Introduction: Coagulation assessment is often missing in microvascular surgery. We aimed at evaluating the predictive value of thromboelastometry for free flap thrombosis in microvascular surgery patients. Conclusions:In LS patients with thrombogenic comorbidities, thromboelastometry supports the detection of hypercoagulability and predicts free flap thrombosis risk. In ES patients, postoperative hypercoagulability did not predict free flap thrombosis. Prolonged surgery time should be considered as a risk factor.
Microvascular free flap surgery, has become an important part of reconstructive surgery during the last decades, as it allows closure of various tissue defects and recovery of organs function. Despite surgical progress resulting in high rates of transferred tissue survival, the risk of pedicle vessels thrombosis still remains a significant problem. A total of 108 articles from Pubmed and Science Direct databases published in 2005–2015 were analysed. This review of the literature assessed the influence of patient-dependent risk factors and different perioperative management strategies on development of microvascular free flap thrombosis. Sufficient evidence for risk associated with hypercoagulation, advanced age and certain comorbidities was identified. Presently, rotational thromboelastometry allows early hypercoagulability detection, significantly changing further patient management. Identification of flap thrombosis promoting surgery-related aspects is also essential in preoperative settings. Choice of anaesthesia and postoperative analgesia, administration of different types and amounts of fluids, blood products and vasoactive agents, temperature control are no less important in perioperative anaesthesiological management. More attention should be focused on timely preoperative evaluation of patient-dependent risk factors, which can influence anaesthesiological and surgical tactics during and after microvascular free flap surgery. Perioperative anaesthesiological management strategy continues to be controversial and therefore it should be performed based on thrombotic risk assessment and patient individual needs, thus improving flap survival rates and surgical outcome.
SummaryIntroductionAneurysmal subarachnoid haemorrhage (SAH) is associated with high mortality and morbidity. Rebleeding, cerebral vasospasm (VS) with delayed cerebral ischemia (DCI) are major complications after SAH associated with poor neurological outcome.Aim of the studyTo summarize the existing research data on the SAH from incidence, risk factors and clinical presentation to diagnostic, monitoring and treatment options after SAH.Materials and MethodsLiterature review was carried out to identify factors associated with SAH using specific keywords (aneurysmal subarachnoid haemorrhage, rebleeding, cerebral vasospasm, delayed cerebral ischemia) in the PUBMED database. In the time period from 2000 to 2019, 34 full articles were reviewed.ResultsAccording to the literature, the key risk factors for cerebral aneurysms and the SAH are hypertension, smoking, chronic alcohol abuse, family history of intracranial aneurysms in first-degree relatives and female sex. The key risk factor for early complication - rebleeding after SAH - is hypertension. The factors responsible for late complications - cerebral VS and DCI after SAH - are initially lower Glasgow coma scale and higher grades of Fisher scale, where grade IV and III predict cerebral VS in 31–37%. Furthermore, hyperglycaemic state, hyponatremia, hypotension and cerebral hypoperfusion, increased level of Troponin correlate with the incidence of cerebral VS and DCI. Although the golden standard to detect cerebral VS is digital subtraction angiography, CT angiography has become a routine examination. Transcranial doppler sonography is recommended and regional cerebral oximetry also seems to be promising. To avoid rebleeding for wide-necked, gigantic aneurysms or when SAH is combined with intraparenchymal hematoma, surgical clipping is preferred. For posterior circulation aneurisms, poor grade SAH and patients with age >70 years superior is endovascular treatment. To avoid late complications, the pharmacological method is used with Nimodipine.ConclusionsSAH is still associated with poor clinical outcome due to the development of early and late complications. The highest risk patients are those with low Glasgow coma scale and high grades of Fisher scale. Timely performed obliteration methods of the ruptured aneurysm are crucial and Nimodipine is the main agent to prevent cerebral VS and DCI.
Summary Introduction. An effective postoperative analgesia is of key importance to facilitate recovery during the immediate postoperative period and to ensure early ambulation. The transversus abdominis plane block (TAP) and ilioinguinal / iliohypogastric nerves block (IHN) are a relatively new regional analgesia techniques that provide a postoperative analgesia in patients undergoing lower abdominal surgery. Aim of the Study. The objective of this study was to compare the analgesic effectiveness of ultrasound guided TAP block versus ultrasound guided IHN block in the post-operative period of unilateral open inguinal hernia repair. Materials and methods. One hundred five consented adult patients scheduled for unilateral open inguinal hernia repair were enrolled in this randomised controlled clinical study. US-guided regional analgesia with 0.5 % of levobupivacaine was performed after induction of general anaesthesia (GA). Patients were randomly allocated into two groups: Group A- 53 patients underwent TAP block vs. Group B- 52 patients underwent IHN block. All patients received a standardised GA. Both groups were comparable for age, gender, ASA, and weight. All patients were scheduled for postoperative pain assessment using a visual analogue scale (VAS) at two definite times: 1- VAS1: when patient was awake and conscious post GA; 2- VAS2: when patient requested a rescue analgesia or patient reached 17 hours post block performance. Results. There were no significant differences in age, gender, ASA, or weight between both groups (p=0.9; p=0.8; p=0.6; p=0.9 respectively). We found out significant differences comparing VAS score over the time, the IHN block had better effect than the TAP block on relieving pain at the VAS1 (p=0.03) and VAS2 (p=0.04). The duration of the blocks in group A and group B was as the following: 2-6.5 hrs= [Mean ± SD: 4.2 ± 1.5 vs. 5 ± 0.8 respectively and p=0.03]; 6.5-17 hrs= [Mean ± SD: 11.9 ± 2.3 vs. 14.4 ± 1.7 respectively and p=0.203]; ≥ 17 hrs= [Mean ± SD: 19 ± 1.1 vs. 20.1 ± 2 respectively and p=0.003]. The results of our study were more favourable for the IHN block in all the 3 timing groups. Conclusions. Ultrasound-guided IHN block provides better pain control and longer duration of action than ultrasound-guided TAP block in the post-operative period of unilateral open inguinal hernia repair. Both regional analgesia techniques: TAP block and IHN block under ultrasound guidance for open inguinal hernia repair are simple, safe and effective pain control methods.
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Background and goal of the studyPerioperative anticoagulation remains a controversial topic in free flap transfer surgery. Furthermore, it is still unclear which patients are particularly prone to free flap thrombosis.We aimed to analyze thrombogenic risk factors and the role of anticoagulation in free flap surgery. Materials and methodsObservational prospective case control study was performed analyzing data from 2014-2017 period. Patient demographical data, including main risk factors for free flap thrombosis (recent trauma, smoking, thrombogenic comorbidities) were registered. Standard coagulation tests, as well as rotational thromboelastometry (RTE) were performed preoperatively; hypercoagulation was defined as functional fibrinogen to platelet ratio (FPR) ≥ 42. Thromboprophylaxis was provided by decision of a surgeon with enoxaparine 40 mg SC once a day, starting 12 hours after surgery. Incidence of free flap thrombosis was analyzed as primary outcome, secondary main thrombotic risk factors were evaluated.
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