Prevención de hemorragias en el posoperatorio temprano de cirugía bariátrica: Papel de la vitamina K / Prevention of hemorrhage in the early postoperative period of bariatric surgery: Role of vitamin K

Introducción: la cirugía bariátrica es el tratamiento más eficaz para la obesidad mórbida. La hemorragia se presenta en el 0,5-5% de las pacientes. La preparación prequirúrgica con dieta líquida y el uso de antibióticos para Helicobacter pylori podría alterar el metabolismo de la vitamina K y asociarse a hemorragia. Objetivo: describir el comportamiento de la concentración de protrombina (basal = B-PT y prequirúrgica = preQ-PT) en estos pacientes. Material y métodos: se realizó un estudio de cohorte prospectivo donde se comparó la concentración de B-PT (15-180 días previos a la cirugía) y la preQ-PT (24 horas previas a la cirugía). Resultados: se incluyeron 194 pacientes, de los cuales el 72% (n = 139) fueron mujeres, de entre 19 y 69 años, con BMI (IMC) 45 (33 a 58) y pérdida de peso prequirúrgica del 7% (-2 a 17). El promedio de B-PT fue 91,9% (DE 9,529), el promedio de la preQ-PT fue 81,1% (DE 10,760); descendió un 10,8% (p < 0,001). No hubo diferencias significativas cuando se comparó el comportamiento en la preQ-PT entre los diferentes subgrupos (uso de antibióticos para Helicobacter pylori, de acuerdo con la pérdida de peso y en relación con la suplementación de vitamina K); sin embargo, siempre se detectó descenso de la preQ-PT. No hubo ninguna complicación hemorrágica (necesidad de transfusiones o reoperación); tampoco hubo muerte por hemorragias ni eventos tromboembólicos. Conclusión: realizar dosaje de protrombina 24 horas antes de la cirugía bariátrica permite detectar alteraciones iatrogénicas de la coagulación inducidas por la dieta y el uso de antibióticos.

Background: bariatric surgery is the most efficient treatment for morbid obesity. Bleeding occurs in 0.5-5% of patients. Pre-surgical preparation with liquid diet and the use of antibiotics for Helicobacter pylori could alter the metabolism of vitamin K and be associated with hemorrhage. Objective: to describe the behavior of the concentration of Prothrombin (basal = B-PT and pre-surgical = preQ-PT) in these patients. Material and methods: a prospective cohort study comparing B-PT concentration (15-180 days prior to surgery) and preQ-PT (24 h prior to surgery) was performed. Results: a total of 194 patients were included in the study, with 72% (n = 139) women aged 19-69 years, BMI 45 (33 to 58) and preoperative weight loss of 7% (-2 to 17). The media B-PT was 91.9% (SD 9.529), the media pre-PT was 81.1% (SD 10.760); declined 10.8% (p <0.001). There was no significant difference when comparing the behavior in the preQ-PT among different subgroups (use of antibiotics for Helicobacter pylori, according to weight loss and in relation to vitamin K supplementation), however, there was always a decrease of the preQ-PT. There were no bleeding complications (need for transfusions or re-intervetion), nor was there death for bleeding or thromboembolic events. Conclusion: prothrombin measurement 24 hours before bariatric surgery allows the detection of iatrogenic coagulation alterations induced by diet and the use of antibiotics.

Resurgimiento de enfermedad hemorrógica del recién nacido. Implicaciones para su prevención / Re-emergence of hemorrhagic disease in newborns. Implications for its prevention

OBJECTIVE: To describe the occurrence of hemorrhagic disease of the newborn (HDN) at a tertiary care pediatric hospital of Morelos state. MATERIAL AND METHODS: A retrospective case series study was conducted between 1997-2000 at Hospital del Niño Morelense (Morelos State Children's Hospital), in 46 newborns aged under 12 weeks. Study subjects were referred from peripheral units with a diagnosis of HDN. RESULTS: The severe late-onset form of HDN was present in 91 of the cases. Fifty-two percent of childbirths were assisted by a physician and 48 by an empiric midwife. Application of vitamin K was unknown in 61 of cases, in 39 it was not applied and in 4 it was applied. The majority of infants presented severe symptoms due to intra-cranial bleeding, 11 died, and 41 had severe disease sequelae. CONCLUSIONS: Given the high prevalence of HDN in the State of Morelos, reproductive health programs should be reviewed and training programs intensified to promote the utilization of vitamin K by physicians and nurses for preventing this disease.

Uso da vitamina K no periodo neonatal: parenteral x oral / Vitamina K in the newborn infant: parenteral x oral use

A vitamina K e amplamente utlizada logo apos o nascimento, para a prevençäo da doença hemorragica do recém-nascido. Esta patologia se apresenta sob varias formas: precoce, "clássica" e tardia, sendo esta última a de maior morbidade, por provocar hemorragias intracranianas. A vitamina K pode ser administrada por via parenteral ou oral, cada qual com suas vantagens e desvantagens. Ao se optar pela forma oral e necessario adotar um esquema de multiplas doses, para que a profilaxia da forma tardia seja eficaz

Effect of oral water soluble vitamin K on PIVKA-II levels in newborns.

Intramuscular administration of vitamin K for prophylaxis against hemorrhagic disease of the newborn has the disadvantage of increased cost, pain, anxiety to parents and risk of transmission of infection. Oral route is a better alternative. Oral absorption of vitamin K has been shown to be equally good using special oral preparations. However, this preparation is not available in India. A prospective study was carried out on 51 full term, healthy breastfed newborns to evaluate if the injectable water soluble preparation of vitamin K (menadione sodium bisulphite) could be as effective. Fourteen babies received 1 mg vitamin K intramuscularly, 24 received 2 mg vitamin K orally while 13 controls did not receive vitamin K at birth. PIVKA-II levels were measured in cord blood and at 72-78 hours of age in all babies as a marker of vitamin K deficiency. The overall PIVKA-II prevalence in cord blood was 64.7%. At 72-78 hours, PIVKA-II was present in 50% of babies in IM group, 58.3% of babies in oral group and in 76.9% of babies in 'no vitamin K' group (p > 0.05). The PIVKA-II levels decreased or did not change at 72-78 hours in 91.6% of babies in oral group versus 92.8% of babies in IM group (p > 0.05). On the other hand, PIVKA-II levels increased in 30.7% of babies who did not receive vitamin K as against in 7.8% of babies receiving vitamin K in either form (p < 0.05). Hence, vitamin K prophylaxis is required for all newborns at birth and injectable vitamin K (menadione sodium bisulphite) given orally to term healthy babies is effective in preventing vitamin K deficiency state.

Comparative study of oral versus injectable vitamin K in neonates.

One hundred term exclusively breast fed babies weighing more than 2.5 kg were evaluated to determine the efficacy of various modes and doses of Vitamin K to prevent hemorrhagic disease of newborn (HDN). The babies were grouped into four categories of 25 each: Group A--1 mg Vitamin K intramuscular (Menadione sodium disulphite) at birth; Group B--0.5 mg Vitamin K intramuscular; Group C--1 mg Vitamin K orally, and group D--no Vitamin K. The prothrombin index was estimated in all babies between 36-72 hours of age. The results revealed a prothrombin index in Groups A, B, C and D as 94.98 +/- 7.64%, 95.08 +/- 9.91%, 92.51 +/- 10.10% and 80.39 +/- 15.90%, respectively. The differences between Groups A, B and C were insignificant. However, Group D, prothrombin index was significantly reduced as compared with the other three groups. It is, therefore, concluded that oral Vitamin K is as effective as injectable Vitamin K and its usage is recommended in our country to reduce complications and costs of parenteral therapy.

Prothrombin time in first week of life with special reference to vitamin K administration.

Prothrombin time was estimated in 100 neonates (80 full term and 20 preterm). Among the full term infants 50 were healthy and 30 sick. Prothrombin time was altered in neonates with birth hypoxia and prematurity (p less than 0.001). Vitamin K administration to anoxic babies resulted in improvement in prothrombin time after 48-72 hours (p less than 0.001). Four newborns has bleeding, 2 had anoxia and 2 were only in preterms who did not receive vitamin K after birth. It is concluded that vitamin K should be given to all preterms and those with difficult deliveries; term, healthy newborns do not need it.

Late hemorrhagic disease of infancy.

Over a period of 1 1/2 years, 9 infants ages ranging between 3 weeks and 7 months presented with the syndrome of late hemorrhagic disease related to vitamin K deficiency. All were exclusively breast fed and had not received vitamin K at birth. Four of these had acute intracranial hemorrhage, of which 2 expired and the surviving 2 have residual neurologic handicap. Of the remaining 5 who had skin and mucosal bleeds, all recovered on administration of vitamin K.

Vitamin K prophylaxis in the neonates by oral route with different dosages.

This paper evaluated the effect of VKP in the neonates by oral route with different dosages compared to the standard parenteral route giving a single dose at birth. Two hundred and thirty-six healthy, breast-fed infants were divided into 4 groups receiving vitamin K1 1 mg intramuscularly and 2, 3, 5 mg orally during 2-4 hours after birth. The vitamin K dependent clotting factors were measured by the thrombotest at the age of 2 weeks and 4-6 weeks. The result showed no statistical differences among these 4 groups regarding the mean prothrombin complex level and the number of PC deficient subjects. Vitamin K prophylaxis in the newborn babies by 2 mg oral route would be benefit and can be applied routinely as well as 1 mg parenteral route to prevent both HDN and APCD syndrome particularly in breast fed infants. The routine practice of giving vitamin K1 prophylaxis 2 mg orally or 0.5-1 mg intramuscularly should be recommended to all newborn infants. Giving VKP by oral route is practical for developing countries because of simple way of administration, low cost, low toxicity, as well as high efficacy.