A critical appraisal of perioperative sleep apnoea management after nasal surgery: A review of up-to-date literature supplemented by findings of a retrospective observational study.

OBJECTIVE: To review the current recommendations on postoperative precautions for obstructive sleep apnoea patients undergoing elective nasal surgery. DESIGN: Retrospective cohort study. SETTING: Department of Otorhinolaryngology and Anesthesiology/Intensive Care, University Teaching Hospital, Rotterdam, the Netherlands. PARTICIPANTS: The medical charts of 61 patients with sleep apnoea who were admitted to the post-anaesthesia care unit between 2016 and 2020, following nasal surgery were reviewed. MAIN OUTCOME MEASURES: Number of respiratory events during post-anaesthesia care unit admission that required medical intervention. RESULTS: In all 61 patients, continuous positive airway pressure could not be used. In 13 patients (8%), decreased oxygen saturation levels were registered during the first postoperative night, and in five of these patients, supplemental oxygen was needed. No other respiratory incidents of medical interventions were registered. CONCLUSIONS: The number of clinically relevant respiratory events of obstructive sleep apnoea patients with bilateral nasal packing following nasal surgery is low. We suggest that the safety of less expensive and less scarce alternatives of postoperative observation should be explored.

Subcutaneous and Mediastinal Emphysema Followed by Group A Beta-Hemolytic Streptococci Mediastinitis. A Complicated Course after Adenotonsillectomy: Case Report.

Tonsillectomy is a commonly performed surgery in the daily practice of an otorhinolaryngologist. For patients as well as health professionals, the best known complication is post-operative bleeding. Among the less noted, but potentially life-threatening, complications are the development of subcutaneous emphysema and the presence of bacteremia due to group A hemolytic streptococci. In this report, we describe a severely complicated clinical course after an uncomplicated adenotonsillectomy in a young boy. Increased awareness of relatively unknown complications after adenotonsillectomy amongst surgeons, pediatricians and anesthesiologists is desirable to facilitate rapid diagnosis and adequate treatment in order to prevent life-threatening situations.

Relationship between tissue perfusion and coagulopathy in traumatic brain injury.

BACKGROUND: Traumatic brain injury (TBI)-related coagulopathy appears to be most prevalent in patients with tissue hypoperfusion, but evidence for this association is scarce. This study investigated the relationship between tissue perfusion and hemostatic derangements in TBI patients. MATERIALS AND METHODS: Coagulation parameters were measured on emergency department admission in patients with TBI (head abbreviated injury scale ≥ 3). The level of hypoperfusion was simultaneously assessed by near-infrared spectroscopy (NIRS) at the forehead and arm, and by base excess and lactate. Coagulopathy was defined as an international normalized ratio > 1.2 and/or activated partial thromboplastin time > 40 s and/or thrombocytopenia (<120 × 10(9)/L). RESULTS: TBI patients with coagulopathy (42%) had more signs of tissue hypoperfusion as indicated by increased lactate levels (2.1 [1.1-3.2] mmol/L versus 1.2 [1.0-1.7] mmol/L; P = 0.017) and a larger base deficit (-3.0 [-4.6 to -2.0] mmol/L versus -0.1 [-2.5 to 1.8] mmol/L; P < 0.001). There was no difference in the cerebral or somatic tissue oxygenation index. However, there was a distinct trend toward a moderate inverse association between the cerebral tissue oxygenation index and D-dimer levels (r=-0.40; P = 0.051) as marker of fibrinolysis. The presence of coagulopathy was associated with an increased inhospital mortality rate (45.5% versus 6.7%; P = 0.002). CONCLUSIONS: This is the first study to investigate the relationship between hemostatic derangements and tissue oxygenation using NIRS in TBI patients. This study showed that TBI-related coagulopathy is more profound in patients with metabolic acidosis and increased lactate levels. Although there was no direct relationship between tissue oxygenation and coagulopathy, we observed an inverse relationship between NIRS tissue oxygenation levels and fibrinolysis.

Low Cerebral Oxygenation Levels during Resuscitation in Out-of-hospital Cardiac Arrest Are Associated with Hyperfibrinolysis.

BACKGROUND: The authors investigated whether patients with out-of-hospital cardiac arrest with an initial low cerebral oxygen level during cardiopulmonary resuscitation are more prone to develop hyperfibrinolysis than patients with normal cerebral oxygenation levels and which part of the fibrinolytic system is involved in this response. METHODS: In 46 patients, hyperfibrinolysis was diagnosed immediately upon emergency department admission using rotational thromboelastometry and defined as a lysis more than 15%. Simultaneously, initial cerebral tissue oxygenation was measured using near-infrared spectroscopy, and oxygen desaturation was defined as a tissue oxygenation index (TOI) of 50% or less. Blood sample analysis included markers for hypoperfusion and fibrinolysis. RESULTS: There was no difference in prehospital cardiopulmonary resuscitation duration between patients with or without hyperfibrinolysis. An initial TOI of 50% or less was associated with more clot lysis (91% [17 to 100%; n = 16]) compared with patients with a normal TOI (6% [4 to 11%]; n = 30; P < 0.001), with lower levels of plasminogen (151.6 ± 61.0 vs. 225.3 ± 47.0 µg/ml; P < 0.001) and higher levels of tissue plasminogen activator (t-PA; 18.3 ± 7.4 vs. 7.9 ± 4.7 ng/ml; P < 0.001) and plasminogen activator inhibitor-1 (19.3 ± 8.9 vs. 12.1 ± 6.1 ng/ml; P = 0.013). There were no differences in (activated) protein C levels among groups. The initial TOI was negatively correlated with t-PA (r = -0.69; P < 0001). Mortality rates were highest in patients with hyperfibrinolysis. CONCLUSION: Activation of the fibrinolytic system is more common in out-of-hospital cardiac arrest patients with an initial cerebral tissue oxygenation value of 50% or less during resuscitation and is linked to increased levels of t-PA rather than involvement of protein C.

Lysis onset time as diagnostic rotational thromboelastometry parameter for fast detection of hyperfibrinolysis.

BACKGROUND: Rotational thromboelastometry is increasingly used to detect hyperfibrinolysis, which is a predictor of unfavorable outcome in patients with coagulation disturbances. In an in vitro study, the authors investigated which thromboelastometric hemostatic parameters could be valuable for fast diagnosis of the severity of hyperfibrinolysis and confirmed their findings in a patient population with hyperfibrinolysis. METHODS: Thromboelastometry was performed after adding increasing concentrations of tissue plasminogen activator (0 to 400 ng/ml) to citrated blood samples of 15 healthy volunteers. Lysis parameters included the clotting time, maximum clot firmness, maximum lysis, and lysis onset time (LOT). The relation of tissue plasminogen activator with the LOT was further investigated in a patient population with out-of-hospital cardiac arrest and hyperfibrinolysis. RESULTS: The LOT showed a dose-dependent association with increasing tissue plasminogen activator concentrations. Late, intermediate, or fulminant hyperfibrinolysis was associated with an average LOT (mean ± SD) of 42.7 ± 13.8, 23.2 ± 8.2, and 17.5 ± 4.6 min in the in vitro study and estimated 42.2 ± 8.3, 29.1 ± 1.2, and 14.6 ± 7.7 min in patients, respectively. The authors found a moderately negative correlation between patient plasma tissue plasminogen activator levels and the LOT (r = -0.67; P = 0.01). CONCLUSION: This study shows that the LOT may be used for fast detection of severe hyperfibrinolysis, with a better resolution than the maximum lysis, and should be further evaluated for optimization of therapeutic strategies in patients with severe clot breakdown.