Monday, October 15, 2018

Perioperative Bleeding Risk Factors

Preoperative Bleeding Risk Factors:
    • Prior bleeding history following surgical procedures
    • Preop coagulopathy
    • Preoperative organ dysfunction
      • Liver disease
      • Kidney disease/renal failure
      • CHF with passive liver congestion
      •  increased LFTs
      •  increased PT
    • History of quantitive or qualitative platelet dysfunction
    • Platelet inhibitors
      • ASA, NSAID
      • GPIIb/IIIa inhibitor
    • Preop anticoagulant use
      • Heparin
      • Warfarin
    • Fibrinolytic administration
      • TPA
      • Streptokinase
      • Urokinase

Intraoperative Course:
    • CPB time (over 150 min increases risk)
    • Administration of blood products
    • Transfusion of “pump blood” or autologous blood (heparinized blood)
    • Administration of antifibrinolytics, DDAVP, or serine protease inhibitor
    • Surgical bleeding sites intraoperative
    • Presence of microvascular bleeding at sternal closure

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Friday, October 5, 2018

Recommendations for perioperative acetylsalicylic acid management.

    Acetylsalicylic acid (ASA) is one of the cornerstones for the treatment of acute and chronic cardiovascular disease. Secondary prevention with ASA has been shown to reduce mortality, MI and cerebrovascular events in different subsets of patients with occlusive cardiovascular disease, but also to increase the risk for bleeding complications.

    Discontinuation before surgery. A meta-analysis of 13 trials with 2399 patients who had CABG that compared administration of ASA preoperatively versus no treatment or treatment with a placebo showed that treatment with ASA reduced the risk for perioperative MI [(odds ratio (OR) 0.56; 95% confidence interval (CI) 0.33–0.96] but did not reduce the mortality rate (OR 1.16; 95% CI 0.42–3.22). Postoperative bleeding, red cell transfusions and surgical re-exploration were increased with ASA. However, the included studies were of low methodological quality. A recent large randomized controlled trial (RCT) compared the administration of ASA (100 mg) on the day of the operation versus the use of a placebo in patients having CABG  and demonstrated no significant effect of treatment with ASA on thrombotic and bleeding perioperative events. However, the included patients were eligible only if they were not using ASA preoperatively or had stopped ASA at least 4 days before the operation. Therefore, a strategy of discontinuation versus continuation was not evaluated. Another RCT on pretreatment demonstrated that a large dose (300 mg) of ASA preoperatively was associated with increased postoperative bleeding but with a lower rate of major cardiovascular events at a 53-month follow-up. Similarly, a small RCT reported that patients pretreated with ASA (300 mg) had significantly more postoperative bleeding (+25%) and that this effect was more pronounced (+137%) in carriers of the glycoprotein (GP) IIIa allele PlA2 . Similar results were presented in a previous meta-analysis , where less bleeding was reported in patients receiving < 325 mg ASA daily. Of note, stopping ASA 5 days before the operation and replacing it with low-molecular-weight heparin (LMWH) increases the risk for bleeding complications and therefore should be abandoned . In summary, the continuation of ASA is associated with more blood loss but fewer ischaemic events during and after CABG surgery. Recent data suggest that the inhibiting effect of ASA on platelet aggregability is clearly susceptible to platelet transfusion , which also argues for the continuation of ASA in patients undergoing elective or urgent CABG. However, in patients who refuse blood transfusions, who undergo non-coronary cardiac surgery or who are at high risk of re-exploration for bleeding—such as complex and redo operations, severe renal insufficiency, haematological disease and hereditary platelet function deficiencies— stopping ASA at least 5 days before surgery should be considered. The increased risk for bleeding complications if ASA and other antithrombotic drugs are not discontinued must be weighed against the potentially increased risk of thrombotic complications during the preoperative cessation period. 


Restart after surgery. In a large prospective observational trial, patients who restarted ASA within 48 h of CABG had a mortality rate of 1.3% compared with a rate of 4.0% among those who did not receive ASA during this period (P < 0.001). ASA therapy was associated with a 48% reduction in the incidence of MI (P < 0.001), a 50% reduction in the incidence of stroke (P = 0.01), a 74% reduction in the incidence of renal failure (P < 0.001) and a 62% reduction in the incidence of bowel infarction (P = 0.01). A systematic review of 7 studies showed that administration of ASA within 6 h of CABG was associated with improved graft patency without increased incidence of bleeding complications. Therefore, ASA should be given to all patients having CABG as soon as there is no concern over bleeding.

Source: 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery

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Saturday, July 7, 2018

HYPERCALCEMIA in critically ill patients


Hypercalcemia is rare in critically ill patients, estimated to be present

in between 1% and 15% of ICU patients. Defined as an increase in
serum calcium above 10.4 mg/dL (2.60 mmol/L), hypercalcemia
usually is caused by excessive bone resorption. 

Sunday, April 22, 2018

Indications for Diagnostic Right-Sided Heart Catheterization


  • Significant valvular pathology
  • Suspected intracardiac shunting 
  • Acute infarct—differentiation of free wall versus septal rupture 
  • Evaluation of right- and/or left-sided heart failure
  • Evaluation of pulmonary hypertension 
  • Severe pulmonary disease 
  • Evaluation of pericardial disease 
  • Constrictive pericarditis 
  • Restrictive cardiomyopathy 
  • Pericardial effusion 
  • Pretransplantation assessment of pulmonary vascular resistance and response to vasodilators

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Tuesday, October 31, 2017

Perioperative anaphilaxis.

    Anaphylaxis is a severe, potentially life-threatening systemic hypersensitivity reaction. The estimated incidence of perioperative anaphylaxis is 1 in 10,000–20,000 anesthetic procedures.

Monday, October 30, 2017

Treatment of Pain in Children. Pain Scales.


    Nonsteroidal anti-inflammatory agents (NSAIDs) are widely used for treatment of mild to moderate pain in children. These agents are particularly useful for supplementation of analgesia with regional/local anesthesia techniques. 

Agents used commonly in children are:
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