Search Results (53)

Background: The Functional Resonance Analysis Method (FRAM) analyses discrepancies between written protocols (Work-as-Imagined) and real-world practice (Work-as-Done) in healthcare. Work-as-Done is created based on multiple stakeholders, leading to variability in reported functions. No guidance exists how to manage this variability. This study examines between-stakeholder variation in Work-as-Done and its impact on differences from Work-as-Imagined in FRAM visualisations. Methods: Two FRAM studies were analysed: delirium diagnosis and treatment (1) and perioperative anticoagulant management in two hospitals (2). Heatmaps visualised between-stakeholder variability of reported functions in Work-as-Done. We assessed the impact of including only functions shared by multiple stakeholders on Work-as-Imagined versus Work-as-Done comparisons. Results: In study 1, 23 of 33 functions were shared among at least two stakeholders. In study 2, stakeholders shared 30 of 33 functions in Hospital 1 and 29 of 32 functions in Hospital 2. Including or excluding functions, e.g., only mentioned by one stakeholder, influenced the observed differences between Work-as-Imagined and Work-as-Done. Conclusions: Between-stakeholder variability in both studies influenced differences between Work-as-Imagined and Work-as-Done, which often is the starting point improving the process. Showing between-stakeholder variability in FRAM studies enhances transparency in researcher decision-making. This supports more informed analysis and discussion in process improvement efforts. Full article

Background: Major orthopedic trauma in patients receiving anticoagulants such as ticagrelor or rivaroxaban poses a significant perioperative challenge, particularly in emergency contexts where bleeding risks are heightened and specific reversal agents may be unavailable. CytoSorb^®, a hemoadsorption device, has demonstrated efficacy in cardiac surgery for drug removal. Its potential application in trauma surgery remains unexplored. Objective: This protocol describes a prospective clinical investigation assessing the feasibility and safety of CytoSorb^® hemoadsorption for the preoperative removal of ticagrelor and rivaroxaban in trauma patients requiring urgent orthopedic surgery. Methods: The proposed intervention involves integrating CytoSorb^® into a dedicated extracorporeal circuit under normothermic conditions (37 °C) with a blood flow of 150–200 mL/min for 300 min. Serial plasma samples will be collected at predefined intervals (0, 30, 60, 120, 240, 300 min) and drug concentrations. The primary outcome is the pharmacokinetic profile of drug clearance. Secondary endpoints include procedural safety, bleeding complications, and the feasibility of timely surgery. Expected Impact: The study aims to provide real-world data on the practical integration of CytoSorb^® for anticoagulant removal in orthopedic trauma care, potentially facilitating earlier surgery and improving perioperative safety. Findings may inform future randomized trials and protocol standardization. Full article

Background: Traumatic brain injury (TBI) is a leading cause of mortality and disability, particularly in patients on anticoagulation therapy. While anticoagulants are linked to higher TBI mortality, the specific impact of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) on severe TBI (sTBI) outcomes remains unclear, especially in light of newer reversal agents. Therefore, this study evaluates long-term mortality and complication risks associated with pre-injury use of DOACs and VKAs in sTBI patients from a large, real-world cohort. Methods: A retrospective cohort study was conducted using the TriNetX global research network, identifying patients with sTBI between 2016 and 2022. Patients were grouped based on pre-injury anticoagulant use: DOAC, VKA, or none. Propensity score matching was performed, adjusting for age, comorbidities, and baseline characteristics. The primary outcome was all-cause mortality at 1-, 3-, 6-, and 12-months post-injury. Secondary outcomes included hospital and surgical complications up to 30 days post-injury. Results: A total of 40,563 patients met the inclusion criteria. At all time intervals, no significant mortality differences were found between the PSM-matched groups. Conclusions: In patients with sTBI, pre-injury DOAC or VKA use was not associated with increased short- or long-term mortality. These findings suggest that, with current perioperative practices, anticoagulation can be managed without adversely affecting outcomes. Full article

Direct oral anticoagulants (DOACs) have been licensed worldwide for several years for various indications. Each year, 10–15% of patients receiving oral anticoagulants will undergo an interventional procedure, and expert groups have issued several guidelines for perioperative management in such situations. According to the PAUSE study, the proposed randomized strategy of stopping DOACs without bridging therapy in patients with atrial fibrillation was associated with low rates of major bleeding and arterial thromboembolism so that its implementation is increasingly safe. The present study was carried out in order to investigate the efficacy and safety of the standardized perioperative DOAC management strategy by measuring the residual activity of oral anticoagulants when stopping them preoperatively in daily practice in a regional hospital. Thirty-two patients were included in the present study. They were patients who suffered from atrial fibrillation or deep vein thrombosis and were receiving an oral anticoagulant, rivaroxaban or apixaban at the indicated dose. These patients underwent an elective surgery or invasive procedure at the Karditsa General Hospital between May 2022 and April 2023. The results showed that in a percentage of >90% of the patients on the day of surgery they had a residual anti-Xa activity below 0.5 U/mL. This rate is considered high and confirms the safety and efficacy of the guideline-recommended protocol for perioperative discontinuation of DOACs. Full article

Objective: In patients with leg injuries, typical symptoms of thrombosis such as painful swelling may be misinterpreted as a consequence of the trauma. This has the potential to result in an unexpected embolism, especially during the perioperative period. This study investigates the incidence of unapparent preoperative deep-vein thrombosis (DVT) in patients with traumatic intraarticular tibial plateau fracture (TPF). A comprehensive analysis was conducted to identify possible risk factors, with particular attention paid to fracture severity and soft tissue injury. Methods: This retrospective single-centre study evaluated patient data from November 2021 to November 2024. It included 72 patients with traumatic intraarticular TPF who underwent surgery and received a preoperative compression ultrasonography screening. Results: The incidence of preoperative DVT was 23.6% (n = 17). Among these, 5.6% (n = 4) exhibited proximal thrombosis, while 18.1% (n = 13) demonstrated distal thrombosis. The fibular veins were predominantly affected (12/17). Patients with DVT suffered high-energy traumata, dislocations, compartment syndromes, and complex fractures (AO/OTA type C3: 82.4% vs. 52.7%) more often than patients without DVT and were more often immobilised with an external fixator. In 47.1% of DVT cases (n = 8), surgery could no longer be postponed, and an inferior vena cava filter was temporarily employed. The removal of the filter was successful in all cases, with no major complications encountered. Conclusions: This study reveals a high incidence (23.6%) of unapparent preoperative DVT in patients with traumatic intraarticular TPF despite prophylactic anticoagulation, particularly in those with severe fractures and soft tissue injuries. Systematic DVT screening and early anticoagulation are crucial to avoid potentially life-threatening complications. Full article

Background/Objectives: Postoperative hemorrhage is the most common complication after Trans-Oral Robotic Surgery (TORS) described in the literature. The aim of this study is to assess the presence of any risk factors that may impact postoperative bleeding. Methods: This was a retrospective study based on the analysis of patient data. Patients undergoing TORS procedures at the ENT Unit of Forlì Hospital from 2008 to 2022 for OSA (obstructive sleep apnea) or oncological disease and with a minimum follow-up of 30 days were included. The comorbidities analyzed were perioperative anticoagulant/antiplatelet therapy and clinicopathological features concerning the pathology. Total bleeding and severe bleeding (which required management in the operating room) were included. Results: A total of 414 patients (106 oncological TORS and 308 OSA TORS patients) were included. Post-TORS bleeding occurred in 47 cases (11.3%) and severe bleeding in 18 cases (4.3%). The pathology (oncology vs. OSA) treated with TORS did not represent a risk factor (p = 0.466). Antiplatelet intake represented an important risk factor (p = 0.002). Postoperative hemorrhage for oncological TORS occurred in 11.3% patients; of these, 6.6% had severe bleeding. Artery ligation during neck dissection prevented the risk of severe bleeding (p < 0.001). In TORS for OSA, postoperative hemorrhage was found in 11.4% cases, of which 3.6% were major bleeding. Neither the degree of OSA nor the association with other concurrent procedures were risk factors for postoperative bleeding in this study. Conclusions: Patients taking perioperative antiplatelet therapy have an almost 5-fold increased risk of developing postoperative bleeding. The pathology (oncology vs. OSA) does not influence the risk of bleeding. Prophylactic arterial ligation during neck dissection significantly decreases the risk of severe bleeding. Full article

Background: The increasing incidence of pelvic ring and acetabular fractures represents a major challenge in the field of trauma surgery. Hemorrhage and thrombosis are among the most severe complications associated with these injuries. The common instability of those fractures, together with an anatomic proximity to blood vessels, increases the risk of perioperative bleeding. Vascular wall irritation during surgery additionally adds to a substantial risk for thrombotic events. Therefore, evaluating the risk for hemorrhage and thrombosis in pelvic ring and acetabular fractures is vital to identify an adequate anticoagulation management. Methods: The incidence of hemorrhagic and thrombotic events, as well as the association of patient characteristics with the investigated outcomes of 16,359 cases, were analyzed retrospectively using data from the German Pelvic Trauma Registry. Moreover, a risk assessment survey was conducted among traumatologists experienced in pelvic ring and acetabular surgery. The results were compared to those of the registry study. Results: A high rate of thrombotic events was found in the middle-age decade (41–50 years). In patients with an age ≤ 40 and >50 years, hemorrhage complications predominated. The logistic regression identified pelvic ring fractures in geriatric patients, acetabular fractures, and Injury Severity Score (ISS) ≥ 16 to be associated with bleeding complications. Factors associated with thrombosis included pelvic ring fractures in non-geriatric patients, acetabular fractures in geriatric and non-geriatric patients, ISS, and male gender. The survey demonstrated that preoperatively, the risk for hemorrhage was considered more significant. Perioperatively, however, thrombosis was regarded as more important. Conclusions: Separate guidelines for prophylactic anticoagulation in pelvic ring and acetabular fractures that also consider individual patient characteristics, such as age, gender, and ISS, are necessary to improve perioperative management and reduce the morbidity and mortality associated with these injuries. Full article

Background: Transoral robotic surgery (TORS) is a minimally invasive procedure that is performed with neck dissection (ND) and postoperative radiotherapy when necessary. This study aimed to review the methods of vascular ligation and ND in cases of TORS for oropharyngeal cancer in Japan. Methods: We enrolled 44 consecutive patients who underwent TORS for laryngopharyngeal cancer between December 2019 and December 2023. Of these, 35 patients who underwent TORS as a first-line treatment for oropharyngeal cancer were included in this study. We retrospectively collected patient data on age, sex, primary tumor location, clinical tumor–node classification, Eastern Cooperative Oncology Group performance status, history of irradiation to the neck, presence of anticoagulants, pathological results, tumor size, total operative duration, console time, length of skin incision operative result, estimated blood loss, late cervical lymph node metastasis, perioperative complications, postoperative hospital stay, postoperative bleeding, period until oral intake after surgery, and swallowing function. Intra- and postoperative outcomes of TORS, TORS + ND (IIa) + vascular ligation, and TORS + ND (II–IV) + vascular ligation. Results: Significant differences were found in operative duration, blood loss during ND, and skin incision length between TORS + ND (IIa) + vascular ligation and TORS + ND (II–IV) + vascular ligation. Console time and blood loss did not significantly differ between the two groups. Each group contained one case of postoperative bleeding. Conclusions: Safe and minimally invasive treatments can be established if vascular ligation and ND are implemented based on appropriate case selection. Full article

Background and Objectives: Total hip replacement and total knee arthroplasty carry a high risk of postoperative venous thromboembolism (VTE); therefore, anticoagulation prophylaxis is recommended in these patients. Unfortunately, there are no guidelines about VTE prophylaxis in patients with hemophilia who underwent these high-risk surgeries. To determine whether these patients have a high risk of VTE, we conducted a retrospective study on patients with hemophilia who underwent elective arthroplasty at our hospital in 2016. Materials and Methods: There were 11 patients with hemophilia A and B who underwent high-risk surgeries. Recombinant factor VIII or IX and also active recombinant Factor VII were used for perioperative hemostasis, and LMWH was administered for thromboembolic prophylaxis. Postoperatively, we collected information on the duration of factor VIII/IX infusion, VTE-prophylaxis, and complications. Results: Postoperative bleeding was minimal in most cases, with an average blood loss of 500 mL. No major thrombotic events were reported, and the need for transfusion was low, with only one patient requiring additional blood products. The VTE prophylaxis included prophylactic enoxaparin and hemostatic treatment. At the 1-year follow-up, we did not find any evidence of clinical VTE in our patients. Conclusions: Better risk stratification is needed to identify patients who would benefit from pharmacological prophylaxis. Total arthroplasty in hemophilic patients is feasible and safe when managed by a multidisciplinary team and supported by tailored antithrombotic prophylaxis protocols. The use of recombinant coagulation factors and LMWH ensures effective bleeding control and thromboembolic prevention, enhancing patient outcomes. These findings underscore the importance of individualized care in this high-risk population. Full article

Background: The spontaneous rupture of the internal iliac artery (IIA) is an exceedingly rare vascular event, typically associated with congenital anomalies or degenerative conditions. This report details an unprecedented case of isolated IIA rupture in an elderly patient with evidence of plaque rupture but devoid of congenital vascular pathology. Case Presentation: An 81-year-old Caucasian male presented to the Emergency Department following a syncopal episode and acute right iliac fossa pain. His significant medical history was atrial fibrillation managed with anticoagulation (Apixaban), non-insulin-dependent diabetes mellitus, and recent hospitalization for multidrug-resistant Klebsiella pneumoniae pneumonia. Initial imaging with contrast-enhanced computed tomography revealed an aneurysmatic dilatation of the right IIA, indicative of rupture. An endovascular repair was performed, employing a combination of stent grafts to achieve proximal and distal sealing and to restore vascular continuity. Outcome: The patient exhibited hemodynamic stability throughout the perioperative period and was transferred to the general ward postoperatively. However, he suffered a recurrent rupture on the 30th postoperative day, prompting a second endovascular intervention to extend the graft landing zone into the common iliac artery. Intraoperative findings confirmed localized plaque rupture as the underlying trigger for the initial vessel rupture. He ultimately achieved clinical stability and was discharged on the 35th postoperative day. Discussion: This case illustrates the critical importance of recognizing spontaneous IIA rupture as a potential complication in elderly patients, particularly in the context of recent severe infections. While the relationship between the rupture and the Klebsiella pneumoniae infection remains speculative, this report underscores the necessity of further research into the role of infectious processes in vascular integrity and susceptibility to rupture. Conclusions: The successful management of this rare and complex vascular emergency using endovascular techniques underscores the evolving landscape of minimally invasive interventions. This case contributes to the limited existing literature on spontaneous IIA rupture and highlights the need for increased clinical vigilance regarding atypical presentations in similar patient populations. Full article

Background and Objectives: Patients taking anticoagulants, particularly warfarin and non-vitamin K oral anticoagulants (NOACs), face an elevated risk of postoperative bleeding during minor oral surgeries, highlighting the urgent need to identify reliable predictors for bleeding complications. In this study, we evaluated the effectiveness of predictors of bleeding complications in patients receiving anticoagulants who underwent minor oral surgeries. Materials and Methods: The electronic medical and dental records of 206 patients who underwent oral surgery at the University of Ulsan Hospital between 2015 and 2023 were retrospectively reviewed. Patients were categorized into those taking warfarin and those taking NOACs, and postoperative bleeding was determined. Risk factors were statistically analyzed using the chi-square or Fisher’s exact test and Student’s t-test. Results: Among the 206 patients (86 on warfarin, 120 on NOACs), 84 (36 on warfarin, 48 on NOACs) experienced bleeding complications following their procedures. Time in the therapeutic range (TTR) and international normalized ratio (INR) values were significantly associated with bleeding complications in the warfarin group, while the type of NOAC was associated with bleeding in the NOAC group. Perioperative bleeding was significantly correlated with postoperative bleeding in both groups. Conclusions: Taken together, these findings highlight the correlations between postoperative bleeding and specific factors associated with anticoagulant drugs in patients that underwent oral surgery. Identifying these predictors can improve patient management by enhancing pre- and perioperative assessments, reducing the risk of bleeding, and optimizing surgical outcomes. Full article

Mortality rates from pulmonary embolism (PE) remain significant, highlighting the need for alternative treatment strategies beyond traditional anticoagulation. Percutaneous interventions, including mechanical thrombectomy and catheter-directed thrombolysis, are emerging as promising options. Given the complex pathophysiology and unique risk profiles of these patients, meticulous multidisciplinary planning is essential. Anesthesiologists play a central role in coordinating care and managing perioperative risks to improve outcomes. This article provides insights into best safety practices and shares experiences from a leading quaternary center. It offers guidance for anesthesia providers to proactively engage in comprehensive risk stratification, participate in multidisciplinary discussions, and support robust contingency planning for managing PE patients undergoing percutaneous interventions in non-operating room anesthesia settings. Full article

Background/Objectives: Patients on chronic anticoagulation undergoing metabolic surgery represent an increased risk of complications, including both bleeding and thrombotic events, such as deep vein thrombosis (DVT) and pulmonary embolism (PE). The optimal perioperative management of patients who are receiving chronic anticoagulation therapy (CAT) is complex. In the colorectal surgery literature, patients on CAT have a 10% rate of peri-procedural bleeding and a 3% rate of thromboembolism. The aim of this study was to evaluate and compare the safety and postoperative outcomes between patients with and without CAT undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at a tertiary referral center in the United Arab Emirates (UAE). Methods: All patients who underwent primary bariatric surgery between September 2015 and July 2019 were retrospectively reviewed. The first group included patients with CAT, and the second group included patients without CAT. Demographics, perioperative outcomes, and postoperative results were examined. Results: Our study included 542 patients, 22 (4%) with CAT and 520 (96%) without CAT. Mean age was 46.3 ± 10.5 years in the CAT group and 36.0 ± 11.7 years in the non-CAT group (p < 0.001); median BMI was 41.8 (range 33.1–61.3) and 42.7 (range 30.1–78.4) kg/m², respectively (p = 0.52). The CAT group had significantly higher rates of hypertension (77.2% vs. 32.5%, p < 0.001), obstructive sleep apnea (81.8% vs. 31.5%, p < 0.001), and coronary artery disease (31.8% vs. 2.8%, p < 0.001). In the CAT group, 8/22 (36.4%) patients underwent Roux-en-Y gastric bypass and 14/22 (63.6%) sleeve gastrectomy, compared to 228/520 (43.8%) and 292/520 (56.2%), respectively, in the non-CAT group (p = 0.51). There were no statistically significant differences in postoperative emergency department (ED) visits (18.1% vs. 24.2%, p = 0.51), early major complications (4.5% vs. 3.4%, p = 0.54), readmission rates within 30 days (4.5% vs. 3.6%, p = 0.56), or late complications (4.5% vs. 4.2%, p = 0.60). Mean length of stay was significantly longer in the CAT group (4.6 vs. 2.6 days, p < 0.001). The mean follow-up was 10 ± 7.3 months for the CAT cohort and 11 ± 9.7 months for the non-CAT cohort (p = 0.22). Weight loss outcomes at 12 months were comparable, with a percent total body weight loss (TBWL) of 27.0 ± 7.3% in the CAT group and 28.9 ± 8.3% in the non-CAT group (p = 0.29). There were no deaths in either group. Conclusions: In this series, at a tertiary referral center in the UAE, metabolic surgery is safe for CAT patients. Multidisciplinary preoperative preparation might be warranted to avert potential complications. Full article

Atrial fibrillation (AF) and cancer are increasingly recognized as interrelated conditions, with cancer patients showing elevated incidences of AF, and there is evidence that AF may sometimes precede cancer diagnoses. This comprehensive review investigates the epidemiology, pathophysiology, and management challenges associated with AF in cancer patients. Epidemiologically, several cancers are more closely related to increased rates of AF, including lung, colorectal, gastrointestinal, and hematologic malignancies. Mechanistically, both AF and cancer share pathophysiological pathways centered on inflammation, oxidative stress, and common cardiovascular risk factors, such as hypertension, obesity, and diabetes. The inflammatory microenvironment in tumors, marked by increased cytokines and growth factors, promotes atrial remodeling and AF susceptibility. Elevated reactive oxygen species (ROS) levels, driven by the metabolic demands of cancer, further contribute to atrial fibrosis and structural changes. Moreover, many anticancer treatments exacerbate AF risk. Management of AF in cancer patients presents many unique challenges and requires a multidisciplinary approach. Rate and rhythm control strategies are complicated by potential drug–drug interactions and limited data surrounding early implementation of rhythm control strategies in cancer patients. Interventional approaches such as catheter ablation, though effective in maintaining sinus rhythm, carry significant perioperative risk in patients with malignancy. Stroke prevention with anticoagulants is essential but requires cautious administration to avoid heightened bleeding risks, particularly in patients undergoing chemotherapy. Further, the limited applicability of standard risk stratification tools like CHA2DS2-VASc in this population complicate decisions regarding anticoagulation. This review highlights the bidirectional relationship between AF and cancer, the difficulties in management, and the critical need for further research in this field. Full article

Background: Surgery often leads to bleeding associated with hypofibrinogenemia. Supplementation with fibrinogen concentrate appears to be effective and safe, although findings from studies are inconsistent. The primary aim of this study was to assess the safety of fibrinogen concentrate during the perioperative period. Methods: This single-centre, prospective, observational study included adult patients undergoing scheduled or emergency surgery related to bleeding coagulopathy and the administration of fibrinogen concentrate. Patients were followed until their discharge from the institution. Comprehensive data were collected, including age, sex, type of surgery, associated comorbidities, anticoagulant and/or anti-aggregating therapy, and the number of blood transfusions. Laboratory data on plasma fibrinogen concentration, haemoglobin, and platelet count before and after surgery were also collected. The primary outcomes were the mortality rate at discharge and any reported thrombotic or thromboembolic events, including deep vein thrombosis, pulmonary embolism, and myocardial infarction. Results: The study included 91 adult patients who had undergone surgery, with 29 surgeries (32%) conducted in an emergency setting. The mean age was 59.2 years, and 53.8% were male. Major bleeding occurred in 29 cases, mainly in older males and those on anticoagulant therapy. The pre-operative fibrinogen level averaged 161 mg/dL, and the average dosage of fibrinogen concentrate administered was 2.7 g. Eight patients died (8.8%), mostly due to septic or cardiogenic shock, with deaths being more frequent in emergency settings. Thromboembolic events occurred in eight patients, none of whom died. No additional adverse events directly related to the administration of fibrinogen concentrate were reported. Conclusions: Our findings suggest a favourable safety profile for fibrinogen concentrate in surgical patients, as evidenced by a low incidence of deaths and thromboembolic events, which were primarily attributed to other factors. Future research should strive to increase statistical robustness to further illuminate clinically significant patient safety measures. Full article