Effect of fibrinogen replacement therapy on bleeding outcomes and 1-year mortality in patients undergoing thoracic aortic surgery: a retrospective cohort study.

PURPOSE: This study aimed to examine the effect of fibrinogen replacement therapy with cryoprecipitate or fibrinogen concentrate on bleeding outcomes and 1-year mortality in patients undergoing thoracic aortic surgery. METHODS: We retrospectively studied 439 consecutive patients who underwent thoracic aortic surgery with cardiopulmonary bypass between January 1st, 2010 and December 31st, 2019 and identified patients who received cryoprecipitate or fibrinogen concentrate (the fibrinogen replacement group) and those who did not (the control group). Multivariate analyses were performed to examine the associations of fibrinogen replacement therapy with perioperative major bleeding (i.e., excessive hemorrhage or blood transfusion), re-exploration for bleeding, and 1-year mortality. RESULTS: There were 285 patients in the fibrinogen replacement group who received 2.2 ± 1.0 g of concentrated fibrinogen amount and 154 patients in the control group. The incidence of major bleeding in the fibrinogen replacement group was less than that in the control group in patients with fibrinogen level < 150 mg/dL during cardiopulmonary bypass (49.7% versus 74.6%, p = 0.0007, multivariate odds ratio; 0.33, 95% confidence intervals; 0.12-0.91, p = 0.03), but not in patients with fibrinogen level ≥ 150 mg/dL (25.0% versus 29.6%, p = 0.51). No significant difference was found in re-exploration for bleeding (1.0% versus 1.3%, p = 1.00) or 1-year mortality (10.4% versus 5.3%, multivariate Cox proportional-hazard ratio; 1.03, 95% confidence intervals; 0.82-1.31, p = 0.74) between the fibrinogen replacement group and the control group. CONCLUSIONS: The results of this study indicate that 2-3 g of fibrinogen replacement reduces the incidence of major bleeding in patients with hypofibrinogenemia during cardiopulmonary bypass in thoracic aortic surgery.

[Efficacy and Indication of Fibrinogen Replacement Therapy in Thoracic Aortic Surgery A Retrospective Cohort Study].

BACKGROUND: Fibrinogen replacement therapy con- tributes to effective hemostasis and saving blood trans- fusions in critical hemorrhage. We retrospectively studied the efficacy and indication for cryoprecipitate or fibrinogen concentrate in thoracic aortic surgery. METHODS: In 169 patients undergoing thoracic aortic surgery, 92 (54.4%) patients received dryoprecipitate or fibrinogen concentrate and 77 (45.6%) patients did not We compared them with regard to postoperative bleeding and perioperative blood transfusion. We deter- mined the effective dose of the fibrinogen in cryopre- cipitate or fibrinogen concentrate for increasing the fibrinogen level. RESULTS: The cutoff value of the fibrinogen level at the end of cardiopulmonary bypass between both groups was 100 mg · dl⁻¹. For a fibrinogen level less than 130 mg · dl⁻¹ during cardiopulmonary bypass, the patients who received cryoprecipitate or fibrinogen concentrate had less postoperative bleeding (P<0.01) and fewer transfusions of total blood, fresh frozen plasma, and platelet concentrates (P<0.05). The effec- tive dose 50 of fibrinogen amount was 0.031-0.051 g - kg⁻¹. CONCLUSIONS: The fibrinogen amount of 2-3 g (per 50-70 kg in body weight) in cryoprecipitate or fibrino- gen concentrate effectively reduces postoperative bleeding and perioperative blood transfusions when a fibrinogen level is less than 100-130 mg · dl⁻¹ during cardiopulmonary bypass.

Perineural but not systemic low-dose dexamethasone prolongs the duration of interscalene block with ropivacaine: a prospective randomized trial.

PURPOSE: To determine the effects of intravenous and perineural dexamethasone on the duration of interscalene brachial plexus block (ISB) with ropivacaine in patients undergoing arthroscopic shoulder surgery. PATIENTS AND METHODS: In this prospective, randomized, placebo-controlled trial, patients presenting for arthroscopic shoulder surgery with an ISB were randomized to receive ropivacaine 0.75% (group C), ropivacaine 0.75% plus perineural dexamethasone 4 mg (group Dperi), or ropivacaine 0.75% plus intravenous dexamethasone 4 mg (group Div). The primary outcome was the duration of analgesia, defined as the time between performance of the block and the first request for analgesic. RESULTS: Thirty-nine patients were randomized. The median times of sensory block in groups C, Dperi, and Div were 11.2 hours (interquartile range [IQR] 8.0-15.0 hours), 18.0 hours (IQR 14.5-19.0 hours), and 14.0 hours (IQR 12.7-15.1 hours), respectively. Significant differences were observed between groups Dperi and C (P=0.001). Kaplan-Meier analysis for the first analgesic request showed significant differences between groups Dperi and C (P=0.005) and between groups Dperi and Div (P=0.008), but not between groups C and Div. CONCLUSION: Perineural but not intravenous administration of 4 mg of dexamethasone significantly prolongs the duration of effective postoperative analgesia resulting from a single-shot ISB with ropivacaine 0.75%.

[Lower thoracic epidural analgesia improves postoperative analgesia following vaginal total hysterectomy].

BACKGROUND: In our hospital, lumbar epidural analgesia had been used for postoperative analgesia following vaginal total hysterectomy (VTH). But some patients experienced severe abdominal pain or numbness of the legs. Therefore we planned a randomized prospective study to compare lower thoracic epidural analgesia and lumbar epidural analgesia following VTH. METHODS: Fifty patients were allocated to two groups: those who received lower thoracic epidural analgesia(T group)and the other who received lumbar epidural analgesia (L group). Both groupsreceived the same continuous epidural analgesia using fentanyl and ropivacaine after the operation. RESULTS: The T group required significantly lower frequency of analgesic agents compared with that of the L group (2.5±1.9 times vs. 1.2±1.1 times, P< 0.05). Fewer patients in the T group had felt numbness in their legs compared to the L group (8% vs. 55%, P<0.05). CONCLUSIONS: Lower thoracic epidural analgesia is more effective to provide postoperative analgesic effect following VTH compared with lumbar epidural analgesia.

[Three cases of latex allergy complicated with anaphylaxis during cesarean section].

UNLABELLED: We experienced three cases of latex anaphylaxis during cesarean section in one year. CASE: 1 A 26-year-old woman underwent emergency cesarean section. Combined spinal-epidural anesthesia was performed and drip infusion of cefazolin sodium was started before operation. After delivery, intravenous injection of methylergometrine maleate and intramyometrial injection of oxytocin were given. Eight minutes after delivery, she complained of dyspnea and edema of eyelids; no change in vital signs were noted. We suspected an anaphylactic reaction and administered antihistamines as well as methylprednisolone. Inhalation of beta-stimulators and sevoflurane using a face mask improved her respiratory symptoms. CASE 2: A 25-year-old woman underwent emergency cesarean section. We noticed wheals involving her eyelids and legs after operation and administered methylprednisolone. CASE 3: A 23-year-old woman underwent elective cesarean section. Five minutes after delivery and oxytocin injection, she complained of edema of eyelids, facial erythematous edema, and dyspnea. We suspected latex anaphylaxis and stopped using latex products. Then, we treated her with antihistamines, methylprednisolone and beta-stimulators. The diagnosis of latex anaphylaxis was made by positive results of skin tests to latex and an increase in the levels of latex-specific immunoglobulin E. We conclude that cesarean section is an important risk factor for latex anaphylaxis.

[Transient paraplegia due to epidural hematoma after catheter withdrawal].

A 58-year-old man with hypertension underwent laparoscopic distal gastrectomy under general and epidural anesthesia. Preoperative laboratory date revealed a normal platelet count and normal coagulation profile. Epidural puncture was successfully performed at the T9-10 intervertebral space on the first attempt without bleeding. An epidural catheter was smoothly inserted 5 cm cephalad. On the third postoperative day, paraplegia due to thoracic epidural hematoma developed shortly after extraction of the catheter. At that time, his blood pressure was 190/102 mmHg because of a pain due to walk. On using a hypotensive drug, his blood pressure fell. Ten minutes later, paraplegia disappeared spontaneously. It is suggested that the spinal cord of the patient was subjected to transient pressure hematoma. A decline in blood pressure may have caused the blood to spread through the epidural space, such that the neurologic symptoms disappeared.