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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)
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 ?
* pain; nausea/vomiting; untreated HTN …
What is it about MMH that leads to the higher risk of bleeding?
Post-Thyroidectomy Haemorrhage
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%
Post-Thyroidectomy Haemorrhage
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
Post-Thyroidectomy Haemorrhage
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%
Post-Thyroidectomy Haemorrhage
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
Post-Thyroidectomy Haemorrhage
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
Post-Thyroidectomy Haemorrhage
Highest Systolic
BP
Thyroid Weight [log-scale]
Post-Thyroidectomy Haemorrhage
Post-Thyroidectomy Haemorrhage
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 ControlSources of variation
Campus BMISystolic BP Ethnicity
Surgical Team Gland Weight
Post-Thyroidectomy Haemorrhage
Post-Thyroidectomy Haemorrhage
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)
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…”
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
Post-Thyroidectomy Haemorrhage
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
Post-Thyroidectomy Haemorrhage
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
Post-Thyroidectomy Haemorrhage
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
Post-Thyroidectomy Haemorrhage
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%)
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”