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PubMed2002

[Technical defects of tourniquet manometers].

The use of a tourniquet causes in 0.013% to 1.15% complications (e.g. delayed wound healing, increased rate of infections, thrombosis, pulmonary embolisms,rhabdomyolysis, and compartment syndromes). The rate of these complications depends on the applied pressure, the duration and the cuff design. Also a technical defect of the pressure gauge can lead to complications. A patient with a peroneal palsy after the use of a tourniquet was referred to the Department for Trauma Surgery of the Medical School of the University of Vienna for medical evidence. As there were no reports in the literature about the occurrence rate of technical defects of tourniquet manometers, we checked all tourniquet pressure gauges used at our clinic. Six from eleven gauges were defect and had to be replaced. To minimize the risk for our patients we recommend to check the calibration of the pressure gauges periodically. With regard to the used pressure rate and duration only different recommendations can be found in literature.

Adult↗
PubMed2000

Perioperative complications of Burch colposuspension.

In a review of the literature on the perioperative complications of Burch colposuspension we found only sparse data associated with this problem. We describe our own experience (> 1800 procedures) and the literature, discussing bleeding/hematoma, injury to the bladder, kinking/injury to the ureters, voiding dysfunction, infection, and rare complications such as deep venous thrombosis, pulmonary embolism, ileus, sepsis, external iliac vein injury and mortality rate. Knowledge of the possible risks and complications of Burch colposuspension may minimize the intraoperative complications and increase postoperative surgical success and patient satisfaction.

Female↗
PubMed2003

Hormone replacement therapy: what is the evidence today?

Based on the most recent studies, it clearly appears that long-term hormone replacement therapy (HRT) prevents fractures but does not improve established coronary artery disease. In addition, HRT leads to a small increase in breast cancer incidence and to a decrease in colorectal cancer incidence. HRT increases the incidence of venous thrombosis, pulmonary embolisms and strokes. As a consequence, HRT can no longer be recommended for primary or secondary prevention of cardiovascular diseases. In addition, it was also demonstrated that HRT was not able to improve cognitive functions and prevent dementia. Therefore regarding daily clinical practice, HRT certainly remains useful to control the symptoms of oestrogen deficiency in recently menopausal patients, but it should definitively no longer be recommended for long-term treatment.

Aged↗
PubMed2007

[Antiphospholipid syndrome].

Antiphospholipid syndrome (APS) is characterized by recurrent arterial or venous thromboembolism or pregnancy loss in association with antibodies directed against anionic phospholipids or plasma proteins bound to anionic phospholipids. A common cause of the huge variety of clinical manifestations is vaso-occlusive disease and not vasculitis in venous or arterial blood vessels of different sizes and sites (i.e. deep vein thrombosis, pulmonary embolism, cerebrovascular disease). In accordance with this, fetal abortion, typically beyond the tenth week of gestation, is also caused by infarctions of blood vessels in the placenta. Establishing the correct diagnosis of APS is not easy. To estimate the risk of thrombotic complications is challenging, as well as the questions of, which, how long and in what strength anticoagulation is recommended. This paper should enable the reader to apply international consensus classification criteria correctly, to interpret the different laboratory tests for anti-phospholipid antibodies and to gain an awareness of the different forms of anticoagulation in order to stratify therapeutic decisions.

Abortion, Habitual↗
PubMed2003

Intravenous immunoglobulins in neurological disorders: safety issues.

IVIg products may be applied for the provision of antibodies in patients with primary or secondary antibody deficiency syndromes or with the aim of immune modulation in patients with autoimmune diseases. The average dose for the provision of antibodies is 400 mg/kg per month while much higher doses are needed 1 to 2 g/kg in a single or in repeated occasions in the treatment of autoimmune diseases e. g. neurological diseases. Indications for treatment have been specified at two consensus meetings (1990 and 1999) and by different groups of experts but off-label use highly exceeds the recommended indications. For this reason risk benefit assessment is of great importance. Adverse events can be categorized as (1) early inflammatory, (2) infectious, (3) rare complications of (mainly) high dose treatment. Early inflammatory reactions are known since the initiation of immunoglobulin treatment, the rate varies greatly 10%-85% and reactions can usually be dealt with by lowering the infusion rate. Viral infections e. g. transmission of viral hepatitis by IVIg have been a problem in certain products until the mid-1990s and industry responded in a fast and efficient manner. Viral safety has been achieved and all IVIg products licensed are considered to be safe in this respect. Rare complications mainly of high dose treatment: renal complications were described already in the mid-1980s they were mainly but not only linked to products containing sucrose, maltose and glucose with or without glycine. These complications are rare (88 patients reported in 30 years) and older patients and patients with conditions predisposing to renal disease were at increased risk. Thromboembolic events were another rare but severe complication of high dose treatment also associated with rapid infusion, deep venous thrombosis, pulmonary embolism, myocardial infarction and stroke have been reported. Possible mechanisms have been discussed.

Humans↗
PubMed1988

Might the aphorism "there is no indication in medicine for a pint of blood" lie behind some of the residual morbidity and mortality of surgery?

Reconsideration of, and some uncertainty about, the risks of whole blood transfusion are stimulating renewed debate around and about transfusion policy. This essay -- 1) considers probable risks of retreating in fright from the approach which has significantly reduced the morbidity and mortality of surgical operations over the last 100 years, so that we may balance them against the known and putative risks of transfusion. 2) questions the universality of the aphorism "There is no indication in medicine for a pint of blood" -- because it presumes and implies that everyone can "tolerate"/not be harmed by/minor blood loss, or minor hypovolaemia from any other cause, and leads surgeons and anaesthetists to aim at "minimising" the degree and duration of hypovolaemia during surgery rather than to prevent it entirely. 3) proposes that circulating volume deficiencies, including small ones, are intrinsically intolerable pathological events to be prevented by a "positive" policy aiming at normovolaemia throughout operative procedures by "priming" patients about to undergo major operations with volume expanders before surgery, minimising their intraoperative blood loss, giving non-blood plasma expanders until dilution threatens significant anaemia, and whole-blood transfusion as a last resort when it does. 4) proposes that averting "minor" short-lived circulating volume depletion might avert the residual "minor" morbidity and mortality caused by venous thrombosis, pulmonary embolism, bronchopneumonia, intestinal ileus, postoperative abdominal distension, wound and anastomotic dehiscence, fat embolism, (alone or in various combinations) and give us a greater (insight into and) control over fluid and electrolyte balance.

Blood Transfusion↗
PubMed2006

The prophylaxis of medical patients for thromboembolism pilot study.

PURPOSE: We assessed the feasibility of a large randomized trial intended to determine whether low-dose heparin prophylaxis given throughout hospitalization reduces mortality and morbidity in general medical patients. SUBJECTS AND METHODS: Hospitalized general medical patients aged more than 60 years at 5 Department of Veterans Affairs (VA) medical centers were randomized to receive enoxaparin 40 mg or identical placebo, given daily by subcutaneous injection until hospital discharge. Outcomes included total mortality at 90 days (the primary outcome) and 1 year, and occurrence in the VA hospital within 90 days of symptomatic deep venous thrombosis, pulmonary embolism, and major bleeding. RESULTS: Only 7.6% of hospitalized patients aged more than 60 years were eligible for the study, although a chart review had predicted 25%. The principal exclusions were prior indication for anticoagulation, anticipated need for anticoagulation, contraindication to heparin, expected hospitalization less than 3 days, and "supportive/palliative care only" status. We randomized 140 patients into each group, 28% of target recruitment. The groups were well matched by age and comorbidities. Death occurred in 13 patients receiving enoxaparin and 14 patients receiving placebo at 90 days (relative risk 0.93, 95% confidence interval 0.26-1.59), and in 36 and 32 patients, respectively, at 1 year (relative risk 1.13, 95% confidence interval 0.66-1.60). Clinical thromboembolic events occurred in 5 patients receiving enoxaparin and 8 patients receiving placebo, and major bleeding occurred in 2 and 5 patients, respectively. CONCLUSIONS: The pilot study indicated that the full study was not feasible. The decision to use prophylaxis pertains to only a small proportion of general medical patients hospitalized at VA medical centers, and this proportion is overestimated by chart review. The effect of low-dose heparin prophylaxis on clinical outcomes in hospitalized general medical patients remains uncertain.

Aged↗
PubMed2006

Effect of postoperative epidural analgesia on morbidity and mortality after lung resection in Medicare patients.

STUDY OBJECTIVE: To perform an analysis of the Medicare claims database in patients undergoing lung resection to determine whether there is an association between postoperative epidural analgesia and mortality. DESIGN: Retrospective cohort (database) design. SETTING: University hospital. MEASUREMENTS: We examined a cohort of 3501 patients obtained from a 5% nationally random sample of 1997 to 2001 Medicare beneficiaries who underwent nonemergency segmental excision of the lung (International Classification of Diseases, 9th Revision, Clinical Modification codes 32.3 and 32.4). Patient data were divided into two groups depending on the presence or absence of billing for postoperative epidural analgesia (Current Procedural Terminology code 01996). The primary outcomes assessed were death at 7 and 30 days after the procedure. The rates of major morbidity (acute myocardial infarction, angina, cardiac dysrhythmias, heart failure, pneumonia, pulmonary edema, respiratory failure, deep venous thrombosis, pulmonary embolism, sepsis, acute renal failure, somnolence, acute cerebrovascular event, transient organic syndrome, and paralytic ileus) were also compared. Multivariate regression analysis incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status was performed to determine whether the presence of postoperative epidural analgesia had an independent effect on mortality or major morbidity. MAIN RESULTS: Multivariate regression analysis showed that the presence of epidural analgesia was associated with a significantly lower odds of death at 7 days (odds ratio, 0.39; 95% confidence interval, 0.19-0.80; P = 0.001) and 30 days (odds ratio, 0.53; 95% confidence interval, 0.35-0.78; P = 0.002) after surgery. There was no difference between the groups with regard to overall major morbidity. CONCLUSIONS: Postoperative epidural analgesia may contribute to lower odds of death after segmental excision of the lung, although the mechanism of such a benefit is not clear from our analysis.

Aged↗
PubMed2004

[Spontaneous muscular haematomas in hemiplegic patients receiving anticoagulation therapy].

INTRODUCTION: Muscular hematomas are frequently reported as a complication of anticoagulation therapy. METHODS: We report six cases of spontaneous muscular hematomas occurring in hemiplegic patients receiving anticoagulation therapy using heparin, low-molecular-weight heparin or fluindione. Anticoagulation therapy was given in prophylactic doses to two patients to prevent deep vein thrombosis and in therapeutic doses to four patients with deep vein thrombosis, pulmonary embolism or cardiac arrhythmia. Two patients experienced episodes of bleeding when heparin and fluindione were temporarily associated. RESULT: Contrary to previous reports, the more frequent site of bleeding was not the ilio-psoas muscle (only 2 patients); hematomas were also observed in hip adductors and gluteus muscles. The most striking finding was the constant location of the hematoma on the hemiplegic side. CONCLUSION: Location on the hemiplegic side can lead to underestimating the frequency of neurologic compression by the hematoma; the diagnosis can nevertheless be established by electromyography. Local signs may not be present, but general signs of hypovolemia and anemia are more frequent. Ultrasound may be the first line investigation but in our experience, the results can be misleading and computed tomography (CT) or MRI are often required to confirm the diagnosis.

Adult↗
PubMedDate not supplied

Intravenous immunoglobulin in secondary progressive multiple sclerosis: randomised placebo-controlled trial.

BACKGROUND: Several double-blind placebo-controlled trials of relapsing-remitting multiple sclerosis have shown beneficial effects of intravenous immunoglobulin (IVIG) on relapse rate and disability. The European Study on Intravenous Immunoglobulin in Multiple Sclerosis set out to test IVIG in the secondary progressive phase of the disease. METHODS: 318 patients with clinically definite secondary progressive multiple sclerosis (mean age 44 years [SD 7]) were randomly assigned IVIG 1 g/kg per month (n=159) or an equivalent volume of placebo (albumin 0.1%; n=159) for 27 months. After baseline investigation, clinical assessments were made every 3 months and MRI was repeated after 12 months and 24 months. The primary outcome was confirmed worsening of disability as defined by the time to first confirmed progression on the expanded disability status scale (EDSS). Analyses were by intention to treat. FINDINGS: 19 patients in the IVIG group and 39 in the placebo group terminated study treatment prematurely but were included in the analyses. IVIG treatment had no beneficial effect on time to confirmed EDSS progression (hazard ratio 1.11 [95% CI 0.80-1.53] for IVIG versus placebo). The annual relapse rate was 0.46 in both groups. No significant differences between the treatment groups were found in any of the other clinical outcome measures or in the change of T2-lesion load over time. The treatment was generally well tolerated, although deep venous thrombosis, pulmonary embolism, or both occurred in seven patients with risk factors for thromboembolism (IVIG six, placebo one). INTERPRETATION: Treatment with IVIG in this study did not show any clinical benefit and therefore cannot be recommended for patients with secondary progressive multiple sclerosis.

Adult↗