International evidence-based recommendations on ultrasound-guided vascular access

n/

Thromboelastograph With Platelet Mapping (TM) Predicts Postoperative Chest Tube Drainage in Patients Undergoing Coronary Artery Bypass Grafting

Objective: The goal of this study was to evaluate the ability of Thromboelastograph with Platelet Mapping (TEG-PM (TM)) to predict postoperative bleeding tendency in patients with a history of recent anti-platelet therapy undergoing coronary artery bypass grafting (CABG). Design: A retrospective analysis. Association between predictor variables (MA(ADP) [maximum amplitude produced by adenosine diphosphate], MA(AA) [maximum amplitude produced by arachidonic acid], percent of platelets inhibited by clopidogrel, percent of platelets inhibited by aspirin) and the outcomes as elevated chest tube drainage (CTD) and blood transfusion were investigated by logistic regression model. CTD was considered elevated if it was \u3e= 600 mL within 12 hours after surgery. Setting: A university hospital. Participants: Patients on antiplatelet therapy scheduled to undergo CABG that had TEG-PM (TM) done as a point-of-care test. Interventions: None. Results: A total of 78 patients had preoperative TEG-PM (TM) test and on-pump CABG surgeries performed on the same day. Among them, 20 patients (25.6%) had elevated CTD. Decreased MA(ADP) (odds ratio [OR] 0.94), increased percent inhibition of platelets by clopidogrel (OR 1.03), and lower body mass index (BMI) (OR 0.78) were significantly associated with elevated CTD. The same parameters were also associated with platelets transfusion: MA(ADP) (OR 0.94), percent of inhibition of platelets by clopidogrel (OR 1.03) and BMI (OR 0.77). Conclusions: TEG-PM (TM) parameters and BMI are predictive of elevated CTD and platelets transfusion. A 1 mm decrease in MA(ADP) increases the likelihood of elevated CTD and the likelihood of platelets transfusion by 6% whereas 1 unit decrease in BMI is associated with an increased likelihood of elevated CTD and platelets transfusion by 22% and 23% respectively. (C) 2014 Elsevier Inc. All rights reserved

Intraoperative Thrombolysis of Massive Pulmonary Embolus During Spine Surgery: Case Report of Survival Complicated by Massive Bleeding and Review of the Literature.

Pulmonary embolism (PE) is a known risk of lumbar spinal fusion surgery that can lead to sudden and unexpected death. Treatment often involves systemic anticoagulation when the risk of potentially fatal hemodynamic deterioration is judged to outweigh the risk of epidural hematoma and paralysis. Acute massive pulmonary embolism with obstruction of more than 50% of the pulmonary arterial tree causes right heart failure, hypotension, and often rapid death, and may require aggressive medical intervention with thrombolytic agents like alteplase, though in the postoperative period this entails an extremely high risk of bleeding and the associated potential neurologic morbidity. We report the first case of intraoperative thrombolytic therapy during spine surgery in a 68-year-old female who developed a massive PE with cardiac arrest while undergoing lumbar instrumented fusion surgery in the prone position and detail the postoperative course that was complicated by severe bleeding