Bleeding in Plastic–Aesthetic Surgery: A Prognostic Pathway with Clinical Application
Sergio Marlino, Barbara Cagli, Andrea Vitale, Andrea Boccia, Stefano
Avvedimento, Gabriele Madonna & Adriano Santorelli
Aesthetic Plastic Surgery
ISSN 0364-216X
Aesth Plast Surg
DOI 10.1007/s00266-019-01557-5
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Results
Intheretrospectivestudy,163patientswereanalyzed.Of these,98.15%ofthepatientsanalyzedhadableedingscore includedinarangebetween0and3.Nopatientsinthis groupshowedanintra-orpostoperativebleedingcomplication.Threepatientsoutof163,representing1.85%,hada bleedingscorebetween4and7.Wewishtopointoutthat onlyonepatientinthisgrouphadmoderatebleedingasa complicationofanon-infectiousseromawithhigherythrocytosis.Wedidnotfindpatient(s)withableedingscore higherthan7(Table 1).Theaimoftheprospectivestudy wasfocusedontheidentificationofpatientsatriskof bleedingbeforetheplannedinterventionusingthebleeding scoreobtainedfromtheretrospectivestudy(Figs. 1, 2).
Intheprospectivestudy,thepatientsanalyzedwere223. Ofthese,98.2%ofthepatientshadableedingscoreina rangebetween0and3.ThesepatientsperformedalevelI exampanel(noabnormalfindingswerehighlighted)before undergoingtheplannedintervention,andnopatienthas shownintraoperativeand/orpostoperativehemorrhagic complications.Threepatients(1.3%)hadableedingscore between4and7.ThesepatientsperformedalevelIIexam panelbeforeundergoingtheplannedintervention.The
levelIIpanelforonepatientshowedPT \ 60andafactor IIdeficiency;therefore,interventionwasplannedwith Prothromplex(30u/kg)andtherewerenointraoperative andpostoperativecomplications.Forthesecondpatient, thelevelIIpanelshowedPT \ 60%,aPTT [ 40s,anda decreaseoffactorsII,V,andXwasfound,sosurgerywas notcarriedout.ThelevelIIpanelofthethirdpatient showedalterationofPTandaPTTandnodecreaseof factorsorplateletsdysfunction;insubsequentinterviews, thepatientreportschronicintakeofibuprofen,sothedrug wassuspendedandtheexamrepeateduntilthenormal valuesreturned,andafter30days,thesurgerywasperformedwithoutcomplications.Onlyonepatient(0.5%) showedaveryhighbleedingscore,correspondingto9. Thispatientdidnotundergosurgerybutwassenttothe referencecenterforfurtheranalysis(Table 2).
Discussion
Theriskofbleedingisanimportantcomplicationthatcan occurduringand/orafteraplasticsurgeryprocedure.The severityandtheconsequencesarevariable,anditis essentialtopreventbleedingepisodestoimprovethefinal
Fig.2 Inquiryrelatedtothe bleedingscore
Table1 Retrospectivestudy
Retrospectivestudy
BleedingscorePatientsincludedintherangeBleedingevents
0–3160(98.15%)0
4–73(1.85%)1 [ 70(=%)0
Insertionofthepatientsanalyzedinthecorrespondingbleedingscore rangeandevaluationofthecorrespondencewiththebleedingevents
Table2 Prospectivestudy
Prospectivestudy
BleedingscorePatientsincludedintherangeClinicalpathway
0–3219(98.2%)PanelIanalysis
4–73(1.3%)PanelIIanalysis [ 71(0.5%)Nooperation
Associationofpatientsinthecorrespondingbleedingscorerangeand indicationofappropriateclinicalpathway
outcomeofthesurgeryandthepostoperativecourse. Preventionofthehemorrhagicriskisagoalthatwewishto achieveinthisstudythroughthegenerationofaquantitativescoreofthebleedingrisk.Thisscorewascalculated usingaformobtainedonthebasisofdatafromtheliterature,aretrospectivevalidationofthebleedingform,and theintroductionintoclinicalpracticeofthebleedingscore. Theresultsobtainedfromtheretrospectivestudyon163 collectedin4yearsshowedthatpatientswithalow bleedingindexhadnointraoperativeand/orpostoperative hemorrhagiccomplications.Onlyonepatientoutofthree withableedingscore4–7(i.e.,ameanbleedingindex) showedhemorrhagiccomplicationinthepostoperative course,inagreementwiththepredictionofthebleeding score.Thesedatavalidatetheeffectivenessofthebleeding indexasapredictorofbleedingevents.Theprospective study,performedon223patientsrecruitedatourcenter, showedthatinthreepatientswithableedingscoreindex between4and7,thelevelIIpanelanalysisconfirmeda mediumriskofincurringbleedingepisodes.Theimportanceofknowingthepatientswhomaycarryahigherrisk ofexcessbleedingistostartprophylacticmaneuversto reducetheriskofbleedingepisodes.Indeed,inourstudy twomedium-riskpatientsweretreatedbeforeundergoing surgery:onewithProthromplexandtheotherwithinterruptionofachronictherapywithibuprofen.Twopatients in223(onewithableedingscorebetween4and7andthe otherwithableedingindexof9)didnotundergosurgery andweresenttothereferencecenterforfurtherinvestigation.Thelowpercentageofpatientsthatwereconsidered atmediumandhighriskforbleedingeventsisinlinewith thelowrateofpostoperativebleedingthatisusually encounteredinaestheticsurgeryprocedures.Inouropinion,wefoundthistypeofbleedingscoreassessmentvery usefulsinceithelpstoroutinelyscreenlargenumberof subjectsinarelativelyfastandreproduciblemanner.In thisstudy,wepotentiallypreventedbleedingcomplications infourpatientswithnoapparentrisk.Thisisarather significantnumberconsideringthatsubjectsundergoing electiveaestheticproceduresareusuallyhealthyand apparentlynormalsubjectswithnospecificrisk.
Theprospectivestudyhasthereforehighlightedthe usefulnessoftheintroductionofthetestfortheassessment ofthebleedingindextodiscriminatepatientsatriskandto interveneinapreventivemannertodefinethemost appropriatediagnosticpathway.
Weareawarethatthelimitofthisstudyisthecohortof patientsenrolledinoneclinic.Thevalidationofthescore requiresprospectivestudiesinothernationalorinternationalcenters.Ourfindingscanpavethewaytoaquantitativeindexthatwillbeusedtorecognize,manage,and preventhemorrhagiccomplicationsofaestheticsurgery.
Acknowledgements WewouldliketothankHealth&Progresss.r.l., Benevento,Italy,forsupportingauthorsintheprojectandpublication ofthisarticle.
Funding Notapplicable.
CompliancewithEthicalStandards
Conflictofinterest Alltheauthorsdeclarednopotentialconflictsof interestwithrespecttotheresearch,authorship,andpublicationof thisarticle.
EthicalApproval Allproceduresperformedinstudiesinvolving humanparticipantswereinaccordancewiththeethicalstandardsof theinstitutionaland/ornationalresearchcommitteeandwiththe1964 HelsinkiDeclarationanditslateramendmentsorcomparableethical standards.
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