[Haemostatic disorders in ENT patients. Part 2: Pathophysiology, diagnostics, clinical feature and therapy]

Management of patients with risk factors

This review addresses concomitant diseases and risk factors in patients treated for diseases of the ears, nose and throat in outpatient and hospital services. Besides heart disease, lung disease, liver disease and kidney disease, this article also covers disorders of coagulation (including therapy with new oral anticoagulants) and electrolyte imbalance. Special attention is paid to the prophylaxis, diagnosis and treatment of perioperative delirium. It is also intended to help optimise the preparation for surgical procedures and pharmacotherapy during the hospital stay.

Risiko von Blutungen nach Adenotomie und Tonsillektomie

BACKGROUND

Hemorrhage after tonsillectomy and adenoidectomy remains a serious complication. Therefore, routine preoperative coagulation screening, including activated partial thromboplastin time (aPTT), prothrombin time (PT) and platelet count (PLC), are regularly performed, also for medicolegal reasons. In the recently published statement of the German Society of Otorhinolaryngology, Head and Neck Surgery the need for routine preoperative coagulation screening is discussed, but so far no standardized procedure had been established. According to this statement - at least for children - routine preoperative coagulation screening is not mandatory as long as the thorough medical history provides no evidence for a coagulation disorder ( http://www.hno.org/kollegen/gerinnung_te_ae.html ). The present study was undertaken to determine the occurrence of postoperative hemorrhage on the one hand, and the incidence of abnormal preoperative routine coagulation parameters or pathological anamnesis findings on the other.

PATIENTS AND METHODS

In 688 patients, a standardized clinical history was obtained using a questionnaire. Coagulation screening included aPTT, PT, and PLC was also carried out. Bleeding complications were then correlated with anamnesis features and abnormalities in coagulation screening.

RESULTS

In 39 (5.7%) of the 688 patients we found abnormal coagulation values, which were confirmed in repeated analyses. In six of these a detailed analysis revealed occult coagulation disorders requiring correction only in the case of bleeding complications who were previously unknown. Fifteen patients were already known to have a coagulation disorder, and the anamnesis identified no additional patient at risk. Thus, 21 patients with coagulation disorders requiring correction in the case of a bleeding complication underwent surgery. However, only eight (38%) of these showed abnormal routine coagulation parameters. Surgical treatment of postoperative hemorrhage was required in 12 patients, all of whom had normal values for aPTT, PT and PLC.

CONCLUSION

The frequently performed determination of routine coagulation parameters (aPTT, PT, PLC) is not able to reliably identify relevant coagulation disorders or to predict the risk for postoperative hemorrhagic complications after adenoidectomy or tonsillectomy.

[Intraoperative adverse events in minor oral surgery. Risk analysis]

AIM OF THE STUDY

The aim of this prospective study was to evaluate oral surgical procedures performed as day surgery under local anesthesia. We examined patients' general condition, and besides checking for intraoperative complications we analyzed postoperative bleeding in patients with hemostatic disorders.

PATIENTS

The patient population consisted of 1540 patients (797 female, 743 male), who underwent a total of 2055 minor oral surgical procedures over a 5-year period (1998-2002). Before the treatment started a data file was made for each patient, which contained information on his or her past medical history, concomitant medication, why the operation was indicated, premedication, anesthetic and surgical techniques applied, and postoperative treatment.

RESULTS

Systemic pathologies influencing surgical decisions were found in 316 patients (20.5%), affecting 676 interventions (32.9%). In 109 patients (5.3% of the 2055) altered hemostasis was found. The surgical procedures recorded were: (operative) tooth extraction (n=394), interventions for surgical conservation of teeth (n=272), treatment for cysts (n=140), surgical revisions (n=46) and preprosthetic surgery (n=19). Passing complications, mostly systemic in nature, occurred during 27 sessions of local anesthesia (1.3%). There were 87 adverse events intraoperatively (4,2%), most of which were confined to the surgical field; specifically 15% of these complications took the form of hemorrhage. We observed no significant correlation between the occurrence of intraoperative complications and patients' gender, predisposing systemic pathologies including bleeding disorders, or age. Postoperative hemorrhage was observed significantly more frequently in patients with impaired hemostasis and required admission to hospital for inpatient treatment in 2 cases.

CONCLUSION

According to our investigation, oral surgery can be performed in patients with compromised general condition with as few intraoperative complications as in patients with no general medical problems. However, in individual cases specific risk factors can be present and oral surgery may be temporarily contraindicated, at least as day surgery.