Results of office-based fluid-air exchange for postvitrectomy hemorrhage in diabetic retinopathy

ABSTRACT Purpose: This study aimed to evaluate the efficacy and clinical outcomes of a one-way fluid-air exchange procedure for the treatment of postvitrectomy diabetic vitreous hemorrhage in patients with proliferative diabetic retinopathy. Methods: This retrospective study included 233 patients with proliferative diabetic retinopathy, who underwent vitrectomy. A one-way fluid-air exchange procedure was performed in 24 eyes of 24 (10.30%) patients with persistent vitreous cavity rebleeding after the operation. Preprocedural and postprocedural best-corrected visual acuity values were achieved. Complications occurring during and after the procedure were analyzed. Results: Significant visual improvement was observed 1 month after the one-way fluid-air exchange procedure (2.62 ± 0.60 LogMAR at baseline vs. 0.85 ± 0.94 LogMAR at postprocedure, p<0.0001). Moreover, 19 (79.17%) eyes needed the procedure once, and 5 (20.83%) eyed had the procedure more than twice. In 3 (12.50%) eyes, reoperation was eventually required because of persistent rebleeding despite several fluid-air exchanges. No complication was observed during the follow-up. Conclusions: The one-way fluid-air exchange procedure can be an excellent alternative to re-vitrectomy for patients with proliferative diabetic retinopathy suffering from postvitrectomy diabetic vitreous hemorrhage by removing the hemorrhagic contents directly and achieving fast recovery of visual function without apparent complications.

Efficacy of new hemostatic techniques in nonvariceal gastrointestinal bleeding: A systematic review and network meta-analysis.

OBJECTIVES: Nonvariceal gastrointestinal bleeding (NVGIB) is a common medical condition with significant mortality and morbidity. Several types of hemostatic modalities are currently available in clinical setting. This systematic review and network meta-analysis aimed to assess the efficacy of these modalities in treating NVGIB. METHODS: PubMed, EMBASE, and the Cochrane Library databases were searched for studies that compared the efficacy of different hemostatic techniques (over-the-scope clip [OTSC], hemostatic powder [HP] and conventional endoscopic treatment [CET]) for NVGIB published up to June 2022. The 30-day rebleeding rate was regarded as the primary outcome. We performed pairwise and network meta-analyses for all treatments. The heterogeneity and transitivity were evaluated. RESULTS: Twenty-two studies were included. Regarding the 30-day rebleeding rate, OTSC and HP plus CET showed superior efficacy in treating NVGIB compared with CET (OTSC vs CET: relative risk [RR] 0.42, 95% confidence interval [CI] 0.28-0.60; HP plus CET vs CET: RR 0.40, 95% CI 0.17-0.87), while OTSC and HP plus CET had comparable efficacy (RR 0.95, 95% CI 0.38-2.31). HP plus CET ranked the highest in the network ranking estimate. The sensitivity analysis showed that it was not robust that OTSC was superior to CET regarding the short-term rebleeding rate and the initial hemostasis rate. While all-cause mortality, bleeding-related mortality and necessity of surgical or angiographic salvage therapy showed no statistically significant difference. CONCLUSION: OTSC and HP plus CET significantly reduced 30-day rebleeding rate compared to CET and had comparable efficacy in the treatment of NVGIB.

Total clipless laparoscopic nephrectomy carried out with the LigaSure device: Preliminary experience.

BACKGROUND: Total laparoscopic nephrectomy has become the standard method for the removal of diseased kidneys. OBJECTIVES: The purpose of this study was to evaluate the feasibility of the LigaSure vessel closure system during laparoscopic nephrectomy. METHODS: From January 2018 to June 2018, the LigaSure device was used in 5 patients undergoing laparoscopic nephrectomy for non functional kidney. Nephrectomy was carried out without the use of clips or sutures for vessel closure. We report intraoperative findings, conversion rates, blood loss, operative time, morbidity, and postoperative outcomes. RESULTS: Median operative time was 45minutes (range 25 to 60min). Median blood loss was 30mL (range 10 to 50mL). No conversions to open surgery were necessary. No patients experienced major bleeding intraoperatively or postoperatively. All patients left the hospital one day after the procedure. Histopathological examination of the removed kidneys was in favor of chronic non specific pyelonephritis. CONCLUSIONS: For the treatment of the renal pedicle during total laparoscopic nephrectomy of a destroyed kidney, the LigaSure device appears to be feasible and effective. Our experience is the first to demonstrate the advantages of LigaSure® in laparoscopic nephrectomy: reduction in operating time, blood loss, transfusions and length of stay in hospital.

Hemostasis control after femoral percutaneous approach: A systematic review and meta-analysis.

BACKGROUND: Hemostasis control after percutaneous endovascular procedures through the femoral approach remains challenging for catheterization laboratory nurses, given method variability. OBJECTIVE: To summarize the available evidence on vascular devices efficacy dedicated to hemostasis control compared to the extrinsic compression after percutaneous procedures in the femoral vein or artery. METHODS: A systematic review with meta-analysis of randomized clinical trials was conducted. We compared different hemostasis methods in adult patients who underwent diagnostic and/or therapeutic procedures through femoral access. The databases searched were PubMed, Embase, CINAHL and Cochrane CENTRAL, and updated on 03/2022. The outcomes included hematoma, pseudoaneurysm, bleeding, minor and major vascular complication, time to hemostasis, device failure, and manual compression repetition. The risk of bias was assessed using the Cochrane Risk of Bias Tool 1.0. Pooled effect sizes on continuous, categorical and proportion variables were estimated with the random effects model. The continuous variables were summarized as the difference between means weighted by the inverse of variance (WMD), and the categorical ones by the summary of relative risks (RR), estimated by the DerSimonian and Laird method. The Freeman-Tukey method was used to estimate the summary effect of proportions. RESULTS: Fifty articles were included in the systematic review. When compared to extrinsic compression, vascular closure devices resulted in a relative risk reduction (RRR) for hematoma: RR 0.82 [95%CI 0.72 to 0.94] and in shorter time to hemostasis WMD -15.06 min [95%CI -17.56 to -12.56]; no association was observed between interventions with vascular closure devices and extrinsic compression for pseudoaneurysm, bleeding, minor and major vascular complications. Compared to extrinsic compression, sealant or gel type devices were compatible with a RRR for hematoma: RR 0.73 [95%CI 0.59 to 0.90]; and metal clip or staple type devices for pseudoaneurysm: RR 0.48 [95%CI 0.25 to 0.90]; and major vascular complication: RR 0.33 [95%CI 0.17 to 0.64]. For each 100 observations, the device failure rate for metal clip or staple was 3.28% [95%CI 1.69 to 6.27]; for suture 6.84% [95%CI 4.93 to 9.41]; for collagen 3.15% [95%CI 2.24 to 4.41]; and for sealant or gel 7.22% [95% CI 5.49 to 9.45]. CONCLUSIONS: Vascular closure devices performed better in hemostasis control. The certainty of the evidence was rated as very low to moderate. REGISTRATION: PROSPERO CRD42019140794.

Rapid hemostasis of the residual inguinal access sites during endovascular procedures: A case report.

BACKGROUND: In endovascular procedures including total percutaneous endovascular aneurysm repair (pEVAR), percutaneous access through the common femoral artery is most commonly performed. Access-site bleeding is a major concern in percutaneous techniques. Herein, we present a case of successful control of continuous oozing using a vascular closure device (VCD) and the application of Surgicel (Johnson & Johnson, United States) over the access tract. CASE SUMMARY: An 82-year-old man presented with an unruptured abdominal aortic aneurysm measuring 83 mm × 75 mm. The patient had a medical history of atrial fibrillation and was receiving rivaroxaban (15 mg/d). Routine pEVAR was performed using the preclose technique with ProGlide (Abbott, Santa Clara, CA, United States). Significant amount of bleeding was observed at the end of the procedure after the deployment of the closure device at the access site. A sheet of Surgicel was applied to the suture thread using a surgical needle. Surgicel was applied to the surface of the artery along the access tract using a pusher, and hemostasis was immediately attained. CONCLUSION: This simple technique is an excellent adjunct to control residual bleeding from the access site following VCD use.

Internal manual compression of the aorta-an effective way to temporarily control pelvic bleeding in obstetrical hemorrhage.

Obstetrical hemorrhage is the leading cause of maternal death, and its treatment frequently involves surgical procedures. In the most serious cases, regardless of the etiology, the priority is to stop the bleeding and obtain the conditions to definitively repair the injury that generates the bleeding. Multiple options for achieving hemostasis have been described, but most of them require extensive training or technological resources that are not available in all hospitals. Internal manual aortic compression is a procedure that is widely used in the management of massive pelvic bleeding; it was first described more than 50 years ago in obstetrics but is rarely used by obstetricians today. We describe in detail the technique for internal manual aortic compression and highlight the simplicity and effectiveness of the procedure, especially as an initial measure, to avoid the metabolic consequences of massive blood loss. We hope that internal manual aortic compression is taken into account by each obstetrician when caring for a pregnant woman with massive bleeding.

Analysis of the efficacy and related influencing factors of pelvic packing in the treatment of intractable postpartum hemorrhage after emergency perinatal hysterectomy / 中华妇产科杂志

Objective:To investigate the effect of pelvic packing on the control of intractable postpartum hemorrhage after emergency perinatal hysterectomy (EPH).Methods:Eleven cases with complete clinical data of pelvic packing due to failure of hemostasis after EPH were collected to evaluate the outcome, complications, hospital stay of pregnant women, and to analyze the factors affecting the effect of pelvic packing. The cases included patients who were admitted to the Third Affiliated Hospital of Guangzhou Medical University after pelvic packing treatment in the other hospital due to continuous bleeding after EPH or who were referred to our hospital for pelvic packing treatment due to continuous bleeding after EPH from January 2014 to August 2021.Results:The median gestational week of 11 pregnant women was 38.3 weeks(38.0-39.9 weeks) , and the methods of termination of pregnancy were cesarean section in 7 cases (7/11) and vaginal delivery in 4 cases (4/11). The median time between postpartum hemorrhage and pelvic tamponade was 10 hours (5-57 hours), the median amount of bleeding was 8 500 ml(4 800-15 600 ml) , the median number of pelvic tamponade was 3 pieces (2-7 pieces), and the median retention time of gauze pad was 6.0 days (3.0-6.0 days). The median frequency of laparotomy in this pregnancy was 3 times (2-3 times), with a maximum of 4 among the 11 cases, the first pelvic packing was successful in hemostasis in 9 cases, and the final successful treatment in all of the 11 cases. All parturients had hemorrhagic shock (11/11) and disseminated intravascular coagulation (11/11) before pelvic packing. Other common complications were multiple organ dysfunction syndrome (9/11), cardiac arrest (4/11), deep vein thrombosis (3/11), septic shock (3/11), and intestinal obstruction (1/11). All parturients took out the gauze after the coagulation function returned to normal and there was no active bleeding. The recovery time of coagulation function in 11 cases was 3 days (3-5 days), the retention time of gauze pad was 6 days (3-6 days), the median length of stay in intensive care unit was 14 days (11-26 days), and the median total length of stay was 22 days (16-49 days).Conclusions:Pelvic packing could be used as a temporary strategy for intractable postpartum hemorrhage after EPH, which provides a key time for injury control resuscitation for patients with unstable vital signs. This technology provides an opportunity for referral to superior medical institutions and further treatment.

Efficacy of different compression methods for hemostasis at the radial artery puncture point after percutaneous coronary intervention / 中国基层医药

Objective:To compare the hemostatic effects and patient comfort of different compression methods for hemostasis after transradial coronary intervention.Methods:A total of 160 patients who received transradial coronary intervention in The Affiliated Hospital of Hangzhou Normal University from October 2018 to February 2020 were included in this study. In group A ( n = 80), patients underwent spiral compression at the puncture point (release for 1 turn at 2 hours after surgery, rotation for 1 circle after 1 hour, and full decompression). In group B ( n = 80), patients underwent spiral compression at the puncture point (release for 1 turn at 2 hours after surgery, rotation for 1 circle after 2 hours, and full decompression). Percutaneous arterial oxygen saturation value in the affected limb, heart rate, and Visual Analog Scale score at different times after surgery, pain and comfort score at 2 and 12 hours post-surgery were compared between the two groups. Results:Percutaneous arterial oxygen saturation value at 4 and 12 hours post-surgery in group A was (96.6 ± 0.7)% and (97.8 ± 0.5)%, respectively, which was significantly higher than that in group B [(96.2 ± 0.6)%, (97.6 ± 0.7)%, t = 3.88, 2.08, both P < 0.05]. There were no significant differences in total score and subscale score of the General Comfort Questionnaire at 2 hours post-surgery between groups A and B (both P < 0.05). At 12 hours post-surgery, scores of psychological and physical subscales and total score of the General Comfort Questionnaire in group A were (23.64 ± 3.02) points, (12.64 ± 2.05) points, (68.25 ± 6.04) points, which were significantly higher than those in group B [(22.20 ± 2.96) points, (11.38 ± 2.47) points, (64.42 ± 6.71) points, t = 3.05, 3.51, 3.79, all P < 0.05]. At 2 hours post-surgery, there was no significant difference in Numerical Rating Scale score between groups A and B ( P > 0.05). At 4 and 12 hours post-surgery, Numerical Rating Scale score in group A was (2.51 ± 0.58) points and (1.75 ± 0.76) points, respectively, which was significantly lower than that in group B [(2.95 ± 0.63) points, (2.31 ± 0.71) points, t = -4.59, -4.82, both P < 0.05). The incidence of complications was significantly lower in group A than in group B (8.75% vs. 20.00%, χ2 = 4.11, P < 0.05). Conclusion:Compression for hemostasis is highly effective by releasing for 1 turn at 2 hours after transradial coronary intervention, rotating for 1 circle after 1 hour, and full compression because it can greatly mitigate pain, ensure the oxygen supply to the affected limbs, and improve patient comfort.

Long-term function of Hydrofit as hemostatic sealant: abridged republication.

The newly-designed hemostatic sealant, Hydrofit, was developed in Japan and consists of a urethane-based polymer without blood products. By applying Hydrofit gel to an anastomosis site on the aorta, water contact initiates a chemical change in the forming elastomer which adheres rapidly and tightly. We experienced an extirpation of Hydrofit gel that had been applied 4 years and 8 months previously in a 42-year-old female who underwent aortic valve replacement and graft replacement of the ascending aorta. The Hydrofit left around the aortic graft suture line was without infection and functioned very well as an elastic sealant for a long period.

Postoperative Complications in Hemorrhoidal Disease and Special Conditions.

BACKGROUND: Hemorrhoidal disease is still one of the most prevalent proctological diseases. Pain is the most common complication after surgery but bleeding, urinary retention and perianal infection are also frequent. There is also an important group of patients, such as those with inflammatory bowel disease, pregnancy or immunosuppression, who can present an increased rate or more severe complications. OBJECTIVE: To describe the complications following different surgical and instrumental techniques for hemorrhoids in a literature review. Special situations were reviewed to determine how they affect the management of the disease. METHODS: During August 2019, a narrative review of hemorrhoid surgery complications and special situations was performed using the Pubmed MESH DATABASE. CONCLUSION: Pain, urinary retention and bleeding remain the most frequent complications after surgery for hemorrhoids; however, special situations must be taken into account in order to choose the best technique to prevent more severe complications.

Prehospital Damage Control: The Management of Volume, Temperature… and Bleeding! / Control de Daños Prehospitalario: ¡Para Los Cristaloides, Para La Hipotermia Y…! ¡Para El Sangrado!

Abstract Damage control resuscitation should be initiated as soon as possible after a trauma event to avoid metabolic decompensation and high mortality rates. The aim of this article is to assess the position of the Trauma and Emergency Surgery Group (CTE) from Cali, Colombia regarding prehospital care, and to present our experience in the implementation of the "Stop the Bleed" initiative within Latin America. Prehospital care is phase 0 of damage control resuscitation. Prehospital damage control must follow the guidelines proposed by the "Stop the Bleed" initiative. We identified that prehospital personnel have a better perception of hemostatic techniques such as tourniquet use than the hospital providers. The use of tourniquets is recommended as a measure to control bleeding. Fluid management should be initiated using low volume crystalloids, ideally 250 cc boluses, maintaining the principle of permissive hypotension with a systolic blood pressure range between 80- and 90-mm Hg. Hypothermia must be management using warmed blankets or the administration of intravenous fluids warmed prior to infusion. However, these prehospital measures should not delay the transfer time of a patient from the scene to the hospital. To conclude, prehospital damage control measures are the first steps in the control of bleeding and the initiation of hemostatic resuscitation in the traumatically injured patient. Early interventions without increasing the transfer time to a hospital are the keys to increase survival rate of severe trauma patients.

Resumen La resucitación en el control de daños debe iniciarse lo más rápido posible después de presentado el evento traumático para evitar descompensación metabólica y aumento de la mortalidad. El objetivo de este artículo es sustentar nuestro enfoque respecto a la atención prehospitalaria y presentar nuestra experiencia en la implementación de la iniciativa "Stop the Bleed" en Latinoamérica. La atención prehospitalaria es la fase Cero de la resucitación del control de daños. Por medio de la implementación de la iniciativa "Stop the Bleed" se identificó que el personal prehospitalario tiene una mejor percepción sobre el uso de técnicas hemostáticas como el torniquete que el personal hospitalario. Se recomienda el uso de torniquetes como medida de control de sangrado en extremidades. El manejo de líquidos debe realizarse usando cristaloides a bajos volúmenes, con bolos de 250 mL para cumplir el principio de la hipotensión permisiva con un rango entre 80 y 90 mm Hg de presión arterial sistólica. Se deben realizar medidas para evitar la hipotermia como el uso de sábanas térmicas o paso de líquidos calientes. Estas medidas no deben retrasar en ningún momento el tiempo de traslado para recibir la atención hospitalaria. En conclusión, la atención prehospitalaria es el paso inicial para garantizar las primeras medidas de control de sangrado y de resucitación hemostática de los pacientes. Realizar intervenciones tempranas sin acortar el tiempo de traslado a la atención hospitalaria son las claves para aumentar la tasa de supervivencia.

Reversal Treatment in Oral Anticoagulant-Related Intracerebral Hemorrhage-An Observational Study Based on the Swedish Stroke Register.

Introduction: Intracerebral hemorrhage (ICH) is the most serious adverse effect of oral anticoagulant (OAC) treatment. The effect of OAC reversal therapy on outcome is uncertain. We compared 90-day survival and functional outcome in patients with OAC-ICH who received OAC reversal therapy with those who did not. Methods: Data from The Swedish Stroke Register (Riksstroke) for all registered cases of OAC-ICH during 2017 (572 patients) were used to obtain information on reversal (n = 369) and non-reversal (n = 203) treatment receiving patients. Univariate and multivariate Cox regression analysis stratified for level of consciousness (LOC) on admission, and adjustment for relevant baseline variables, was used to compare 90-day Hazard Ratios (HR) for mortality. Results: Sixty-five percent of patients received reversal treatment. These patients were younger, more often pre-stroke independent and alert at presentation. Withholding reversal treatment was associated with an increased death rate (HR = 1.47; 95% CI: 1.08-2.01) in a Cox regression model stratified for LOC and adjusted for baseline imbalances. Additional factors associated with an increased 90-day death rate were male sex (HR = 1.42; 95% CI: 1.06-1.92), age (HR = 1.05; 95% CI: 1.02-1.07), and intraventricular hemorrhage (HR = 2.41; CI: 1.77-3.29). Conclusion: In this large observational study 35% of patients with OAC-ICH did not receive reversal treatment. Patients receiving OAC-reversal treatment had an improved 90-day mortality outcome compared to those not receiving treatment. Mortality was strongly related to LOC. Further, and larger, studies are required to determine which patient groups may benefit from reversal therapy and in whom non-reversal is adequate.

[Intrauterine balloon tamponade combined with temporary abdominal aortic balloon occlusion in the management of women with placenta accreta spectrum:a randomized controlled trial].

Objective: To access the effectiveness and safety of the intrauterine balloon tamponade verse gauze packing combined with temporary abdominal aortic balloon occlusion in the management of placenta accreta spectrum (PAS). Methods: This was an open-label, randomized controlled trial conducted in Nanjing Drum Tower Hospital. The patients suspected with PAS for uterine preservation surgery under the multidisciplinary team care were recruited between Aug 2015 and Jan 2018. When bleeding could not be achieved after fetus delivered, and a temporary abdominal aortic balloon occlusion and the compression sutures as needed, the women were randomly allocated 1∶1 into balloon tamponade (n=81) or gauze packing (n=80) group. The primary outcome was successful bleeding arrests by avoiding second line surgeries. The secondary outcomes included the volume of blood loss during and after cesarean section, the rate of PPH, incidence and amount of blood transfusion, hysterectomy, postpartum pain, ICU admission, need for re-laparotomy, and the length of hospital stay, readmission, and interventional radiology complications. Results: All the women [100% (81/81)] in the balloon group were obtained hemostasis without further intervention, significantly higher than 88% (70/80) in the gauze group (P=0.001). Before uterine tamponade, blood loss were 820 ml (620-1 230) ml and 850 ml (605-1 442) ml, while placenta bed were sutured in 96%（78/81, 77/80） respectively (P>0.05).The proportion of blood loss≥1 000 ml was higher in the gauze group than that in the balloon group (P=0.006). Maternal adverse events involving total blood loss, puerperal morbidity and postpartum pain occurred more frequently in the gauze group (P<0.05). The following outcome showed no statistically significant difference between the two groups: the vascular occlusion time, the dose of radiation, and interventional radiology complication (P>0.05). The median volume infused into the lower and upper balloons is 70 ml (50-100 ml) and 180 ml (100-240 ml). Conclusions: Incrauterine balloon tamponade is as effective as gauze packing in hemostasis following the placenta delivery in PAS. Compared with gauze packing, the uterine balloon tamponade is more effective.

Single Angio-Seal vascular closure device for transfemoral access exceeding 8F.

BACKGROUND: This was a retrospective single-center evaluation for off-label use of a single Angio-Seal-VIP 8F vascular closure device (VCD) (Terumo Interventional Systems, Somerset, NJ, USA) for retrograde transfemoral arterial access exceeding 8F. METHODS: Between 2010 and 2018, in 32 consecutive patients (3 females; mean age 67±9; range 46-86 years) retrograde femoral access was performed in 48 groins for aortoiliac stent or stent graft implantations using 9-14F sheaths. For vascular closure, one single Angio-Seal™-VIP 8F was used. Procedural success, closure-related complications, and risk factors were retrospectively evaluated using patient characteristics, duplex-ultrasound, and contrast-enhanced computed tomography angiography (CTA). Receiver-operating-characteristics were used for statistical analysis. RESULTS: Technical success for deployment of VCD was 100%. Visual inspection and duplex-ultrasound confirmed immediate hemostasis in 100%. Postinterventional CTA depicted major vascular access site complications in 6.3% (3/48 groins) requiring surgical treatment. A subgroup of 13 patients underwent surgical cut-down one day after VCD deployment as part of a two-staged complex endovascular aortic aneurysm repair procedure, allowing for visual assessment of prior used undersized Angio-SealTM. Patient's height (p=0.028) and severe access site calcifications (p=0.028) proved as predictors for one vessel occlusion and two pseudoaneurysms. Low body-mass-index (BMI) showed a non-significant trend. Sheath-size, common femoral artery depth, or body weight were not indicative for occurrence of complications. CONCLUSIONS: In selected cases, without availability of appropriate VCDs, a single Angio-SealTM-VIP 8F served as a feasible option to achieve sufficient hemostasis of transfemoral access exceeding 8F without relevant bleeding complications. Very low BMI, tall body-height, and severe atherosclerosis were identified to predispose to access site complications.

Prehospital Damage Control: The Management of Volume, Temperature and Bleeding!

Damage control resuscitation should be initiated as soon as possible after a trauma event to avoid metabolic decompensation and high mortality rates. The aim of this article is to assess the position of the Trauma and Emergency Surgery Group (CTE) from Cali, Colombia regarding prehospital care, and to present our experience in the implementation of the "Stop the Bleed" initiative within Latin America. Prehospital care is phase 0 of damage control resuscitation. Prehospital damage control must follow the guidelines proposed by the "Stop the Bleed" initiative. We identified that prehospital personnel have a better perception of hemostatic techniques such as tourniquet use than the hospital providers. The use of tourniquets is recommended as a measure to control bleeding. Fluid management should be initiated using low volume crystalloids, ideally 250 cc boluses, maintaining the principle of permissive hypotension with a systolic blood pressure range between 80- and 90-mm Hg. Hypothermia must be management using warmed blankets or the administration of intravenous fluids warmed prior to infusion. However, these prehospital measures should not delay the transfer time of a patient from the scene to the hospital. To conclude, prehospital damage control measures are the first steps in the control of bleeding and the initiation of hemostatic resuscitation in the traumatically injured patient. Early interventions without increasing the transfer time to a hospital are the keys to increase survival rate of severe trauma patients.

La resucitación en el control de daños debe iniciarse lo más rápido posible después de presentado el evento traumático para evitar descompensación metabólica y aumento de la mortalidad. El objetivo de este artículo es sustentar nuestro enfoque respecto a la atención prehospitalaria y presentar nuestra experiencia en la implementación de la iniciativa "Stop the Bleed" en Latinoamérica. La atención prehospitalaria es la fase Cero de la resucitación del control de daños. Por medio de la implementación de la iniciativa "Stop the Bleed" se identificó que el personal prehospitalario tiene una mejor percepción sobre el uso de técnicas hemostáticas como el torniquete que el personal hospitalario. Se recomienda el uso de torniquetes como medida de control de sangrado en extremidades. El manejo de líquidos debe realizarse usando cristaloides a bajos volúmenes, con bolos de 250 mL para cumplir el principio de la hipotensión permisiva con un rango entre 80 y 90 mm Hg de presión arterial sistólica. Se deben realizar medidas para evitar la hipotermia como el uso de sábanas térmicas o paso de líquidos calientes. Estas medidas no deben retrasar en ningún momento el tiempo de traslado para recibir la atención hospitalaria. En conclusión, la atención prehospitalaria es el paso inicial para garantizar las primeras medidas de control de sangrado y de resucitación hemostática de los pacientes. Realizar intervenciones tempranas sin acortar el tiempo de traslado a la atención hospitalaria son las claves para aumentar la tasa de supervivencia.

Nonoperative Management (NOM) of most liver injuries impairs the mastery of intraoperative hemostasis.

BACKGROUND: Nonoperative management (NOM) of most liver injury (LI) compromises teaching of technical skills required for intraoperative LI hemostasis. This study assesses this void. METHODS: The records of patients (pts) admitted for LI during two years (1/1/16-12/31/17) were compared to pts treated during two-year intervals for the last six decades. Treatment included NOM, operation only (OR/only), suture (Sut), tractotomy (Tra), dearterialization (HAL), and resection (Res). RESULTS: During 2016/2017, 41 pts had penetrating (23) or blunt (18) LI. Treatment for penetrating LI was NOM (4), OR/only (12), and hemostasis (7) with Sut (3), HAL (1), Tra (1), and Res (2). Treatment for blunt LI was NOM (16) and OR/only (2). 14 residents performed an average of 0.5 procedures. During six decades, LI requiring hemostasis was 121, 114, 30, 48, 17, and 7 per decade. Concomitantly, the percent having NOM or OR/only was 46%, 47%, 62%, 59%, 72%, and 83%. CONCLUSION: NOM precludes adequate training for hemostasis of LI. Technical proficiency for LI hemostasis requires training in Advanced Trauma Operative Management (ATOM), Advanced Surgical Skills for Exposure in Trauma (ASSET), and rotation through a liver transplant or hepatobiliary service.

CEGP-003 Spray Has a Similar Hemostatic Effect to Epinephrine Injection in Cases of Acute Upper Gastrointestinal Bleeding.

BACKGROUND: Endoscopically applicable hemostatic agents have been demonstrated to have high initial hemostasis rates in cases of upper gastrointestinal bleeding (UGIB). AIMS: The authors developed a new hemostatic powder (CEGP-003) and evaluated its hemostatic and ulcer healing effects in UGIB. METHODS: Patients with peptic ulcer or post-endoscopic resection bleeding were randomly assigned to be treated by epinephrine injection or CEGP-003 spray. All patients were placed under observation for 3 days and underwent second-look endoscopy. The primary outcome was initial hemostasis rate, and the secondary outcomes were rebleeding rate and ulcer healing effect. RESULTS: Seventy-two patients with UGIB were enrolled in this study. Causes of bleeding were peptic ulcer (15, 20.5%), post-endoscopic mucosal resection (11, 15.1%), and post-endoscopic submucosal dissection bleeding (47, 64.4%). Initial hemostasis was achieved in 89.2% (34/37) of patients in the epinephrine group and in 100% (35/35) in the CEGP-003 group (p = 0.115). Rebleeding occurred in 2.7% (1/37) and 8.6% (3/35) in the epinephrine and CEGP-003 groups, respectively (p = 0.35). Three days after endoscopic hemostasis, the ulcer healing effects of epinephrine and CEGP-003 were similar (p = 0.79). CONCLUSION: This study shows that CEGP-003 spray has a hemostatic effect similar to epinephrine in terms of initial hemostasis and rebleeding rates. The authors consider CEGP-003 a potential therapeutic tool for UGIB as a definitive or bridge therapy and that it is particularly useful for oozing lesions after endoscopic resection.

Injecting hemostatic matrix in the path of biopsies: efficacy, potential complications, and the management of such complications.

OBJECTIVE: To describe the technique of injecting hemostatic matrix, as well as the experience of our interventional radiology department in its application. MATERIALS AND METHODS: We conducted a single-center study with retrospective analysis of the experience of our group in the use of hemostatic gelatin matrix in percutaneous biopsies. RESULTS: In a total of 73 biopsies in different organs, such as the liver, kidney, and spleen, hemostatic gelatin matrix was introduced into the coaxial needle. The only complication observed was migration of the hemostatic matrix to the left kidney collecting system, and that was resolved with clinical treatment. There were no cases of bleeding after the injection of hemostatic matrix. CONCLUSION: The use of hemostatic matrices in the path of percutaneous biopsies is another tool available for consideration in minimally invasive procedures.

OBJETIVO: Descrever a técnica de injeção de matrizes hemostáticas e a experiência do nosso serviço de radiologia intervencionista na sua aplicação. MATERIAIS E MÉTODOS: Foi realizado estudo unicêntrico com análise retrospectiva da experiência do nosso grupo na utilização de matriz hemostática gelatinosa em biópsias percutâneas. RESULTADOS: Foram realizadas 73 biópsias com utilização de matriz hemostática gelatinosa no trajeto da agulha coaxial em diferentes órgãos, como fígado, rim, baço, entre outros. A única complicação observada foi a migração da matriz hemostática para o sistema coletor do rim esquerdo, sendo solucionada com tratamento clínico. Não foram observados casos de sangramento no trajeto das biópsias após a injeção de matrizes hemostáticas. CONCLUSÃO: O uso de matrizes hemostáticas no trajeto de biópsias percutâneas é mais uma ferramenta disponível a ser considerada nos procedimentos minimamente invasivos.

Injecting hemostatic matrix in the path of biopsies: efficacy, potential complications, and the management of such complications / Injeção de matrizes hemostáticas no trajeto de biópsias: eficácia, possíveis complicações e o manejo dessas complicações

Abstract Objective: To describe the technique of injecting hemostatic matrix, as well as the experience of our interventional radiology department in its application. Materials and Methods: We conducted a single-center study with retrospective analysis of the experience of our group in the use of hemostatic gelatin matrix in percutaneous biopsies. Results: In a total of 73 biopsies in different organs, such as the liver, kidney, and spleen, hemostatic gelatin matrix was introduced into the coaxial needle. The only complication observed was migration of the hemostatic matrix to the left kidney collecting system, and that was resolved with clinical treatment. There were no cases of bleeding after the injection of hemostatic matrix. Conclusion: The use of hemostatic matrices in the path of percutaneous biopsies is another tool available for consideration in minimally invasive procedures.

Resumo Objetivo: Descrever a técnica de injeção de matrizes hemostáticas e a experiência do nosso serviço de radiologia intervencionista na sua aplicação. Materiais e Métodos: Foi realizado estudo unicêntrico com análise retrospectiva da experiência do nosso grupo na utilização de matriz hemostática gelatinosa em biópsias percutâneas. Resultados: Foram realizadas 73 biópsias com utilização de matriz hemostática gelatinosa no trajeto da agulha coaxial em diferentes órgãos, como fígado, rim, baço, entre outros. A única complicação observada foi a migração da matriz hemostática para o sistema coletor do rim esquerdo, sendo solucionada com tratamento clínico. Não foram observados casos de sangramento no trajeto das biópsias após a injeção de matrizes hemostáticas. Conclusão: O uso de matrizes hemostáticas no trajeto de biópsias percutâneas é mais uma ferramenta disponível a ser considerada nos procedimentos minimamente invasivos.

Agentes hemostáticos tópicos em cirurgia: revisão e perspectivas / Topical hemostatic agents in surgery: review and prospects

RESUMO A hemostasia tem papel crítico e importância fundamental em todos os procedimentos cirúrgicos. Seu manejo possui diversos pontos chaves, que se iniciam por boa técnica operatória e adequado suporte anestésico. Determinadas situações, como hemorragias graves resultantes de trauma penetrante, por exemplo, não dependem exclusivamente do controle da equipe cirúrgica e necessitam do apoio de novas soluções que diminuam ou controlem a hemorragia. Desde os tempos antigos, um marco da medicina é atuar no controle da hemorragia e, mais recentemente, na facilitação da hemostasia pela aplicação de agentes tópicos, seja por compressão manual ou agentes modernos. Na última década, o número de diferentes agentes hemostáticos tópicos cresceu drasticamente. Para que o cirurgião moderno escolha o agente correto no momento correto, é essencial que conheça o mecanismo de ação, entenda a eficácia e os possíveis efeitos adversos relacionados a cada agente. Assim, a grande variedade de hemostáticos tópicos, somada à ausência de um artigo de revisão na literatura nacional sobre este tópico, nos estimulou a elaborar este manuscrito. Aqui relatamos uma revisão detalhada sobre os agentes hemostáticos tópicos mais comumente utilizados nas especialidades cirúrgicas.

ABSTRACT Hemostasis plays a critical and fundamental role in all surgical procedures. Its management has several key points that start with good operative technique and adequate anesthetic support. Certain situations, such as severe bleeding resulting from penetrating trauma, do not depend exclusively on the control of the surgical team and require the support of new solutions that decrease or control bleeding. Since ancient times, a hallmark of medicine has been to act in the control of hemorrhage, and more recently, in the facilitation of hemostasis by the application of topical agents by either manual compression or modern agents. In the last decade, the number of different topical hemostatic agents has grown dramatically. For the modern surgeon to choose the right agent at the right time, it is essential that he/she understands the mechanisms of action, the effectiveness and the possible adverse effects related to each agent. Thus, the great variety of topical hemostatics, coupled with the absence of a review article in the national literature on this topic, stimulated us to elaborate this manuscript. Here we report a detailed review of the topical hemostatic agents most commonly used in surgical specialties.