Control of massive hemorrhage (MH) is a life-saving intervention. The use of tourniquets has been studied in prehospital and battlefield settings but not in aquatic environments.

The aim of this research is to assess the control of MH in an aquatic environment by analyzing the usability of two tourniquet models with different adjustment mechanisms: windlass rod versus ratchet.

A pilot simulation study was conducted using a randomized crossover design to assess the control of MH resulting from an upper extremity arterial perforation in an aquatic setting. A sample of 24 trained lifeguards performed two randomized tests: one using a windlass-based Combat Application Tourniquet 7 Gen (T-CAT) and the other using a ratchet-based OMNA Marine Tourniquet (T-OMNA) specifically designed for aquatic use on a training arm for hemorrhage control. The tests were conducted after swimming an approximate distance of 100 meters and the tourniquets were applied while in the water. The following parameters were recorded: time of rescue (rescue phases and tourniquet application), perceived fatigue, and technical actions related to tourniquet skills.

With the T-OMNA, 46% of the lifeguards successfully stopped the MH compared to 21% with the T-CAT (P = .015). The approach swim time was 135 seconds with the T-OMNA and 131 seconds with the T-CAT (P = .42). The total time (swim time plus tourniquet placement) was 174 seconds with the T-OMNA and 177 seconds with the T-CAT (P = .55). The adjustment time (from securing the Velcro to completing the manipulation of the windlass or ratchet) for the T-OMNA was faster than with the T-CAT (six seconds versus 19 seconds; P < .001; effect size [ES] = 0.83). The perceived fatigue was high, with a score of seven out of ten in both tests (P = .46).

Lifeguards in this study demonstrated the ability to use both tourniquets during aquatic rescues under conditions of fatigue. The tourniquet with the ratcheting-fixation system controlled hemorrhage in less time than the windlass rod-based tourniquet, although achieving complete bleeding control had a low success rate.

Rhinosinusitis is one of the most common reasons for a visit to otolaryngology clinics. Some patients are candidates for sinus surgery. Infiltration of 1:100 000 adrenaline in the pterygopalatine fossa was studied, with the aim of evaluating the effect on bleeding in the surgical field.

This double-blind clinical trial was conducted in 2021–2022 on 40 candidates for endoscopic sinus surgery. For each patient, one side of the pterygopalatine fossa was randomly selected to be infiltrated with a vasoconstrictor. Surgical field bleeding on each side was evaluated.

Blood loss was 35.8 ± 20.9 ml in the study group and 38.4 ± 23.7 ml for the control group, with no statistically significant difference between groups (p = 0.49). In addition, there was no difference between the two groups in terms of the surgical field based on Boezaart scores.

Although there are some recommendations on the usage of vasoconstrictors via the pterygopalatine foramen, debate remains.

The Stop the Bleed campaign provided civilians with tourniquet application training and increased the demand for tourniquets among the general population, which led to the development of new commercially available devices. However, most widely available tourniquets have not undergone testing by regulatory bodies and their efficacy remains unknown.

This study aimed to compare the efficacy and performance of Combat Application Tourniquets (CAT) versus uncertified tourniquets.

This study compared 25 CAT with 50 commercially available “look-alike” tourniquets (LA-TQ) resembling the CAT. The CAT and the LA-TQ were compared for cost, size, and tested during one-hour and six-hour applications on a manikin’s leg. The outcomes were force applied, force variation during the application, and tourniquet rupture rate.

The LA-TQ were cheaper (US$6.07 versus US$27.19), shorter, and had higher inter-device variability than the CAT (90.1 [SE = 0.5] cm versus 94.5 [SE = 0.1] cm; P <.001). The CAT applied a significantly greater force during the initial application when compared to the LA-TQ (65 [SE = 3] N versus 14 [SE = 1] N; P <.001). While the initial application force was maintained for up to six hours in both groups, the CAT group applied an increased force during one-hour applications (group effect: F [1,73] = 105.65; P <.001) and during six-hour applications (group effect: F [1,12] = 9.79; P = .009). The rupture rate differed between the CAT and the LA-TQ (0% versus 4%).

The LA-TQ applied a significantly lower force and had a higher rupture rate compared to the CAT, potentially affecting tourniquet performance in the context of public bleeding control. These findings warrant increased layperson education within the framework of the Stop the Bleed campaign and further investigations on the effectiveness of uncertified devices in real-world applications.

To describe the epidemiology of severe bleeding in the immediate post-operative period in children who undergo cardiopulmonary bypass surgery using the Bleeding Assessment Scale for critically Ill Children (BASIC).

Retrospective cohort study in a paediatric ICU from 2015 to 2020.

356 children were enrolled; 59% were male with median (IQR) age 2.1 (0.5–8) years. Fifty-seven patients (16%) had severe bleeding in the first 24 hours post-operatively. Severe bleeding was observed more frequently in younger and smaller children with longer bypass and cross-clamp times (p-values <0.001), in addition to higher surgical complexity (p = 0.048). Those with severe bleeding received significantly more red blood cells, platelets, plasma, and cryoprecipitate in the paediatric ICU following surgery (all p-values <0.001). No laboratory values obtained on paediatric ICU admission were able to predict severe post-operative bleeding. Those with severe bleeding had significantly less paediatric ICU-free days (p = 0.010) and mechanical ventilation-free days (p = 0.013) as compared to those without severe bleeding.

Applying the BASIC definition to our cohort, severe bleeding occurred in 16% of children in the first day following cardiopulmonary bypass. Severe bleeding was associated with worse clinical outcomes. Standard laboratory assays do not predict bleeding warranting further study of available laboratory tests.

In recent years, more and more attention has been paid to the risks of using SSRIs. This group of antidepressants may be associated with an increased risk of gastrointestinal bleeding. This risk would be even further increased with concomitant use of NSAIDs. A number of studies have described this interaction, however they reported conflicting results.

Our objective was to investigate the risk of gastrointestinal bleeding with SSRIs, with or without NSAID use.

We performed a literature search, using Pubmed, EMBASE, and Cochrane library, in order to investigate controlled trials, cohort, case-control and cross-sectional studies that reported the incidence of gastrointestinal bleeding s on SSRIs with or without concurrent NSAID use, compared to placebo or no treatment.

15 case-control studies and 4 cohort studies were included in the analysis. There was an increased risk of gastrointestinal bleeding with SSRIs in the cohort studies and case-control studies. The risk of gastrointestinal bleeding was even further increased with the combined use of both SSRIs and NSAIDs.

SSRIs are associated with a modest increase of gastrointestinal bleeding. However, this risk is significantly increased when SSRIs are used in combination with NSAIDs. Psychiatrists should be aware of the hazards in prescribing these medications together.

No significant relationships.

Neonates are at high risk of bleeding after open-heart surgery. We sought to determine pre-operative and intra-operative risk factors for increased bleeding after neonatal open-heart surgery with cardiopulmonary bypass.

We conducted a retrospective cohort study of neonates (0–30 days old) who underwent open-heart surgery with cardiopulmonary bypass from January, 2009, to March, 2013. Cardiac diagnosis; demographic and surgical data; and blood products, haemostatic agents, and anti-thrombotic agents administered before, during, and within 24 hours after surgery were abstracted from the electronic health record and anaesthesia records. The outcome of interest was chest tube output (in ml/kg body weight) within 24 hours. Relationships between chest tube output and putative associated factors were evaluated by unadjusted and adjusted linear regression.

The cohort consisted of 107 neonates, of whom 79% had a Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Mortality Category of 4 or 5. Median chest tube output was 37 ml/kg (range 9–655 ml/kg). Age, African-American race, and longer durations of surgery and cardiopulmonary bypass each had statistically significant associations with increased chest tube output in unadjusted analyses. In multivariable analysis, African-American race retained an independent, statistically significant association with increased chest tube output; the geometric mean of chest tube output among African-American neonates was 71% higher than that of Caucasians (95% confidence interval, 29–125%; p = 0.001).

Among neonates with CHD undergoing open-heart surgery with cardiopulmonary bypass, African-American race is independently associated with greater chest tube output over the first 24 hours post-operatively.

Current practice for the treatment of traumatic hemorrhage includes fluid resuscitation and the administration of blood products. The administration of tranexamic acid (TXA) within 8 hours of injury has been shown to significantly reduce mortality in a large, prospective, randomized controlled trial. As a result, TXA is widely used in trauma centres to manage trauma patients with major bleeding. The primary aim of this study was to assess the compliance of TXA administration at a level-one trauma centre in Hamilton, Ontario, Canada.

We conducted a retrospective medical record review of consecutive adult trauma patients received at the Hamilton General Hospital between January 1, 2012 and December 31, 2014. Compliance with TXA administration was based on the inclusion criteria of the CRASH–2 trial.

Five hundred and thirty-four of 2,475 trauma patients met the inclusion criteria for TXA administration. Twenty-one patients who received TXA at peripheral hospital prior to their arrival at the level-one trauma centre were excluded from the analysis, and 18 patients were excluded due to missing data. One hundred and thirty-four patients received TXA, representing a compliance rate of 27%. Mean time from arrival to TXA administration was 47 minutes. Compliance increased for those who required massive transfusion and as the number of criteria for TXA administration increased.

Compliance with TXA administration to trauma patients with suspected major bleeding was low. Quality improvement strategies aimed at increasing appropriate use of TXA are warranted.

Paediatric tonsillectomy is a common procedure and one of the first skills acquired by surgical trainees. Post-tonsillectomy bleeding is one of the most significant complications. This study examined post-tonsillectomy bleed rates associated with technology and level of surgical experience.

Data were collected on all tonsillectomies performed by surgical consultants (n = 6) and trainees (n = 10) at affiliated hospitals over a nine-month period. Hospital records were audited for post-tonsillectomy bleeding re-admissions and returns to the operating theatre.

A total of 1396 tonsillectomies were performed (279 by trainees, 1117 by consultant surgeons). Primary post-tonsillectomy bleed rates were equivalent between trainees and consultants. Secondary bleed rates were significantly greater for trainees (10.0 per cent) compared to consultants (3.3 per cent), as were return to operating theatre rates (2.5 per cent vs 0.7 per cent). Amongst consultants, technology used was not associated with differences in secondary post-tonsillectomy bleeding and returns to the operating theatre.

Our data suggest that experience of the surgeon may have greater bearing on post-tonsillectomy bleed rates than the technology used.