life-threatening haemorrhage following thyroid surgery randall morton, terina pollock...

Life-Threatening Haemorrhage Following

Thyroid Surgery

Randall Morton, Terina PollockCounties-Manukau District Health Board

Auckland University

• CMDHB General & Thyroid Surgeons• Alain Vandal, Statistician

Acknowledgements:

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”

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)


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?


HQSC Cohort AnalysisJan 2002 - Apr 2012

n = 621

Mean Age (SD) 48.3 (+14.5)Median BMI (IQR) 29.2 (9.8)ASA 1/2 509 82%Smoker 201 32.4%Pre-existing HTN 186 32.3%Female gender 525 85% European 182 29% Maori 175 28% Pacific Is 115 18.5%


Observations on Thyroid Surgery

Total Thyroidectomy 360 58%Mean (SD) Thyroid weight (gm) 91.9 (+96.5)Median (range) Thyroid weight (gm) 52.7 (4-520)Benign disease 487 78%Surgery @ MSC 413 67%Number w post-op Systolic BP >150 mmHg 265 47%Median (range) High Systolic BP post-op 150 98 - 230

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

HQSC Cohort AnalysisJan 2002 - Apr 2012


ASA status n.s.Wound Drain n.s.Surgical Time n.s.

Surgical team 0.13

Ethnicity 0.024BMI 0.022Location of Surgery 0.013Highest post-op BP 0.007Gland Weight 0.001

Univariate Analysis CMDHB data

European (182)

Pacific (115)

Maori (175)

Asian (149)

2.2%

1.7%

6.1%

0%


Regression Analysis

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

95% CI = 1.01 - 1.09

Highest post-op Systolic BPp = 0.016, [OR: 1.39 (per 10 mmHg)]

95% CI=1.09-1.76

Relative Risk: BP

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

100 110 120 130 140 150 160 170 180 190 200 210 220 230


Regression Analysis

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

95% CI = 1.01 - 1.09

Highest post-op Systolic BPp = 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


Highest Systolic

BP

Thyroid Weight [log-scale]


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


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 ControlSources of variation

Campus BMISystolic BP Ethnicity

Surgical Team Gland Weight


n = 30,142

Br J Surg 2012; 99: 373 – 379

519 (1.7%)Rate range:0.4 - 2.8%

Br J Surg 2012; 99: 373 – 379

Rate range:0.4 - 2.8%

519 (1.7%)

(4/994)

(9/318)CMDHB

Highest Systolic

BP

Thyroid Weight [log-scale]

2 cases - bled before PACU (no pre-bleed systolic BP recorded)2 cases - late bleeds (drains*2)


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


Abs Risk (BP)

0

1

2

3

4

5

6

7

<140 140-150 150-175 >175

Abs Risk (Size {wt})

0

1

2

3

4

5

6

7

<20 20-60 60-130 >130

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


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


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


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%)


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”

life-threatening haemorrhage following thyroid surgery randall morton, terina pollock...

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