Immediate and delayed complications of adenotonsillectomy

<p class="abstract"><strong>Background:</strong> Tonsillectomy with or without adenoidectomy is the commonest pediatric otorhinolaryngological procedure. The aim of the present study was to compare the intraoperative (immediate) and postoperative (delayed) complications between in conventional and coablation tonsillectomy in children.</p><p class="abstract"><strong>Methods:</strong> This observational study was conducted among 100 children between 5 and 15 years who had conventional tonsillectomy and 50 children who had coblation tonsillectomy. Intraoperative and postoperative complications were observed and compared between two groups. </p><p class="abstract"><strong>Results:</strong> Of the total 150 children, 64 (42.7%) were males and 86 (57.3%) were females with mean age of 9.42±2.67 years. Common preoperative symptoms were odynophagia (96.0%), throat pain (95.3%) and difficult swallowing (89.3%). Among the intraoperative anesthetic complications, compression of endotracheal tube was observed in 19 (12.7%), accidental extubation in 10 (6.7%) and dislodging of loose tooth in 9 (6.0%) patients. Regarding intraoperative surgical complications, primary hemorrhage was seen in 43 (28.7%), edema uvula in 39 (26.0%) and pillar injury in 33 (22.0%) patients. Commonest postoperative complication was oropharyngeal pain (18.7%) followed by primary hemorrhage (14.0%) and nausea, vomiting (13.3%). Immediate complications like primary haemorrhage (p value 0.0001) and uvula edema (p value 0.018) were significantly associated with conventional tonsillectomy group while delayed complications like secondary haemorrhage (p value 0.011) and referred otalgia (p value 0.0001) were with coblation tonsillectomy group.</p><p class="abstract"><strong>Conclusions:</strong> Compression of endotracheal tube and primary hemorrhage were the commonest intraoperative anesthetic and surgical complication respectively. Immediate complications were significantly associated with conventional tonsillectomy group while delayed complications were with coblation tonsillectomies.</p>

External Soft-Tissue Hemostatic Clamp Compared to a Compression Tourniquet as Primary Hemorrhage Control Device in Pilot Flow Model Study

Introduction:Acute blood loss represents a leading cause of death in both civilian and battlefield trauma, despite the prioritization of massive hemorrhage control by well-adopted trauma guidelines. Current Tactical Combat Casualty Care (TCCC) and Tactical Emergency Casualty Care (TECC) guidelines recommend the application of a tourniquet to treat life-threatening extremity hemorrhages. While extremely effective at controlling blood loss, the proper application of a tourniquet is associated with severe pain and could lead to transient loss of limb function impeding the ability to self-extricate or effectively employ weapons systems. As a potential alternative, Innovative Trauma Care (San Antonio, Texas USA) has developed an external soft-tissue hemostatic clamp that could potentially provide effective hemorrhage control without the aforementioned complications and loss of limb function. Thus, this study sought to investigate the effectiveness of blood loss control by an external soft-tissue hemostatic clamp versus a compression tourniquet.Hypothesis:The external soft-tissue hemostatic clamp would be non-inferior at controlling intravascular fluid loss after damage to the femoral and popliteal arteries in a normotensive, coagulopathic, cadaveric lower-extremity flow model using an inert blood analogue, as compared to a compression tourniquet.Methods:Using a fresh cadaveric model with simulated vascular flow, this study sought to compare the effectiveness of the external soft-tissue hemostatic clamp versus the compression tourniquet to control fluid loss in simulated trauma resulting in femoral and posterior tibial artery lacerations using a coagulopathic, normotensive, cadaveric-extremity flow model. A sample of 16 fresh, un-embalmed, human cadaver lower extremities was used in this randomized, balanced two-treatment, two-period, two-sequence, crossover design. Statistical significance of the treatment comparisons was assessed with paired t-tests. Results were expressed as the mean and standard deviation (SD).Results:Mean intravascular fluid loss was increased from simulated arterial wounds with the external soft-tissue hemostatic clamp as compared to the compression tourniquet at the lower leg (119.8mL versus 15.9mL; P &lt;.001) and in the thigh (103.1mL versus 5.2mL; P &lt;.001).Conclusion:In this hemorrhagic, coagulopathic, cadaveric-extremity experimental flow model, the use of the external soft-tissue hemostatic clamp as a hasty hemostatic adjunct was associated with statistically significant greater fluid loss than with the use of the compression tourniquet.Paquette R, Bierle R, Wampler D, Allen P, Cooley C, Ramos R, Michalek J, Gerhardt RT. External soft-tissue hemostatic clamp compared to a compression tourniquet as primary hemorrhage control device in pilot flow model study. Prehosp Disaster Med. 2019;34(2):175–181

Abstract 192: Pressure Methods for Primary Hemorrhage Control

Introduction: Hemorrhage is the primary cause of death in 35% of traumatic mortalities. However, guidelines give little guidance regarding the best method of applying direct pressure including the mechanics of applying the pressure. Hypothesis: The purpose of this study is to compare the force generated using different techniques of force application. Additionally, we aimed to measure the pressure generated by a pressure wrap using two commonly used types of bandages in comparison to manual pressure. Methods: In this IRB approved study, subjects were recruited as a convenience sample of medical providers during a weekly medical conference. A standardized bleeding simulator (Z-Medica) with a flat force sensitive resistor was used in this study to measure force. Subjects were randomized to application order of each of the following techniques: the finger pads of 3 digits of the right hand, 3 fingers of the right hand with the opposing hand applying counter pressure, or 3 digits of each of two hands on top of the other. The subjects were asked to hold pressure at each application for 10 seconds and all completed each method sequentially. Subjects then applied a compression wrap using either an elastic wrap or self-adhesive wrap. Researchers were not blinded during data collection, but data analysts were blinded to the groups. Results: Thirty-three subjects were enrolled and all had data available for analysis. Twenty-two were residents, 11 attending physicians, 22 were male, and the average age was 34.2 years (range 26-63). Two hand pressure application generated the most amount of force averaging a constant of 3.75 (SD 1.54) lbs. This was statistically different from one hand application which generated an average of 3.00 (SD 1.29) lbs of force (p <0.001). Comparison of opposing hands to single hand and two hands to opposing hands did not reach statistical significance. Neither pressure wrap technique generated a comparable amount of force to that of manual pressure [0.70 (SD 0.49) lbs vs 1 hand with 10 4x4” gauze pads (p <0.001)]. Conclusions: In this model of bleeding, medical personnel generated the most force when two hands were used to apply pressure over the wound. This study also demonstrated direct manual pressure generated much higher pressures than a pressure dressing.

Rates of local procedural-related structural injury following clipping or coiling of anterior communicating artery aneurysms

BackgroundSurgical clipping and endovascular coiling yield similar functional outcomes for the treatment of saccular aneurysms of the anterior communicating (ACOM) artery. However, surgical treatment may be associated with greater rates of cognitive impairment due to injury of adjacent structures. We aimed to quantify the rates of injury (infarction/hemorrhage) for both clipping and coiling of ACOM aneurysms.MethodsThis was a retrospective dual-center radiological investigation of a consecutive series of patients with ruptured and unruptured ACOM aneurysms treated between January 2011 and October 2014. Post-treatment CT or MRI was assessed for new ischemic or hemorrhagic injury. Injury relating to the primary hemorrhage or vasospasm was differentiated. Univariate analysis using χ2 tests and multivariate analysis using binary logistic regression was used.Results66 patients treated with clipping were compared with 93 patients treated with coiling. 32/66 (48.5%) patients in the clipping group suffered treatment-related injury (31 ischemic, 1 hemorrhagic) compared with 4/93 (4.4%) patients in the coiling group (3 ischemic, 1 hemorrhagic) (p<0.0001). For patients with subarachnoid hemorrhage, the multivariate OR for infarction for clipping over coiling was 24.42 (95% CI 5.84 to 102.14), p<0.0001. The most common site of infarction was the basal forebrain (28/66 patients, 42.4%), with bilateral infarction in 4. There was injury of the septal/subcallosal region in 12/66 patients (18%).ConclusionsClipping of ACOM aneurysms is associated with significantly higher rates of structural injury than coiling, and this may be a reason for superior cognitive outcomes in patients treated with coiling in previously published studies.

Abstract WP302: Racial Differences in Imaging Characteristics and Risk Factors for Primary Intracerebral Hemorrhage: Final Results from the DECIPHER Study

Background: Previous studies have reported racial differences in the incidence, location and risk factors for primary intracerebral hemorrhage (ICH). We now report differences in imaging characteristics and risk factors for ICH from the DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) study. Methods: DECIPHER is a longitudinal, multicenter, MRI-based, natural history study of racial differences in primary ICH. Inclusion criteria were: primary ICH, age ≥ 18, baseline and 1 year MRI scan obtained. Clinical and demographic data were collected on all subjects. Results: A total of 193 subjects of black or white race were enrolled. Subject characteristics overall and by race are provided in the table. Black subjects were younger, had a higher rate of hypertension, cocaine use, and were more frequently smokers. White subjects had a higher rate of hyperlipidemia. A lobar ICH location was more frequent in the white subjects, while infratentorial hemorrhages were more common in blacks. 60% of blacks had 1 or more microbleeds compared to 52% of whites (NS), and blacks tended to have more severe white matter disease. Conclusions: In the DECIPHER study, there were significant racial differences both in the risk factors for primary ICH and in the imaging characteristics. Compared to whites, blacks have a greater rate of hypertension, as well as cocaine and tobacco use. Imaging findings are indicative of a more severe underlying small vessel vasculopathy in the black cohort. The risk factor information may be used to enhance prevention programs tailored for black communities at risk of ICH, while imaging data may provide a useful biomarker to assess the impact of these interventions.

Spontaneous Primary Intraventricular Hemorrhage: Clinical Features and Early Outcome

Purpose. Primary hemorrhage in the ventricular system without a recognizable parenchymal component is very rare. This single-center retrospective study aimed to further characterize the clinical characteristics and early outcome of this stroke subtype. Methods. All patients with primary intraventricular hemorrhage included in a prospective hospital-based stroke registry over a 19-year period were assessed. A standardized protocol with 161 items, including demographics, risk factors, clinical data, neuroimaging findings, and outcome, was used for data collection. A comparison was made between the groups of primary intraventricular hemorrhage and subcortical intracerebral hemorrhage. Predictors of primary intraventricular hemorrhage were identified by logistic regression analysis. Results. There were 12 patients with primary intraventricular hemorrhage (0.31% of all cases of stroke included in the database) and 133 in the cohort of subcortical hemorrhage. Very old age (≥85 years) (odds ratio (OR) 9.89), atrial fibrillation (OR 8.92), headache (OR 6.89), and altered consciousness (OR 4.36) were independent predictors of intraventricular hemorrhage. The overall in-hospital mortality rate was 41.7% (5/12) but increased to 60% (3/5) in patients aged 85 years or older. Conclusion. Although primary intraventricular hemorrhage is uncommon, it is a severe clinical condition with a high early mortality. The prognosis is particularly poor in very old patients.

Thrombin and hemin as central factors in the mechanisms of intracerebral hemorrhage–induced secondary brain injury and as potential targets for intervention

Intracerebral hemorrhage (ICH) is a subtype of stoke that may cause significant morbidity and mortality. Brain injury due to ICH initially occurs within the first few hours as a result of mass effect due to hematoma formation. However, there is increasing interest in the mechanisms of secondary brain injury as many patients continue to deteriorate clinically despite no signs of rehemorrhage or hematoma expansion. This continued insult after primary hemorrhage is believed to be mediated by the cytotoxic, excitotoxic, oxidative, and inflammatory effects of intraparenchymal blood. The main factors responsible for this injury are thrombin and erythrocyte contents such as hemoglobin. Therapies including thrombin inhibitors, N-methyl-D-aspartate antagonists, chelators to bind free iron, and antiinflammatory drugs are currently under investigation for reducing this secondary brain injury. This review will discuss the molecular mechanisms of brain injury as a result of intraparenchymal blood, potential targets for therapeutic intervention, and treatment strategies currently in development.