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PubMed1990

Positional precautions in needle aspiration lung biopsy.

The authors performed 308 needle aspiration biopsies of parenchymal lung masses. The patients were then placed with the puncture site down for a period of at least 1 hour or until air leakage stopped. Coughing, talking, and activity were restricted. Complications included pneumothorax, at a rate of 25.0%, and chest tube placement, at a rate of 1.6%. In a subgroup of 262 patients who required only one pleural puncture at biopsy, a pneumothorax rate of 17.9% and a chest tube placement rate of 0.4% were encountered. When compared with a similar series of 143 control patients, significant reductions in both pneumothorax rate (P = .0004) and chest tube placement rate (P = .0001) were demonstrated.

Biopsy, Needle↗
PubMed1998

The clinical relevance of hemoglobin, platelet, and serotonin changes in sequestered and circulating blood during cardiopulmonary bypass.

OBJECTIVE: To determine how hemoglobin (Hb), platelet, and serotonin concentrations change during cardiopulmonary bypass (CPB) in sequestered blood from the pulmonary artery compared with circulating systemic blood; and to determine the correlation between platelet and serotonin variability at the two sites and clinical outcome measurements related to hemodynamics and blood loss. DESIGN: A prospective clinical study. SETTING: A university hospital. PARTICIPANTS: Twenty patients undergoing elective aortocoronary bypass. INTERVENTIONS: Measurements of Hb, platelet, and serotonin concentrations were performed before, during, and after CPB on paired blood samples from the pulmonary artery and the radial artery. Hemodynamic measurements were recorded before and after CPB and chest tube drainage was recorded postoperatively. MEASUREMENTS AND MAIN RESULTS: The Hb, platelet, and serotonin concentrations were all significantly different between radial artery and pulmonary artery samples at the different measurement times (p < 0.001, analysis of variance [ANOVA] for repeated measures). Hb, platelet, and serotonin concentrations were all significantly increased in the pulmonary artery at the time of aortic cross-clamping compared with the corresponding radial artery blood samples (p < 0.0005, ANOVA). During the period of ischemic arrest, Hb was unchanged in the pulmonary artery and remained significantly increased compared with systemic blood (p < 0.0005, ANOVA). Serotonin concentrations in both systemic and sequestered pulmonary artery blood had significant correlation with cardiac index (CI), right ventricular ejection fraction (REF), and systemic vascular resistance index (SVRI; p < or = 0.006, least squares analysis). Postoperative chest tube drainage most closely correlated with the platelet counts measured in both the radial and pulmonary arteries at the start of CPB (p < 0.05, least squares analysis). CONCLUSION: During CPB, there were significant differences in Hb, platelet, and serotonin concentrations in sequestered pulmonary artery blood compared with circulating systemic blood. The initial differences and subsequent changes were most likely attributable to decreased hemodilution and a different pattern of platelet activation in the pulmonary artery blood compared with the systemic blood. Despite the hematologic differences, serotonin concentration and platelet counts in the pulmonary artery blood had significant correlation to indices of cardiac function and postoperative chest tube drainage, respectively. Platelet and serotonin changes in sequestered pulmonary artery blood were also associated with some of the adverse consequences of CPB.

Analysis of Variance↗
PubMed1991

A simple method for creating subcutaneous tunnels.

A trocar chest tube is an excellent tunneling device. It is readily available in a variety of sizes in all hospitals. It requires no special ordering and is inexpensive. The trocar chest tube glides through subcutaneous tissues easily, resulting in less trauma to the tissue compared with the forceful passage of poorly suited, large, blunt-tipped instruments. Operating room personnel are more likely to be familiar with the location of common trocar chest tubes than infrequently used commercial tunnelers. The option of creating curved tunnels when necessary broadens the applications of this disposable, easy to use instrument.

Adipose Tissue↗
PubMed2006

Thorax ultrasound in the management of pediatric pneumonias complicated with empyema.

The aim of this work is to prospectively study the value of thoracic ultrasound (US) before pleural drainage in children with parapneumonic effusion (PPE). All children hospitalized for PPE, identified by thoracic radiography, underwent US to assess pleural loculation, echogenicity, and pleural fluid quantity. From August 2001 to July 2003, 52 children were examined. US was performed on 48 of these children, of whom 35 received chest tube drainage and 13 only received clinical treatment. US identified 38 patients with free flowing and 10 with loculated pleural fluid. About 25 of the free flowing (65.8%) and 10 (100%) of the loculated patients received chest tube drainage. Echogenicity was anechoic in 13, echoic without septations in 17 and echoic with septations in 18. Chest tube drainage was required in 6 anechoic (46.15%), 14 echoic without septations (82.35%), and 15 echoic with septations (83.33%). Quantity of fluid estimated by US varied from 20 to 860 ml. Effusion volume was higher in patients that were echoic with septations and loculated effusions. Pleural glucose and pH were lower, and LDH was higher in loculated PPE patients. In conclusion, US is an auxiliary exam for determining whether thoracic drainage is needed in parapneumonic effusion; loculated or echoic effusion should be drained, and free anechoic fluid needs further investigation.

Adolescent↗
PubMed1996

Early administration of intrapleural streptokinase in the treatment of multiloculated pleural effusions and pleural empyemas.

In the treatment of multiloculated pleural effusions and empyemas tube thoracostomy often fails and more aggressive surgical therapy is required. Intrapleural administration of fibrinolytics is a valuable alternative. Between October 1994 and December 1995 28 patients (aged 22 to 62 years) with multiloculated pleural effusions were treated with intrapleural instillations of streptokinase after unsuccessful conventional chest tube drainage. Twenty-three pleural effusions were grossly purulent, others were loculated effusions with low pH. The most common cause of the pleural effusions was pneumonia. Duration of illness before hospitalization was 3 to 105 (mean 21.8) days. Treatment with streptokinase was started most commonly one day after chest tube placement. Once a day after clamping the chest tube streptokinase was administered intrapleurally for 10-15 minutes as a solution of 250,000 units in 100 ml normal saline. The tube remained clamped for 3 hours. Two to 8 (mean 3.7) instillations per patient were needed. Twenty-one cases (72.4%) showed excellent resolution of pleural effusion and needed no more therapy. However, one patient died in hospital due to purulent meningitis and bilateral pneumonia. Eight patients needed further surgical treatment, e.g. decortication, in 5 cases together with wedge lung resection. Eleven patients experienced some adverse effects of streptokinase therapy, most frequently chest pain and elevation of body temperature in one case pleural effusion became hemorrhagic, and one patient had nasal bleeding. We conclude that usage of intrapleural streptokinase in the treatment of multiloculated pleural effusions (including pleural empyemas) reduces the need for major surgical interventions in quite a large group of patients.

Adult↗
PubMed1999

[Thoracic drainage in trauma emergencies].

A group of 191 cases of emergency tube thoracostomy for acute trauma reviewed retrospectively from March 1993 to March 1998 is reported. Of this group 169 were men and 22 were women. Their ages ranged from 16 to 73 years. The causes were as follows: 89 cases (46%) road accident; 33 cases (17%) accidental trauma; 33 cases (17%) someone else violence (assault, gunshot or stab wound); 15 cases (8%) work accident; 11 cases (6%) domestic accident and 5 cases (3%) iatrogenic trauma. In 32 patients a diagnosis of pneumothorax was made (2 tension, 11 for penetrating chest injuries, 19 after blunt trauma). In 2 cases of tension pneumothorax and in 3 cases of open pneumothorax a chest tube (24-28 Fr) in the third space in the mid-clavicular line was introduced. In the other patients it was decided to place a chest tube in the mid-axillary line in the fifth intercostal space to drain pneumothorax. Only in 7 cases suction was necessary. Fifty-four hemothorax (3 bilateral) were treated in 11 cases using thoracentesis, while the remaining cases were treated using the insertion of multiple drainage holes in the intercostal space (fifth in the mid-axillary line directed inferiorly and posteriorly). One hundred and three were the cases of hemopneumothorax: 24 of them received 2 chest tubes, the first (20-26 Fr) apically in the second intercostal space in the mid-clavicular line, the second (32-38 Fr) in the fifth intercostal space in the mid-axillary line. All the other cases were treated using a single thoracostomy. In 14 cases suction was applied. Two cases of chylothorax resolved by a large tube positioned in the chest (fifth intercostal space in the mid-axillary line) with a constant negative pressure were also observed. Duration of tube drainage ranged from 4 and 18 days, with an average of 11 days. Five infections of thoracostomy site and 1 empyema resolved by rethoracotomy were observed. Moreover, there were 3 complications: 2 subcutaneous placements and 1 little laceration of the lung. Thirty-one drained patients were operated: in 5 cases thoracotomy and laparotomy (2 exitus in tabula); only thoracotomy in 8 cases; 19 laparotomy and thoracostomy (1 exitus in tabula).

Accidents, Home↗
PubMed1996

Diagnostic accuracy and safety of CT-guided percutaneous needle aspiration biopsy of the lung: comparison of small and large pulmonary nodules.

OBJECTIVE: The purpose of this study was to compare the diagnostic accuracy and safety of CT-guided percutaneous needle aspiration biopsy of pulmonary nodules less than or equal to 1.5 cm in diameter with those of nodules greater than 1.5 cm in diameter. MATERIALS AND METHODS: We retrospectively reviewed a consecutive series of 97 patients who underwent CT-guided percutaneous needle aspiration biopsy of a lung nodule and then surgical resection (n = 95) or autopsy (n = 2). By examining CT images, we classified 27 nodules as small ( < or = 1.5 cm) and 70 nodules as large ( > 1.5 cm). Diagnostic accuracy was calculated by comparing cytologic diagnoses based on biopsy with final diagnoses based on histologic findings from surgery or autopsy. Each case was reviewed for possible complications, including pneumothorax and chest tube placement. RESULTS: The diagnostic accuracy of CT-guided percutaneous needle aspiration biopsy of large nodules was 96%. The diagnostic accuracy for small nodules was 74%, a statistically significant difference (p < .05). The prevalences of pneumothorax in our population were nearly identical for small and large nodules (22 and 21%, respectively). The prevalence of chest tube placement in our population was approximately 2%. The prevalences of chest tube placement were 0% for small nodules and 3% for large nodules. CONCLUSION: CT-guided percutaneous needle aspiration biopsy is significantly less accurate for small pulmonary nodules than for large pulmonary nodules, but the complication rates for both are low.

Adult↗
PubMed1981

Subvisceral pleural air in neonates with respiratory distress.

We reviewed our cases of persistent extrapulmonary air following chest tube placement and decided to test the hypothesis that this entity may represent collections of air beneath the visceral pleura. We describe ten patients who had this entity despite one or more chest tubes per pleural cavity, and described the creation of subvisceral pleural blebs in preterm lambs with respiratory distress requiring mechanical ventilation. We conclude that (1) subvisceral pleural air may occur in infants with respiratory distress and, thus, may be inaccessible to chest-tube drainage, and (2) centrifugal dissection of air, though poorly appreciated previously, may play an important role in the pathogenesis of extrapulmonary air.

Animals↗
PubMed2004

[Urgent or emergent coronary revascularization using bilateral internal thoracic artery after previous clopidogrel antiplatelet therapy].

BACKGROUND: Application of clopidogrel before diagnostic or therapeutical percutaneous coronary interventions has become standard for stent-thrombosis prevention. The irreversible platelet inhibition causes increasing bleeding complications if urgent coronary artery bypass grafting becomes necessary. This study evaluates the effect on bleeding complications of clopidogrel in urgent CABG using bilateral internal thoracic artery (ITA) and saphenous veins in all patients. METHODS: We retrospectively analyzed 166 patients (operated between 1/00-12/02) with urgent or emergency CABG, using both ITAs and compared 83 patients with previous (within 5 days) clopidogrel and aspirin application to 83 patients without clopidogrel. We evaluated chest tube output, reexploration rate and necessity of blood products, ventilation time and ICU stay. RESULTS: Both groups were comparable with age, gender, number of performed anastomoses (mean 4/ patient). Chest tube output (24 h) was higher in the clopidogrel group (935 +/- 599 ml vs 754 +/- 335 ml (p = 0.018)), as well as reexploration rate with 7.2% (6 of 83) vs 0% (0 of 83) (p < 0.001). Number of blood products in the clopidogrel group for red cells was 2.41 +/- 1.88 U vs 1.84 +/- 1.47 U p = 0.03, for plateletes 0.43 +/- 0.88 U vs 0.024 +/- 0.22 p = 0.0001, for fresh frozen plasma 0.41 +/- 1.14 U vs 0.096 +/- 0.59 U p = 0.029. Mechanical ventilation time was 11.35 +/- 8.77 h vs 10.57 +/- 9.12 h p = 0.51, ICU stay 32.1 +/- 21.8 h vs. 29.8 +/- 21.1 h (p = 0.48). CONCLUSIONS: Previous application of clopidogrel in combination with aspirin before urgent CABG induces increased chest tube output, reexploration rate and necessity of blood products, especially of plateletes. Nevertheless, routine use of both ITAs in patients after clopidogrel exposure can be performed with acceptable bleeding complications.

Aged↗
PubMed2000

Aprotinin and tranexamic acid for high transfusion risk cardiac surgery.

BACKGROUND: Studies have shown that aprotinin and tranexamic acid can reduce postoperative blood loss after cardiac operation. However, which drug is more efficacious in a higher risk surgical group of patients, has yet to be defined in a randomized study. METHODS: With informed consent, 80 patients undergoing elective high transfusion risk cardiac procedures (repeat sternotomy, multiple valve, combined procedures, or aortic arch operation) were randomized in a double-blind fashion, to receive either high dose aprotinin or tranexamic acid. Patient and operative characteristics, chest tube drainage and transfusion requirements were recorded. RESULTS: There was no significant difference between the 2 treatment groups with respect to age, cardiopulmonary bypass time, complications (myocardial infarction, stroke, death), chest tube drainage (6, 12, or 24 hours), blood transfusions up to 24 hours postoperatively, total allogeneic blood transfusions for entire hospital stay, or induction/postoperative hemoglobin levels. However, multiple regression analysis revealed a positive relationship between cardiopulmonary bypass time and 24 hour blood loss in the tranexamic acid group (p = 0.001), unlike the aprotinin group where 24 hour blood loss is independent of cardiopulmonary bypass time (p = 0.423). CONCLUSIONS: Overall, there was no significant difference in blood loss, or transfusion requirements, when patients received either aprotinin or tranexamic acid for high transfusion risk cardiac operation. Aprotinin, when given as an infusion in a high-dose regimen, was able to negate the usual positive effect of cardiopulmonary bypass time on chest tube blood loss.

Antifibrinolytic Agents↗
PubMed1995

CT of the chest: minimal tube current required for good image quality with the least radiation dose.

OBJECTIVE: We wanted to determine minimal tube current (mAs) required for consistently good image quality on conventional 10-mm collimation chest CT and effect of tube current reduction on detection of mediastinal and lung abnormalities. Tube current reduction is desirable to reduce patient radiation dose. SUBJECTS AND METHODS: Prospectively, 30 consecutive patients (mean weight, 68 kg; range, 34-93 kg) older than 45 undergoing conventional chest CT with standard technique (120 kVp, 400 mAs) had four additional sections imaged at reduced tube current (200, 140, 80, 20 mAs) at two levels (tracheal carina and left atrium). CT scans were evaluated in random order by two independent observers who were blinded to technical factors used. Subjective image quality was graded on a five-point scale from non-diagnostic to excellent. Visualization of mediastinal adenopathy (n = 18), pleural plaques (n = 17), effusions (n = 28), lung parenchymal nodules (n = 37), and emphysema (n = 15) were assessed. The 400 mAs scan was considered the reference standard. RESULTS: When compared with the reference technique (400 mAs), the first and second (200 mAs and 140 mAs) reduction levels showed no significant difference (p > .05) in subjective image quality. A significant difference (p < .001) was seen at the third and fourth (80 mAs and 20 mAs) reduction levels. However, no significant difference (p > .05) was seen in detection of mediastinal or lung parenchymal abnormalities with different tube currents. CONCLUSION: A twofold reduction in tube current (400-140 mAs) and resultant radiation dose did not cause a significant change in subjective image quality or in detection of mediastinal or lung abnormalities with conventional chest CT. One hundred forty milliampere-seconds is the minimal tube current required to provide good image quality in patients of average weight.

Aged↗
PubMed2006

Intrapleural cisplatin and OK432 therapy for malignant pleural effusion caused by non-small cell lung cancer.

OBJECTIVE: To evaluate the efficacy of combined intrapleural therapy with cisplatin, an antineoplastic agent, and OK432, a sclerosing agent, in controlling malignant pleural effusions, when compared with monotherapy with either agent. METHODS: A total of 49 non-small cell lung cancer patients with malignant pleural effusion were randomly assigned to one of three groups: intrapleural cisplatin therapy (n = 17), intrapleural OK432 therapy (n = 17), or both (n = 15). They were compared in terms of success rate, duration of indwelling chest tube and adverse reactions. RESULTS: Rates of pleural effusion recurrence within 180 days following cisplatin, OK432, or combination therapy were 64.7%, 52.9% and 13.3%, respectively, being significantly lower in the combination therapy group (P = 0.01). The mean duration of chest tube drainage was 8.4 days, 5.5 days and 12.9 days, respectively, being significantly longer in the combination therapy group (P < 0.001). All procedures were well tolerated. CONCLUSIONS: Although chest tube drainage took longer because of the time required for multiple administration of the agents, intrapleural combination therapy with cisplatin and OK432 was more effective in controlling malignant pleural effusions due to non-small cell lung cancer than monotherapy with either agent.

Aged↗
PubMed1988

Lung perforation complicating tube thoracostomy: pathologic description of three cases.

Insertion of a chest tube into the pleural space is standard therapy for a variety of pleural abnormalities. Three cases are described of lung perforation secondary to this procedure. In all three cases the tube had been inserted with the use of a trocar, and in two there were pleural adhesions in the vicinity of the puncture; in none was the perforation suspected clinically or considered to contribute to patient death. Pathologic features included one or two pleural holes continuous with a parenchymal tract of variable length. In one case, there was early epithelialization of the inner surface of the tract, suggesting that some of these may remain patent and be seen as incidental findings long after their formation. Two of the cases were identified among 18 patients who had had chest tubes inserted and came to autopsy over a similar period, implying that the incidence of the complication is greater than is generally appreciated. Reasons for this under appreciation are the lack or nonspecificity of clinical and radiographic findings and the ease with which perforation can be overlooked at autopsy.

Aged↗
PubMed1982

Position may stop pneumothorax progression in dogs.

We attempted to see what the effect of position was on the rate of pneumothorax formation. In 6 anesthetized spontaneously breathing dogs in the left decubitus position, a chest tube was inserted into the right hemithorax. A right-sided pneumothorax was induced by percutaneous transthoracic insertion of a 20-gauge needle into the lung. Once a constant rate of pneumothorax formation occurred, the dogs were alternated between 3 min of no evacuation by the chest tube with the puncture site up (left decubitus) or down (right decubitus). The pneumothorax that accumulated was always evacuated immediately thereafter with the chest tube in the highest position (left decubitus). In every case, the rate of pneumothorax formation decreased with the puncture site down rather than with it up. Furthermore, this maneuver caused the site of leak to completely seal 11 of 21 times in which the puncture site was placed dependent. There was, however, no significant change in the rate of pneumothorax formation with the puncture site kept in the nondependent position. These results are consistent with the hypothesis that placing the site of pleural gas leak in the most dependent position causes a reduction in alveolar size as well as the alveolar to pleural pressure gradient in the region surrounding the leak. Both of these factors would tend to slow the rate of pneumothorax formation and allow sealing of the puncture site.

Animals↗
PubMedDate not supplied

Thoracoscopy in the evaluation and management of thoracic trauma.

Video-thoracoscopy was used to evaluate and manage patients after thoracic trauma. It was used in 29 patients. Indications included retained hemothorax in 16 patients, empyema in 11, evaluation for the source of thoracic bleeding in 1, and an airleak in 1. The mechanism of injury was blunt trauma in 8 cases, 10 with stab wounds, and 11 with gunshot wounds. In blunt trauma, thoracoscopy was carried out an average of 11.7 days post injury, chest tubes were removed after an average of 7 days post thoracoscopy, and discharge averaged 10.7 days after thoracoscopy. The failure rate was 12.5% with no mortality. In stab wounds, it was carried out an average of 8.8 days post injury, chest tube removal occurred after 6.1 days, and discharge averaged 7.8 days after thoracoscopy. The failure rate was 20% with no mortality. In gunshot wounds, it was carried out an average of 7.5 days after injury, chest tubes were removed after 9.9 days, and discharge averaged 16 days post thoracoscopy. The failure rate was 9% with a mortality of 9%. Overall, the failure rate for thoracoscopy was 13.8% (4/29). The mortality rate was 3.5% (1/29). It was successfully performed up to 30 days post injury. It proved to be effective in the management of empyema, evacuation of clotted hemothorax, and diagnosis of ongoing thoracic bleeding.

Humans↗
PubMed1999

Intrapleural streptokinase in the management of malignant multiloculated pleural effusions.

OBJECTIVE: Pleural effusions are a frequent complication of malignancy and cause considerable morbidity from dyspnea. The drainage and control of malignant effusions relieve symptoms and maintain quality of life but these are difficult in patients with multiloculated effusions in whom drainage usually fails. This observational series reports the use of intrapleural streptokinase (IPSK) in the management of malignant multiloculated pleural effusions resistant to standard chest tube drainage. METHODS: Ten consecutive patients with malignant multiloculated pleural effusions, aged 39 to 89 years, were given 250,000-IU doses of IPSK twice daily after failure to drain the effusions with a standard chest tube because of multiloculation and multiseptation, as demonstrated by CT or ultrasound scanning. Outcome was assessed by radiographic improvement and symptom control. RESULTS: All 10 patients responded to between 500,000 and 1,500,000 IU of streptokinase. There was an increase in pleural fluid drained (mean volume+/-SD; pre-IPSK, 843+/-690 mL; post-IPSK, 2,368+/-1,051 mL; p < 0.001, paired t test), and radiographic improvement was seen in all 10 patients. All subjects tolerated the instillation of streptokinase well. One subject required opiate analgesia for transient chest pain, and there were no hemorrhagic or allergic complications. One patient died of unrelated septicemia. CONCLUSIONS: This series suggests that IPSK may be useful in the drainage of malignant multiloculated pleural effusions in patients who fail to drain adequately with a standard chest tube. Malignant pleural effusions should not be considered a contraindication to IPSK.

Adult↗
PubMed2002

Management of spontaneous pneumothorax: are British Thoracic Society guidelines being followed?

In 1993, the British Thoracic Society (BTS) issued guidelines for the management of spontaneous pneumothorax. The aim of this study was to determine the level of adherence to and awareness of these guidelines at a London teaching hospital. A retrospective case note audit of 59 episodes of acute spontaneous pneumothorax was performed. In patients undergoing intervention, the initial procedure was simple aspiration in 32 (73%) and chest tube insertion in 12 (27%) cases, contrasting with the BTS recommendation that aspiration should be attempted first in all such patients. Simple aspiration was successful on 34% of occasions. Successful aspiration was associated with a significantly shorter hospital stay (median 3, range 1-11 days) than either failed aspiration (7, 3-66 days; p=0.003) or chest tube insertion without aspiration (9, 3-16 days; p=0.005). Other areas where practice differed from the BTS guidelines were clamping of chest tubes and use of a pursestring suture for wound closure. A follow up questionnaire survey suggested a lack of familiarity with the guidelines. These findings indicate that current management of spontaneous pneumothorax deviates from the BTS guidelines in a number of potentially important respects. Attention should be directed to improving awareness of and access to clinical guidelines.

Adolescent↗
PubMed1995

Safety of patent ductus arteriosus closure in premature infants without tube thoracostomy.

During a 30-month period, 34 premature infants underwent surgical closure of a patent ductus arteriosus. The mean gestational age at birth was 25 +/- 0.3 weeks and the mean age at the time of operation was 3 +/- 0.3 weeks (mean weight, 829 +/- 54 g). Indomethacin therapy had failed in 32 patients, and 2 had contraindications to its use. The initial 8 patients had parascapular incision and ligation of the patent ductus arteriosus; the last 26 patients had a short transaxillary incision and clipping. The average duration of the operation from the time of incision to skin closure was 36 +/- 2 minutes (range, 15 to 65 minutes). One patient (3%) needed chest tube insertion intraoperatively because of visceral pleura disruption. Two patients (5.8%) had a "small pneumothorax" (< 10% of the lung field) that resolved within 24 hours. There was no morbidity or mortality directly related to the operative procedure, although 3 patients (8.8%) ultimately died from problems related to their severe prematurity. We conclude that surgical closure of patent ductus arteriosus without chest tube drainage can be accomplished safely in premature infants. Postoperative nursing care is simplified and the cost is reduced because the need for the chest tube and drainage system is eliminated and the number of chest radiograms needed postoperatively is reduced.

Blood Loss, Surgical↗