Life-Threatening Haemorrhage Following Thyroid Surgery
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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:. Post-Thyroidectomy Haemorrhage. 870/ 65,962 ( 1.3% ).

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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:


Post-Thyroidectomy Haemorrhage

870/ 65,962 (1.3%)

Promberger et al Br J Surg (2012) 519/30,142 (1.7%)

“no definite perioperative risk factor has been identified to predict occurrence of cervical haematoma”

CMDHB audit

2000-2002

4/94 (4.25%)

274/ 32,160 (0.8%)

Bononi M, et al. “Incidence and circumstances of cervical hematoma complicating thyroidectomy …” Head Neck 2010; 32:1173-1177


Post-Thyroidectomy Haemorrhage

CMDHB Thyroid Surgery

2002-08

7/406 (1.7%)

7 cases of RTT matched from contemporaneous controls for:

Gender; Ethnicity; Operation; Pathology; Campus; Age

  • Logistic regression:

  • post-op systolic BP >150 mmHg

  • (p = 0.005)

MSC 1/241 (0.4%)

MMH 6/165 (3.6%)


Post-Thyroidectomy Haemorrhage

  • 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 ?

  • What is it about MMH that leads to the higher risk of bleeding?

* pain; nausea/vomiting; untreated HTN …


Post-Thyroidectomy Haemorrhage

HQSC Cohort Analysis

Jan 2002 - Apr 2012

n = 621


Post-Thyroidectomy Haemorrhage

HQSC Cohort Analysis

Jan 2002 - Apr 2012

Observations on Thyroid Surgery

post-operative bleeds: 15/621 (2.4%)


Post-Thyroidectomy Haemorrhage

Univariate Analysis CMDHB data

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


Post-Thyroidectomy Haemorrhage

Regression Analysis

Highest post-op Systolic BP

p = 0.016, [OR: 1.39 (per 10 mmHg)]

95% CI=1.09-1.76

Thyroid Size (weight)

p = 0.0072 [OR 1.05 (per 10 gms)]

95% CI = 1.01 - 1.09


Post-Thyroidectomy Haemorrhage

Regression Analysis

Highest post-op Systolic BP

p = 0.016, [OR: 1.39 (per 10 mmHg)]

95% CI=1.09-1.76

Thyroid Size (weight)

p = 0.0072 [OR 1.05 (per 10 gms)]

95% CI = 1.01 - 1.09

Statistical Issues

  • 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

Surgical Team: there is some statistical effect of surgical team

- inclusion improves the fit for the statistical model


Post-Thyroidectomy Haemorrhage

Highest Systolic

BP

Thyroid Weight

[log-scale]




Post-Thyroidectomy Haemorrhage

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


Post-Thyroidectomy Haemorrhage

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



n = 30,142

Br J Surg2012;99: 373 – 379

Rate range:

0.4 - 2.8%

519 (1.7%)


CMDHB

Br J Surg2012;99: 373 – 379

(4/994)

519 (1.7%)

Rate range:

0.4 - 2.8%

(9/318)


Post-Thyroidectomy Haemorrhage

Highest Systolic

BP

2 cases - bled before PACU

(no pre-bleed systolic BP recorded)

2 cases - late bleeds (drains*2)

Thyroid Weight

[log-scale]


Post-Thyroidectomy Haemorrhage

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…”

While Intra-operative Mortality risk has “disappeared”,

Post-operative Haemorrhage remains life-threatening

Liston R“Lectures on the operations of surgery and on diseases and accidents requiring operations.”Lea and Blanchard, Philadelphia, 1846; pp 318-326.


Post-Thyroidectomy Haemorrhage

Statistical Issue

  • 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


Post-Thyroidectomy Haemorrhage

What factors can we influence to try to avoid post-operative Haematoma formation?

  • Hospital/Surgeon Volume

  • Vessel Management (Surgeon)

  • Trendelenburg/ Valsalva (Surgeon)

  • Surgical Drains (Surgeon)

  • Nausea/ Vomiting control (Anaesthetist)

  • NSAIDs/ pain relief (Anaesthetist)

  • Other (Patient/Disease);

    - BMI/ Gland size/ Medication/ etc


Post-Thyroidectomy Haemorrhage

Arch Surg. 2009;144(12):1167-1174

  • 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


Post-Thyroidectomy Haemorrhage

870/ 65,962 (1.3%)

Promberger et al Br J Surg (2012) 519/30,142 (1.7%)

“no definite perioperative risk factor has been identified to predict occurrence of cervical haematoma”

CMDHB audit

2000-2002

4/94 (4.25%)

274/ 32,160 (0.8%)

Bergenfelz et al. Lang Arch Surg (2008): 77/3660 (2.1%)

Bononi M, et al. “Incidence and circumstances of cervical hematoma complicating thyroidectomy …” Head Neck 2010; 32:1173-1177


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