Littérature scientifique sur le sujet « Post-Procedural bleeding »

Background: The main treatment goal for immune thrombocytopenia (ITP) is to reduce bleeding risk, requiring extra precautions during procedures. Adjusting platelet thresholds with ITP treatments is usually recommended, but platelet transfusions are commonly used despite their controversial benefits. This study aims to evaluate the effectiveness of platelet transfusion in reducing post-procedure bleeding risk and to identify predictive indicators of post-procedure bleeding. Methods: This study used a nationally representative database to develop a model to predict the risk of post-procedure bleeding in patients with ITP. Machine learning analyses, including random forest feature importance and Shapley additive explanations (SHAP) values, were employed. This contained a total of 34 post-procedural bleeding risk factors, including the amount of platelet transfusion. Results: The random forest model had an area under the receiver-operating characteristic curve of 93.6%. The analysis identified the following variables as most important: amount of platelet transfusion, high-risk procedure, use of anticoagulant drugs, no use of antiplatelet or anticoagulant drugs, anemia, age, low-risk procedure, moderate-risk procedure, ITP treatment, and newly diagnosed ITP. Amount of platelet transfusion, high-risk procedures, use of anticoagulant drugs, anemia, ITP treatment, and newly diagnosed ITP positively correlated with post-procedure bleeding risk. In contrast, no use of antiplatelet or anticoagulant drugs and moderate- or low-risk procedures were negatively associated with post-procedure bleeding risk. In the SHAP dependence plot, the amount of platelet transfusion was associated with high-risk procedures. Additionally, among patients undergoing high-risk procedures, the likelihood of post-procedure bleeding increased with age. Conclusions: Platelet transfusion does not significantly reduce the risk of post-procedural bleeding in patients with ITP. The risk of post-procedural bleeding is more closely related to the bleeding risk of the procedure and the patient's medical condition. Minimizing inappropriate platelet transfusions and addressing factors that can increase bleeding risk before procedures are crucial. Keywords: Immune thrombocytopenia, Procedure, Platelet transfusion, Bleeding risk, Machine learning analysis

Abstract Background and study aims An increasing number of patients have been using anticoagulants including anti-vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs); however, in patients using anticoagulants, limited data are available with regard to the risks of gastrointestinal bleeding and thromboembolic events during the peri-endoscopic period. We aimed to evaluate the peri-endoscopic bleeding and thrombotic risks in patients administered VKAs or DOACs. Patients and methods Consecutive patients using anticoagulants who underwent endoscopic biopsy, mucosal resection, or submucosal dissection were prospectively enrolled across 11 hospitals. The primary outcome assessed was difference in incidence of post-procedural gastrointestinal bleeding in patients using VKAs and DOACs. Duration of hospitalization and peri-procedural thromboembolic events were also compared. Results We enrolled 174 patients using VKAs and 37 using DOACs. In total, 16 patients using VKA were excluded from the analysis because of cancellation of endoscopic procedures and contraindications to the use of DOACs; 128 (81 %) patients using VKAs and 17 (46 %) using DOACs received heparin-bridging therapy (HB). The rate of post-procedural gastrointestinal bleeding in DOAC users was similar to that in VKA users (16.2 % vs. 16.4 %, P = 1.000). Duration of hospitalization was significantly longer in patients using VKAs than in those using DOACs (median 15 vs. 7 days, P < 0.0001). Myocardial infarction occurred during pre-endoscopic HB in one patient using VKAs. Conclusion DOAC administration showed similar post-procedural gastrointestinal bleeding risk to VKA administration in patients undergoing endoscopic procedures, but it shortened the hospital stay.

Background: Hemorrhoids occur in up to 80% of the population, involving any age and affecting males and females equally1 First and second-degree hemorrhoids can be treated conveniently on an out-patient basis by sclerotherapy and rubber band ligation 2. This study aims at comparing outcomes of these modalities for the treatment of grade I and II bleeding hemorrhoids.Methods: In NKP Salve institute of Medical Sciences and Research Centre hospital based nonrandomized comparative study, patients clinically diagnosed as Grade I and II bleeding hemorrhoids were included. Subjects were divided in into two groups i.e Barron’s banding and Injection of Sclerosant. The post procedural complications for the first 24 hrs were recorded, follow up was taken at regular intervals and any complications were recorded.Results: A total of 50 patients were enrolled with mean age 42.01 years and a male preponderance, with 31 males and 19 females. Barron’s banding was carried out in 25 subjects and the 25 subjects were subjected to Injection of sclerosant the mean duration taken for Injection of sclerosant was 13.6 min and in Barron’s banding 16.4 min. In the first 24hrs post procedural bleeding was observed in 40% subjects in the Barron’s banding group and 52% in the injection of sclerosant group. For post procedural pain the mean VAS score in the Barron’s group was 1.84 and 0.96 in injection of sclerosant group, follow up at 3rd month showed 16% recurrence of bleeding and 32% in injection of sclerosant group.Conclusions: Injection of sclerosant is better than Barron’s banding procedure in terms of post procedural pain.

In the study, we comment on the article by Qu et al . Internal hemorrhoids are the most common anorectal disorders worldwide with bleeding, prolapse, and difficulty in defecation. Endoscopic rubber band ligation (ERBL) is a safe, convenient, quick, and economical outpatient procedure. The main goal of ERBL is to alleviate prolapse, but the high incidence of recurrence and post-procedural pain are of clinical concern. Polidocanol foam as a local hemostatic and anesthetic agent could reduce the rates of post-procedural pain and bleeding. Endoscopic polidocanol foam sclerobanding (EFSB) is a novel approach that could lift the mucosa for easy ligation and promote increased scarring in the submucosal tissue which translates into long-term relief from prolapse recurrence and reduced 24-h post-procedural pain. The study by Qu et al is a novel multi-center prospective randomized study to compare ERBL and EFSB in patients with grades II and III internal hemorrhoids with one-year follow-up. Results showed that EFSB is a novel therapy for internal hemorrhoids, but future studies with a larger sample, multiple treatment sessions, and long-term follow-up are required to confirm these findings.

A percutaneous renal biopsy is an essential tool for the diagnosis of various renal diseases; however, post-biopsy bleeding is a major complication. Hemocoagulase is a detoxified and purified snake venom enzyme that is widely used to prevent post-procedural bleeding. In this study, we retrospectively analyzed the effect of hemocoagulase on post-renal biopsy bleeding. We included 221 patients who underwent percutaneous renal biopsy between April 2017 and December 2020 and analyzed post-renal biopsy hemoglobin (Hb) decline in patients who were administered a periprocedural hemocoagulase injection. After the renal biopsy, the mean Hb decrease in the entire patient cohort was 0.33 ± 0.84 g/dL. Periprocedural hemocoagulase injection lowered the Hb decline post-renal biopsy (0.50 ± 0.87 vs. 0.23 ± 0.80 g/dL, p = 0.0204). The propensity-matched cohort was also adjusted for factors influencing postprocedural bleeding; periprocedural hemocoagulase injection reduced the Hb decline post-renal biopsy (0.56 ± 0.89 vs. 0.17 ± 0.74 g/dL, p = 0.006). There were no adverse events (e.g., thrombosis and anaphylactic shock) due to hemocoagulase. Our study demonstrated the beneficial effect of hemocoagulase on post-renal biopsy Hb decline, suggesting its clinical value in preventing post-renal biopsy bleeding.

Objective: To review safety and efficacy of percutaneous microwave ablation (MWA) for post-procedural haemostasis. Methods: Institutional databases retrospective research identified 10 cases of iatrogenic bleeding who underwent percutaneous MWA for post-procedural haemostasis. Ultrasound examination with Doppler and contrast enhancement identified a source of active bleeding prior to ablation; additionally they were used as guiding modality for antenna insertion whilst, post-ablation, assessed the lack of active extravasation. Target locations included liver intercostal space spleen and thyroid gland. Technical success was defined as positioning of the antenna on the desired location. Treatment end point was considered the disappearance of active extravasation in both Doppler imaging and contrast-enhanced ultrasound. Results: Technical success (i.e. positioning of the antenna on the desired location) was achieved in all cases. No complications were noted. All patients post MWA remained haemodynamically stable with no need for transfusion and were discharged from the hospital the next morning. Imaging and clinical follow-up in all patients before exiting the hospital did not depict any sign of active extravasation or bleeding. Conclusion: Our limited experience reports preliminary data showing that MWA could be added in the armamentarium of percutaneous therapies for iatrogenic bleeding. More prospective studies with larger patient samples are necessary for verification of this technique as well as for drawing broader conclusions in order to evaluate the place of percutaneous ablation in the treatment algorithm of haemorrhage. Advances in knowledge: Percutaneous ablation might have a role in haemostasis in well-selected cases

Chalazion is an eye lid lesion caused by the blockage and swelling of Meibomian glands and are very common in occurrence. Incision and curettage of chalazion is a minor procedure and is recommended for the ones resisting conservative medical treatment. Here an atypical case report of surgical management of post procedural haemorrhage of an upper left eye chalazion in a hypertensive patient is presented. The patient reported with haemorrhage soon after an uneventful chalazion incision procedure. The site of incision was successfully cauterized to manage the bleeding as it did not respond to pressure applications to stop the bleeding. Cauterization is a minimally invasive approach which is effective and safe method to manage post-operative bleeding complications from a chalazion incision.

In patients with atrial fibrillation and high stroke risk, anticoagulation with direct oral anticoagulants or vitamin K antagonists is the standard of care for stroke prevention. The benefit of anticoagulation is driven by attenuating the risk of thrombus formation in the left atrial appendage. Percutaneous left atrial appendage occlusion offers an alternative therapeutic strategy for stroke prevention in patients with high bleeding risk or contraindications for long-term anticoagulation. This review of the current literature delineates the standard protocols of peri- and post-procedural anticoagulation/antithrombotic therapy after left atrial appendage occlusion, the complications of the procedure, and the risk of device-related thrombosis and of incomplete occlusion of the appendage. Finally,the limitations and gaps in the literature are identified.

La cirrhose est une maladie chronique du foie associée à des perturbations complexes de l'hémostase. Les patients atteints de cirrhose peuvent présenter des saignements, notamment après des gestes invasifs, qui sont associés à une morbi-mortalité élevée. Une meilleure compréhension de l'hémostase complexe des patients atteints de cirrhose et une meilleure prédiction des saignements post-procéduraux sont donc nécessaires pour améliorer la prise en charge de ces patients. L'objectif de mon travail était : (a) d'étudier deux acteurs de l'hémostase, la protéase nexine 1 (PN-1) et les vésicules extracellulaires (VE), dont le rôle dans l'équilibre hémostatique des patients atteints de cirrhose est inconnu ; (b) affiner la prédiction des hémorragies post-procédures invasives. Premièrement, j'ai mesuré par ELISA la concentration plasmatique de PN1 dans une cohorte prospective de patients atteints de cirrhose, tous stades confondus, chez qui les données cliniques, biologiques, hémodynamiques et radiologiques étaient disponibles ainsi que la survie à un an (« cohorte suivi»), et dans une cohorte prospective de patients atteints de cirrhose tous stades confondus qui ont eu un une biopsie hépatique (« cohorte PBH »). Dans la « cohorte suivi », la concentration de PN-1 était plus élevée dans le plasma des patients atteints de cirrhose comparée aux témoins sains et augmentait avec la gravité de la cirrhose. Les patients dont la concentration de PN-1 était supérieure au seuil défini par l'indice de Youden pour diagnostiquer le décès à un an avaient une incidence cumulée de décès à 1 an supérieure aux patients dont la concentration de PN1 était inférieure à ce seuil. Dans la « cohorte PBH », la concentration de PN-1 n'était pas associée à la survenue de saignements post-PBH. Une thromboélastométrie rotationnelle a été réalisée dans du plasma riche en plaquettes de patients atteints de cirrhose décompensée stable Child Pugh B/C, en présence ou non d'un anticorps bloquant la PN-1. Les résultats montraient que l'inhibition de la PN-1 induisaient une fibrinolyse plus précoce. Deuxièmement, j'ai regardé l'impact des VE sur la coagulation en réalisant des tests de génération de thrombine sur du plasma avec VE et sans VE (retirées par ultracentrifugation), provenant de patients atteints de cirrhose (tous stades de sévérité). J'ai constaté que le retrait des VE du plasma de patients atteints de cirrhose avait peu d'impact sur la génération de thrombine alors que l'impact était fort avec le plasma de témoins sains, suggérant que leur rôle était moindre dans la coagulation dans la cirrhose. Troisièmement, afin d'améliorer la prédiction des saignements post-procéduraux, j'ai (i) étudié l'intérêt d'un bilan d'hémostase exhaustif chez 302 patients atteints de cirrhose et j'ai constaté que celui-ci n'améliorait pas la prédiction des saignements ; (ii) interrogé 52 experts internationaux sur le risque de saignement associé aux procédures invasives. Les résultats ont permis d'établir un consensus pour 52 procédures invasives, 17 étant classées à haut risque de saignement et 35 à bas risque et également de définir des seuils de tests d'hémostase (plaquettes, INR, TCA, fibrinogène) permettant de réaliser une procédure invasive en toute sécurité. En conclusion, mes résultats montrent que, par rapport aux individus sains, l'hémostase des malades atteints de cirrhose est caractérisée par (a) une augmentation de la concentration circulante de PN-1 ; (b) un rôle de PN-1 dans la fibrinolyse puisqu'elle inhibe une fibrinolyse excessive ; (c) une perte du rôle des VEs dans la génération de thrombine. D'un point de vue pratique, ni les tests d'hémostase globaux ni la concentration circulante de PN-1 ne permettent de prédire la survenue de saignement post-PBH. Le consensus d'expert que j'ai obtenu permet de classer les procédures invasives pour affiner les futures études et guider la prise de décision clinique
Cirrhosis is a chronic liver disease associated with complex disturbances of hemostasis. Patients with cirrhosis may experience bleeding, particularly after invasive procedures, which is associated with high morbidity and mortality. A better understanding of the complex hemostasis of patients with cirrhosis and better prediction of post-procedural bleeding are therefore needed to improve the management of these patients. The aim of my work was: (a) to study two players in hemostasis, the protease nexin 1 (PN-1) and extracellular vesicles (EVs), whose role in the hemostatic balance of patients with cirrhosis is unknown; (b) to refine the prediction of invasive post-procedural bleeding. Firstly, I measured plasma PN1 concentration by ELISA in a prospective cohort of patients with cirrhosis of all stages for whom clinical, biological, hemodynamic and radiological data were available, as well as one-year survival ("outcome cohort"), and in a prospective cohort of patients with cirrhosis of all stages who underwent liver biopsy ("LB cohort").In the "outcome cohort", the concentration of PN-1 was higher in the plasma of patients with cirrhosis compared with healthy controls, and increased with the severity of cirrhosis. Patients whose PN-1 concentration was above the threshold defined by the Youden index for diagnosing death at 1 year had a higher cumulative incidence of death at 1 year than patients whose PN1 concentration was below this threshold. In the "LB cohort", PN-1 concentration was not associated with the occurrence of post-LB bleeding. Rotational thromboelastometry was performed in platelet-rich plasma from patients with stable decompensated Child Pugh B/C cirrhosis, in the presence or absence of a PN-1-blocking antibody. The results showed that PN-1 inhibition induced earlier fibrinolysis. Secondly, I looked at the impact of EVs on coagulation by performing thrombin generation assays on plasma with EVs and without EVs (removed by ultracentrifugation), from patients with cirrhosis (all stages of severity). I found that removal of EVs from the plasma of cirrhosis patients had little impact on thrombin generation, whereas the impact was strong with plasma from healthy controls, suggesting that their role was less in coagulation in cirrhosis. Thirdly, in order to improve the prediction of post-procedural bleeding, I (i) studied the value of a comprehensive hemostasis work-up in 302 patients with cirrhosis and found that it did not improve bleeding prediction; (ii) surveyed 52 international experts on the bleeding risk associated with invasive procedures. The results enabled us to establish a consensus for 52 invasive procedures, 17 being classified as high risk of bleeding and 35 as low risk, and also to define thresholds for haemostasis tests (platelets, INR, aPTT, fibrinogen) enabling an invasive procedure to be carried out safely. In conclusion, my results show that, compared with healthy individuals, the hemostasis of patients with cirrhosis is characterized by (a) an increase in the circulating concentration of PN-1; (b) a role for PN-1 in fibrinolysis, since it inhibits excessive fibrinolysis; (c) a loss of the role of VEs in thrombin generation. From a practical point of view, neither global hemostasis tests nor circulating PN-1 concentration are predictive of post-LB bleeding. The expert consensus I have obtained allows us to classify invasive procedures to refine future studies and guide clinical decision-making

This chapter discusses how to prevent postoperative bleeding with the placement of tunneled dialysis catheters. Tunneled intravenous chest catheters, particularly dialysis catheters, sometimes result in oozing or frank bleeding from the incisions during the first 24 hours after placement. This problem is exacerbated by the large diameter and stiffness of these catheters. Moreover, patients requiring these catheters frequently suffer from abnormal hemostasis profiles—an elevated international normalized ratio, thrombocytopenia, or abnormal platelet function due to uremia is commonly seen. The technique discussed in this chapter ensures that the potential bleeding sites throughout the operative site and tract are coated and permeated by a hemostatic agent.

Following a technically successful procedure, it is the post-procedural care of the patient that will often dictate both short- and long-term outcomes. Post-procedural care involves close monitoring of the patient for early complications, which may be secondary to the procedure itself or the presenting complaint. Immediate complications following percutaneous coronary intervention (PCI) may occur due to bleeding, most commonly at the access site, or due to early cardiac complications, often related to technical issues during the procedure. Non-cardiac complications, such as the development of contrast nephropathy, will become apparent in the hours or days following the initial procedure. Prompt and accurate identification of post-procedural complications is essential if they are to be managed effectively, and identification of the ‘at risk’ patient may also facilitate early identification of problems when they do occur. Complication rates are higher in patients with acute coronary syndromes, often exacerbated by aggressive antithrombotic regimens, and also in older patients with comorbid conditions. The type of care and length of stay will also vary according to the clinical context and needs to be carefully considered once the PCI has been performed. Following discharge, the longer-term management of residual coronary disease and recurrent ischaemia along with appropriate secondary prevention may all affect longer-term outcome. This chapter will examine the issues surrounding the immediate and longer-term care of the patient following PCI.

Circumcision, a common surgical procedure characterized by the excision of the penile foreskin, traditionally integrates cultural, religious, and occasionally, medical contexts, continues to spark extensive discussion and research due to its spectrum of potential complications. Although generally considered safe, the complication rate varies between 2% and 10%. This study explores and categorizes the complications into common issues such as bleeding and infection; less common, yet notably impactful issues like injuries to the glans and urethra; and potential long-term psychological effects. A notable focus is directed toward procedural and post-operative aspects, examining different techniques like the Plastibell, Gomco clamp, and Alisclamp, each presenting varied complications and success rates. Furthermore, the exploration delves into specific cases, exemplifying potential catastrophic results like necrotizing fasciitis and significant urethral damage. Through a lens that balances clinical outcomes with ethical considerations, the discourse further ventures into the psychological and quality-of-life implications for affected individuals and their caregivers. This comprehensive analysis aims not only to highlight the physical and psychological risks associated with circumcision but also to catalyze a continual, multifaceted discussion among healthcare professionals to refine practice protocols, elevate patient safety standards, and examine the ethical contours enveloping non-medical circumcisions in pediatric populations.