Case Report: Case report: Administration of anticoagulant therapy after neuro-anesthesia procedure for hemorrhagic stroke patients with COVID-19 complications and its ethical and medicolegal consideration

Background: Ethical dilemmas can occur in any situation in clinical medicine. In patients undergoing neuro-anesthesia for surgical procedure evacuation of intracerebral hemorrhage with a history of hemorrhagic stroke, anticoagulants should not be given because they can cause recurrent bleeding. Meanwhile, at the same time, the patient could also be infected with coronavirus disease 2019 (COVID-19), one of treatment is the administration of anticoagulants. Methods: A case report. A 46-year-old male patient was admitted to hospital with a loss of consciousness and was diagnosed with intracerebral hemorrhage due to a hemorrhagic stroke and was confirmed positive for COVID-19. Giving anticoagulants to patients is considered counterproductive so, an ethical dilemma arises. For this reason, a joint conference was held to obtain the best ethical and medicolegal solutions for the patient. Results: By using several methods of resolving ethical dilemmas such as basic ethical principles, supporting ethical principles, and medicolegal considerations, it was decided that the patient was not to be given anticoagulants. Conclusions: Giving anticoagulants to hemorrhagic stroke patients is dangerous even though it is beneficial for COVID-19 patients, so here the principle of risk-benefit balance is applied to patients who prioritize risk prevention rather than providing benefits. This is also supported by the prima facie principle by prioritizing the principle of non-maleficence rather than beneficence, the minus malum principle by seeking the lowest risk, and the double effect principle by making the best decision even in a slightly less favorable way as well as the medicolegal aspect by assessing patient safety and risk management.

Prevention of thrombosis in patients with gastrointestinal bleedings, anticoagulant therapy: literature review

Background. Analysis of the causes of unfavorable outcomes in gastrointestinal bleedings shows that one of the directions in improving the results of treatment of such patients is not only improving the methods of non-operative (endoscopic + drug) hemostasis, but also predicting the risk of recurrent bleeding, prevention and treatment of thromboembolic complications. Objective: to study the risks of thromboembolic complications in patients with gastrointestinal bleedings and the prospects for anticoagulant therapy. Materials and methods. The review analyzes the results of clinical studies investigating the risks of thromboembolic complications, clarification of risk groups, volumes and methods of prevention; identifies the most promising effective and safe methods. The critical analysis was carried out based on the study and systematization of scientific researches presented on specialized medical sites. Results. The basis for a reasonable determination of the risk of thrombotic complications in patients with gastrointestinal bleedings is an objective assessment of the balance between the mechanisms of bleeding and thrombosis. Prevention of thromboembolic complications in patients with gastrointestinal bleedings is carried out taking into account individual characteristics. The therapy should consider risk factors both for the development of rebleeding and thromboembolic complications. Thromboelastography is a modern and adequate method for monitoring blood homeostasis at all stages of treatment. Conclusions. A multidisciplinary approach with the participation of surgeons and anesthesiologists is required to make a decision on the prescription, scope and methods of therapy. Such a decision must be justified, taking into account many factors. It is important to consider the mechanisms of action of hemostatic and anticoagulant drugs. Consideration and systematization of all these data does not exclude, but, on the contrary, provides an individual approach to each patient, the determination of an individual strategy with an optimal ratio of the risks of developing rebleeding and prevention of thromboembolic complications.

Experimental study of the possibility of topical application of polyvinylpyrrolidone for epistaxis

Nasal packing is widely used in patients with epistaxis, especially in cases where it is impossible to electrocoagulate the bleeding vessel. The disadvantages of gauze packing are well known. First of all, this is the risk of recurrent bleeding after removing the tampons from the nose. The cause of recurrent epistaxis is the activation of local fibrinolysis during prolonged stay of the tampon in the nasal cavity. To overcome this drawback, we have proposed the topical application of polyvinylpyrrolidone (PVP). In an experiment on animals, the absence of a damaging effect of PVP on mucociliary transport was proved.

Association of ABO Blood Type with Bleeding Severity in Patients with Acute Gastroesophageal Variceal Bleeding

Background and Objectives: ABO blood types have been implicated as potential risk factors for various hemorrhagic diseases. No study has investigated the association between gastroesophageal variceal bleeding and ABO blood types. We aimed to evaluate the impact of ABO blood types on mortality and bleeding risk in acute gastroesophageal variceal bleeding. Materials and Methods: This is a retrospective observational study. Patients presenting with acute gastroesophageal varices bleeding diagnosed by endoscopy were enrolled, and were divided by blood type into a type O group and non-type O group. The outcomes were death within 30 days and the proportion of further bleeding. We used generalized linear mixed-effects models to analyze the outcomes. Results: A total of 327 patients and 648 records of emergency room visits were included. The 30-day mortality was 14.8% (21 of 142 patients) in the type O group, and 16.2% (30 of 185 patients) in the non-type O group (p = 0.532). Further bleeding within 30 days occurred in 34 cases (12.6%) in the type O group, and in 26 cases (6.9%) in the non-type O group (p = 0.539). Conclusions: There was no significant difference in blood transfusion volume in 24 h, recurrent bleeding rates, or mortality between patients with blood type O and those with non-type O.

Small Bowel Metastatic Melanoma: An Emblematic “Coal-Black” Appearance at Videocapsule Endoscopy

A 80-year-old woman underwent vulvar melanoma resection and segmental lung resection for pulmonary metastasis. Immunotherapy with Nivolumab was performed. One year later, the patient was admitted for gastrointestinal (GI) recurrent bleeding and severe anemia. Esophagoastroduodenoscopy and colonoscopy did not show any abnormality, while videocapsule endoscopy (VCE) revealed an irregular and exophytic whitish area with a “coal-black” central depression. Small bowel resection was performed and histological examination revealed S100 protein strongly positive melanoma metastasis. The patient died six months later from disease progression. A “coal-black” appearance of intestinal metastatic melanoma has been described only twice before this report. In one case the patient had been treated by immunotherapy with interferon A and dendritic cell-based vaccination. In our patient, it is presumable that the picture we observed was a consequence of Nivolumab treatment inducing the disappearance of melanocytes in the area surrounding the metastasis with the onset of the central coal-black lesion encircled by whitish tissue. This picture should be emblematic of intestinal metastatic melanoma in subjects treated with immunotherapy showing occult/obscure bleeding.

Efficacy of Trans-nasal Endoscopic Sphenopalatine Artery Ligation in the Management of Recurrent Posterior Epistaxis

Background: Recurrent posterior epistaxis is a challenging problem for most otolaryngologists. Of the several proposed treatment modalities, endoscopic ligation of SPA (Sphenopalatine artery) provides a simple and effective solution with relatively minor complications. Objectives: Aim of this study was to find out the success rate and complications of endoscopic ligation of SPA in the management of recurrent posterior epistaxis. Materials and Methods: This was an observational study conducted from Jan 2019 to Jan 2021. Total 60 patients were included in this study. Inclusion criteria were - recurrent epistaxis (at least 4 episodes in last 2 months) with bleeding point not seen in anterior rhinoscopy, Failure of previous conservative management with medications and nasal packing, age between 18–60 years of both sexes. All the patients underwent trans-nasal endoscopic Sphenopalatine artery ligation, and patients were followed up for 12 weeks to identify repeated bleeding and to evaluate complications. Results: In this study male to female ratio was 1.5:1. Mean age of study group was 44.66 (±8.62) years. No recurrent bleeding occurred in 51 (85%) and in 9 (15%) nasal bleeding occurred in the 2 months postoperative period. Anesthesia of incisor teeth occurred in 18 patients (30%), 22 patients (37%) complained about increased nasal crusting. Conclusion: Endoscopic ligation of Sphenopalatine artery shows good outcome in prevention of further episodes of epistaxis in most patients. Although some minor complications can occur, these are manageable. KYAMC Journal. 2021;12(3): 133-137

Special aspects of intensive care of patients with complicated diverticulosis of the colon

This study presented examination and treatment results of 129 patients with bleeding from the lower gastrointestinal tract who were treated at the Alexandrovskaya Hospital of St. Petersburg in the period from 2012 to 2017. Examination and treatment were performed in the intensive care unit following current clinical guidelines, taking into account the identified concomitant diseases. Endoscopic examination of the colon is the main diagnostic method for the pathological processes that caused bleeding from the lower gastrointestinal tract. Conservative therapy has been demonstrated effectiveness, and urgent surgical treatment was not needed. The main drug therapy included antifibrinolytic drugs and fresh-frozen plasma preparations. Continuous parenteral administration of proteolysis inhibitors was mandatory. Intensive therapy included correction of hemodynamic disturbances and respiratory failure and restoration of the volume of the circulating blood and plasma. Such an approach was found to be 90% effective. In patients with diverticular disease, bleeding from the colonic diverticula develops in one-third of cases. However, if additional risk factors are present, their frequency reaches 50%, often causing death. Continuous or recurrent bleeding is an indication of surgery. In our study, the conservative method of stopping bleeding from the colonic diverticula was possible in all cases. In general, the disease correlated with the age of the patients. In 68 (53%) patients, bleeding occurred despite anticoagulant or antiplatelet therapy. Patients with bleeding from colonic diverticula do not require urgent surgical intervention, and these patients may require admission to the intensive care unit. Intensive care should include the provision of antifibrinolytic drugs, proteolysis inhibitors, and fresh-frozen plasma.

Angiographic features and transarterial embolization of retained placenta with abnormal vaginal bleeding

Objectives To clarify characteristic angiographic features and clinical efficacy of selective transarterial embolization (TAE) of retained placenta with abnormal vaginal bleeding. Methods The study cohort comprised 22 patients (mean age, 33.5 years; range, 22–24 years) who underwent selective TAE for retained placenta with abnormal bleeding between January 2018 and December 2020 at our institution. Angiographic images were reviewed by two certified radiologists with consensus. Medical records were reviewed to evaluate the efficacy of TAE. Angiographic features of retained placenta, technical success (disappearance of abnormal findings on angiography), complications, clinical outcomes (hemostatic effects and recurrent bleeding) were evaluated. Results Pelvic angiography showed a dilated vascular channel mimicking arteriovenous fistulas or an aneurysm contiguous with dilated uterine arteries in the mid-arterial–capillary phase in 20 patients; it showed contrast brush in the remaining two patients. TAE technical success was achieved in all patients. No major complications were observed in any patients. Fifteen patients were followed up with expectant management after TAE; all but one patient showed no re-bleeding during the follow-up period (mean follow-up interval, 3.4 months; range, 1–17 months). One patient showed minor rebleeding, which resolved spontaneously. Seven patients underwent scheduled hysteroscopic resection within 1 week after TAE, and no excessive bleeding was observed during or after the surgical procedure in all seven patients. Conclusions The characteristic angiographic feature of retained placenta is “dilated vascular channel that mimic low flow AVM.” TAE is a safe and effective treatment to manage retained placenta with abnormal bleeding.

Nontraumatic Subarachnoid Hemorrhage

Subarachnoid hemorrhage (SAH) is defined as blood in the subarachnoid space. Nontraumatic SAH is most commonly caused by rupture of an aneurysm located at the circle of Willis. Patients often present with acute thunderclap headache but also may lose consciousness or have focal neurologic deficits. Detection of an aneurysm, if present, and its treatment are needed urgently to prevent recurrent bleeding. Patients with nontraumatic SAH are prone to numerous complications that require preventative measures, early recognition, and treatment.