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Life-Threatening Haemorrhage Following Thyroid Surgery PowerPoint Presentation

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Description : Check out this medical presentation on Endocrine Surgery, which is titled "Life-Threatening Haemorrhage Following Thyroid Surgery", to know about thr life-threatening haemorrhage following thyroid surgery.

Tags : Endocrine Surgery, Haemorrhage, Thyroid Surgery

Published on : Jul 20, 2021 | Views : 1397 | Downloads : 5

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Slide 1-

Life-Threatening Haemorrhage Following Thyroid Surgery Randall Morton, Terina Pollock Counties-Manukau District Health Board Auckland University CMDHB General & Thyroid Surgeons Alain Vandal, Statistician Acknowledgements:
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Promberger et al Br J Surg (2012) 519/30,142 (1.7%) 870/ 65,962 (1.3%) 274/ 32,160 (0.8%) Post-Thyroidectomy Haemorrhage CMDHB audit 2000-2002 4/94 (4.25%) Bononi M, et al. “Incidence and circumstances of cervical hematoma complicating thyroidectomy …” Head Neck 2010; 32:1173-1177 “no definite perioperative risk factor has been identified to predict occurrence of cervical haematoma”
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MSC 1/241 (0.4%) MMH 6/165 (3.6%) CMDHB Thyroid Surgery 2002-08 7/406 (1.7%) Gender; Ethnicity; Operation; Pathology; Campus; Age 7 cases of RTT matched from contemporaneous controls for: Logistic regression: post-op systolic BP >150 mmHg (p = 0.005) Post-Thyroidectomy Haemorrhage
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Questions: What is the profile for systolic BP after thyroid surgery ? How many thyroidectomies have high BP and not bleed ? What factors* are associated with/ lead to high systolic BP ? Is there a “safe” level of post-thyroidectomy systolic BP ? * pain; nausea/vomiting; untreated HTN … What is it about MMH that leads to the higher risk of bleeding?
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HQSC Cohort Analysis Jan 2002 - Apr 2012 n = 621
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Observations on Thyroid Surgery post-operative bleeds: 15/621 (2.4%) HQSC Cohort Analysis Jan 2002 - Apr 2012
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ASA status n.s. Wound Drain n.s. Surgical Time n.s. Surgical team 0.13 Ethnicity 0.024 BMI 0.022 Location of Surgery 0.013 Highest post-op BP 0.007 Gland Weight 0.001 Univariate Analysis CMDHB data
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Regression Analysis Thyroid Size (weight) p = 0.0072 [OR 1.05 (per 10 gms)] 95% CI = 1.01 - 1.09 Highest post-op Systolic BP p = 0.016, [OR: 1.39 (per 10 mmHg)] 95% CI=1.09-1.76
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Regression Analysis Thyroid Size (weight) p = 0.0072 [OR 1.05 (per 10 gms)] 95% CI = 1.01 - 1.09 Highest post-op Systolic BP p = 0.016, [OR: 1.39 (per 10 mmHg)] 95% CI=1.09-1.76 Statistical Issues Surgical Team: there is some statistical effect of surgical team - inclusion improves the fit for the statistical model Thyroid Weight: non-normal distribution skewed to larger thyroids weight loses significance when data log-transformed [OR: 1.44 (each doubling of weight) CI = 0.91-2.29] Campus (MMH/MSC): confounding between campus and surgical team
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Highest Systolic BP Thyroid Weight [log-scale]
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SUMMARY Post-thyroidectomy haematoma is a life-threatening risk, but the risk should be ~ 1% or less Post-Anaesthetic Systolic Blood pressure is associated with bleeding in CMDHB (but not necessarily causative) CMDHB is making some progress (esp in MSC) in reducing our risk Controlling systolic blood pressure may help reduce the risk of post-op haemorrhage
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IMPLICATIONS FOR CMDHB Introduce SPC* methodology for Thyroid Surgery Agree BP management from time of booking surgery Agreement for post-op management protocols Methodology to capture process information Monitor at least 2 years … Include other DHBs ? *Statistical Process Control Sources of variation Campus BMI Systolic BP Ethnicity Surgical Team Gland Weight
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n = 30,142 Br J Surg 2012; 99: 373 – 379 519 (1.7%) Rate range: 0.4 - 2.8%
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Br J Surg 2012; 99: 373 – 379 Rate range: 0.4 - 2.8% 519 (1.7%) (4/994) (9/318)
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Highest Systolic BP Thyroid Weight [log-scale] 2 cases - bled before PACU (no pre-bleed systolic BP recorded) 2 cases - late bleeds (drains*2)
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Robert Liston (1794-1847) “… You could not cut the thyroid gland out of a living body in its sound condition without risking the death of the patient from hemorrhage…” Liston R “Lectures on the operations of surgery and on diseases and accidents requiring operations.” Lea and Blanchard, Philadelphia, 1846; pp 318-326. While Intra-operative Mortality risk has “disappeared”, Post-operative Haemorrhage remains life-threatening
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Thyroid Weight: non-normal distribution skewed to larger thyroids weight loses significance when data log-transformed OR: 1.44 (each doubling of weight) CI = 0.91-2.29 Statistical Issue
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Hospital/Surgeon Volume Vessel Management (Surgeon) Trendelenburg/ Valsalva (Surgeon) Surgical Drains (Surgeon) Nausea/ Vomiting control (Anaesthetist) NSAIDs/ pain relief (Anaesthetist) What factors can we influence to try to avoid post-operative Haematoma formation? Other (Patient/Disease); - BMI/ Gland size/ Medication/ etc
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Technology has allowed: Better control of bleeding during thyroid surgery General reduction in surgical blood loss While Intra-operative Mortality risk has “disappeared”, Post-operative Haemorrhage remains life-threatening Arch Surg. 2009;144(12):1167-1174
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Bergenfelz et al. Lang Arch Surg (2008): 77/3660 (2.1%) Promberger et al Br J Surg (2012) 519/30,142 (1.7%) 870/ 65,962 (1.3%) 274/ 32,160 (0.8%) Post-Thyroidectomy Haemorrhage CMDHB audit 2000-2002 4/94 (4.25%) Bononi M, et al. “Incidence and circumstances of cervical hematoma complicating thyroidectomy …” Head Neck 2010; 32:1173-1177 “no definite perioperative risk factor has been identified to predict occurrence of cervical haematoma”