score for patients with ACS. METHODS: Independent predictors of bleeding reported by the GRACE Registry were utilized. Variables with odds ratio (OR) > 2.5 in that Registry added 3 points (previous history of bleeding), OR = 1.5-2.4 added 2 points (creatinine clearance < 30 ml/min, female gender) and those with OR < 1.5 added 1 point (clearance between 30 and 60 ml/min, each 10 years of age>30, ST-deviation, peripheral artery disease and smoking). The score was validated in a cohort of 383 individuals with ACS. In-hospital bleeding was defined as hematocrit fall > 10 percent, blood transfusion > 2 units, intracerebral bleeding or fatal bleeding. RESULTS: The incidence of bleeding events was 3.1 percent and the score's C-statistics was 0.66 (95 percent CI = 0.52-0.80), indicating a predictive ability towards these events. Those with a score > 7 had 6 percent incidence of bleeding, compared with 1.9 percent if the score was < 7 (RR = 3.2; 95 percentCI = 1.04-9.9; p = 0.03). There was an interaction between a score > 7 and greater risk imposed by treatment with Clopidogrel (p = 0.02), IIb/IIIa blockers (p = 0.06) and surgical revascularization (p < 0.001). CONCLUSION: The score discriminates bleeding risk and is potentially useful in clinical decision-making during ACS.

FUNDAMENTO: Sangrado es una complicación grave en pacientes tratados por síndromes coronarios agudos (SCA) con antitrombóticos y terapias invasivas. Consecuentemente, el beneficio de esas terapias debe ser analizado contra los potenciales riesgos de complicaciones hemorrágicas. De esta forma, la determinación de un escore para estimar el riesgo individual de sangrado puede representar una importante herramienta en la toma de decisiones clínicas. OBJETIVO: Crear y validar un escore de riesgo de sangrado para pacientes con SCA. MÉTODOS: Fueron utilizados predictores independientes de sangrado relatados por el Registro GRACE. Variables con odds ratio (OR) > 2,5 en ese Registro sumaron 3 puntos (histórico anterior de sangrado), OR=1,5-2,4 sumaron 2 puntos (clearance de creatinina < 30 ml/min, sexo femenino) y aquellas con OR < 1,5 sumaron 1 punto (clearance = 30-60 ml/min, a cada 10 años de edad > 30, infra o supra-desnivel del segmento ST, enfermedad arterial periférica y tabaco). El escore fue validado en una cohorte de 383 individuos con SCA. Sangrado intrahospitalario fue definido como caída de hematocrito > 10 por ciento, transfusión de sangre > 2 unidades, sangrado intracerebral o sangrado fatal. RESULTADOS: La incidencia de eventos hemorrágicos fue de 3,1 por ciento y la estadística-C del escore fue 0,66 (IC95 por ciento = 0,52-0,80), indicando capacidad predictiva para esos eventos. Aquellos con escore > 7 presentaron 6 por ciento de incidencia de sangrado, comparados con 1,9 por ciento si el escore era < 7 (RR=3,2; IC95 por ciento=1,04-9,9; P=0,03). Hubo una interacción entre un escore > 7 y un mayor riesgo impuesto por el tratamiento con Clopidogrel (P=0,02), bloqueadores IIb/IIIa (P=0,06) y revascularización quirúrgica (P<0,001). CONCLUSIÓN: El escore discrimina el riesgo de sangrado y es potencialmente útil en la toma de decisión clínica en SCA.

[Validation of a score for predicting bleeding events during acute coronary syndromes]. / Validação de um escore para predição de eventos hemorrágicos em síndromes coronarianas agudas.

BACKGROUND: bleeding is a major complication in patients treated for acute coronary syndromes (ACS) with antithrombotic and invasive therapies. Consequently, the benefit of such therapies should be balanced against the potential risk of hemorrhagic complications. Therefore, a score to estimate individual risk of bleeding might represent an important tool in clinical decision-making. OBJECTIVE: this study aims to create and validate a bleeding risk score for patients with ACS. METHODS: independent predictors of bleeding reported by the GRACE Registry were utilized. Variables with odds ratio (OR) > 2.5 in that Registry added 3 points (previous history of bleeding), OR = 1.5-2.4 added 2 points (creatinine clearance < 30 ml/min, female gender) and those with OR < 1.5 added 1 point (clearance between 30 and 60 ml/min, each 10 years of age>30, ST-deviation, peripheral artery disease and smoking). The score was validated in a cohort of 383 individuals with ACS. In-hospital bleeding was defined as hematocrit fall > 10%, blood transfusion > 2 units, intracerebral bleeding or fatal bleeding. RESULTS: the incidence of bleeding events was 3.1% and the score's C-statistics was 0.66 (95% CI = 0.52-0.80), indicating a predictive ability towards these events. Those with a score > 7 had 6% incidence of bleeding, compared with 1.9% if the score was < 7 (RR = 3.2; 95%CI = 1.04-9.9; p = 0.03). There was an interaction between a score > 7 and greater risk imposed by treatment with Clopidogrel (p = 0.02), IIb/IIIa blockers (p = 0.06) and surgical revascularization (p < 0.001). CONCLUSION: the score discriminates bleeding risk and is potentially useful in clinical decision-making during ACS.

Idiopathic thrombocytopenic purpura presenting as post-extraction hemorrhage.

AIM: The aim of this article is to present a case of idiopathic thrombocytopenic purpura (ITP) in order to emphasize the importance of the clinical exam since the anamnesis leads to a diagnostic hypothesis of ITP. BACKGROUND: Acute ITP is considered an autoimmune disease characterized by the production of antibodies against platelets, antigens produced by a viral infection, or a platelet sparing drug combination. These antibodies adhere to platelets and are recognized and destroyed by the reticulo-endothelial system. Consequently, the platelet count gradually diminishes and is insufficient for the maintenance of primary hemostasis. REPORT: A 77-year-old woman presented with post-extraction intermittent bleeding. The physical examination revealed discoloration of the skin, multiple petechiae, hematomas, ecchymosis of the upper lip, bruises all over the body, gingiva that bled spontaneously, and a malformed blood clot at the extraction site of tooth #44. The hematological exams confirmed the hypothesis of ITP. The patient was immediately hospitalized in the Hematology Department of a local hospital and received platelet replacement, hydration, medication, and general care. After the spontaneous bleeding stopped, the malformed clot was removed using alveolar curettage along with a thorough cleaning of the extraction site with a 0.9% saline solution before suturing the wound and prescribing medication. After the sixth day of hospitalization, the patient presented with the following results: Hb: 12.3 mg/dL, Ht: 36.1%, and PC: 87,000 mm3. The patient was then discharged and was placed under outpatient follow-up care. SUMMARY: The importance of the clinical exam must be emphasized since the anamnesis leads to a diagnostic hypothesis of ITP and provides the dental surgeon with an opportunity to make important systemic alterations to improve the prognosis of a patient with ITP.

A temperatura da pele pode ser um indicador para hemorragia grave no pós-operatório? / Can skin temperature be a clue for predicting excessive postoperative bleeding?

OBJETIVO: O objetivo deste estudo é avaliar a hipotermia residual pós-operatória e sua duração, assim como discutir se a hipotermia tardia pode ser um marcador de sangramento excessivo. MÉTODO: Neste estudo retrospectivo, os registros de 12 pacientes que tiveram re-intervenção por causa de sangramento no período pós-operatório foram revisados e suas durações, que foram desde o primeiro minuto em Unidade de Terapia Intensiva até a pele alcançar uma temperatura de 36,5 graus Celsius. O tempo de duração da Circulação Extracorpórea (CEC) foi anotado. Também foi registrado o tempo ativado de coagulação (TCA). A temperatura mais baixa do corpo durante a operação foi medida. Um grupo de controle foi criado (n=16) aleatoriamente, formado por pacientes que não precisariam de re-intervenção e no qual a duração da CEC foi similar à do grupo de estudo. Todos os parâmetros foram comparados entre dois grupos com a versão do software SSPSs. RESULTADOS: As durações desde o primeiro minuto no tratamento intensivo até a temperatura da pele alcançar 36.5 graus Celsius foram significantemente mais longas no grupo de estudo (p=0,0001). TAC pré-operatório e pós-operatório não foram diferentes (p=0,312 e p=0,576 respectivamente). A menor temperatura do corpo não foi diferente (p=0,157). CONCLUSÕES: Nossos achados indicam que a temperatura da pele é importante no sangramento excessivo que leva à re-intervenção. Hipotermia pode ser o motivo ou a causa do sangramento.

OBJECTIVE: The purpose of this study was to investigate whether postoperative hypothermia evaluated by skin temperature can be a clue of excessive bleeding requiring re-exploration. METHODS: In this retrospective study, the records of 12 patients who needed re-exploration due to bleeding in the postoperative period were reviewed and the time from the first minute in the intensive care unit until the skin temperature reached 36.5°C was measured. Cardiopulmonary bypass (CPB) durations were noted as were preoperative and postoperative Activated Clotting Times (ACT) and the lowest body temperatures during the operation. A control group was formed of 16 randomly chosen patients who did not need re-exploration with CPB times similar to the study group. All parameters were compared between the two groups using the SPSS software version 10.0. RESULTS: The length of time from the first minute in the intensive care unit until skin temperatures reached 36.5°C were significantly longer in the study group (p=0.0001). Preoperative and postoperative ACT were not significantly different (p=0.312 and p=0.576 respectively). The lowest body temperatures were also not significantly different (p=0.157). CONCLUSIONS: Our findings show that skin temperature is an important indicator of excessive bleeding with a need for re-exploration. Hypothermia may be a reason for this or may be a result of the bleeding.

[Preoperative markers for risk of post-tonsillectomy bleeding in adults]. / Marcadores de riesgo preoperatorio en la hemorragia postamigdalectomía en adultos.

OBJECTIVE: To identify preoperative markers indicative of an increased risk of postoperative hemorrhage after tonsillectomy in adults. SETTING: Tertiary referral hospital. DESIGN: A retrospective 1:3 case-control study (19 post-tonsillectomy hemorrhage [PTH] cases versus a sample of 58 controls stratified by age and sex). SUBJECTS: Adults over 17 years of age who underwent tonsillectomy from 1989 to 1999 were included. MAIN OUTCOME MEASUREMENTS: Height, weight, percentage of excess weight, body area, systolic and diastolic blood pressure, smoking, drinking, hemoglobin and hematocrit levels, platelet count, partial thromboplastin time, prothrombin activity, fibrinogen, ASA index (physical state classification of the American Society of Anesthesiology), and history of peritonsillar abscess. RESULTS: The risk of PTH in adults was greater in patients with systolic blood pressure > or = 140 mm Hg (OR = 9.46, p = 0.01) and low hematocrit (< 37 for women and < 42 for men, OR = 3.46, p = 0.04). Hemoglobin levels < 12.5 also resulted in an increased risk of PTH in women (OR = 4.79, p = 0.058). CONCLUSIONS: Our findings show that systolic hypertension and anemia may be significant risk factors for PTH in adults.

Cerebellar hemorrhage after supratentorial surgery for treatment of epilepsy: report of three cases.

OBJECTIVE AND IMPORTANCE: We report three cases of cerebellar hemorrhage complicating supratentorial craniotomies for the treatment of epilepsy. In a literature review, we identified only four similar cases of cerebellar hemorrhage after temporal lobectomy for the treatment of epilepsy. CLINICAL PRESENTATION AND RESULTS: Three young and otherwise healthy patients underwent frontal, occipital, and temporal resections for the treatment of refractory epilepsy. The hemorrhage manifested as peduncular tremor, ataxia, and decerebrate posturing presenting early in the postoperative period. The diagnosis was established by computed tomography and/or magnetic resonance imaging. Benign outcomes were observed for all patients. CONCLUSION: Based on the available data, it is our opinion that brain dislocation resulting from excessive intraoperative cerebrospinal fluid drainage is a possible mechanism for this rare complication of supratentorial craniotomy. The overdrainage seems to be less hazardous when the procedure is performed for the removal of space-occupying mass lesions. In contrast, the resection of nonexpanding tissues, such as in lobectomies for the treatment of epilepsy, may be an additional risk factor, because the incidence of this complication seems to be higher in these situations.

Algunos aspectos del manejo perioperatorio de recién nacidos o lactantes sometidos a cirugía cardíaca / Some aspects about perioperatory management of newborns or infants submitted to cardiac surgery

El principal objetivo en el cuidado del paciente cardioquirúrgico debe ser la protección de las funciones cardíacas y pulmonares y la mantención de la homeostrasis