EFFECT OF PREOPERATIVE STEROIDS ON PERIOPERATIVE AND POSTOPERATIVE HAEMORRHAGE IN PATIENTS UNRERGOING FESS AT SKMCH, MUZAFFARPUR, BIHAR

Objective: To compare the effect of preoperative oral steroids (prednisolone) on perioperative and postoperative hemorrhage in patients undergoing functional endoscopic sinus surgery for chronic sinusitis with those who do not receive steroids. Design:Randomized controlled trials. Place and duration of study:This study was conducted in ENT Department of Sri Krishna Medical College and Hospital (SKMCH), Muzaffarpur, Bihar from April 2020 to March 2021. Material and Methods: After getting informed consent total of 60 patients who fullled the inclusion criteria were selected and functional endoscopic sinus surgery was carried out. They were divided into two groups of 30 each by using random number tables. Group A received prednisolone in a dose of 01 mg/kg body weight for 01 week prior to surgery (last day of dose being the day prior to operative day) while group B (control group) did not receive any steroid. Results:There was a signicant difference in both perioperative and postoperative hemorrhage with better control rates in group A. Conclusion: Prednisolone given preoperatively signicantly reduces the morbidity that is perioperative and postoperative hemorrhage thus early recovery to normal life style in patients undergoing functional endoscopic sinus surgery for chronic sinusitis.

Transcatheter Artery Embolization for Postoperative Haemorrhage after Arterio-Venous Malformation – Safer Option

Introduction: Hemorrhage is one of the commonest and dreaded complications especially with pelvic surgeries. Gestational trophoblastic neoplasias (GTN) are notorious for their propensity to bleed torrentially and metastasis to vital organs. GTN is associated with an arterio-venous malformation (AVM) about 10-15% of the time, which can lead to bleeding after surgery or after complete remission. After the failure of conventional management with chemotherapy or surgery one is compelled to take another modality of management. One of such methods is the use of transcatheter artery embolization in cases of GTN or post-hysterectomy cases of GTN. Transcatheter artery embolization (TAE) was effective in controlling bleeding due to arterio-venous malformation in 96% of cases.Case: 46 years P2L2A5 (para 2, living issue 2, abortion 5) post-hysterectomy patient presented with bleeding from the vagina after surgery. Twice she underwent vaginal vault repair after hysterectomy but failed. Ultrasonography (USG) showed arterio-venous malformation (AVM); angiography revealed massive extravasation from (left internal iliac artery and abnormal vascularity from the right internal iliac. She was taken up for bilateral internal iliac arteries embolization but again had a heavy bout of bleeding after one week. CT scan confirmed a residual lesion and she underwent a repeat embolization after which the bleeding stopped. Serum BHCG was advised during workup and it was 1997 IU/ml. A diagnosis of GTN was confirmed. The patient was discharged after two cycles of chemotherapy with advice to review for the third one on an outpatient department basis.Conclusion: We concluded that TAE is an effective and safer alternative to surgery in postoperative bleeding from AV malformation in the case of GTN. It can be repeated and should be made to more liberal use in emergency settings.

Practical model to identify liver transplant recipients at low risk of postoperative haemorrhage, bile leakage and ascites

Background This study aimed to identify a subgroup of recipients at low risk of haemorrhage, bile leakage and ascites following liver transplantation (LT). Methods Factors associated with significant postoperative ascites (more than 10 ml/kg on postoperative day 5), bile leakage and haemorrhage after LT were identified using three separate multivariable analyses in patients who had LT in 2010–2019. A model predicting the absence of all three outcomes was created and validated internally using bootstrap procedure. Results Overall, 944 recipients underwent LT. Rates of ascites, bile leakage and haemorrhage were 34.9, 7.7 and 6.0 per cent respectively. The 90-day mortality rate was 7.0 per cent. Partial liver graft (relative risk (RR) 1.31; P = 0.021), intraoperative ascites (more than 10 ml/kg suctioned after laparotomy) (RR 2.05; P = 0.001), malnutrition (RR 1.27; P = 0.006), portal vein thrombosis (RR 1.56; P = 0.024) and intraoperative blood loss greater than 1000 ml (RR 1.39; P = 0.003) were independently associated with postoperative ascites and/or bile leak and/or haemorrhage, and were introduced in the model. The model was well calibrated and predicted the absence of all three outcomes with an area under the curve of 0.76 (P = 0.001). Of the 944 patients, 218 (23.1 per cent) fulfilled the five criteria of the model, and 9.6 per cent experienced postoperative ascites (RR 0.22; P = 0.001), 1.8 per cent haemorrhage (RR 0.21; P = 0.033), 4.1 per cent bile leak (RR 0.54; P = 0.048), 40.4 per cent severe complications (RR 0.70; P = 0.001) and 1.4 per cent 90-day mortality (RR 0.13; P = 0.004). Conclusion A practical model has been provided to identify patients at low risk of ascites, bile leakage and haemorrhage after LT; these patients could potentially qualify for inclusion in non-abdominal drainage protocols.

Effect of pre-incisional infiltration of 0.5% ropivacaine versus placebo in post-operative pain relief among patients undergoing tonsillectomy under general anaesthesia: a comparative study

<p><strong>Background:</strong> Pain is the most common complaint in the immediate post-tonsillectomy period. Inadequate post-tonsillectomy pain management has many drawbacks. Ropivacaine is a new long acting local anaesthetic, structurally closely related to bupivacaine.</p><p><strong>Methods: </strong>It was a prospective double blinded randomized control trial on a total of 50 patients who were posted for tonsillectomy. Randomization of each patient was done into two groups one of which had received 4 ml of 0.5% ropivacaine hydrochloride solution and other 4 ml normal saline. Data entry and analysis was done with (SPSS IBM) version 21.0. Both univariate and bivariate analysis done. Proportions were calculated for qualitative variables and mean with standard deviation was done for quantitative variables. Required tests of significance such as Chi square test and independent test were applied. Significance of p value is taken as p&lt;0.05. Postoperative pain, first post op oral intake, duration of post-operative hospital stay, and postoperative haemorrhage was assessed. The intensity of postoperative pain was assessed on behavioural observational pain Scale and Wong baker faces pain rating scale.</p><p><strong>Results:</strong> Pre-incisional infiltration of 0.5% Ropivacaine was an effective method to reduce post-operative pain in patients undergoing tonsillectomy under GA. Effect of Ropivacaine was statistically significant (p&lt;0.05).</p><p><strong>Conclusions:</strong> We recommend the use of 0.5% ropivacaine pre-incisional infiltration in patients undergoing tonsillectomy.</p>

Trial protocol: preoperative administration of tranexamic acid in sleeve gastrectomy (PATAS) to reduce haemorrhage rates. A randomised controlled trial

IntroductionFast-track protocols often include short-term thromboprophylaxis and short length of hospital stay. These treatment strategies may negatively affect the occurrence and diagnosis of postoperative haemorrhage. Over the years, the rates of venous thromboembolic events (VTEs) have decreased, while there seems to be an increase in the occurrence of postoperative haemorrhage. Tranexamic acid (TXA) can potentially lower the incidence of postoperative haemorrhage. This trial aims to investigate whether preoperative administration of TXA reduces the preoperative and postoperative haemorrhage rates in laparoscopic sleeve gastrectomy (LSG).Methods and analysisThis is a single centre double-blind randomised placebo-controlled trial. Patients undergoing an LSG are included after obtaining informed consent. Patients are randomised between two groups: (1) administration of placebo infusion and (2) administration of 1500 mg TXA. In both groups, the infusions will be administered during the induction phase of the procedure. Primary outcome measures are preoperative use of haemostatic clips, postoperative haemoglobin decrease and postoperative haemorrhage. Secondary outcome measure is the rates of VTE.Ethics and disseminationThe protocol version 3 was approved by the medical ethical committee Medical Research Ethics Committees United (MEC-U), Nieuwegein, on 29 July 2019. The trial results will be submitted for publication in a peer-reviewed journal and at conference presentations.Trial registration numberThe Netherlands Trial Registry (NL8029); Pre-results.

Incidence, aetiology and outcomes of major postoperative haemorrhage after pulmonary lobectomy

OBJECTIVES Post-lobectomy bleeding is uncommon and rarely studied. In this study, we aimed to determine the incidence of post-lobectomy haemorrhage and compare the outcomes of reoperation and non-operative management. METHODS We conducted a single-institution review of lobectomy cases from 2009 to 2018. The patients were divided into two groups based on the treatment for postoperative bleeding: reoperation or transfusion of packed red blood cells with observation. Transfusion correcting intraoperative blood loss was excluded. One or more criteria defined postoperative bleeding: (i) drop in haematocrit ≥10 or (ii) frank, sustained chest tube bleeding with or without associated hypotension. Covariates included demographics, comorbidities and operative characteristics. Outcomes were operative mortality, complications, length of hospital stay and readmission within 30 days. RESULTS Following 1960 lobectomies (92% malignant disease, 8% non-malignant), haemorrhage occurred in 42 cases (2.1%), leading to reoperation in 27 (1.4%), and non-operative management in 15 (0.8%). The median time to reoperation was 17 h. No source of bleeding was identified in 44% of re-explorations. Patients with postoperative haemorrhage were more often male (64.3% vs 41.2%; P < 0.01) and more likely to have preoperative anaemia (45.2% vs 26.5%; P = 0.01), prior median sternotomy (14.3% vs 6.0%; P = 0.04), an infectious indication (7.1% vs 1.8%; P = 0.01) and operative adhesiolysis (45.2% vs 25.8%; P = 0.01). Compared with non-operative management, reoperation was associated with fewer units of packed red blood cells transfusion (0.4 vs 1.9; P < 0.001), while complication rates were similar and 30-day mortality was absent in either group. CONCLUSIONS Haemorrhage after lobectomy is associated with multiple risk factors. Reoperation may avoid transfusion. A prospective study should optimize timing and selection of operative and non-operative management.

Early Laparotomy: A Necessity for Postoperative Intraperitoneal Hemorrhage

Introduction: Haemorrhage is considered the dreaded complications following any surgery. “Relaparotomy” is a better described terminology for a repeat case postoperative haemorrhage in gynecological surgeries. With increased awareness and early detection and subsequent rise in gynaecological operations have led additional incidence of relaparotomies and further in morbidity and mortality. Methods: The study was conducted from April 2006 - March 2017 including cases of re/laparotomy for intraperitoneal bleeding at TUTH, Nepal. Results: There were 27 cases of intraperitoneal hemorrhage majorly from 20 abdominal surgeries comprising 12(44.4%) abdominal hysterectomies, 6 (22.2%) laparotomy, 1(3.7%) each of diagnostic laparoscopy and abdomino perineal approach and 7(26%) vaginal hysterectomies. Features of hypovolaemic shock in 14(51.8%), marked abdominal distention in 9(33.3%) and blood loss of 400 to 3000 ml was observed. Five (18.5%) cases of active bleeding from pedicales were secured. Oozing from various sites (10, 37%) cured with haemostatic sutures. Generalised oozing post diagonistic laproroscopy, subtotal hysterectomy was done (1, 3.7%). In 2 (7.4%) cases bleeding from fallopian tube and mesosapinx were sutured. Six (22.2%) hematomas were evacuated and bleeders secured. Dissection of left uterosacrial ligament and tearing of infundibulopelvic ligaments (1, 3.7%) were reinforced and sutured. Sputter in the vault (1, 3.7%) were ligated and isolated rise in PT (1, 3.7%) with FFP transfusion. Two succumbed to death, one following diagnostic laparoscopy from adult respiratory distress syndrome and next from VH with PFR anesthetic complications. Conclusion: Proper closure of surgical incision with the right technique, appropriate ligature, careful tying of the blood vessel, monitoring pulse rate and blood pressure in postoperative cases can minimize the morbidity and mortality.

P118 A novel technique for repair of the vertebral artery during cranial surgery

ObjectivesTo demonstrate a novel/alternative technique for repair of the vertebral artery intraoperatively.DesignLeft-sided retromastoid craniotomy in one patient.SubjectsA 61-year-old male patient with meningioma in the foramen magnum encasing the vertebral artery on the left side.MethodsStandard retrosigmoid craniotomy performed with preservation of transverse and sigmoid sinuses. The dura was opened and the cerebellum was retracted with CSF release. The tumour was debulked gradually. The attempt to peel the tumour from the vertebral artery resulted in arterial bleeding. The hole in the artery was sealed using an N-hydroxysuccinimide functionalised polyethylene glycol-coated collagen patch (Hemopatch®, Baxter Healthcare Ltd) as an onlay, applying pressure for 2 minutes. Another patch was applied for further support and the artery checked for haemostasis. The dura was closed with 3–0 vicryl and Hemopatch® onlay after further tumour debulking.ResultsHaemostasis of the vertebral artery was achieved at 140 mmHg SBP and a catheter angiogram found no dissection or false lumen. The patient did not suffer postoperative haemorrhage and after three months of inpatient rehabilitation was discharged with significantly improved cranial nerve function. There was no CSF leak.ConclusionsHaemostasis was successfully achieved in the vertebral artery with this novel technique. It can prove to be important in such scenarios where direct cross-clamping and arterial repair is technically challenging and can lead to brainstem ischemia.

Twelve autologous blood transfusions in eight cats with haemoperitoneum

Objectives The objectives of this study were to describe the clinical use and outcome of autologous transfusions in cats with intracavitary haemorrhage. Methods A retrospective descriptive study was performed. Computerised medical records of a single referral centre were searched for cats receiving an autotransfusion. Medical records were evaluated for underlying disease process, autotransfusion technique, autotransfusion volume, time period over which the autotransfusion was given, packed cell volume (PCV) pre- and post-autotransfusion, percentage rise in PCV, use of other blood products and any complications of the procedure. Survival to discharge and survival at 2 months was documented. Results Between July 2012 and March 2018 a total of 12 autotransfusions were performed in eight cats. All patients were diagnosed with haemoperitoneum. Four of the eight cats were diagnosed with abdominal neoplasia, three had postoperative haemorrhage and one had a traumatic haemoperitoneum. Three cats received more than one autotransfusion. Blood was collected using a 23 G butterfly catheter and 20 ml syringe in 7/12 collections, a 23 G needle and 20 ml syringe in 2/12 collections and directly into syringes from the open abdomen at the time of surgery in 3/12 collections. A median volume of 50 ml (range 25–80 ml) was collected and administered, meaning a median volume of 16.5 ml/kg (range 9–26 ml/kg) was administered. The autologous transfusions were given over a median of 3 h (0.25–6 h). Five cats were given another blood product alongside the autotransfusion. Median percentage PCV increase was 5% (range 1–7%). Anticoagulant was used in 5/12 autotransfusions. No clinically relevant adverse effects were reported. Six of the eight cats survived to discharge. Two month survival was 60% (3/5). Conclusions and relevance Autologous transfusion appears to be a safe and effective technique for stabilising cats with haemoperitoneum. This technique allows rapid and cheap provision of blood and avoids the need for an allogenic blood donor.