Safety of "needle" regional anaesthesia for anterior segment surgery under antiplatelet agents and anticoagulants therapies

Introduction

Cataracts preferentially affect the elderly. More than 560,000 procedures are performed annually in France on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet and/or anticoagulants. Haemorrhagic complications resulting from cataract surgery and/or eye regional anaesthesia are rare but can lead to serious damage to eye function.

Patients and methods

In this study, we compared the management care of two types of antiplatelet and/or anticoagulants successively utilizing the following procedure: first, the cessation of antiplatelet agents and anticoagulants were relayed with rapid elimination agents (constituting our reference “before” cohort [November 2004–May 2005]), then the antiplatelet or anticoagulant management was continued without stint according to recent data from literature (constituting our “after” cohort (April 2007–March 2008)).

Results

A reference population, consisting of 229 patients, was operated on exclusively with “surgical” sub-Tenon's anaesthesia. A second group, consisting of 178 patients, was operated on using “needle” regional anaesthesia. In both populations, nearly 33% of patients received antiplatelet or anticoagulant treatment. The incidence of subconjonctival haemorrhage occurred more frequently when anticoagulants agents were relayed (33% vs 0%; P < 0,05), but there was no significant difference with antiplatelet agents (23% vs 8%; NS). The most common non-bleeding event was Chemosis and related to the type of anaesthetic technique utilized, although not serious it tended to jeopardize surgical comfort (anticoagulants: 35% vs 36% (NS), antiplatelet agents: 38% vs 40%; NS).

Conclusion

The technical changes do not explain fully that occurrence of the HSC, in patients under anticoagulant treatment, decreased in the second period. The achievement of “needle” regional anaesthesia in the anterior segment eye surgery is a safe technique that does not require stopping antiplatelet treatment or anticoagulation.     

Helicobacter pylori and Bleeding Duodenal Ulcer: Prevalence of the Infection and Role of Non-steroidal Anti-inflammatory Drugs

Background: Several authors have reported low prevalence of Helicobacter pylori infection in patients with upper gastrointestinal bleeding (UGIB). Our aim was to study the prevalence of H. pylori in bleeding duodenal ulcer (DU), with both invasive and non-invasive methods, and to assess the role of non-steroidal anti-inflammatory drugs (NSAIDs). Methods: Ninety-two patients with bleeding DU were prospectively studied. The use of NSAIDs was evaluated by specific questionnaire. As a control group, 428 patients undergoing outpatient evaluation for the investigation of dyspepsia and found to have a DU at endoscopy were included. At endoscopy, two antral biopsies were obtained (H&E stain). A 13C-urea breath test was carried out in all patients. Breath test was repeated in patients treated with omeprazole during the hospitalization if H. pylori was not detected with the first test. Results: Gastric biopsies could be obtained in 39 patients with UGIB. Three patients with UGIB treated with omeprazole and being H. pylori negative with the first breath test were finally considered infected with the second test. Overall, 92.4% (95% CI, 85%-96%) of the patients with UGIB were infected (89.7% with histology and 92.4% with breath test (P = 0.15)). Concordance kappa value for both diagnostic tests was 0.64. NSAID intake was more frequent in patients with UGIB (34%) than in those without UGIB (5.6%) (P &lt; 0.001), while H. pylori infection was less frequent in patients with UGIB (92.4% (85%-96%)) than in those without UGIB (99.1% (98%-100%); P &lt; 0.001). Even in patients with UGIB, NSAID intake was the only risk factor in 5% of cases. The proportion of cases without H. pylori infection and without NSAID intake was very low in both bleeding and non-bleeding ulcers (2% and 0.5%, respectively; P = 0.146). H. pylori prevalence in bleeding ulcers was of 84% (67%-93%) in patients with NSAID intake, and 96.7% (89%-99%) when patients taking NSAIDs were excluded. In the multivariate analysis, NSAID intake (odds ratio, 9.8 (5.2-18.4)) correlated with UGIB; however, neither H. pylori status nor the interaction between H. pylori infection and NSAID intake correlated with UGIB. In the multivariate analysis in the subgroup of patients with UGIB, NSAID use was the only variable which correlated with H. pylori prevalence (odds ratio, 0.18 (0.03-0.97)). Conclusions: The most important factor associated with H. pylori-negative bleeding DU is NSAID use, and if this factor is excluded prevalence of infection is almost 100% (97%), similar to that found in patients with non-bleeding DU (and without NSAID intake). Bleeding DU patients with neither H. pylori infection nor NSAID use are extremely rare (only 2%), which suggests that the pathogenesis of bleeding DU is similar to that of non-complicated DU disease.     

Unusual cause of haemorrhage from surgical wound in a child

Haemorrhage from a surgical wound can be from many potential sources such as injury to vessel, muscle and bone; bleeding disorders; incomplete haemostasis; pseudoaneurysm; and neovascularisation. We report an unusual cause of haemorrhage from the surgical incision in a 9-year-old child. We emphasize that a high index of suspicion is required for early diagnosis, and pseudoaneurysm and neoangiogenesis should be considered in the differential diagnosis of soft tissue masses resulting from direct, blunt trauma even in children.     

Intracranial tumour haemorrhage following intravenous thrombolysis

Intravenous administration of thrombolytic agents is considered to be contraindicated in patients with intracranial neoplasms. However, only a single case of thrombolysis-related intracranial tumour haemorrhage has been reported to our knowledge and several studies have suggested that systemic thrombolysis can be safely carried out in these patients. Here we report a patient who developed haemorrhage into a previously unknown intracranial tumour following intravenous thrombolysis for acute myocardial ST-elevation infarction. Identification of abnormal tissue during surgical haematoma evacuation initiated histopathological examination which revealed meningioma World Health Organization Grade I. Intracranial tumours may represent the causative pathology in cases of thrombolysis-related intracranial haemorrhage and this should be considered in the treatment of these patients.     

Management of Geriatric Patient with Epulis Fissuratum Using Liquid Nitrogen Cryosurgery: A Case Report

The aim of this report is to present a case showing the treatment of Epulis fissuratum in relation to an ill fitting denture, in a debilitated geriatric patient with a novel technique using liquid nitrogen cryosurgery. Management of geriatric patients can be quite challenging due to the presence of various diseases. Epulis fissuratum associated with an ill fitting denture greatly hinders mastication and produces discomfort and pain to the patient. The liquid nitrogen cryosurgery can be used effectively in its management, due to its excellent haemorrhage control and postoperative healing. A 71-year-old male reported with Epulis fissuratum in the vestibular sulcus, which was associated with an ill- fitting denture. The patient was a known hypertensive and diabetic, presently on anti-coagulant therapy with previous history of myocardial infarction. Liquid nitrogen cryosurgery was used for the treatment of the lesion. During the procedure, nil haemorrhage was achieved and the postoperative healing was satisfactory. Liquid nitrogen cryosurgery hence can be used effectively in debilitated geriatric patients as it has the boon of achieving excellent haemostasis, good healing with minimal postoperative oedema and pain, maintaining an aseptic environment. This novel technique can be effectively used by dentists in the treatment of Epulis fissuratum besides it can also be used in treatment of other oral soft tissue pathologies achieving a plethora of benefits.     

Trueness verification in European external quality assessment schemes: time to care about the quality of the samples

Ischaemic and haemorrhagic stroke may cause haemostatic abnormalities, apart from concomitant brain damage. In this study, some blood coagulation and fibrinolysis parameters were investigated in 30 patients with ischaemic stroke (atherothrombotic) and 30 with haemorrhagic (20 with intracerebral and 10 with subarachnoid haemorrhage) stroke. The following parameters were determined within the first 24 h after stroke: prothrombin time (PT%), activated partial thromboplastin time (aPTT), fibrinogen, activity of FVII, antithrombin, plasmin inhibitor (PI) and fibrin D-dimer. Significant decreases in PT%, FVII activity and antithrombin as well as an increase in fibrinogen and D-dimer were noticed in ischaemic stroke and in both groups of patients with haemorrhagic stroke. PI levels were significantly lower in subarachnoid haemorrhage patients compared with those in controls and those in both the intracerebral haemorrhage and the ischaemic stroke patients. With the exception of this difference, there were no other differences between ischaemic stroke and the two types of haemorrhagic stroke. This could indicate that haemostatic abnormalities are a consequence of brain damage rather than primary haemostatic activation during thrombosis and/or bleeding in the acute phase of stroke. A decrease in the plasmin inhibitor could suggest excessive fibrinolysis in subarachnoid haemorrhage.     

EFFECTS OF NONPEPTIDE V1a AND V2 ANTAGONISTS ON BLOOD PRESSURE FAST OSCILLATIONS IN CONSCIOUS RATS

This paper describes the effects of vasopressin nonpeptide selective V_1a (OPC-21268) and V₂ (OPC-31260) antagonists on fast blood pressure (BP) oscillations in conscious non-haemorrhaged and haemorrhaged rats. Equidistant sampling at 20 Hz allowed direct spectral analysis of BP on 30 overlapping 2048 point-time series. In non-haemorrhaged rats, V_1a antagonist (5 mg/kg; i.v) reduced BP and low-frequency (LF-BP) component while subsequent administration of V₂ antagonist (1 mg/kg; i.v) reversed these changes and enhanced the very low-frequency (VLF-BP) component. In haemorrhaged rats (5-15 ml/kg/min) V₂ antagonist pre-treatment enhanced the VLF-BP component during normotensive bleeding, while the V_1a antagonist pre-treatment modified BP variability after hypotensive haemorrhage by enhancing the HF-SBP component. The results suggest that under normotensive conditions vasopressin by the stimulation of both V_1a and V₂ receptors buffers BP variability in the VLF-BP frequency domain. In addition, under hypotensive conditions vasopressin, by the stimulation of V_1a receptors buffers the respiration-induced HF-BP oscillation.     

重症急性胰腺炎术后腹腔内大出血患者的护理

目的 探讨重症急性胰腺炎(SAP)引起的腹腔内出血的原因和护理经验.方法 对1998年3月-2007年3月哈尔滨医科大学附属第二医院SAP术后并发腹腔内大出血的19例患者的临床资料进行回顾性分析.结果 除了1例经止血药及局部压迫治疗未止血后经直视下缝扎止血外,其余病例止血效果良好.本组死亡4例.结论 SAP术后腹腔内大出血的死亡率高,一旦发现应该及时处理,以改善患者的预后.     

Bipallidal haemorrhage after ethylene glycol intoxication

Acute or subacute bipallidal lesion, an uncommon radiological feature produced by metabolic disorders or poisoning, has never been attributed to ethylene glycol (EG) intoxication. This 50-year-old Afro-Caribbean alcoholic man had unexplained loss of consciousness. Blood tests showed osmolar gap. Drug screening was positive for EG at 6.06 mmol/l. Brain CT revealed bilateral pallidal haemorrhage. Pallidal haematoma, which could be related to deposition of oxalate crystals issued from EG metabolism, should lead to toxicological screening.     

Prevention and management of severe intra-operative and post-operative bleeding in gynaecologic surgery

Severe intra-operative and post-operative bleeding is a potentially life-threatening complication of gynaecologic surgery. A sound clinical judgement and the adequate assessment and preparation of the patient are the best pre-operative means to avoid its occurrence. Intra-operative prevention requires knowledge of surgical anatomy and haemostatic techniques. The management of haemorrhagic complications can be extremely challenging. Its success depends on the perfect integration of surgical expertise, the supporting role of the anaesthesiologist and on the availability of a fully equipped interventional radiology team with much experience. A methodical and stepwise surgical approach is needed to selectively dissect and identify the bleeding site without damaging adjacent structures. In case of more diffuse or massive bleeding, the performance of a bilateral ligation of the anterior branch of the internal iliac arteries at an early stage is an appropriate measure. The anaesthesiologist is responsible for the maintenance of the patient’s haemodynamic function and the prevention of coagulopathy. Compression or atraumatic clamping of the aorta or placement of a pelvic packing can be temporarily applied to stabilize the patient’s condition. Only once this is achieved, can the subsequent option of angiographic arterial embolisation be considered.