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How to surgically manage a recurrent lumbar herniated nucleus pulposus (HNP)
Published in Gregory D. Schroeder, Ali A. Baaj, Alexander R. Vaccaro, Revision Spine Surgery, 2019
Taylor Paziuk, Matthew S. Galetta, Jeffrey A. Rihn
If the disc is extruded, it can be removed with a pituitary rongeur. If there is still annulus covering the protruded disc, a number 15 blade scalpel can be used to make an annulotomy to remove the underlying protruded disc. Occasionally, an extruded fragment will be difficult to retrieve from its location ventral to the thecal sac and traversing nerve root. A nerve hook can be used to hook the extruded fragment and pull it out of its ventral location. Once the discectomy is felt to be complete, the adequacy of discectomy and decompression should be confirmed with a nerve hook and/or Woodson, making sure to check that both the exiting and traversing nerve roots of the involved level are free of compression. Hemostasis is best obtained with bipolar electrocautery and a hemostatic agent such as Floseal. The wound should be copiously irrigated prior to closure, and the anesthesiologist should perform a Valsalva maneuver to ensure adequate hemostasis and the absence of spinal fluid leakage.
Control of intraocular hemorrhage during vitrectomy
Published in A Peyman MD Gholam, A Meffert MD Stephen, D Conway MD FACS Mandi, Chiasson Trisha, Vitreoretinal Surgical Techniques, 2019
Bovine thrombin, a commercially available lyophilized powder, is diluted with balanced salt solution to a concentration of 100 U/ml. For vitrectomy, two infusion bottles are used in the set-up: one with a thrombin mixture (100 U/ml bottle) and the other with regular infusion fluid. They are connected to the infusion cannula through a three-way stopcock. The thrombin mixture can be accessed quickly in situations that require better hemostatic control. When intraocular hemostasis is achieved, the intraocular thrombin is washed out with regular infusion fluid to decrease the risk of postoperative inflammation and unwanted clot formation. The potential toxicity of thrombin limits the usefulness of this hemostatic agent, and it should only be used if necessary to complete the surgical procedure.
Pediatric abdominal trauma
Published in David E. Wesson, Bindi Naik-Mathuria, Pediatric Trauma, 2017
Lauren Gillory, Bindi Naik-Mathuria
Although NOM of high-grade liver injuries has gained widespread acceptance [77, 78], the fact remains that some blunt hepatic trauma will require operative intervention. Initial attempts at controlling bleeding from the liver may include direct manual pressure, packing, and the Pringle maneuver (occlusion of the portal triad). If there is an obvious source of bleeding that can be easily addressed, this may be accomplished using cautery, argon beam coagulation, or application of a topical hemostatic agent. Hepatorrhaphy is another option using an absorbable suture on a large, blunt-tipped needle to approximate the edges of a significant laceration. If none of these interventions is successful, liver hemorrhage may require advanced maneuvers to achieve control. In young children, the sternum can be rapidly divided to achieve control of the suprahepatic inferior vena cava and achieve complete hepatic vascular isolation. Once the hemorrhage subsides, the injury can be more effectively evaluated and addressed. At times, it may be needed to pack the liver and proceed to transarterial embolization for deep arterial injuries. In contrast to the spleen, which can be removed when hemostasis cannot be achieved, liver resection should be reserved for the most extreme circumstances and adequate liver must be preserved to maintain function.
A Comparative Efficacy Evaluation of Recombinant Topical Thrombin (RECOTHROM®) With A Gelatin Sponge Carrier Versus Topical Oxidized Regenerated Cellulose (TABOTAMP®/SURGICEL®) In A Porcine Liver Bleeding Model
Published in Journal of Investigative Surgery, 2021
Paul Slezak, Claudia Keibl, Dirk Labahn, Anna Schmidbauer, Yuri Genyk, Heinz Gulle
Once the hemostatic agent had been applied to the lesion, residual bleeding rates and time to hemostasis were assessed by application of fresh dry gauze over the hemostatic agent for 30 seconds followed by careful removal of the gauze and visual assessment of bleeding through and around the hemostatic agent for up to 1 minute. Hemostasis was defined as the absence of observable active bleeding or the absence of sustained soaking of blood into the hemostatic material within the observation period of 1 minute. In the case of bleeding during that period, fresh gauze was re-applied immediately for 30 seconds followed by another minute of observation. This was repeated for up to 10 minutes, or until hemostasis was achieved, whichever came first. A treatment was regarded as a failure if hemostasis was not achieved within 10 minutes.
Impact of an active hemostatic product treatment approach on bleeding-related complications and hospital costs among inpatient surgeries in the United States
Published in Journal of Medical Economics, 2021
David A. Iannitti, Chong Kim, Diane Ito, Josh Epstein
As no evidence-based practice guidelines are currently available to facilitate clinically informed decisions on approaches to hemostasis, certain tools or processes may be utilized to help guide surgeons on selecting the optimal hemostatic agent based on critical factors such as bleeding severity, bleeding risk and surgery type. The VIBe scale26, among others, is a validated measure to evaluate the level of bleeding severity in open surgical procedures across surgical specialties26. Graded on a 5-point scale from 0 (no bleeding) to 4 (life threatening), this measure provides a standardized assessment of bleeding severity, which may provide the surgeon with critical information to help inform hemostatic product choice. During higher grades of bleeding, surgeons should consider an active hemostatic agent as the first approach.
Breakthrough bleeding episodes in pediatric severe hemophilia a patients with and without inhibitors receiving emicizumab prophylaxis: a single-center retrospective review
Published in Pediatric Hematology and Oncology, 2022
Eman Hassan, Jayashree Motwani
The decision to give an additional hemostatic agent or not is based on the nature of bleeding, circumstances of the occurrence, severity, location, and the possibility of documenting it by imaging if required. Major and minor bleeding are classified according to the International Society of Thrombosis and Hemostasis.12All minor bleeds, are treated with antifibrinolytic (tranexamic acid) at a dose of 25 mg/kg three times daily for one to three days. Topical measures (applying ice, antifibrinolytics for topical use, and local hemostasis) can be sufficient to stop bleeding. Escalation from antifibrinolytic agents to either factor replacement or BPAs is based on the response.All major bleeds, require hemostatic agents in addition to antifibrinolytic administration.� For patients with inhibitors, rFVIIa is the first-line treatment at a dose of 90–120 μg/kg.� Non-inhibitor patients are given rFVIII (dose is decided according to the site of bleeding).� The first injection of factor replacement can be administered at home after medical advice from the hemophilia unit (HU). Further doses of factor replacement are decided according to the severity and response to initial measures. If repetitive injections are likely, hospital admission is considered.