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Emergent procedures for oropharyngeal bleeding during the COVID-19 pandemic: Protection of medical staff. Am J Otolaryngol 2020; 41:102583. [PMID: 32516658 PMCID: PMC7832434 DOI: 10.1016/j.amjoto.2020.102583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/25/2020] [Indexed: 12/02/2022]
Abstract
During an ongoing pandemic of COVID-19, controlling the oropharyngeal bleeding, such as post-tonsillectomy hemorrhage, with cauterization is considered a very vulnerable procedure for medical staff because of high probability of exposure to aerosolized secretion. The authors aimed to introduce an appropriate treatment protocol for oropharyngeal bleeding that provides first aid to patients while protecting medical staff at high-risk of infection such as COVID-19.
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Archer NM, Forbes PW, Dargie J, Manganella J, Licameli GR, Kenna MA, Brugnara C. Association of Blood Type With Postsurgical Mucosal Bleeding in Pediatric Patients Undergoing Tonsillectomy With or Without Adenoidectomy. JAMA Netw Open 2020; 3:e201804. [PMID: 32232448 PMCID: PMC7109594 DOI: 10.1001/jamanetworkopen.2020.1804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Blood type (BT) O has been identified as a risk factor for bleeding complications, while non-O BTs may increase risk for thromboembolic events. Limited data are available in children undergoing tonsillectomy with or without adenoidectomy. OBJECTIVE To determine whether BT O is associated with hemorrhage after tonsillectomy with or without adenoidectomy. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of patients younger than 22 years who underwent tonsillectomy with or without adenoidectomy at a single institution between January 1, 2008, and August 7, 2017. Statistical analysis was performed from November 2017 to January 2019. MAIN OUTCOMES AND MEASURES Prevalence of hemorrhage following surgery was defined as any bleeding requiring cauterization up to 1 month after the procedure. Data on sex, age, von Willebrand disease (VWD) status, BT, white blood cell counts, and platelet counts closest to date of surgery were collected from an electronic medical record system, and the association of these factors with hemorrhage following surgery was investigated. RESULTS A total of 14 951 pediatric patients (median [range] age, 5.6 [0.8-21.9] years; 6956 [46.5%] female) underwent tonsillectomy with or without adenoidectomy. Prevalence of hemorrhage following the procedure was 3.9% (578 patients) for the full cohort and 2.8% (362 of 13 065) for patients with no BT identified or preprocedure VWD panel results at baseline. Children who had a BT identified and/or a VWD panel before surgery had higher bleeding rates (BT only, 14.9% [172 of 1156]; preprocedure VWD panel only, 4.6% [28 of 607]; and BT and preprocedure VWD panel, 13.0% [16 of 123]), all of which were significantly different from the baseline bleeding rate (P < .001). While the bleeding rates in children with BT O were not statistically different from those with non-O BT (14.8% and 14.6%, respectively; P > .99), mean von Willebrand factor values were statistically different (mean [SD] von Willebrand factor antigen level in O group, 86.9 [42.4] IU/dL in the O group vs 118.0 [53.8] IU/dL in the non-O group; P = .002; and mean [SD] von Willebrand factor ristocetin-cofactor in the O group, 72.2 [44.3] IU/dL vs 112.6 [68.0] IU/dL in the non-O group; P = .001). In addition, children older than 12 years had increased bleeding rates in the full cohort (8.3% vs 3.2%), in the testing-naive cohort (6.5% vs 2.3%), and in those with a preprocedure VWD panel only (13.5% vs 3.1%) compared with children aged 12 years or younger. CONCLUSIONS AND RELEVANCE Type O blood was not a risk factor associated with hemorrhage after tonsillectomy with or without adenoidectomy despite lower baseline von Willebrand factor antigen and von Willebrand factor ristocetin-cofactor values in children with BT O vs those with non-O BT in our study cohort. No association was found between VWD status and bleeding, and there was no difference in VWD panel values in those who experienced hemorrhage vs those who did not within BT groups. Further studies elucidating the utility of von Willebrand factor values for children undergoing tonsillectomy with or without adenoidectomy are needed.
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Affiliation(s)
- Natasha M. Archer
- Pediatric Hematology, Oncology Dana-Farber, Children’s Hospital Blood Disorders and Cancer Center, Boston, Massachusetts
| | - Peter W. Forbes
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts
| | - Jenna Dargie
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Juliana Manganella
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Greg R. Licameli
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Margaret A. Kenna
- Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Carlo Brugnara
- Laboratory Medicine, Boston Children's Hospital, Boston, Massachusetts
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Becke K, Eich C, Höhne C, Jöhr M, Machotta A, Schreiber M, Sümpelmann R. Choosing Wisely in pediatric anesthesia: An interpretation from the German Scientific Working Group of Paediatric Anaesthesia (WAKKA). Paediatr Anaesth 2018; 28:588-596. [PMID: 29851190 DOI: 10.1111/pan.13383] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2018] [Indexed: 12/13/2022]
Abstract
Inspired by the Choosing Wisely initiative, a group of pediatric anesthesiologists representing the German Working Group on Paediatric Anaesthesia (WAKKA) coined and agreed upon 10 concise positive ("dos") or negative ("don'ts") evidence-based recommendations. (i) In infants and children with robust indications for surgical, interventional, or diagnostic procedures, anesthesia or sedation should not be avoided or delayed due to the potential neurotoxicity associated with the exposure to anesthetics. (ii) In children without relevant preexisting illnesses (ie, ASA status I/II) who are scheduled for elective minor or medium-risk surgical procedures, no routine blood tests should be performed. (iii) Parental presence during the induction of anesthesia should be an option for children whenever possible. (iv) Perioperative fasting should be safe and child-friendly with shorter real fasting times and more liberal postoperative drinking and enteral feeding. (v) Perioperative fluid therapy should be safe and effective with physiologically composed balanced electrolyte solutions to maintain a normal extracellular fluid volume; addition of 1%-2.5% glucose to avoid lipolysis, hypoglycemia, and hyperglycemia, and colloids as needed to maintain a normal blood volume. (vi) To achieve safe and successful airway management, the locally accepted airway algorithm and continued teaching and training of basic and alternative techniques of ventilation and endotracheal intubation are required. (vii) Ultrasound and imaging systems (eg, transillumination) should be available for achieving central venous access and challenging peripheral venous and arterial access. (viii) Perioperative disturbances of the patient's homeostasis, such as hypotension, hypocapnia, hypothermia, hypoglycemia, hyponatremia, and severe anemia, should not be ignored and should be prevented or treated immediately. (ix) Pediatric patients with an elevated perioperative risk, eg, preterm and term neonates, infants, and critically ill children, should be treated at institutions where all caregivers have sufficient expertise and continuous clinical exposure to such patients. (x) A strategy for preventing postoperative vomiting, emergence delirium, and acute pain should be a part of every anesthetic procedure.
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Affiliation(s)
- Karin Becke
- Department of Anaesthesia and Intensive Care, Cnopf Children's Hospital/Hospital Hallerwiese, Nürnberg, Germany
| | - Christoph Eich
- Department of Anaesthesia, Paediatric Intensive Care and Emergency Medicine, Auf der Bult Children's Hospital, Hannover, Germany
| | - Claudia Höhne
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Martin Jöhr
- Department of Anaesthesia, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Andreas Machotta
- Department of Anaesthesiology, Sophia Children's Hospital, Erasmus MC, Rotterdam, The Netherlands
| | - Markus Schreiber
- Department of Anaesthesiology, University Hospital Ulm, Ulm, Germany
| | - Robert Sümpelmann
- Clinic for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
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Chang IS, Kang KT, Tseng CC, Weng WC, Hsiao TY, Lee PL, Hsu WC. Revisits after adenotonsillectomy in children with sleep-disordered breathing: A retrospective single-institution study. Clin Otolaryngol 2017; 43:39-46. [DOI: 10.1111/coa.12899] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2017] [Indexed: 12/17/2022]
Affiliation(s)
- I.-S. Chang
- Department of Otolaryngology; National Taiwan University; College of Medicine and National Taiwan University Hospital; Taipei Taiwan
| | - K.-T. Kang
- Department of Otolaryngology; National Taiwan University; College of Medicine and National Taiwan University Hospital; Taipei Taiwan
- Department of Otolaryngology; Taipei Hospital, Ministry of Health and Welfare; New Taipei City Taiwan
| | - C.-C. Tseng
- Department of Otolaryngology; National Taiwan University; College of Medicine and National Taiwan University Hospital; Taipei Taiwan
| | - W.-C. Weng
- Sleep Center; National Taiwan University Hospital; Taipei Taiwan
- Department of Pediatrics; National Taiwan University Hospital; Taipei Taiwan
| | - T.-Y. Hsiao
- Department of Otolaryngology; National Taiwan University; College of Medicine and National Taiwan University Hospital; Taipei Taiwan
| | - P.-L. Lee
- Sleep Center; National Taiwan University Hospital; Taipei Taiwan
- Department of Internal Medicine; National Taiwan University Hospital; Taipei Taiwan
| | - W.-C. Hsu
- Department of Otolaryngology; National Taiwan University; College of Medicine and National Taiwan University Hospital; Taipei Taiwan
- Sleep Center; National Taiwan University Hospital; Taipei Taiwan
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Kang KT, Chang IS, Tseng CC, Weng WC, Hsiao TY, Lee PL, Hsu WC. Impacts of disease severity on postoperative complications in children with sleep-disordered breathing. Laryngoscope 2017; 127:2646-2652. [DOI: 10.1002/lary.26539] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 12/04/2016] [Accepted: 01/23/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Kun-Tai Kang
- Department of Otolaryngology; National Taiwan University, College of Medicine and National Taiwan University Hospital; Taipei Taiwan
- Department of Otolaryngology; Taipei Hospital, Ministry of Health and Welfare; New Taipei City Taiwan
| | - I-Sheng Chang
- Department of Otolaryngology; National Taiwan University, College of Medicine and National Taiwan University Hospital; Taipei Taiwan
| | - Chia-Chen Tseng
- Department of Otolaryngology; National Taiwan University, College of Medicine and National Taiwan University Hospital; Taipei Taiwan
| | - Wen-Chin Weng
- Sleep Center; National Taiwan University Hospital; Taipei Taiwan
- Department of Pediatrics; National Taiwan University Hospital; Taipei Taiwan
| | - Tzu-Yu Hsiao
- Department of Otolaryngology; National Taiwan University, College of Medicine and National Taiwan University Hospital; Taipei Taiwan
| | - Pei-Lin Lee
- Sleep Center; National Taiwan University Hospital; Taipei Taiwan
- Department of Internal Medicine; National Taiwan University Hospital; Taipei Taiwan
| | - Wei-Chung Hsu
- Department of Otolaryngology; National Taiwan University, College of Medicine and National Taiwan University Hospital; Taipei Taiwan
- Sleep Center; National Taiwan University Hospital; Taipei Taiwan
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Mohammed H, ALtamimi ZAR, Sheikh R, Al Taweel H, Ganesan S. Recurrent Post Tonsillectomy Secondary Hemorrhage in Patients with Factor XIII Deficiency: A Case Series and Review of Literature. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:850-854. [PMID: 27843132 PMCID: PMC5111571 DOI: 10.12659/ajcr.900391] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Case series Patients: Male, 20 • Male, 4 • Male, 27 • Male, 25 • Female, 5 • Female, 26 Final Diagnosis: Post tonsillectomy secondary hemorrhage Symptoms: Bleeding • bleeding per oral Medication: — Clinical Procedure: Control of post tonsillectomy secondary hemorrhage Specialty: Otolaryngology
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Affiliation(s)
- Hassen Mohammed
- Department of Otorhinolaryngology and Head & Neck Surgery (ORL-HNS), Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Zaid Abu Rajab ALtamimi
- Department of Otorhinolaryngology and Head & Neck Surgery (ORL-HNS), Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Rashid Sheikh
- Department of Otorhinolaryngology and Head & Neck Surgery (ORL-HNS), Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Hayam Al Taweel
- Department of Otorhinolaryngology and Head & Neck Surgery (ORL-HNS), Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Shanmugam Ganesan
- Department of Otorhinolaryngology and Head & Neck Surgery (ORL-HNS), Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
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Stokken JK, Halderman A, Recinos PF, Woodard TD, Sindwani R. Strategies for Improving Visualization During Endoscopic Skull Base Surgery. Otolaryngol Clin North Am 2016; 49:131-40. [PMID: 26614833 DOI: 10.1016/j.otc.2015.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The nasal cavity has a robust vascular supply, and bleeding is a primary obstacle to the minimally invasive skull base technique. Venous bleeding, including the cavernous sinus, can be managed with various techniques using hemostatic materials and pressure. A thorough understanding of the skull base vascular anatomy is vital for avoiding injury to major arteries and having confidence to control venous bleeding to optimize the endoscopic view and tumor resection.
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Affiliation(s)
- Janalee K Stokken
- Department of Otolaryngology, Head and Neck Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Ashleigh Halderman
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA
| | - Pablo F Recinos
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Troy D Woodard
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Raj Sindwani
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/A71, Cleveland, OH 44195, USA; Minimally Invasive Cranial Base and Pituitary Surgery Program, Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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9
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Adekwu A, Adoga AS, Gav TA. Our experience with pre-operative haemostatic assessment of paediatric patients undergoing adenotonsillectomy at Federal Medical Centre, Makurdi. Afr J Paediatr Surg 2016; 13:69-72. [PMID: 27251655 PMCID: PMC4955445 DOI: 10.4103/0189-6725.182559] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In 2-4% of all patients requiring adenoidectomy, tonsillectomy or adenotonsillectomy, pre-operative screening tests for coagulation disorders are indicated to detect surgical bleeding complications. However, because of cost effect on the patients, the usefulness of these tests is being challenged. We therefore highlight our experience in paediatric patients undergoing adenoidectomy, tonsillectomy or both in our centre. PATIENTS AND METHODS This is a 3½-year analysis of the data of 165 paediatric patients who had adenoidectomy, tonsillectomy or both over the study period. The data collected included age, sex, procedure done and detailed clinical bleeding history. RESULTS A total of 165 children had either adenoidectomy or tonsillectomy, or both. There were 76 males and 89 females giving a male to female ratio of 1:1.2. Their ages ranged from 10 months to 18 years. Eighty-five (51.5%) patients had adenotonsillectomy, 48 (29.1%) and 32 (19.4%) had only tonsillectomies and adenoidectomies, respectively. Only 11 (6.7%) families volunteered the history of either prolonged bleeding with minor injury on the skin or occasional slight nose bleeding. Six (3.6%) patients including 3 of the children with positive family history had posttonsillectomy bleed, out of which 4 (66.7%) were moderate whereas the remaining 2 (33.3%) were severe bleeding, which was not statistically significant (P = 0.041). The two cases of severe bleeding had fresh whole blood transfused whereas the rest that had no bleeding issues were discharged home 48 h postoperatively. CONCLUSION Our experience in this study suggests that detailed bleeding history is necessary as well as pre-operative haemostatic assessment, if available and affordable for paediatric patients undergoing adenotonsillectomy.
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Affiliation(s)
- Amali Adekwu
- Department of Surgery, College of Health Sciences, Benue State University, Makurdi, Nigeria
| | - Agida Samuel Adoga
- Department of Otorhinolaryngology Head and Neck Surgery, College of Medical Sciences, University of Jos, Jos, Nigeria
| | - Terna Ambrose Gav
- Department of Surgery, Benue State University Teaching Hospital, Makurdi, Nigeria
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10
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Li R, Swaelens C, Vandermijnsbrugge F, Cantinieaux B. Applying a direct aPTT ratio (PlatelinLS/ActinFS) permits to identify rapidly and reliably a bleeding-related factor deficiency or a lupus anticoagulant sequential to an isolated prolongation of aPTT in paediatric pre-operative screening. Eur J Haematol 2015; 96:578-85. [DOI: 10.1111/ejh.12634] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2015] [Indexed: 01/01/2023]
Affiliation(s)
- Rong Li
- Laboratory of Haematology; iris-Lab; Institut Jules Bordet and Saint Pierre University Hospital; Université Libre de Bruxelles; Brussels Belgium
| | - Caroline Swaelens
- Laboratory of Haematology; iris-Lab; Institut Jules Bordet and Saint Pierre University Hospital; Université Libre de Bruxelles; Brussels Belgium
| | - Francine Vandermijnsbrugge
- Laboratory of Haematology; iris-Lab; Institut Jules Bordet and Saint Pierre University Hospital; Université Libre de Bruxelles; Brussels Belgium
| | - Brigitte Cantinieaux
- Laboratory of Haematology; iris-Lab; Institut Jules Bordet and Saint Pierre University Hospital; Université Libre de Bruxelles; Brussels Belgium
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Yang MMH, Singhal A, Au N, Hengel AR. Impact of preoperative laboratory investigation and blood cross-match on clinical management of pediatric neurosurgical patients. Childs Nerv Syst 2015; 31:533-9. [PMID: 25694024 DOI: 10.1007/s00381-015-2617-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 01/04/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Studies in the adult literature suggest that preoperative laboratory investigations and cross-match are performed unnecessarily and rarely lead to changes in clinical management. The purposes of this study were the following: (1) to explore whether preoperative laboratory investigations in neurosurgical children alter clinical management and (2) to determine the utilization of cross-matched blood perioperatively in elective pediatric neurosurgical cases. METHODS We reviewed pediatric patient charts for elective neurosurgery procedures (June 2010-June 2014) at out institution. Variables collected include preoperative complete blood count (CBC), electrolytes, coagulation, group and screen, and cross-match. A goal of the review was to identify instances of altered clinical management, as a consequence of preoperative blood work. The number of cross-matched blood units transfused perioperatively was also determined. RESULTS Four hundred seventy-seven electively scheduled pediatric neurosurgical patients were reviewed. Preoperative CBC was done on 294, and 39.8 % had at least one laboratory abnormality. Electrolytes (84 patients) and coagulation panels (241 patients) were abnormal in 23.8 and 24.5 %, respectively. The preoperative investigations led to a change in clinical management in three patients, two of which were associated with significant past medical history. Group and screen test was performed in 62.5 % of patients and 57.9 % had their blood cross-matched. Perioperative blood transfusions (71 % of these patients were under 3 years of age) were received by 3.6 % of patients (17/477). The cross-match to transfusion ratio was 16. CONCLUSION This study suggests that the results of preoperative laboratory exams have limited value, apart from cases with oncology and complex preexisting conditions. Additionally, cross-matching might be excessively conducted in elective pediatric neurosurgical cases.
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Affiliation(s)
- Michael M H Yang
- Division of Neurosurgery, Department of Surgery, University of British Columbia and BC Children's Hospital, Vancouver, BC, Canada
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Becke K. Anesthesia for ORL surgery in children. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 13:Doc04. [PMID: 25587364 PMCID: PMC4273165 DOI: 10.3205/cto000107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
ORL procedures are the most common operations in children – an optimal anesthetic management provides an uncomplicated, safe perioperative process with as little discomfort for the child as possible. Children at risk must already be identified preoperatively: the combination of ORL surgery, airway susceptibility and age below 3 years can increase the risk of perioperative respiratory adverse events. Postoperatively, it is important to prevent complications such as pain and PONV by dedicated prevention and treatment strategies, as well as to recognize and treat respiratory or circulatory complications competently. Interdisciplinary guidelines and agreements as well as the overall competence of the team have the potential to improve patient safety and outcome in children.
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Affiliation(s)
- Karin Becke
- Abteilung für Anästhesie und Intensivmedizin, Klinik Hallerwiese/Cnopf'sche Kinderklinik, Diakonie Neuendettelsau, Nürnberg, Germany
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Zaballos M, López-Álvarez S, Argente P, López A. Preoperative tests recommendations in adult patients for ambulatory surgery. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:29-41. [PMID: 25146773 DOI: 10.1016/j.redar.2014.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 07/08/2014] [Indexed: 06/03/2023]
Abstract
Anesthetic assessment traditionally included a series of laboratory tests intended to detect undiagnosed diseases, and to ensure that the patient undergoes surgery following safety criteria. These tests, without a specific clinical indication, are expensive, of questionable diagnostic value and often useless. In the context of outpatient surgery, recent evidence suggests that patients of any age without significant comorbidity, ASA physical status gradei and grade ii, do not need additional preoperative tests routinely. The aim of the present recommendations is to determine the general indications in which these tests should be performed in ASA gradei and grade ii patients undergoing ambulatory surgery.
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Affiliation(s)
- M Zaballos
- Servicio de Anestesiología-Reanimación y Terapéutica del Dolor, Hospital Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, España.
| | - S López-Álvarez
- Servicio de Anestesiología-Reanimación y Terapéutica del Dolor, Hospital Abente y Lago, Complejo Hospitalario Universitario A Coruña, A Coruña, España
| | - P Argente
- Servicio de Anestesiología-Reanimación y Terapéutica del Dolor, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - A López
- Servicio de Anestesiología-Reanimación y Terapéutica del Dolor, Hospital Universitario Clínico, Barcelona, España
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14
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Levy JH, Szlam F, Wolberg AS, Winkler A. Clinical Use of the Activated Partial Thromboplastin Time and Prothrombin Time for Screening. Clin Lab Med 2014; 34:453-77. [DOI: 10.1016/j.cll.2014.06.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Thompson ME, Kohring JM, McFann K, McNair B, Hansen JK, Miller NH. Predicting excessive hemorrhage in adolescent idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion. Spine J 2014; 14:1392-8. [PMID: 24139751 DOI: 10.1016/j.spinee.2013.08.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Revised: 07/07/2013] [Accepted: 08/21/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Blood loss in patients with adolescent idiopathic scoliosis (AIS) who are undergoing posterior spinal instrumentation and fusion (PSIF) varies greatly. The reason for this wide range is not clear. There are reports of unexpected massive hemorrhage during these surgeries. Many studies reflect authors' preferences for describing blood loss in terms of levels fused, weight, or percent blood volume. PURPOSE We sought to define excessive blood loss clinically, determine its incidence in our study population, and identify associated variables. Results are intended to inform perioperative preparation for these cases. Results may be used to inform prospective study designs. STUDY DESIGN This was a retrospective uncontrolled case series. PATIENT SAMPLE A total of 311 consecutive AIS PSIF cases during the years 2005-2010 performed at Children's Hospital Colorado were studied. OUTCOME MEASURES We measured estimated blood loss (EBL) and its association with multiple patient, surgical, and anesthetic variables. METHODS Thirty-one variables potentially related to blood loss were collected retrospectively from electronic medical records for analysis. When no cases of clearly excessive blood loss were identified on the basis of visual examination of EBL distribution, we chose to use the top 10% of blood loss cases as an arbitrary determinant of excessive blood loss. Three cut-off strategies captured the top 10% of EBL cases with little variation in who was selected: 1) >1,700 mL of EBL, 2) >50% EBL/estimated blood volume, and 3) >150 mL/level fused EBL. Variables were compared with the χ(2) test, Fisher exact, or t-tests, when appropriate. A generalized linear mixed logistic model was used to determine the probability of excessive blood loss based on the number of levels fused. RESULTS The average EBL was 89.17 mL/level fused (range, 45-133 mL). EBL fit a progressively wider distribution as surgical complexity (number of levels fused) increased. Number of levels fused (p<.0001), operative time (p=.0139), number of screws (p<.0001), and maximal preoperative Cobb angle (p=.0491) were significantly associated with excessive blood loss. The variable that was most strongly associated with excessive blood loss was the number of levels fused, with ≥12 levels having a probability of >10% of excessive hemorrhage. CONCLUSION Excessive blood loss may be an arbitrary number until future research suggests otherwise. We show that the probability of exceeding one of our arbitrary definitions is approximately 10% when 12 or more levels are fused. If a 10% incidence of excessive blood loss is determined to be clinically relevant, teams might wish to pursue hematologic consultation and maximal blood conservation strategy when 12 or more levels are planned for fusion.
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Affiliation(s)
- Mark E Thompson
- Department of Anesthesiology, Children's Hospital Colorado, University of Denver, 13123 E. 16th Ave., Box B090, Aurora, CO 80045, USA.
| | - Jessica M Kohring
- Department of Orthopaedics, University of Utah School of Medicine, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Kim McFann
- Colorado School of Public Health, University of Colorado Denver, Colorado Biostatistics Consortium, 12477 E. 19th Ave., Building 406, Room 100, Aurora, CO 80045, USA
| | - Bryan McNair
- Colorado School of Public Health, University of Colorado Denver, Colorado Biostatistics Consortium, 12477 E. 19th Ave., Building 406, Room 100, Aurora, CO 80045, USA
| | - Jennifer K Hansen
- Department of Anesthesiology, The University of Kansas Medical Center, 3901 Rainbow Blvd, Mailstop 1034, Kansas City, KS 66160, USA
| | - Nancy H Miller
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Children's Hospital Colorado, University of Colorado Denver, 13123 E. 16th Ave., Box 060, Aurora, CO 80045, USA
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Abstract
The value of routine coagulation testing instead of bleeding history alone in children, to predict bleeding risk prior to tonsillectomy and adenoidectomy has been questioned. Our objectives are to identify the causes of abnormal PT and/or aPTT in these patients, and to determine whether routine preoperative coagulation testing is effective in identifying children with a clinically significant coagulation abnormality prior to undergoing a procedure. In this study, data were extracted by chart review for 854 patients referred to the pediatric hematology service at Stony Brook University for the evaluation of an elevated PT and/or aPTT on preoperative testing. Seven hundred and ninety two of 854 reviewed charts (92.7%) contained sufficient data for analysis. On repeat testing, 393 (49.6%) had a laboratory abnormality identified. A potentially significant coagulation abnormality was identified in 32 of 792 patients (4%). For the remaining 760 patients, the most common diagnosis was a lupus anticoagulant (n = 98, 24.6%) or a "presumed" lupus anticoagulant (n = 166, 41.6%). A positive personal or family bleeding history was documented in 268 patients (268/792 = 33.8%). Of these patients, only 107 (39.9%) had an abnormality identified on further work-up. Seventeen of the 32 patients with clinically significant bleeding disorders identified were found to have a positive bleeding history (17/32 = 53.1%). Routine preoperative coagulation testing identifies only a small number of children at increased risk for surgical bleeding. However, a "positive" bleeding history identifies only 60% of children found to have a clinically significant coagulation abnormality. Routine preoperative coagulation testing may serve as a useful adjunct to clinical history.
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Affiliation(s)
- Neha Bhasin
- 1Pediatrics, University of Iowa, Iowa City, Iowa, USA
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Windfuhr JP. Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2013; 12:Doc08. [PMID: 24403976 PMCID: PMC3884543 DOI: 10.3205/cto000100] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN). METHODS A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany. RESULTS The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2). CONCLUSION Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.
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Affiliation(s)
- Jochen P. Windfuhr
- Department of Otorhinolaryngology, Plastic Head and Neck Surgery, Kliniken Maria Hilf, Mönchengladbach, Germany
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Pre-interventional haemostatic assessment: Guidelines from the French Society of Anaesthesia and Intensive Care. Eur J Anaesthesiol 2013; 30:142-62. [PMID: 23435255 DOI: 10.1097/eja.0b013e32835f66cd] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Recently the French Society of Anaesthesia and Intensive Care (Société Française d'Anesthésie et de Réanimation [SFAR]) issued recommendations for the prescription of routine preoperative testing before a surgical or non-surgical procedure, requiring any type of anaesthesia. Thirty clinical specialists performed a systematic analysis of the literature, and recommendations were then developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. One part of these guidelines is dedicated to haemostatic assessment. The goal of pre-anaesthetic screening for congenital or acquired haemostatic disorders is to prevent perioperative haemorrhagic complications through appropriate medical and surgical management. Preoperative assessment of bleeding risk requires a detailed patient interview to determine any personal or family history of haemorrhagic diathesis, and a physical examination is necessary in order to detect signs of coagulopathy. Laboratory investigation of haemostasis should be prescribed, not systematically, but depending on clinical evaluation and patient history. Standard tests (prothrombin time, activated partial thromboplastin time, platelet count) have a low positive predictive value for bleeding risk in the general population. Patients with no history of haemorrhagic diathesis and no conditions liable to interfere with haemostasis should not undergo pre-interventional haemostasis testing. Conversely, the existence of a positive history or a disease that could interfere with haemostasis should be an indication for clinically appropriate testing.
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An evidence-based threshold for thrombocytopenia associated with clinically significant bleeding in pediatric intensive care unit patients. Pediatr Crit Care Med 2012; 13:e316-22. [PMID: 22760429 DOI: 10.1097/pcc.0b013e31824ea28d] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the epidemiology and identify the risk factors for clinically significant bleeding in the pediatric intensive care unit. DESIGN A retrospective cohort study over 6 months with up to 7 days of observation for each patient. SETTING The pediatric intensive care unit in a tertiary care children's hospital. PATIENTS Three hundred twenty-six consecutive patients admitted to the pediatric intensive care unit during the study period, with 214 eligible for inclusion. MEASUREMENTS AND MAIN RESULTS Clinically significant bleeding, defined using a composite of outcomes. Clinically significant bleeding occurred in 19 patients (8.9%). Recursive partitioning identified a platelet count <100 × 10/L as being associated with clinically significant bleeding. Other factors associated with increased risk included mechanical ventilation, antibiotic and antacid medications, the performance of multiple procedures, and cardiac surgery. Episodes of clinically significant bleeding were observed at a median of 9.8 hrs after admission. CONCLUSIONS Clinically significant bleeding is a more common complication for pediatric intensive care unit patients than has been previously reported. The evidence-based threshold for thrombocytopenia identified as a risk factor should be further investigated in a prospective study.
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Emeklibas N, Kammerer I, Bach J, Sack FU, Hellstern P. Preoperative hemostasis and its association with bleeding and blood component transfusion requirements in cardiopulmonary bypass surgery. Transfusion 2012; 53:1226-34. [DOI: 10.1111/j.1537-2995.2012.03885.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sarny S, Ossimitz G, Habermann W, Stammberger H. Preoperative coagulation screening prior to tonsillectomy in adults: current practice and recommendations. Eur Arch Otorhinolaryngol 2012; 270:1099-104. [PMID: 22791470 DOI: 10.1007/s00405-012-2099-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 06/18/2012] [Indexed: 11/28/2022]
Abstract
The hypotheses of the study are: (1) a positive history of coagulopathy predicts a higher postoperative haemorrhage risk, (2) a positive laboratory screening for coagulopathy can forecast a higher haemorrhage risk and (3) the haemorrhage risk in patients with known bleeding disorder is elevated. In a multicentre study information on 3,041 tonsillectomies in adults over 9 months, from 1st October 2009 until 30th June 2010, was evaluated. The outcome variables were patient characteristics, postoperative haemorrhage, history of coagulopathy and laboratory screening for coagulopathy. A history of coagulopathy and laboratory screening for coagulopathy were performed in almost all patients (98.6 %, 2,998/3,041). The overall haemorrhage rate was 16 %, including all bleeding episodes after extubation, with 4.8 % returning to theatre. A positive history was reported in 2 % (55/3,041) and a positive laboratory screening in 3 % (94/3,041) of all patients. A positive history is significantly associated with a higher risk of postoperative haemorrhage (31 %, 17/55, p < 0.002) compared to patients with a negative history (16 %, 387/2,497). A positive laboratory for coagulopathy was not significantly associated with an increased haemorrhage risk (20 %, 19/94, p < 0.235) compared to patients with a negative laboratory (16 %, 390/2,249). The haemorrhage risk for adults with a bleeding disorder is twice as high (31 %, 17/55) as for adults without bleeding disorder (16 %, 476/2,973). In conclusion, an adult patient's history of coagulopathy should be taken prior to tonsillectomy as a positive history doubles the haemorrhage risk while a laboratory screening for coagulopathy has no significant power to predict an elevated haemorrhage risk. Bleeding disorders double the risk of postoperative haemorrhage.
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Affiliation(s)
- Stephanie Sarny
- Department of General Oto-Rhino-Laryngology, Head and Neck Surgery, Medical University of Graz, Auenbruggerplatz 26-28, 8036, Graz, Austria.
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Stevenson AN, Myer CM, Shuler MD, Singer PS. Complications and legal outcomes of tonsillectomy malpractice claims. Laryngoscope 2011; 122:71-4. [DOI: 10.1002/lary.22438] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 09/09/2011] [Accepted: 09/16/2011] [Indexed: 12/14/2022]
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Zaher G, Al-Noury K. The value of routine preoperative testing in the prediction of operative hemorrhage in adenotonsillectomy. Indian J Otolaryngol Head Neck Surg 2011; 66:30-6. [PMID: 24533357 DOI: 10.1007/s12070-011-0285-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 08/12/2011] [Indexed: 11/27/2022] Open
Abstract
Medical records were reviewed to identify subjects who ranged in age from 1 to 18 years and who had undergone tonsillectomy with or without adenoidectomy. Data obtained included patient demographic information, relevant medical history, history of hemorrhage, family history of hemorrhagic disorders, and drug history. Laboratory data obtained included a baseline coagulation screening to determine prothrombin time, activated partial thromboplastin time, and platelet count. Values were classified as within normal limits or as abnormally prolonged according to the local laboratory reference values. The incidence of postoperative hemorrhage in healthy subjects was evaluated, and the correlation between having a medical history of hemorrhage and an abnormal coagulation screen was assessed. We found that the medical history of the patients studied had positive predictive value of 42.8%, and a negative predictive value of 99.1%. The preoperative coagulation screening had a positive predictive value of 50%, and a negative predictive value of 93.6%.
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Affiliation(s)
- Galila Zaher
- Departments of Hematology, King Abdulaziz University Hospital, 80205, Jeddah, 21589 Saudi Arabia
| | - Khaled Al-Noury
- Department of Otolaryngology, Head and Neck Surgery, King Abdulaziz University Hospital, 80205, Jeddah, 21589 Saudi Arabia ; 35135, Jeddah, 21488 Saudi Arabia
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Significance of advanced haemostasis investigation in recurrent, severe post-tonsillectomy bleeding. The Journal of Laryngology & Otology 2011; 125:952-7. [DOI: 10.1017/s0022215111000879] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:To evaluate the significance of advanced post-operative haemostasis investigation in cases of recurrent, severe post-tonsillectomy bleeding.Materials and methods:Of the 120 patients treated at our tertiary centre between 2006 and 2010 due to post-tonsillectomy haemorrhage, 22 with recurrent, severe episodes of bleeding underwent further, advanced haemostasis investigation.Results:Underlying haemorrhagic disease was not diagnosed in any case. Isolated abnormal clotting factor levels were identified in two patients. Decreased fibrinogen concentration due to dilutional coagulopathy was found in nine cases (40.9 per cent).Conclusion:Recurrent, severe post-tonsillectomy haemorrhage is rarely related to undiagnosed haemostatic disorders. Thus, advanced haemostasis studies have little therapeutic relevance. However, repetitive post-tonsillectomy bleeding may be related to decreased fibrinogen levels due to dilutional coagulopathy. Therefore, fibrinogen concentration should be tested, and dilutional coagulopathy treated promptly.
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Zumtobel M, Frei K. Occurrence of coagulation factor deficiency in post-tonsillectomy hemorrhage. Wien Klin Wochenschr 2011; 123:241-4. [PMID: 21479651 DOI: 10.1007/s00508-011-1560-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2010] [Accepted: 01/03/2011] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Tonsillectomy is one of the most common surgical procedures in Otorhinolaryngology and approximately 500 tonsillectomies are performed annually at the University Hospital of Vienna. Substantial postoperative bleeding is observed in 1.8% of cases, which is comparable to frequencies of 2-4% reported in other studies. Currently, routine pre-surgical coagulation investigations to predict bleeding status do not include the analysis of individual coagulation factors. MATERIAL AND METHODS Within 2007 complete coagulation diagnostics were carried out in three patients presenting with recurrent (2-7 times) post-tonsillectomy hemorrhage but normal pre-surgical coagulation status parameters. RESULTS After the appearance of recurrent late bleeding, single factor diagnostic analysis revealed the causes to be factor XIIa deficiency, reduced factor XIIIa or von Willebrand disease. Recurrent late bleeding was stopped by the application of coagulation active plasma. CONCLUSION This study shows that, even if routine diagnostics show normal pre-surgical coagulation findings, the investigation of single factors in cases of post-surgical late bleeding may identify coagulation disorders allowing the application of tailored therapy. Including such analysis in pre-operative diagnostics could therefore significantly help to limit postoperative bleeding.
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Affiliation(s)
- Michaela Zumtobel
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Austria
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An assessment of the utility of unselected coagulation screening in general hospital practice. Blood Coagul Fibrinolysis 2011; 22:106-9. [DOI: 10.1097/mbc.0b013e3283432fb7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cooper JD, Smith KJ, Ritchey AK. A cost-effectiveness analysis of coagulation testing prior to tonsillectomy and adenoidectomy in children. Pediatr Blood Cancer 2010; 55:1153-9. [PMID: 20672369 DOI: 10.1002/pbc.22708] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The American Society of Pediatric Otolaryngology recommends pre-operative coagulation testing only when indicated by history or physical exam. Nevertheless, many surgeons test all children scheduled for tonsillectomy and/or adenoidectomy (T&A). Studies of pre-operative screening have had conflicting results. A decision analysis model was constructed to address the costs and health outcome states of pre-operative screening strategies in children. PROCEDURE A 14-day Markov model evaluated three strategies: (1) test all children for coagulation disorders; (2) test only those children with a pertinent history; and (3) perform no pre-operative testing. A literature search and a review of national databases estimated probabilities, costs, and utility data. Parameters then were varied widely in sensitivity analyses. Using a societal perspective and a cycle length of 1 day, we compared the strategies based on total costs and quality-adjusted life years (QALYs). RESULTS Total costs for the strategies were $3,200 for testing all children, $3,083 for testing only those with a history finding, and $3,077 for not testing. Total utilities were 0.02579, 0.02654, and 0.02659 QALYs, respectively. Cost-effectiveness ratios were most sensitive to variation in the cost of post-operative care and the probability of post-operative bleeding. The strategy of not testing was dominant in all sensitivity analyses. CONCLUSIONS Our results demonstrate that not performing preoperative testing is the most cost-effective strategy. This was persistent in sensitivity analyses, indicating that the model was robust. These data may be helpful to institutions and organizations to formulate policies regarding pre-operative coagulation for children without previous diagnoses of bleeding disorders.
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Affiliation(s)
- James D Cooper
- Division of Hematology/Oncology/BMT, Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15224, USA.
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Timperley D, Sacks R, Parkinson RJ, Harvey RJ. Perioperative and intraoperative maneuvers to optimize surgical outcomes in skull base surgery. Otolaryngol Clin North Am 2010; 43:699-730. [PMID: 20599078 DOI: 10.1016/j.otc.2010.04.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
There are many approaches to obtaining a workable endoscopic surgical field in sinus surgery. With extended sinus and transdural endoscopic surgery, a more rigid approach must be taken. There are 3 main factors that invariably lead to poor surgical outcomes in endoscopic sinus and skull base surgery: bleeding, inadequate access, and unidentified anatomic anomalies. Bleeding is arguably the most common reason for incomplete resection. An understanding of microvascular and macrovascular bleeding allows a more structured approach to improve the surgical field in extended endoscopic surgery. The endoscopic surgeon should always be comfortable in performing the same procedure as an open operation. However, converting or abandoning an endoscopic procedure should rarely occur because much of this decision making should take place preoperatively. Along with poor hemostasis, inadequate access is an important cause of poor outcome. Evaluation of the anatomy involved by pathology but also the anatomy that must be removed to allow adequate exposure is important. This article reviews the current techniques used to ensure optimal surgical conditions and outcomes.
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Affiliation(s)
- Daniel Timperley
- Rhinology and Skull Base, Department of Otolaryngology/Skull Base Surgery, St Vincent's Hospital, 354 Victoria Street, Sydney, NSW 2010, Australia
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Flood VH, Friedman KD, Gill JC, Morateck PA, Wren JS, Scott JP, Montgomery RR. Limitations of the ristocetin cofactor assay in measurement of von Willebrand factor function. J Thromb Haemost 2009; 7:1832-9. [PMID: 19694940 PMCID: PMC3825106 DOI: 10.1111/j.1538-7836.2009.03594.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Type 2M von Willebrand disease (VWD) is characterized by a qualitative defect in von Willebrand factor (VWF) and diagnosed by a disproportionate decrease in VWF ristocetin cofactor activity (VWF:RCo) as compared with VWF antigen (VWF:Ag). OBJECTIVE We report here on the spurious diagnosis of VWD in a patient with a sequence variation in the ristocetin-binding domain of VWF. PATIENTS/METHODS The index case had a VWF:RCo of 11 IU dL(-1), with VWF:RCo/VWF:Ag ratio of 0.09. DNA sequencing revealed a novel P1467S mutation in a known ristocetin-binding region of the A1 domain. Because of the discrepancy between the laboratory findings, consistent with type 2M VWD, and the patient's lack of bleeding symptoms, further studies were performed to determine whether this mutation affected VWF function or merely reduced its ability to interact with ristocetin. RESULTS Studies with recombinant VWF showed normal platelet binding with botrocetin, but a significant decrease in binding in response to ristocetin. Ristocetin-induced binding to recombinant GPIb was also absent, but normal binding was seen when a gain-of-function GPIb construct was used in the absence of ristocetin. VWF function under shear stress was normal when analyzed with a cone and plate(let) analyzer. CONCLUSIONS The decreased VWF:RCo seen with the P1467S sequence variation likely represents an artifact as a result of the use of ristocetin to measure VWF activity. The normal VWF function in other assays correlates with the lack of hemorrhagic symptoms, and suggests the need for more physiologically relevant assays of VWF function.
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Affiliation(s)
- V H Flood
- Division of Hematology/Oncology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.
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Assessment of the risk of bleeding in patients undergoing surgery or invasive procedures: Guidelines of the Italian Society for Haemostasis and Thrombosis (SISET). Thromb Res 2009; 124:e6-e12. [DOI: 10.1016/j.thromres.2009.08.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Revised: 07/20/2009] [Accepted: 08/04/2009] [Indexed: 11/21/2022]
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Pajot S, Asehnoune K, Le Roux C, Léturgie C, Surbled M, Bazin V, Lejus C. [Evaluation of the haemostasis before a central block in children: what is the French anaesthesiologist's attitude?]. ACTA ACUST UNITED AC 2008; 28:3-10. [PMID: 19062242 DOI: 10.1016/j.annfar.2008.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2008] [Accepted: 10/22/2008] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Because of the lack of controlled studies, there is no consensus regarding the practice of routine haemostasis tests before neuraxial blockade in children. The purpose of this study was to describe the French surgical practice about the preoperative evaluation of coagulation in children who were scheduled for paediatric neuraxial anaesthesia. STUDY DESIGN Descriptive analysis of the practice. METHODS A telephone survey for coagulation screening was conducted in French surgical paediatric units, known to perform paediatric neuraxial anaesthesia on a routine basis. The aim of the standardized questionnaire was to evaluate the expertise in performance of neuraxial block, the modalities of the preoperative haemostasis screening, and the indications of biological tests and to assess whether a standardized team procedure was used. RESULTS Forty-two hospitals (27 universities, 10 general hospitals and five private institutions) were contacted; 61 anaesthesiologists with an expertise with central block answered the survey. Thirty-five institutions used a standardized procedure and 57,1% of them undertook routines tests only in children who are not walking. In the remaining 42,9%, the strategy was to screen systematically all patients whatever their age, familial and personal history as well as physical examination. However, only 54% of the anaesthesiologists performed an extensive physical examination in order to detect symptoms in favour of signs of haemostatic disorders. CONCLUSION While numerous data suggest that routine testing does not to provide much extra information in the absence of a positive history, a systematic strategy is still widely applied in children. Guidelines need to be developed to insure the safety of oriented tests.
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Affiliation(s)
- S Pajot
- Service d'anesthésie et de réanimation chirurgicale, Hôtel-Dieu-hôpital Mère-Enfant, CHU de Nantes, place Alexis-Ricardeau, 44093 Nantes cedex 01, France
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Stuck BA, Götte K, Windfuhr JP, Genzwürker H, Schroten H, Tenenbaum T. Tonsillectomy in children. DEUTSCHES ARZTEBLATT INTERNATIONAL 2008; 105:852-60; quiz 860-1. [PMID: 19561812 PMCID: PMC2689639 DOI: 10.3238/arztebl.2008.0852] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Accepted: 08/28/2008] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Tonsillectomy is one of the most frequently performed surgical interventions in children. In the following, indications, preoperative evaluation, surgical techniques and postoperative complications will be discussed. METHODS Literature search in PubMed (National Library of Medicine) focusing on publications in German or English up to June 2008. RESULTS Indications are selected infectious diseases, upper airway obstruction for example due to tonsillar hypertrophy, and a suspected malignancy. Viral infections of the tonsils without upper airway obstruction are not an indication for surgery; in the case of acute bacterial tonsillitis, tonsillectomy is no longer recommended. In recurrent tonsillitis, tonsillectomy is only effective in specific and narrow indications. The indication for tonsillectomy in sleep-disordered breathing due to adenotonsillar hypertrophy has to be based on clinical assessment, medical history, and a sleep history. The most relevant risk factors are obstructive sleep apnea and coagulation disorders. A standardized history regarding hemostasis and bleeding is mandatory, and is superior to routine coagulation tests. Postoperative bleeding is still the most relevant complication of tonsillectomy and is always an emergency situation. CONCLUSION Tonsillectomy is one of the most frequently performed interventions in children but should be considered with care, as life-threatening complications can occur.
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Affiliation(s)
- Boris A Stuck
- Universitäts-HNO-Klinik Mannheim,Theodor-Kutzer-Ufer 1-3, Mannheim, Germany.
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Stuck BA, Genzwürker HV. [Tonsillectomy in children: preoperative evaluation of risk factors]. Anaesthesist 2008; 57:499-504. [PMID: 18311551 DOI: 10.1007/s00101-008-1337-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Tonsillectomy is one of the most frequently performed surgical procedures in children and is associated with a relatively high risk of postoperative complications. The question often arises whether paediatric obstructive sleep apnoea should be diagnosed with preoperative sleep testing and whether preoperative coagulation tests should be performed in every child undergoing tonsillectomy. In order to answer these questions, the relevant German and English literature was analysed. Adenotonsillectomy in childhood usually resolves the underlying sleep-related breathing disorder. Nevertheless, especially in children with clinical risk factors such as severe sleep apnoea, obesity or craniofacial malformation, respiratory complications should be expected in the postoperative phase. Routine sleep tests prior to tonsillectomy are neither necessary nor practical for preoperative evaluation. Inherited coagulation disorders have only a limited effect on the occurrence of postoperative bleeding and the predictive value of routine coagulation tests is limited. As long as a thorough clinical history is negative, routine coagulation tests are not helpful or necessary prior to tonsillectomy in children.
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Affiliation(s)
- B A Stuck
- Schlafmedizinisches Zentrum, Universitäts-HNO-Klinik, Medizinische Fakultät, Universitätsklinikum Mannheim, 68135 Mannheim.
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Gerlinger I, Török L, Nagy Á, Patzkó Á, Losonczy H, Pytel J. Frequency of coagulopathies in cases with post-tonsillectomy bleeding. Orv Hetil 2008; 149:441-6. [DOI: 10.1556/oh.2008.28249] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
A tonsillectomiát követő legsúlyosabb komplikáció az utóvérzés. Primer post-tonsillectomiás vérzésről akkor beszélünk, ha az a műtétet követően a nem megfelelően ellátott artériák vérzése miatt 24 órán belül fordul elő. Szekunder post-tonsillectomiás vérzés esetében a komplikáció az 1–10. posztoperatív nap egyikén, legnagyobb gyakorisággal az 5–8. napon jelentkezik. A szekunder vérzések rizikófaktorait illetően az irodalom rendkívül ellentmondásos.
Célkitűzés:
A szerzők azt a kérdést vizsgálták, hogy a rejtett coagulopathiáknak van-e oki szerepe a post-tonsillectomiás vérzésekben, valamint hogy a műtét előtti általános hematológiai szűrésnek van-e létjogosultsága.
Módszer:
Vizsgálataik során a 2002 és 2004 között a PTE Fül-orr-gégészeti és Fej-nyaksebészeti Klinikájára utóvérzés miatt felvett 115 beteg közül 107 esetben (59 nő, 48 férfi, átlagéletkor 29 év ± 10,9 év) kezdeményeztek utánvizsgálatot a thrombocytaszám, a vérzési idő, a trombinidő (TI), az aktivált parciális tromboplasztinidő (aPTI), a protrombin/INR ráta és a fibrinogénszint meghatározásával.
Eredmények:
Az utánvizsgálaton 58 beteg vett részt, közülük 28 esetben (49%) észleltünk kóros értékeket. A kóros értékeket mutatók számára javasolt izolált faktormeghatározáson 19 beteg (68%) vett részt, végül 2 betegben, az utánvizsgálaton megjelentek 3,4%-ában igazolták a korábban nem ismeretes, rejtett coagulopathiát (egy esetben izolált VII. faktorszintcsökkenést, egy esetben kombinált VII. és XII. faktorszintcsökkenést). Meglepő, hogy 3, anticoncipienst szedő nőbetegben trombózisra hajlamosító IX. faktorszint-emelkedést diagnosztizáltak.
Következtetések:
Vizsgálataikból számos gyakorlati következtetés vonható le: 1. a mindenkire kiterjedő szűrés nem tűnik költséghatékonynak; 2. elsősorban gyermekkorban és pozitív családi anamnézis esetében, valamint pozitív fizikális vizsgálat és gyanút keltő preoperatív anamnesztikus adatok (ismételt orrvérzések!) ismeretében a coagulopathia oka lehet az utóvérzésnek; 3. a legérzékenyebb haemostaseologiai paraméter beteganyagukban az aktivált parciális tromboplasztinidő (aPTI) volt (15/28 kóros érték); 4. a coagulopathia az esetek többségében öröklődő betegség, ezért egy beteg diagnosztizálása segíthet a családtagok vérzékenységének felderítésében is; 5. a szekunder utóvérzések döntő többsége bipoláris olló és bipoláris csipesz használata mellett fordult elő; 6. ugyancsak fontos tanulság, hogy a vérzési idő korrekt vizsgálatára csakis az Ivy-módszer a megbízható technika.
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Affiliation(s)
- Imre Gerlinger
- 1 Pécsi Tudományegyetem, Általános Orvostudományi Kar Fül-orr-gégészeti és Fej-nyaksebészeti Klinika Pécs Munkácsy Mihály utca 2. 7621
| | - László Török
- 1 Pécsi Tudományegyetem, Általános Orvostudományi Kar Fül-orr-gégészeti és Fej-nyaksebészeti Klinika Pécs Munkácsy Mihály utca 2. 7621
| | - Ágnes Nagy
- 2 Pécsi Tudományegyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika, Hematológiai Osztály Pécs
| | - Ágnes Patzkó
- 1 Pécsi Tudományegyetem, Általános Orvostudományi Kar Fül-orr-gégészeti és Fej-nyaksebészeti Klinika Pécs Munkácsy Mihály utca 2. 7621
| | - Hajna Losonczy
- 2 Pécsi Tudományegyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika, Hematológiai Osztály Pécs
| | - József Pytel
- 1 Pécsi Tudományegyetem, Általános Orvostudományi Kar Fül-orr-gégészeti és Fej-nyaksebészeti Klinika Pécs Munkácsy Mihály utca 2. 7621
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Chee YL, Crawford JC, Watson HG, Greaves M. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. Br J Haematol 2008; 140:496-504. [DOI: 10.1111/j.1365-2141.2007.06968.x] [Citation(s) in RCA: 291] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Scheckenbach K, Bier H, Hoffmann TK, Windfuhr JP, Bas M, Laws HJ, Plettenberg C, Wagenmann M. Risiko von Blutungen nach Adenotomie und Tonsillektomie. HNO 2007; 56:312-20. [PMID: 17581692 DOI: 10.1007/s00106-007-1585-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- K Scheckenbach
- Klinik für Hals-, Nasen-, Ohren-Krankheiten, Medizinische Einrichtungen der Heinrich Heine-Universität Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Deutschland.
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Lippi G, Franchini M, Poli G, Salvagno GL, Montagnana M, Guidi GC. Is the activated partial thromboplastin time suitable to screen for von Willebrand factor deficiencies? Blood Coagul Fibrinolysis 2007; 18:361-4. [PMID: 17473578 DOI: 10.1097/mbc.0b013e32810fd872] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The diagnostic approach to von Willebrand factor deficiencies is challenging and requires discretionary use of laboratory resources. Although extensive preoperative testing is not recommended, the activated partial thromboplastin time may be useful, especially in selected categories of patients. To establish the diagnostic sensitivity of this test to identify isolate von Willebrand factor deficiencies, 204 consecutive patients underwent a routine preoperative screening consisting of activated partial thromboplastin time, von Willebrand factor antigen, intrinsic pathway clotting factors activity, lupus anticoagulants and thrombin time. Thirty-seven patients were diagnosed with haemostasis disturbances other than von Willebrand factor deficiencies and were excluded from the evaluation. Isolated von Willebrand factor deficiency was diagnosed in 11 of the remaining 167 patients. A significant correlation was observed between von Willebrand factor antigen and activated partial thromboplastin time. Receiver operating characteristic curve analysis showed an area under the curve of 0.982 (95% confidence interval: 0.972-0.992; P < 0.001). At the 1.17 upper limit of the activated partial thromboplastin time, sensitivity and specificity were 100 and 85%, respectively, with negative and positive predictive values of 100 and 31%, respectively. These results demonstrate that activated partial thromboplastin time has an excellent diagnostic sensitivity and a satisfactory specificity for identifying isolated von Willebrand factor deficiencies.
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Affiliation(s)
- Giuseppe Lippi
- Sezione di Chimica e Microscopia Clinica, Dipartimento di Scienze Morfologico-Biomediche, Università degli Studi di Verona, Ospedale Policlinico G.B. Rossi, Piazzale Scuro 10, 37134 Verona, Italy.
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Javed F, Sadri M, Uddin J, Mortimore S, Parker D. A completed audit cycle on post-tonsillectomy haemorrhage rate: coblation versus standard tonsillectomy. Acta Otolaryngol 2007; 127:300-4. [PMID: 17364368 DOI: 10.1080/00016480600895052] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
CONCLUSION A significant reduction in post-tonsillectomy secondary haemorrhage rate was observed after coblation tonsillectomy was abandoned in our department. OBJECTIVE Comparison of the postoperative haemorrhage rate following coblation tonsillectomy and routine dissection tonsillectomy. PATIENTS AND METHODS This was a retrospective study. In the first audit period, 441 sequential tonsillectomies between January and September 2002 were reviewed. Coblation was compared with cold steel and diathermy dissection with either ties and/or diathermy used for haemostasis. Coblation tonsillectomy was subsequently abandoned in our unit and, in the second audit period, all tonsillectomies (n=416) between July 2003 and August 2004 were included. Statistical analysis was performed using the chi2 test. RESULTS The overall primary haemorrhage rate in the first audit cycle was 1.8% (8/441). In the second cycle with no coblation procedures, 1.4% of patients (6/416) suffered from primary haemorrhage (c.f. 8/441 (1.8%) in the first cycle, p=0.666). Secondary haemorrhage, was seen among 15.4% of patients (68/441) in the first audit cycle. In the second cycle, after coblation was discontinued, the secondary haemorrhage rate fell significantly (p<0.001) to 5.8% (24/416). A breakdown of the results of cold steel/diathermy and coblation techniques in both adults and children is also presented.
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Affiliation(s)
- F Javed
- Department of Otorhinolaryngology, Derbyshire Royal Infirmary, UK
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Yuan S, Ferrell C, Chandler WL. Comparing the prothrombin time INR versus the APTT to evaluate the coagulopathy of acute trauma. Thromb Res 2007; 120:29-37. [PMID: 16887171 DOI: 10.1016/j.thromres.2006.07.002] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2006] [Revised: 06/15/2006] [Accepted: 07/07/2006] [Indexed: 11/17/2022]
Abstract
INTRODUCTION In trauma patients, PT/INR or aPTT cutoffs of > or =1.5x normal are often used as triggers for the transfusion of plasma. MATERIAL AND METHODS To evaluate the ability of the PT/INR or aPTT to predict low coagulation factor levels, these tests were compared to coagulation factor levels in samples with artificially prepared single and multiple factor deficiencies, 9 heparin-contaminated samples, 10 lupus inhibitor-containing samples, 21 samples with elevated factor VIII levels, and 35 samples from acute trauma patients. RESULTS AND CONCLUSIONS The PT/INR and aPTT showed comparable sensitivity for single or multiple factor deficiencies in artificially deficient plasmas, but the PT/INR was more sensitive than the aPTT to low coagulation factor levels in actual trauma patients (sensitivity 84% versus 50%). The aPTT can show false positives with lupus anticoagulants and heparin contamination and false negatives in samples with elevated factor VIII. Thus, in the acute trauma setting, the PT/INR cutoff is a more reliable indicator of reduced coagulation factor levels.
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Affiliation(s)
- Shan Yuan
- Department of Laboratory Medicine, Box 357110, University of Washington, Seattle, WA 98195-7110, USA
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Kitszel A, Poznańska M, Krawczuk-Rybak M. Ocena zaburzeń krzepnięcia u dzieci zakwalifikowanych do adeno/tonsilektomii. Otolaryngol Pol 2007; 61:158-61. [PMID: 17668802 DOI: 10.1016/s0030-6657(07)70405-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The routine pre-operative evaluation of children undergoing elective tonsillectomy and/or adenoidectomy includes coagulation screening tests. THE PURPOSE OF THE STUDY detection of coagulation defects in children with planned tonsillectomy and/or adenoidectomy. MATERIAL AND METHODS In our study we examined 68 children with abnormal coagulation profile, age 1-17 (average 7.5), 43 male and 25 female. All children underwent coagulation tests (APTT, PT, INR, D-dimer, fibrynogen). In case of twice indicated coagulopathy we diagnosed the levels of the coagulation protein factors. RESULTS After second verification 15/68 (22%) patients presented prolonged APTT and/or PT. The most common disorder was isolated prolongation of APTT--47/53 (89%), 3/53 (5.5%) had prolonged PT and 3/53 (5.5%) had both disorders in the same time. After vitamin K admission in 19/53 (36%) coagulation tests returned to normal. 13/53 (24%) patients had the factor XII deficiency, 1 patient had a low activity of von Willebrand factor and temporary deficient of factor VIII. In one case we found temporary deficiency of factors VIII and IX and one boy had isolated, temporary deficiency of factor IX. Rest of patients 21/53 (40%), in which the activity of coagulation factors were normal, underwent surgery despite prolonged APTT without any bleeding during or after surgery. CONCLUSIONS The coagulation disorders in analized group of children were unstable or inessential, but in a group of 3/68 (4%) nondiagnosed disorders of coagulation tests, may due to heavy bleeding during or after surgery.
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Affiliation(s)
- Anna Kitszel
- Klinika Onkologii Dzieciecej AM, Samodzielny Publiczny Dzieciecy Szpital Kliniczny w Białymstoku
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Abstract
To assess the likelihood of significant bleeding disorders in children with prolonged activated partial thromboplastin times (aPTTs), a retrospective chart review was performed. Data analyses determined that in the absence of symptoms and a negative family history, the diagnosis of a bleeding disorder was unlikely in an individual with a prolonged aPTT (negative predictive value = 80%). Conversely, a prolonged aPTT was predictive (positive predictive value = 62%) in the presence of both clinical symptoms and a documented family history. The scope of laboratory investigation in any child with a prolonged aPTT should be tempered by the clinical presentation and the associated personal and family histories.
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Affiliation(s)
- Mona D Shah
- Department of Pediatrics, Rainbow Babies and Children's Hospital, University Hospitals of Cleveland, Cleveland, OH, USA
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Burd RS, Mellender SJ, Tobias JD. Neonatal and childhood perioperative considerations. Surg Clin North Am 2006; 86:227-47, vii. [PMID: 16580921 DOI: 10.1016/j.suc.2005.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Randall S Burd
- Department of Surgery, Division of Pediatric Surgery, Robert Wood Johnson Medical School, One Robert Wood Johnson Place, P.O. Box 19, New Brunswick, NJ 08903, USA.
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Ajimura FY, Maia ASSF, Hachiya A, Watanabe AS, Nunes MDPT, Martins MDA, Machado FS. Preoperative laboratory evaluation of patients aged over 40 years undergoing elective non-cardiac surgery. SAO PAULO MED J 2005; 123:50-3. [PMID: 15947829 DOI: 10.1590/s1516-31802005000200003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
CONTEXT AND OBJECTIVE Although it is generally agreed that a medical history and physical examination should be obtained as part of preoperative evaluation, there is still substantial controversy about the additional benefits of preoperative screening tests. The objective of the present study was to determine the percentage of abnormalities on laboratory tests among a population that underwent non-cardiac surgery and to correlate these tests with changes in preoperative evaluation management. DESIGN AND SETTING Cross-sectional study, carried out in a University Hospital. METHODS 991 patients aged over 40 years undergoing elective non-cardiac surgery from July 1997 to January 2000 were studied. Blood cell count, serum sodium, potassium, urea and creatinine, prothrombin, thrombin and partial thromboplastin time, electrocardiogram and chest X-ray were evaluated. RESULTS Out of the 957 electrocardiograms performed, some type of abnormality was found in 504 cases (50.9%) and, among the 646 chest X-rays requested, 271 (42.0%) displayed alterations. Laboratory tests showed abnormal values ranging from 5.1% (prothrombin time) to 41.0% (hematocrit). Increased percentages of abnormal tests with increasing patient age were also observed. CONCLUSIONS Although there were substantial numbers of screening test abnormalities in preoperative evaluations, these results seldom interfered in patient management.
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Affiliation(s)
- Fábio Yoshito Ajimura
- Department of Medicine, School of Medicine, Universidade de São Paulo, Av. Dr. Arnaldo 455, São Paulo, Brazil CEP 01246-903
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Affiliation(s)
- M Greaves
- Department of Medicine and Therapeutics, Polwarth, Foresterhill, Aberdeen AB25 2ZD, UK.
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Kay DJ, Mehta V, Goldsmith AJ. Perioperative adenotonsillectomy management in children: current practices. Laryngoscope 2003; 113:592-7. [PMID: 12671412 DOI: 10.1097/00005537-200304000-00002] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the current practices of preoperative evaluation, surgical techniques, and postoperative treatment of pediatric adenotonsillectomy. STUDY DESIGN Forty-one-item survey measuring the frequency of different evaluations, procedures, and treatments performed, including selected case scenarios, with all items scored on a five-point ordinal scale ranking frequency. METHODS The entire membership of the American Society of Pediatric Otolaryngology (ASPO) and active fellows and members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) residing in New York state were anonymously surveyed through mail-in questionnaires. RESULTS History alone was the most frequent modality for diagnosing both adenoid enlargement and obstructive sleep apnea. The most common preoperative laboratory test ordered before an adenotonsillectomy is a complete blood cell count; ASPO members ordered fewer preoperative laboratory tests than AAO-HNS members. Unipolar cautery is the most frequently used tonsillectomy technique, and curettage followed by cautery is the most popular adenoidectomy technique. Steroids are the most common intraoperative medication administered during an adenotonsillectomy, and office visits remain the most frequently used methods of assessing adenotonsillectomy patients postoperatively. CONCLUSIONS Although there are statistically significant trends uncovered by the survey, the results reflect a lack of consensus regarding adenotonsillectomy management. Further randomized controlled trials or large-scale outcomes projects are much needed to evaluate critically the current practices of pediatric adenotonsillectomies. Additional efforts may also be required to use the information from these studies in effecting changes in actual practice patterns, moving us toward a more evidence-based paradigm of treating pediatric adenotonsillar disease.
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Affiliation(s)
- David J Kay
- Department of Otolaryngology, State University of New York-Downstate, Brooklyn, New York, USA.
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Sandoval C, Garcia C, Visintainer P, Ozkaynak MF, Jayabose S. The usefulness of preoperative screening for bleeding disorders. Clin Pediatr (Phila) 2003; 42:247-50. [PMID: 12739923 DOI: 10.1177/000992280304200308] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Claudio Sandoval
- Department of Pediatrics, New York Medical College, Munger Pavilion Room 110, Valhalla, New York 10595, USA
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Fernández A, Sánchez Canet I, Gómez Fiñana M, López-Escámez JA. [Tonsillectomy by electrical dissection: risk factors of postoperative hemorrhage in children]. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2002; 53:21-6. [PMID: 11998514 DOI: 10.1016/s0001-6519(02)78276-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To identify pre or intraoperative risk factors that could indicate a higher risk for post-tonsillectomy hemorrhage (PTH) in children undergoing electrocautery dissection. SET-UP: Primary referral hospital. DESIGN A retrospective study of 163 post-tonsillectomy children comparing 7 cases of PTH with 156 cases with no PTH. SAMPLE This study includes children under the age of 18 that underwent tonsillectomy by dissection between 1997 and 2000. OUTCOME PARAMETERS Age, sex, height, weight, body mass index, hemoglobin level, hematocrit, platelet count activated partial thromboplastin time (APTT), fibrinogen, ASA index (physical state classification of the American Society of Anesthesiology) and type of hemostasis. RESULTS Prevalence of PTH was 4.29% in the cohort sample. The risk of PTH in children following tonsillectomy by electrodissection is significantly increased in patients over 15 years of age (OR = 8.46, p = 0.04) and when ligatures are used for hemostasis (OR = 8.62, p = 0.02). Activated partial thromboplastin time > or = 32 seconds is marginally significant (OR = 7.82, p = 0.05). CONCLUSIONS Our findings show that tonsillectomy by electrodissection has an increased risk of bleeding in older children and when ligatures are used for hemostasis.
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Affiliation(s)
- A Fernández
- Departamento de ORL, Area de Cirugía, Hospital de Poniente, El Ejido, Almería
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Asaf T, Reuveni H, Yermiahu T, Leiberman A, Gurman G, Porat A, Schlaeffer P, Shifra S, Kapelushnik J. The need for routine pre-operative coagulation screening tests (prothrombin time PT/partial thromboplastin time PTT) for healthy children undergoing elective tonsillectomy and/or adenoidectomy. Int J Pediatr Otorhinolaryngol 2001; 61:217-22. [PMID: 11700191 DOI: 10.1016/s0165-5876(01)00574-2] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In some medical centers, the routine pre-operative evaluation of healthy children undergoing elective tonsillectomy and/or adenoidectomy (T and A) includes coagulation screening tests (PT, prothrombin Time; PTT, partial thromboplastin time; and INR, international normalized ratio). In this retrospective study, we determined whether there is a positive correlation between prolonged PT/PTT/INR tests in healthy children, with no prior medical history of coagulation problems, and bleeding during surgery and/or bleeding in the month following surgery. We reviewed the records of 416 elective T and A surgeries performed at the Soroka University Medical Center in Beer-Sheva, Israel, over the course of 1999. One hundred and twenty-one (29.1%) patients had preoperative prolonged PT values but only four (3.3%) of these patients experienced light bleeding during surgery. Seven (5.8%) of the 121 patients with prolonged PT tests experienced bleeding episodes during the 1st month subsequent to the surgery. Of the 65 (15.6%) patients who had prolonged pre-operative INR values, only three (4.6%) experienced light bleeding during surgery. Two (3.1%) patients with prolonged INR values experienced light bleeding during the 1st month subsequent to surgery. Sixty-one (14.7%) patients had prolonged first preoperative PTT values, only five of whom (8.2%) experienced light bleeding during surgery. Two (3.3%) of the 61 with prolonged PTT values experienced light bleeding during the 1st month subsequent to surgery. We therefore concluded that pre-operative coagulation screening tests provide low sensitivity and low bleeding predictive value. As such, routine coagulation tests before T &A are not indicated unless a medical history of bleeding tendency is suspected.
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Affiliation(s)
- T Asaf
- Pediatric Hemato-Oncology Unit, Soroka University Medical Center, P.O. Box 151, Beer-Sheva 84101, Israel
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Bléry C. [Evaluation of preoperative hemostasis: a change for continuity?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2001; 20:669-71. [PMID: 11695284 DOI: 10.1016/s0750-7658(01)00450-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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