4. Discussion
thrombosis, bleeding, hypothermia, blood loss, intraoperative blood loss, postoperative bleeding, Failure of haemostasis, thrombotic, bipolar electrocautery, hypertrophy, haemostasis failure, adenoid mass, postadenoidectomy haemorrhage, trauma
THROMBOSIS, BLEEDING, BLOOD LOSS, EVENT, POSTOPERATIVE BLEEDING, HYPERTROPHY, INTRAOPERATIVE BLOOD LOSS, POSTOPERATIVE HAEMORRHAGE, COLD
There are many studies in the literature regarding the haemostatic effect of different topical agents for bleeding control during adenoidectomy. Most authors agree that topical agents such as hydrogen peroxide, tranexamic acid, saline solutions, and vasoconstrictor/epinephrine dilutions applied locally to the nasopharynx seem to be the most effective in controlling haemostasis after such surgery [One study regarding the effect of saline solution irrigation during adenoidectomy haemostasis reported that saline solutions are effective haemostatic agents, especially at hot temperatures (50 °C). The haemostatic effect of hot saline solutions (at 50 °C) was significantly higher compared to the use of cold saline solutions (at 4 °C) [We could not find any studies regarding the use of continuous suctioning—a simpler and costless method to stop bleeding during adenoidectomy that is readily available during surgery. No side effects were noted regarding cold air use. Studies investigating lowering the local temperature (for vasoconstriction) at the nasopharyngeal level during adenoidectomy haemostasis report using irrigation of the nasopharynx with cold (4 °C) saline solutions. Most authors agree that cold solutions are less effective in controlling blood loss after adenoidectomy compared with hot solutions [Many studies have been conducted to investigate the effects of hypothermia on haemostasis in vitro and in vivo, and these have yielded contradictory results. One of these studies found that mild hypothermia during surgery significantly increases blood loss by 16% (4–26%) and increases the relative risk of transfusion [As studies show, when the local body temperature drops below 37 °C, platelets become more predisposed to activation by thrombotic stimuli, an event known as priming. The enhanced ability of platelets to prime at peripheral blood sites, where temperatures are lower and the chances of trauma are higher, is thought to have evolved as a protective and adaptative effect against bleeding in humans, whereas more central body sites have greater protection against thrombosis [On exposure to cold, some authors report a marked increase in the affinity of the postjunctional alpha-adrenoreceptors for norepinephrine, resulting in a powerful vasoconstriction and consequent cessation of blood flow to the perypheric tissues (this phenomenon, called hunting reaction was first seen in dogs, then in humans) [In the endeavour of offering some explanation for the haemostatis effect of continuous suctioning, we measured the local nasopharyngeal temperature in some of our patients. The protocol of our study did not include assessing the local temperature of every patient enrolled in this study. The mean local temperature we measured intraoperatively at the adenoid area after use of cold air suctioning for 3 min (the device set at 150 mbar) in some of our patients is 34.4 °C, corresponding to mild hypothermia; our study reports enhanced haemostasis in these children, corresponding to data from the literature regarding the effects of mild hypothermia on haemostasis.Using a metallic suctioning tube at the patient’s nasopharyngeal level is not the only way to create locally mild hypothermia, as this effect (“cold air effect”) can be reproduced regardless of the suctioning probe’s material (plastic as well) and form.After statistically analysing the data collected in our study and comparing the two groups, we found that the mean operative time during adenoidectomy, mean haemostasis time, and the mean intraoperative blood loss were significantly lower in children in whom continuous suctioning was used during haemostasis. Moreover, the need for electrocautery use because of haemostasis failure is higher in group B of patients in the absence of cold air suction use during adenoidectomy haemostasis. Absolutely no side-effects were noted in our patients in group A (continuous suctioning).Choosing the studied sample size followed calculations performed by our statistical analyst. Moreover, it was the number of patients operated on by the three designated surgeons on 2 days per week during the study period of 6 months. The sample was small enough to be economically efficient and large enough to draw conclusions that warrant further extension of this study to larger samples of patients.The mean operative time (duration of the adenoidectomy procedure) in group A (continuous suctioning group) was 11.48 min, while in group B it was 14.49 min; the difference is statistically significant (The average haemostasis times were 8.67 min in group A (cold air) and 10.97 min in group B. The comparison of these values is statistically significant (The number of cotton packings used (reflecting in a semiquantitative manner the intraoperative blood loss) for group A patients was on average 6.04, while for group B patients it was on average 8.68. The comparison between these mean values is also statistically significant (Failure of haemostasis and the need for bipolar electrocautery application to the nasopharynx were recorded in four patients in group A (4 out of 70 patients) and in 22 patients in group B (22 out of the total 70 patients). The difference is also statistically significant (In terms of early postadenoidectomy haemorrhage (during the first 24 h after surgery), there was no significant difference between group A and group B. Thus, we can conclude that cold air use does not interfere with early postoperative bleeding after adenoidectomy.The dimensions of the adenoid mass were not taken into consideration in this study as an independent factor, as studies show operative time or postoperative haemorrhage risk do not correlate with the grade of hypertrophy of the adenoid mass [Limitations of this study could be the number of enrolled patients (the effects of cold air suction during adenoidectomy haemostasis could benefit from studies on a larger number of patients; however, the size of our sample group is large enough to warrant statistical analysis and offer a correlation hypothesis). The fact that this study is based on a single—centre experience—with a consequently uniform surgical technique and general anaesthesia. The method for assessing intraoperative blood loss through counting the number of cotton packings used for each surgical procedure is a semiquantitative procedure that could eventually be perfected.