Effects of Preoperative Intravenous Versus Subcutaneous Tranexamic Acid on Postoperative Periorbital Ecchymosis and Edema Following Upper Eyelid Blepharoplasty: A Prospective, Randomized, Double-Blinded, Placebo-Controlled, Comparative Study.

PURPOSE: To compare the effects of preoperative tranexamic acid (TXA) administered intravenously (IV) versus subcutaneously on postoperative ecchymosis and edema in patients undergoing bilateral upper eyelid blepharoplasty. METHODS: A prospective, double-blinded, placebo-controlled study of patients undergoing bilateral upper eyelid blepharoplasty at a single-center. Eligible participants were randomized to preoperatively receive either (1) 1 g of TXA in 100 ml normal saline IV, (2) 50 µl/ml of TXA in local anesthesia, or (3) no TXA. Primary outcomes included ecchymosis and edema at postoperative day 1 (POD1) and 7 (POD7). Secondary outcomes included operative time, pain, time until resuming activities of daily living, patient satisfaction, and adverse events. RESULTS: By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), ecchymosis scores were significantly lower on POD1 (1.31 vs. 1.56 vs. 2.09, p = 0.02) and on POD7 (0.51 vs. 0.66 vs. 0.98, p = 0.04) among those that received TXA. By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), significant reductions in edema scores occurred in those that received TXA on POD1 (1.59 vs. 1.43 vs. 1.91, p = 0.005) and on POD7 (0.85 vs. 0.60 vs. 0.99, p = 0.04). By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA) patients treated with intravenous and local subcutaneous TXA preoperatively were more likely to experience shorter operative times (10.8 vs. 11.8 vs. 12.9 minutes, p = 0.01), reduced time to resuming activities of daily livings (1.6 vs. 1.6 vs. 2.3 days, p < 0.0001), and higher satisfaction scores at POD1 (8.8 vs. 8.7 vs. 7.9, p = 0.0002). No adverse events occurred were reported. CONCLUSION: In an analysis of 106 patients, preoperative TXA administered either IV or subcutaneously safely reduced postoperative ecchymosis and edema in patients undergoing upper eyelid blepharoplasty. While statistical superiority between intravenous versus local subcutaneous TXA treatment was not definitively identified, our results suggest clinical superiority with IV dosing.

A practical approach to a comprehensive epicardial and epiaortic echocardiographic examination.

OBJECTIVE: More than a decade before the introduction of intraoperative transesophageal echocardiography (TEE), epicardial echocardiography was already in use as a diagnostic imaging modality to assist cardiac surgeons and anesthesiologists with clinical decision making. Although TEE has since become increasingly more popular, epicardial echocardiography may be the most convenient intraoperative imaging technique when TEE probe placement cannot be performed or is contraindicated. The authors developed a comprehensive examination protocol for the intraoperative interrogation of cardiac structures using an epicardial/epiaortic echocardiographic approach. DESIGN: Retrospective analysis of patient's medical records. SETTING: Single-center academic tertiary care hospital. PARTICIPANTS: Patients undergoing cardiac surgery. INTERVENTIONS: A total of 10 echocardiographic views were obtained for imaging cardiac structures, the ascending aorta, and proximal aortic arch. The described imaging planes permit the evaluation of ventricular performance, valvular function, cardiac structural abnormalities, and aortic disease. MEASUREMENTS AND MAIN RESULTS: A comprehensive epicardial/epiaortic echocardiographic examination was performed in 20 patients undergoing cardiac surgery requiring a full sternotomy. The described imaging planes were obtained in all patients in less than 8 minutes (range, 3.5-8 minutes; mean, 5.5 minutes). CONCLUSION: The present manuscript delineates a protocol for performing a comprehensive, intraoperative epicardial/epiaortic echocardiographic examination. Echocardiographic imaging planes of cardiac and aortic anatomy are described. This protocol may be useful for cardiac surgeons and anesthesiologists seeking to use this technique as a cardiac imaging modality that is complementary to TEE.

Neutrophil-derived glutamate regulates vascular endothelial barrier function.

Endothelial barrier function is altered by the release of soluble polymorphonuclear leukocyte (PMN)-derived mediators during inflammatory states. However, endogenous pathways to describe such changes are only recently appreciated. Using an in vitro endothelial paracellular permeability model, cell-free supernatants from formylmethionylleucylphenylalanine-stimulated PMNs were observed to significantly alter endothelial permeability. Biophysical and biochemical analysis of PMN supernatants identified PMN-derived glutamate in modulating endothelial permeability. Furthermore, novel expression of metabotropic glutamate receptor 1 (mGluR1), mGluR4, and mGluR5 by human brain and dermal microvascular endothelial cells was demonstrated by reverse transcription-PCR, in situ hybridization, immunofluorescence, and Western blot analysis. Treatment of human brain endothelia with glutamate or selective, mGluR group I or III agonists resulted in a time-dependent loss of phosphorylated vasodilator-stimulated phosphoprotein (VASP) and significantly increased endothelial permeability. Glutamate-induced decreases in brain endothelial barrier function and phosphorylated VASP were significantly attenuated by pretreatment of human brain endothelia with selective mGluR antagonists. These observations were extended to an in vivo hypoxic mouse model in which pretreatment with mGluR antagonists significantly decreased fluorescein isothiocyanate-dextran flux across the blood-brain barrier. We conclude that activated human PMNs release glutamate and that endothelial expression of group I or III mGluRs function to decrease human brain endothelial VASP phosphorylation and barrier function. These results identify a novel pathway by which PMN-derived glutamate may regulate human endothelial barrier function.