Blood loss,replacement, and associated morbidity in infants and children undergoing craniofacial surgery

Background: Pediatric craniofacial reconstruction (CFR) procedures involve wide scalp dissections with multiple osteotomies and have been associated with significant morbidity. The aim of this study was to document the incidence of clinically important problems, particularly related to blood loss, and perform a risk factor analysis. Methods:  Records of all patients who underwent craniofacial surgery at the Children’s Hospital of Philadelphia between December 1, 2001 and January 1, 2006 were reviewed. Data were collected from the electronic anesthesia record, intensive care unit (ICU) progress notes, and discharge summary. All intraoperative laboratory values and all laboratory values obtained upon arrival in the ICU were recorded. A multivariable analysis was performed to evaluate associations between elements of intraoperative management and the following clinical outcomes: intraoperative hypotension, intraoperative metabolic acidosis, presence of a postoperative coagulation test abnormality, and postoperative administration of hemostatic blood products. Results:  Data for 159 patients were reviewed. The mean volume of packed red blood cells transfused intraoperatively was 51 ml·kg^?1. Multivariable analysis revealed that intraoperative administration of albumin was strongly correlated with both an increased incidence of postoperative coagulation derangements and postoperative administration of hemostatic blood products (Odds Ratio 5.9, 2.8, respectively), while intraoperative fresh frozen plasma (FFP) administration was associated with an opposite effect (Odds Ratio 0.94, 0.97, respectively). Conclusions:  In pediatric CFR procedures where the volume of blood loss routinely exceeds one blood volume, intraoperative administration of FFP favorably impacted postoperative laboratory coagulation parameters.     

Intracerebral hemorrhage after carotid endarterectomy

A series of 14 patients with intracerebral hemorrhage after carotid endarterectomy is reviewed. This complication occurred in 0.6% of 2362 consecutive carotid endarterectomies performed at the Mayo Clinic from 1972 through 1986. All hemorrhages occurred within the first 2 weeks after operation and were ipsilateral to the side of the operation. Eight patients died, and only two made a good recovery. Significant risk factors are hypertension and chronic hemispheric hypoperfusion with impaired autoregulation. The "normal pressure-hyperperfusion breakthrough" syndrome was considered to be operative in 12 of the 14 patients. Nine patients had documented hyperperfusion (at least 100% increase of baseline cerebral blood flow) at the time of surgery. In an additional three patients, normal perfusion-pressure breakthrough was inferred by the clinical course and radiological findings, as well as by the absence of alternative explanations. Patients at risk for postendarterectomy intracerebral hemorrhage include those who have a clinical history suggestive of hemodynamic cerebral ischemia, severe carotid stenosis with limited hemispheric collateral flow, and postendarterectomy hyperperfusion, as measured by intraoperative cerebral blood flow. To minimize the risk of hemorrhage in these patients, strict maintenance of blood pressure at normotensive or even relatively hypotensive levels during the intraoperative and early postoperative periods is advised.     

近红外光谱技术在高血压脑出血术中监测运用的探讨

目的 探讨近红外光谱技术（NIRs）在术前、术中、术后对高血压脑出血病人颅内压（ICP）、脑灌注压（CPP）和生命体征的影响。方法 将高血压脑出血病人20例按健侧及患侧术前、术中、术后监测病人ICP、CPP、脑组织血氧饱和度（rScO2）和生命体征变化,并进行相关性分析。结果 随着手术的进程,患者的CPP值逐渐升高,ICP值逐渐降低,组间差异具有统计学意义（P<0.05）。患侧术前、术中、术后两两比较显示,患侧术前、术中、术后患者的ICP较健侧降低（P<0.05）,ICP在术中、术后亦均低于术前（P<0.05）;术后病人CPP高于健侧（P<0.05）。术前、术中、术后病人的rScO2、脉搏血氧饱和度、心率、收缩压、舒张压、平均动脉压和体温差异均无统计学意义（P>0.05）。术前、术中、术后高血压脑出血患者rScO2水平与CPP呈负相关（P<0.05）,与ICP、平均动脉压呈正相关关系（P<0.05）。结论 NIRs在高血压脑出血病人术前、术中、术后监测可及时获得出血的情况,有助于临床早期诊断和治疗。     

近红外光谱技术在高血压脑出血术中监测运用的探讨

目的 探讨近红外光谱技术（NIRs）在术前、术中、术后对高血压脑出血病人颅内压（ICP）、脑灌注压（CPP）和生命体征的影响。方法 将高血压脑出血病人20例按健侧及患侧术前、术中、术后监测病人ICP、CPP、脑组织血氧饱和度（rScO2）和生命体征变化,并进行相关性分析。结果 随着手术的进程,患者的CPP值逐渐升高,ICP值逐渐降低,组间差异具有统计学意义（P<0.05）。患侧术前、术中、术后两两比较显示,患侧术前、术中、术后患者的ICP较健侧降低（P<0.05）,ICP在术中、术后亦均低于术前（P<0.05）;术后病人CPP高于健侧（P<0.05）。术前、术中、术后病人的rScO2、脉搏血氧饱和度、心率、收缩压、舒张压、平均动脉压和体温差异均无统计学意义（P>0.05）。术前、术中、术后高血压脑出血患者rScO2水平与CPP呈负相关（P<0.05）,与ICP、平均动脉压呈正相关关系（P<0.05）。结论 NIRs在高血压脑出血病人术前、术中、术后监测可及时获得出血的情况,有助于临床早期诊断和治疗。     

Multiple factor analysis of urine leaks after retroperitoneal laparoscopic partial nephrectomy

Laparoscopic partial nephrectomy (LPN) is increasingly becoming a definitive therapeutic option for the treatment of small (less than 4 cm) and select moderate-sized (less than 7 cm) renal tumors. Postoperative hemorrhage and urine leak are the most pertinent complications after nephron-sparing surgery, open or laparoscopic. To our knowledge, the risk factors of urine leaks after retroperitoneal LPN have not been studied. We retrospectively analyzed our experience with retroperitoneal LPN to determine risk factors for postoperative urine leak complications. The records of 236 patients who underwent retroperitoneal LPN for renal tumor from March 2003 to October 2010 were reviewed retrospectively. Urine leak was strictly defined as continued urine output from the drain after postoperative day 2. In our series, 39 patients (16.5%) had urine leak complications. On multivariate analysis, mean estimated blood loss (p = 0.0120) and computed tomography angiogram (CTA) examination (p = 0.0286) were independent predictive factors of urine leaks. Moreover, the intraoperative blood loss was significantly reduced in patients undergoing CTA examination (p = 0.0375). Our investigation showed that factors such as intraoperative blood loss and CTA examination are predictors of urine leaks after retroperitoneal LPN. Less intraoperative blood loss to obtain a clear operative field and meticulous suturing technique are necessary to reduce urine leak probability.     

非心脏手术患者术后谵妄的危险因素

目的 筛选非心脏手术患者发生术后谵妄的危险因素.方法 择期围术期有可疑危险因素的非心脏手术患者480例,年龄18～92岁,根据术后3 d内是否发生谵妄分为术后谵妄组和非术后谵妄组.可疑危险因素进行组间比较后,将差异有统计学意义的因素进行logistic回归分析,筛选发生术后谵妄的危险因素.结果 79例术后发生谵妄,发生率为16.5%.logistic回归分析结果显示,老龄、全身麻醉、手术时间≥3 h、术后Price-Henry疼痛评分为4分、合并肺气肿、饮酒≥3次/周是发生术后谵妄的独立危险因素(P＜0.05),相对危险度依次为1.924、0.188、2.251、1.752、18.954、1.779.结论 老龄、全身麻醉、长时间手术、术后剧烈疼痛、合并肺气肿、长期饮酒是非心脏手术患者发生术后谵妄的危险因素.     

神经内镜下行基底节脑出血血肿清除术的临床体会

［摘要］ 目的 研究神经内镜下血肿清除术和传统开颅血肿清除术治疗基底节脑出血的临床疗效差异。方法 选取2017年01月01日至2018年08月31日期间我科收治的基底节脑出血患者作为研究对象,采用倾向性匹配原则分为开颅组和内镜组,分别为49例和53例,以保证两组患者病情的可比性。开颅组进行传统开颅血肿清除术,内镜组进行完全内镜下血肿清除术,然后比较两组患者的术中和术后相关信息、术后并发症差异、临床预后差异,以评价两种手术方式的优弊。结果 开颅组患者和内镜组患者在手术用时、血肿清楚率、再出血发生率上并无统计学差异（P>0.05）,但内镜组患者在术中出血量低于开颅组,术后2周、3个月时GCS评分要高于开颅组,差异有统计学意义（P<0.05）;开颅组和内镜组患者术后出现肺部感染、泌尿系感染、静脉血栓、消化道出血、术口感染、术后癫痫上无统计学差异（P>0.05）,但在术后脑水肿的发生率上内镜组低于开颅组,差异有统计学意义（P<0.05;内镜组患者在术后3个月时的GOS评分、ADL评分平均秩次均高于开颅组,差异有统计学意义（P<0.05）。结论 对基底节脑出血的手术治疗,内镜下血肿清除术优于传统血肿清除术。     

急性ANH 联合低中心静脉压对肝癌手术患者凝血功能的影响

目的：观察急性等容血液稀释（ANH）联合低中心静脉压（ANH+LCVP）在肝癌手术中对患者凝血功能的影响。 方法：40例ASA I~II级拟行肝癌切除手术患者随机均分为观察组与对照组,观察组于全麻后行ANH,入室到肝实质横断分离完成前行控制性LCVP,对照组按常规处理。记录患者术中、术后的出血量和术后因腹腔出血需再次手术的患者例数,以及不同时间点患者的血红蛋白（Hb）、红细胞压积（HCT）、血小板（PLT）、纤维蛋白原（FIB）、活化部分凝血酶时间（APTT）、凝血酶原时间（PT）、国际标准化比例（INR）,凝血时间（ACT）、血块凝结速率（CR）、血小板功能（PF）等。 结果：观察组患者术中出血量明显少于对照组（P<0.05）,而术后出血量两组间差异无统计学意义（P>0.05）,两组均无因继发性出血而再次手术的患者;观察组在采血后、肝癌切除后、恢复容量后Hb、HCT、PLT、FIB、CR、PF较术前均明显下降,APTT、PT、INR、ACT较术前均明显升高,但恢复容量后比肝癌切除前各指标均明显改善（P<0.05）;对照组患者从手术开始至结束,Hb、HCT、PLT、FIB、CR、PF呈进行性降低,APTT、PT、INR、ACT呈进行性升高;手术结束后观察组各项指标明显较对照组改善（P<0.05）。 结论：ANH+LCVP能够减少术中出血,对患者的凝血功能有一定的影响,但是不会导致异常出血,可以安全应用肝癌手术中。

     

围手术期全程血液管理在老年腰椎退行性疾病治疗中的应用

目的观察围手术期全程血液管理对老年腰椎退行性疾病患者术中出血量、术后引流量以及输血量的影响,探讨减少围手术期出血的有效方法。方法回顾性分析2014年1月—2016年12月收治的90例老年退行性腰椎疾病患者,早期45例患者采用围手术期常规血液管理模式(常规组),后期45例患者采用围手术期全程血管理模式(全程组)。记录并比较2组患者手术时间、术中出血量、术后引流量、输血例数及输血量、血红蛋白浓度和红细胞压积。结果全程组手术时间、术中出血量、术后引流量、输血例数、输血量均低于常规组,术后3 d及1周血红蛋白浓度、红细胞压积均高于常规组,差异均具有统计学意义(P0.05)。结论老年腰椎退行性疾病患者采用围手术期全程血液管理可有效降低术中出血量和术后引流量,降低输血量和输血率,有利于患者术后恢复。     

Early postoperative hemorrhage requiring urgent surgical reintervention after orthotopic liver transplantation

Hemorrhage is a common complication in the early postoperative period after orthotopic liver transplantation (OLT) and surgical reintervention may be necessary. We sought to assess the incidence as well as to identify potential risk factors for bleeding requiring surgical reintervention in the early postoperative period. From January 2003 to December 2005, we retrospectively reviewed the courses of 261 patients who underwent OLT. We analyzed the pretransplantation parameters, transplantation features, and clinical data for surgical reintervention due to early postoperative hemorrhage. Twenty-two of 261 patients (8.4%) had early postoperative hemorrhage requiring urgent surgical reintervention during the initial hospital stay. In-hospital mortality of the patients with hemorrhage (9/22; 41%) was significantly higher than that of other patients (29/239; 12.1%; P < .001). The surgical problem was the main cause of hemorrhage (18/22; 81.8%). More intraoperative blood transfusions were necessary for patients with hemorrhage than for other patients. Furthermore, a greater number of blood transfusions, including red blood cells, plasma, and platelet concentrates, during the transplantation procedure correlated with a greater mortality. In conclusion, early postoperative hemorrhage requiring urgent surgical reintervention is a severe complication with a high mortality. It is mainly caused by errors in surgical technique. Blood transfusion during transplantation was correlated with a higher mortality.     

Transcranial Doppler monitoring of cerebral blood velocity during craniotomy

Transcranial Doppler techniques were used to monitor blood velocity in cerebral arteries continuously during 14 neurosurgical operations performed on 13 patients, including 12 craniotomies. Stable Doppler signals were obtained for prolonged periods of time, and they correlated with intraoperative events. Monitoring during spontaneous blood pressure and CO2 variations allowed assessment of autoregulatory capacity. In particular, 5 of the 7 patients receiving craniotomy for aneurysmal subarachnoid hemorrhage had impaired autoregulation. A 30 to 50% decrease in Doppler velocities was seen in 7 patients after etomidate administration. Early experience suggests that transcranial Doppler monitoring during craniotomy is feasible and can indicate the effects of operative events on blood flow as well as provide an assessment of cerebral autoregulation.     

Asymptomatic intracerebral hemorrhage under strict blood pressure control due to postoperative cerebral hyperperfusion in a patient with moyamoya disease

We report a case of moyamoya disease manifesting as asymptomatic intracerebral hemorrhage due to postoperative cerebral hyperperfusion, despite the prophylactic intensive blood pressure control. This 35-year-old man initially suffered from right upper quadrantanopsia and was found to have cerebral infarction in the left occipital lobe due to moyamoya disease. He also manifested preoperatively a small intracerebral hemorrhage at the left caudate nucleus. The left cerebral hemisphere showed apparent hemodynamic compromise, thus he underwent left superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis with indirect pial synangiosis. He was subjected to prophylactic strict blood pressure control postoperatively to avoid hyperperfusion syndrome. The N-isopropyl-p-¹²³I-Iodoamphetamine SPECT (¹²³I-IMP-SPECT) 1 day after surgery showed intense increase in cerebral blood flow (CBF) at the site of the anastomosis, and further blood pressure lowering was attempted. He did not suffer from neurologic deterioration during the postoperative period, while computed tomography (CT) 7 days after surgery revealed asymptomatic intracerebral hematoma (ICH) at the subcortex under the site of the anastomosis. Cerebral hyperperfusion is a potential complication of revascularization surgery for moyamoya disease. Accurate diagnosis and proper management of hyperperfusion are essential to avoid deleterious neurologic event due to hyperperfusion.     

破裂性腹主动脉瘤的急救及围手术期危险因素：附27例报告

目的:探讨破裂性腹主动脉瘤(r AAA)的急救经验及围手术期危险因素。方法:回顾性分析2007年1月—2015年9月间救治的27例r AAA患者的临床资料,其中男20例,女7例;中位年龄72岁;18例行开腹手术,6例腔内治疗(包括1例行杂交手术)。总结诊治过程、围术期情况及随访结果,并分析影响预后的因素。结果:术前死亡3例,术中死亡1例,术后死亡9例,术后死因有急性肾衰、急性呼衰、腹腔间隔室综合征、心肌梗塞、消化道出血,最终均出现多器官功能衰竭。总体抢救成功率为51.9%(14/27),开腹手术和腔内治疗成功率分别为50.0%(9/18)和83.3%(5/6)。围术期存活和死亡患者间的临床参数比较显示,发病到就诊时间、术前收缩压、术前肌酐、术中出血量及输血量、术中尿量的差异有统计学意义(均P0.05)。结论:r AAA病情危重,病死率高,尽早确诊后应紧急外科治疗控制出血,加强围术期管理。在r AAA的救治中,腔内治疗是一种有效的治疗手段。     

A study on postoperative management and pre-and postoperative changes of blood volume in orthopedic surgery (author's transl)

In order to apply adequate postoperative management of patients in the orthopedic surgery, the in vivo effects of the operations were investigated in the present study, from various viewpoints such as circulatory functions, metabolism of proteins, and hepatic and renal functions. In addition, the circulating blood volumes were determined in order to know the variations in the amount of blood loss from the operated regions during and after operations so as to improve the operative and postoperative management. On the basis of the results, the countermeasures against the adverse variations in blood volume were also investigated. Pediatric patients were found to be prone to develop more appreciable systemic postoperative reactions than those in adult ages, especially so in those of circulatory system, peripheral blood, hepatic functions, and protein metabolism, and also prone to be more affected by operative procedures. Senile patients were found to be prone to have less reserve capacity in circulation, peripheral blood, renal functions, and protein metabolism, and also prone to show delayed postoperative reactions and slower recoveries. The results of measurement of circulating blood volume in pre- and postoperations revealed that the loss of circulating blood in most patients was greater than the bleeding weight during the operation measured by gause count, and that, on the day following the operation, the blood volume was reduced by about 10-15% than those immediately after the operation. It was concluded that, as a whole, no changes causing serious deviation from the normal physiological ranges occur except in pediatric and senile patients. On the basis of the above findings, most appreciable systemic postoperative reactions of the operative procedures in orthopedic surgery would be attributed to by loss of blood volume during operations and that the postoperative hemorrhage from bone structure (which is usually difficult to control) or the postoperative hemorrhage after removal of air tourniquet would be almost negligible.     

Guglielmi detachable coil: report of intraoperative complications

The newest therapy for cerebral aneurysm is the Guglielmi detachable coil (GDC). The authors describe the anesthetic management of two patients with intraoperative subarachnoid hemorrhage during Guglielmi coil placement. Various treatments for intraoperative hemorrhage are discussed, as are other common complications that can occur during placement of intravascular, intracranial coils. The placement of a ventriculostomy was a major contributing factor in the good outcome of both patients. Consideration should be given to placement of a ventriculostomy before the GDC procedure. Although the GDC procedure offers much promise, it is not a benign procedure and has its own set of complications that will no doubt challenge the neuroanesthesiologist.     

Alpha blockade in preoperative preparation of patients with pheochromocytomas

Preoperative preparation in pheochromocytoma is usually performed by alpha-adrenergic blockers. We retrospectively reviewed the efficiency of phenoxybenzamine, prazosin, and doxazosin in preoperative preparation. Phenoxybenzamine was used for preoperative preparation of 21 pheochromocytoma patients, prazosin was used in 11 patients, and doxazosin was used in 17 patients. Intraoperative and early postoperative blood pressure records and postoperative volume replacement records were reviewed. Intraoperative hypertension occurred in 17 patients in the phenoxybenzamine group (81%), eight patients in the prazosin group (73%), and 14 patients in the doxazosin group (82%). There was no statistical difference among the groups (P > 0.05). There was also no significant difference between postoperative blood pressure measurements and the operative and postoperative volume replacements. We have found that there were no significant difference in the operative and postoperative blood pressure and plasma volume control among the three groups. We conclude that pheochromocytoma surgery is safe with any of these preoperative medications.     

An elderly patient without evidence of major organ damage following severe hemodilution caused by massive intraoperative hemorrhage

An 82-year-old woman with hematemesis was admitted to our hospital. Diagnosis of bleeding from gastric ulcer was made and an emergency operation was performed. Although she fell into sudden hypotension, ventricular tachycardia and severe hemodilution lasting for 45 minutes (minimum hemoglobin concentration of 1.8 g x dl(-1)) caused by intraoperative massive hemorrhage, she recovered without any apparent postoperative damage in major organs. The major reasons for evading organ damage may be attributable to maintenance of blood pressure and circulatory volume, and to early medication for prevention of systemic inflammatory response syndrome or disseminated intravascular coagulation.     

Factors affecting postmusculoskeletal tumour surgery wound problem treatment with negative pressure wound therapy

The aim of the study is to investigate the risk factors identified in literature that have been associated with prolonged Negative Pressure Wound Therapy (NPWT). Our study included patients who developed local wound problems after bone or soft tissue sarcoma surgery with negative margin at our clinic between 2012 and 2018 and treated with NPWT. All patients were followed up of at least 6 months. Sex, albumin level, skin infiltration, type of wound problem, postoperative intensive care unit (ICU) requirement, and intraoperative blood loss were found to be influential factors on NPWT > 10 sessions. We conclude that treatment may be prolonged and the necessary precautions need to be taken in patients with an impaired preoperative nutritional condition, with intraoperative high amount of blood loss, and with long postoperative stays in the ICU as well as if the underlying cause for wound problem is an infection.     

肝下下腔静脉阻断与控制性低中心静脉压在复杂肝切除术中应用的比较

目的:比较肝下下腔静脉(IIVC)阻断与控制性低中心静脉压(CLCVP)技术在复杂肝切除术中应用的安全性及有效性。方法:回顾性分析2016年3月—2017年12月行复杂肝切除术的103例原发性肝癌患者临床资料,术中所有患者均采用Pringle法控制入肝血流,其中56例行IIVC阻断(IIVC阻断组),47例行CLCVP技术(CLCVP组)降低中心静脉压(CVP)。比较两组切肝过程中CVP的变化、切肝过程出血量、手术总出血量、术中尿量、输血率、术后并发症发生率、术后肝功能与肾功能变化。结果:两组患者一般资料差异无统计学意义(均P0.05)。与切肝前对比,两组患者在切肝过程中CVP均明显下降,但IIVC阻断组CVP较CLCVP降低更明显,且IIVC阻断组切肝过程中出血量、手术总出血量、术后第3天ALT和术后第3、7天TBIL均明显低于CLCVP组(均P0.05)。两组患者术中尿量、输血率及术后并发症发生率、肾功能情况差异无统计学意义(均P0.05)。结论:IIVC阻断联合Pringle法操作简单方便,相对于CLCVP技术,其对全身血流动力学影响较小,肝功能恢复更快,且更容易降低CVP,减少术中肝脏断面出血,有利于提高复杂肝切除术的安全性。     

Blood transfusion and increased risk for vasospasm and poor outcome after subarachnoid hemorrhage

OBJECT: Nitric oxide (NO) metabolism may influence vasospasm after subarachnoid hemorrhage (SAH). It has been demonstrated in recent studies that erythrocytes carry NO for release in vessels, whereas transfused erythrocytes may lack stored NO. Several converging lines of evidence also indicate that blood transfusion may exacerbate poor outcomes in some critically ill patients. In this study the authors hypothesized that patients with SAH who received red blood cell (RBC) transfusions were at greater risk for vasospasm and poor outcome. METHODS: The authors retrospectively reviewed a prospective observational database, including hospital records, computerized tomography (CT) scans, and pre- and postoperative four-vessel angiograms, in which the management methods used in 441 patients undergoing surgery for ruptured cerebral aneurysms were described. Two hundred seventy patients (61.2%) received an RBC transfusion during their hospital stay. After adjustment for Hunt and Hess grade, SAH grade on CT scans, delay between rupture and surgery, smoking status, and intraoperative aneurysm rupture, a worse outcome was more likely in patients who received intraoperative blood (odds ratio [OR] 2.44, confidence interval [CI] 1.32-4.52; 120 patients). Intraoperative RBC transfusion did not influence subsequent angiographically confirmed vasospasm (OR 0.92, CI 0.6-1.4). Worse outcome was observed in patients who received blood postoperatively (OR 1.81, CI 1.21-2.7), but not after adjustments were made for confounding variables (OR 1.48, CI 0.83-2.63). Angiographic vasospasm was observed in 217 patients and, after adjusting for confounding variables, was more frequent among patients who received postoperative RBC transfusion (OR 1.68, CI 1.02-2.75). Among patients in whom angiographically confirmed vasospasm developed there was a tendency to have received more blood than in those with no vasospasm; however, a clear dose-dependent response was not observed. CONCLUSIONS: Development of angiographically confirmed vasospasm after SAH is associated with postoperative RBC transfusion and worse outcome is associated with intraoperative RBC transfusion. Before blood is transfused, patients with SAH should be carefully assessed to determine if they are symptomatic because of anemia.