Post-Tonsillectomy Ibuprofen: Is There a Dose-Dependent Bleeding Risk?
The Laryngoscope. 2021
OBJECTIVES/HYPOTHESIS Post-tonsillectomy hemorrhage (PTH) is a potentially life-threatening complication. A recent meta-analysis suggests that ibuprofen may increase the risk of PTH. The aims of this study were to 1) re-evaluate the effect of ibuprofen on PTH given additional recent evidence and 2) to evaluate a potential dose effect of ibuprofen. STUDY DESIGN Meta-analysis and meta-regression; single-institution retrospective review. METHODS We conducted a systematic review of the literature and a meta-analysis of 12 studies comparing postoperative ibuprofen analgesia to non-nonsteroidal anti-inflammatory drug (NSAID) controls. Next, we performed a meta-regression analysis to assess for an effect of dose, if any, on rates of PTH. Five studies specifying a dose of 5 mg/kg (828 patients, 1,411 controls) and 7 studies using 10 mg/kg (5,633 patients, 7,656 controls) were included. We then conducted a novel single-institution, retrospective review of data for 1,046 patients prescribed intermediate-dose 7.5 mg/kg ibuprofen. RESULTS Ibuprofen was not associated with an increased rate of PTH (log odds ratio [OR], 0.21; 95% confidence interval [CI] -0.15, 0.57). Meta-regression showed that ibuprofen dose (5 and 10 mg/kg) did not have a statistically significant effect on PTH (OR, 1.32; 95% CI 0.30, 5.84). Uncontrolled, aggregate rates of PTH across all studies were 2.29% (N = 828) for 5 mg/kg and 4.65% (N = 5,633) for 10 mg/kg dosing. The rate of secondary hemorrhage in patients prescribed 7.5 mg/kg ibuprofen was 3.10% (N = 1,046). CONCLUSION We found no statistically significant increased risk of PTH when ibuprofen is prescribed at the low or high range of commonly used clinical dosages, compared to a non-ibuprofen regimen. Further studies with less heterogeneity are needed to determine if there is a clinically relevant dose-dependent difference in PTH with ibuprofen. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
The wound healing effect of local leukocyte platelet-rich plasma after total hip arthroplasty: A randomized controlled trial
Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society. 2021
Rapid wound closure is important after arthroplasty procedures to prevent postoperative complications. Platelets are rich in growth factors and leukocytes contribute to innate immunity. We hypothesized that topical leukocyte platelet-rich plasma (L-PRP) derived from the blood of patients would be beneficial to wound healing. In this randomized controlled trial, patients subjected to elective total hip arthroplasty (THA) were assigned by concealed allocation either L-PRP application onto the sutured fascia or no application (control) after the THA intervention. In addition, all patients received 1.5 g protein/kg, 5 g L-arginine, 500 mg vitamin C and 44 mg zinc daily over the 4-week postoperative period to obtain optimal nutrition. The primary endpoint was complete healing of the skin incision. The secondary endpoints were blood transfusions, length of hospital stay, pain and wound infections. Sixteen patients in the L-PRP group and 17 patients in the control group completed the trial. L-PRP treatment accelerated complete wound healing after 3 weeks (seven in the L-PRP group vs. zero in the control group, p = 0.003) and after 4 weeks (12 in the L-PRP group vs. six in the control group, p = 0.037). No postoperative superficial wound infections occurred within 4 weeks, and there were no significant differences in the other secondary outcomes. L-PRP generated in 10 sex-matched healthy volunteers revealed increased concentrations of platelets (5.8-fold) and leukocytes (2.3-fold) compared with those in whole blood. Furthermore, the concentration of keratinocyte mitogen epidermal growth factor in L-PRP (380 ± 130 pg/ml, mean ± SD) was higher (p < 0.001) than that in serum (130 ± 26 pg/ml). In conclusion, a single intraoperative local application of L-PRP promoted wound healing after THA, possibly mediated by EGF receptor agonists.
Patient-centered comparative outcome analysis of platelet-rich fibrin-reinforced vestibular incision subperiosteal tunnel access technique and Zucchelli's technique
Journal of Indian Society of Periodontology. 2021;25(4):320-329
BACKGROUND Multiple gingival recession (MGR) coverage, especially in esthetic area, demands a high patient satisfaction. Coronally advanced flap modifications, namely Zucchelli's technique (ZT) and vestibular incision subperiosteal tunnel access (VISTA), are techniques, recommended in the correction of MGR. AIM: The purpose was to comparatively analyze the ZT and VISTA technique reinforced with the platelet-rich fibrin membrane in the management of MGR. MATERIALS AND METHODS This split-mouth, randomized study comprised 16 consenting, systemically healthy participants. The bilateral Miller's multiple class I and II lesions were managed with ZT and VISTA technique and had a follow-up period of 18 months. Gingival thickness (GT), mean percentage of root coverage, and patient-centered outcome scales, including patient comfort score, patient esthetic score, and hypersensitivity score, were the primary outcome measures. Further clinical parameters assessed were gingival index, probing depth, clinical attachment level, and width of keratinized gingiva. STATISTICAL ANALYSIS AND RESULTS Paired t-test and unpaired t-test were used for intragroup comparison and intergroup analysis, respectively. While both the techniques exhibited high root coverage percentage (VISTA 93.95% and ZT: 96.84%), statistically significant difference was noted with patient esthetic score and surgical mortality score in VISTA. CONCLUSION Both ZT and VISTA were effective in terms of root coverage and GT augmentation in MGR management. From the patient's perspective, they preferred VISTA technique over ZT, stating its minimal postoperative morbidity and improved esthetic outcome. Hence, within the limitations of this study, the VISTA technique was found to be a superior alternative compared to that of ZT in MGR management.
Iron supplementation for patients undergoing cardiac surgery: a systematic review and meta-analysis of randomized controlled trials
Canadian journal of anaesthesia = Journal canadien d'anesthesie. 2021
PURPOSE Iron supplementation has been evaluated in several randomized controlled trials (RCTs) for its potential to increase baseline hemoglobin and decrease red blood cell transfusion during cardiac surgery. This study's main objective was to evaluate the current evidence for iron administration in cardiac surgery patients. METHODS We searched MEDLINE, EMBASE, CENTRAL, Web of Science databases, and Google Scholar from inception to 19 November 2020 for RCTs evaluating perioperative iron administration in adult patients undergoing cardiac surgery. The RCTs were assessed using a risk of bias assessment and the quality of evidence was assessed using the grading of recommendations, assessments, development, and evaluations. RESULTS We reviewed 1,767 citations, and five studies (n = 554) met the inclusion criteria. The use of iron showed no statistical difference in incidence of transfusion (risk ratio, 0.86; 95% confidence interval, 0.65 to 1.13). Trial sequential analysis suggested an optimal information size of 1,132 participants, which the accrued information size did not reach. CONCLUSION The current literature does not support or refute the routine use of iron therapy in cardiac surgery patients. TRIAL REGISTRATION PROSPERO (CRD42020161927); registered 19 December 2019.
Patients undergoing cardiac surgery (5 studies, n= 554).
Placebo, or no-treatment.
Based on the pooling of data from four trials (n= 449), the use of iron showed no statistical difference in the incidence of transfusion (RR, 0.86). There was low heterogeneity between studies (I2 = 0%). One trial (n= 60) reported a significant decrease in the number of red blood cells transfused (mean differences, -1.0 units). All five trials (n= 554) showed no difference in serious adverse events using iron therapy (risk difference, 0.0).
One-year efficacy of platelet-rich plasma for moderate-to-severe carpal tunnel syndrome: A prospective, randomized, double-blind, controlled trial
Archives of physical medicine and rehabilitation. 2021
OBJECTIVE To assess the therapeutic effect of platelet-rich plasma (PRP) for moderate-to-severe carpal tunnel syndrome (CTS). DESIGN A prospective, randomized, double-blinded, controlled trial (1-year follow-up). SETTING Outpatient of local medical center settings. PARTICIPANTS Twenty-six patients who were diagnosed with bilateral moderate-to-severe CTS (total 52 wrists) were included. For each patient, one wrist was randomized into either the PRP or control group and the contralateral wrist of the same patient was allocated to another group. Twenty-four patients were included in the final data analysis. INTERVENTIONS The wrists in the PRP group received a single ultrasound-guided dose of PRP injection (3.5 mL), and the control group received a single ultrasound-guided injection with normal saline (3.5 mL). MAIN OUTCOME MEASURES The Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) scores were used as the primary outcome. Secondary outcomes encompassed the cross-sectional area of the median nerve and electrophysiological study. Assessments were conducted prior to injection and 1, 3, 6, and 12 months post-injection. RESULTS Compared to the control group, the PRP group exhibited significant improvements in BCTQ severity scores at all time-points, BCTQ functional scores at the 6(th) month, and cross-sectional area at the 12(th) month post-injection (P<0.0125). CONCLUSIONS A single dose of ultrasound-guided perineural PRP injection can provide therapeutic effect for 1 year post-injection.
A Systematic Review and Meta-Analysis Evaluating the Impact of Tranexamic Acid Administration in Aesthetic Plastic Surgery
Aesthetic surgery journal. 2021
BACKGROUND Recent evidence suggests tranexamic acid (TXA) may improve outcomes in aesthetic surgery patients. OBJECTIVES This systematic review aimed to investigate the impact of TXA use in aesthetic plastic surgery on bleeding and aesthetic outcomes. METHODS A systematic literature search was conducted to identify studies evaluating TXA use in aesthetic plastic surgery. The primary outcome of interest was perioperative bleeding, reported as total blood loss (TBL), ecchymosis, and hematoma formation. Meta-analyses analyzing TBL, and postoperative hematoma were performed. RESULTS Of 287 identified articles, 14 studies evaluating TXA use in rhinoplasty (6), rhytidectomy (3), liposuction (3), reduction mammaplasty (1), and blepharoplasty (1) were included for analysis. Of 820 total patients, 446 (54.4%) received TXA. Meta-analysis demonstrated TXA is associated with 26.3mL average blood loss reduction (95% CI: -40.0mL to -12.7mL, p < 0.001) and suggested a trend toward decreased odds of postoperative hematoma with TXA use (OR: 0.280, 95% CI: 0.076 - 1.029, p = 0.055). Heterogeneity among reporting of other outcomes precluded meta-analysis; however, 5 of 7 studies found significantly decreased postoperative ecchymosis levels within 7 days of surgery, three studies found statistically significant reductions in postoperative drain output, and one study reported significantly improved surgical site quality for patients who received TXA (p = 0.001). CONCLUSIONS TXA is associated with decreased blood loss and a trend toward decreased hematoma formation in aesthetic plastic surgery. Its use has the potential to increase patient satisfaction with postoperative recovery and decrease costs associated with complications, including hematoma evacuation.
A Literature Review to Assess Blood Loss in Minimally Invasive Liver Surgery Versus in Open Liver Resection
Aim and objectives The aim of the study was to assess the amount of blood loss in minimally invasive hepatectomy and open liver resection for both benign and neoplastic conditions. Introduction Minimally invasive surgery has progressively developed to a stage where once-novel and highly specialized surgical techniques are now common practice. Colorectal surgery is the key example that has shown minimally invasive surgery as highly beneficial. Successes in the colorectal laparoscopic approach have now been integrated into the speciality of hepatopancreaticobiiary (HPB) surgery. In this review, we will compare the amount of blood loss in minimally invasive liver resection with the more traditional approach of open liver resection. Methods A literature review was conducted which included the length of patient mobilization as a postoperative complication following laparoscopic and open liver resections. Medline, PubMed, and Cochrane were accessed to review previously published studies. Twelve studies were selected, and all of them were in English, ranged from the year 2000 to 2020. Results Eleven out of the 12 included studies indicated that minimally invasive liver resection is associated with reduced blood loss. Conclusion In comparing both minimally invasive liver resection and classic open surgery, minimally invasive liver resection was shown to have reduced blood loss; this was seen in both malignant and benign tumours. Therefore, laparoscopic liver resection could be favoured over the classical open approach to avoid excessive blood loss intra-operatively.
The effect of tranexamic acid on blood loss in orthognathic surgery: a randomized, placebo-controlled, equivalence study
International journal of oral and maxillofacial surgery. 2021
Orthognathic surgery can cause substantial bleeding. Recent meta-analyses concluded that there is a statistically significant reduction in perioperative blood loss with the preventive use of tranexamic acid (TA). However, the mean reported difference in bleeding was moderate, and the clinical relevance of this blood-sparing effect remains debated. We therefore conducted a prospective, double-blind, randomized, placebo-controlled equivalence study of the effect of TA in patients undergoing Lefort I or bimaxillary osteotomies. Our main outcome measure was total blood loss on postoperative day 1. The equivalence margin was ± 250 ml for the difference in blood loss and its 95% confidence interval. One hundred and forty-seven patients were randomized, of which 122 underwent bimaxillary osteotomies. Blood loss in the treatment group was 682 ± 323 vs. 875 ± 492 ml. The mean difference in bleeding was -132 [-243; -21] ml as per-protocol, but -193 [-329; -57] ml in intention-to-treat: the limits of this confidence interval exceeded the margin of equivalence. Similar results were obtained when analysing only patients undergoing bimaxillary osteotomy. Haemoglobin decreased by 1.8 ± 1.2 g/dl with TA, vs. 2.6 ± 1.1 g/dl with placebo (p<0.001). Our study did not demonstrate equivalence between TA and placebo on perioperative blood loss in orthognathic surgery. TA may reduce blood loss but without evidence of clinical consequences.
Optimal timing of endoscopy for acute upper gastrointestinal bleeding: a systematic review and meta-analysis
Internal and emergency medicine. 2021
Acute upper gastrointestinal bleeding (UGIB) is the most common indication for urgent endoscopy, but the correct timing of endoscopy in these patients is still debated. Our systematic review with meta-analysis was aimed at investigating the potential clinical benefit of very early endoscopy for UGIB patients. We performed an electronic literature search of PubMed, Scopus, Web of Science and the Cochrane Library up to 23rd May 2020 and considered only randomised controlled trials (RCTs) comparing management of UGIB patients by very early vs early endoscopy. Only five RCTs were considered eligible for quantitative analysis, with a total population of 926 cases (468 in the very early endoscopy arm and 458 in the early). The meta-analysis showed no statistically significant benefit for very early endoscopy compared to early endoscopy in terms of risk of rebleeding, mortality, ICU admission, blood transfusion, surgery and length of hospital stay. However, our results showed a significantly higher need for haemostatic treatment when very early endoscopy was performed (RR 1.23, 95% CI 1.06-1.42, p < 0.01) in comparison to early endoscopy.
Role of Using a Thromboelastometry-Based Protocol for Transfusion Management in Combined Coronary Artery Bypass Grafting and Valve Surgery: A Randomized Clinical Trail
Indian journal of hematology & blood transfusion : an official journal of Indian Society of Hematology and Blood Transfusion. 2021;37(3):422-429
The aim of this study was to evaluate the impact of using a thromboelastometry-based protocol on transfusion requirements in patients undergoing combined coronary artery bypass grafting (CABG) and valve surgery. 80 adult patients scheduled for elective combined CABG and valve surgery were included in this clinical trial study. Patients were randomly allocated to the thromboelastometry (ROTEM) (n = 40) or control groups (n = 40). In the ROTEM group, transfusion was directed according to a thromboelastometry-based protocol. In the control group, transfusion was conducted according to the routine practices including conventional coagulation testing and clinical judgments. Finally, transfusion requirements were compared between groups. Use of thromboelastometry- based protocol resulted in 67% reduction in blood products units' consumption as well as 23% in the percentage of patients transfused. This reduction was especially evident in relation to fresh frozen plasma (FFP) and platelet consumption. No significant differences were found both in the percentage of patients receiving RBC and number of transfused RBC units. Using thromboelastometry tests incorporated a protocol results in reduction of transfusion requirements in patients undergoing elective combined CABG and valve surgery.